Tag: compliance
On May 26, Centers for Medicare & Medicaid Services (CMS) outlined additional unspecified diagnosis codes the agency is excluding from both ICD-9 and ICD-10 reporting beginning January 2, 2017. The technical alert states the codes, “will not be accepted in the in the Alleged Cause of Injury, Incident or Illness (Field 15) or in any ICD Diagnosis Code field starting with Field 18. Updates to previously submitted records using these excluded codes, will also be rejected.” These additions and upcoming changes to the ICD-10 codeset underline the need for clinical documentation improvement and ICD-10 training, experts say, as code and rule freezes are lifted by the healthcare payment agency. ICD-10-CM will include 1900 new codes and several more changes and deletions. Attention to documentation quality will be paramount. Impacts Workers’ Comp and Auto CMS writes that this change supersedes the applicable language in the MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting Liability Insurance (Including Self-Insurance), No Fault Insurance, and Workers’ Compensation User Guide (Version 4.9). The following ICD-9-CM will be added to the list of excluded diagnosis codes: 999.9 (Other and unspecified complications of medical care, not elsewhere classified) The following ICD-10-CM will be added to the list of excluded diagnosis codes: T88.7XXA (Unspecified adverse effect of drug or medicament, initial encounter) T88.7XXD (Unspecified adverse effect of drug or medicament, subsequent encounter) T88.7XXS (Unspecified adverse effect of drug or medicament, sequela) T88.8XXA (Other specified complications of surgical and medical care, not elsewhere classified, initial encounter) T88.8XXD (Other specified complications of surgical and medical care, not elsewhere classified, subsequent encounter) T88.8XXS (Other specified complications of surgical and medical care, not elsewhere classified, sequela) T88.9XXA (Complication of surgical and medical care, unspecified, initial encounter) · T88.9XXD (Complication of surgical and medical care, unspecified, subsequent encounter) T88.9XXS (Complication of surgical and medical care, unspecified, sequela) Read the Technical Alert here: https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Non-Group-Health-Plans/Downloads/New-Downloads/Technical-Alert-New-Excluded-Diagnosis-Codes.pdf
An add-on code is a HCPCS/CPT code that describes a service that, with one exception (see next paragraph), is always performed in conjunction with another primary service. An add-on code with one exception is eligible for payment only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on code with one exception is never eligible for payment if it is the only procedure reported by a practitioner. The Internet Only Manual, Claims Processing Manual, Publication 100-04, Chapter 12, Section 0.6.12(I) requires a provider to report CPT code 99292 (Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service)) without its primary code CPT code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) if two or more physicians of the same specialty in a group practice provide critical care services to the same patient on the same date of service. For the same date of service only one physician of the same specialty in the group practice may report CPT code 99291 with or without CPT code 99292, and the other physician(s) must report their critical care services with CPT code 99292. Add-on codes may be identified in three ways per CMS Transmittal 2636 The code is listed in this CR or subsequent ones as a Type I, Type II, or Type III, add-on code. On the Medicare Physician Fee Schedule Database an add-on code generally has a global surgery period of \"ZZZ\". In the CPT Manual an add-on code is designated by the symbol \"+\". The code descriptor of an add-on code generally includes phrases such as \"each additional\" or \"(List separately in addition to primary procedure).\" CMS has divided the add-on codes into three Groups to distinguish the payment policy for each group. Type I – This type of add-on code has a limited number of identifiable primary procedure codes. The CR lists the Type I add-on codes with their acceptable primary procedure codes. A Type I add-on code, with one exception, is eligible for payment if one of the listed primary procedure codes is also eligible for payment to the same practitioner for the same patient on the same date of service Type II –. A Type II add-on code does not have a specific list of primary procedure codes. The CR lists the Type II add-on codes without any primary procedure codes. Claims processing contractors are encouraged to develop their own lists of primary procedure codes for this type of add-on codes. Like the Type I add-on codes, a Type II add-on code is eligible for payment if an acceptable primary procedure code as determined by the claims processing contractor is also eligible for payment to the same practitioner for the same patient on the same date of service. Type III – The third type of add-on code has some, but not all, specific primary procedure codes identified in the CPT® manual. CMS advises claims processing contractors that the primary procedure codes in the CPT® manual are not exclusive, and encourages contractors to develop their own lists of additional primary procedure codes. To reference the Type I, Type II or Type III lists of CMS add-on CPT® codes, see the bottom pages of the transmittal here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2636CP.pdf
On June 24, CMS released a change request informing contractors of new CLIA waived tests approved by the Food and Drug Administration. Since these tests are marketed immediately after approval, CMS must notify its contractors of the new tests so that the contractors can accurately process claims. There are 30 newly added waived complexity tests. This recurring update notification applies to Chapter 16, Medicare Claims Processing Manual, section 70.8 of the IOM. Your Medicare Administrative contractor (MAC) will not search their files to either retract payment or retroactively pay claims; however, they should adjust such claims brought to their attention. The following tests are approved by the FDA as waived tests under CLIA (QW Modifier required): CPT Code Effective Date Description G0434QW from August 21, 2015 to December 31, 2015 Healgen Scientific LLC, Healgen Multi-Drug Urine Test Dip Card G0477QW on and after January 1, 2016 Healgen Scientific LLC, Healgen Multi-Drug Urine Test Dip Card G0477QW March 8, 2016 Tanner Scientific Multi-Panel Drug Test Cup G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Marijuana Easy Cup G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Marijuana Split Key Cup G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Marijuana Test Cassette G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Marijuana Test Dip Card G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Metamphetamine Easy Cup G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Metamphetamine Split Key Cup G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Metamphetamine Test Cassette G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Metamphetamine Test Dip Card G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Morphine Easy Cup G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Morphine Split Key Cup G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Morphine Test Cassette G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Morphine Test Dip Card 87338QW March 22, 2016 Meridian Bioscience Immunocard STAT! HpSA (Stool) G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Amphetamine Dip Card G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Amphetamine Quick Cup G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Amphetamine Strip G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Amphetamine Turn-Key Split Cup G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Cocaine Dip Card G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Cocaine Quick Cup G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Cocaine Strip G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Cocaine Turn-Key Split Cup G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Morphine Dip Card G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Morphine Quick Cup G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Morphine Strip G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Morphine Turn-Key Split Cup G0477QW April 21, 2016 Chemtron Biotech, Inc. Chemtrue Multi-Panel Drug Screen Cup Tests G0477QW April 21, 2016 Chemtron Biotech, Inc. Chemtrue Multi-Panel Drug Screen Cup Effective date: October 1, 2016 Implementation date: October 3, 2016 View the Transmittal here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3563CP.pdf
Back in 1996, the Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote correct coding and prevent inappropriate payment of Medicare Part B claims. As this is an automated prepayment review by CMS, the NCCI edits reduce payment error by identifying coding errors made by providers. In 2009, 7.8 % of Medicare dollars did not comply with one of more Medicare coverage, coding, billing or payment rules, translating into $24.1 billion dollars in Medicare overpayments and underpayments annually. The NCCI edits define when two HCPCS/CPT® procedure codes may not be reported together except under special circumstances. The Centers for Medicare & Medicaid Services (CMS) based the NCCI coding policies on current coding conventions, coding guidelines, national and local Medicare policies (NCDs and LCDs), and standard medical and surgical practice. Coding polices and guidelines require that procedures are reported with the most comprehensive CPT® code that describes the services performed. For example, a coder should not report a Basic Metabolic Panel (BMP, CPT® 80047) with a Comprehensive Metabolic Panel CMP,CPT® code 80053) as all the analytes in CPT® 80047 BMP are a subset of the Comprehensive Metabolic Panel and would have been already performed as part of that procedure. As a claim is processed by the Medicare contractor, the system tests every pair of procedure codes to determine if they comply with the NCCI edit policy. This means every code pair reported for the same date of service for the same beneficiary by the same provider is reviewed against the NCCI-edit tables. If a pair of codes on the claim matches (“hits”) a pair in the NCCI edit table, the “Column Two” code of the edit pair is denied for payment. Using the CMP/BMP example above, in the NCCI edit tables, CPT® 80047 is the “Column Two” code and would have payment denied. NCCI-associated modifiers are used to indicate the special circumstances such as when the procedures are performed at different anatomic sites, a separate procedure or repeat clinical diagnostic laboratory test. If an edit allows use of NCCI-associated modifiers, the two procedure codes may be reported together. NCCI-associated modifiers may not be used to bypass an edit unless the criteria for use of the modifier are met. Each active NCCI edit has a modifier indicator of 0 or 1. A modifier indicator of “0” indicates that an edit can never be bypassed even if a modifier is used. In other words, the Column 2 code of the edit will be denied. A modifier indicator of “1” indicates that an edit may be bypassed with an appropriate modifier appended to the Column 1 and/or Column 2 code. The NCCI-associated modifiers are: E1, E2, E3, E4, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, LC, LD, RC, LT, RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9, 25, 27, 58, 59, 78, 79, and 91. In January 1, 2013, additional modifiers were added to the list of NCCI-associated modifiers that will allow an edit to be bypassed when the modifier is used correctly (i.e., edits with modifier indicator of “1”). These were LM (left main coronary artery), RI (ramus intermedius), 24 (unrelated evaluation and management service by the same physician during a postoperative period), and 57 (decision for surgery). Effective Jan 15, 2015, new more specific modifiers become effective (see also Compliance Matters, Sept 2014) supplementing Modifier -59 (Distinct Procedural Service). XE Separate Encounter: A Service That Is Distinct Because It Occurred During A Separate Encounter XS Separate Structure: A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure XP Separate Practitioner: A Service That Is Distinct Because It Was Performed By A Different Practitioner XU Unusual Non-Overlapping Service: The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service These modifiers, collectively referred to as -X{EPSU} modifiers, define specific subsets of the -59 modifier. CMS will not stop recognizing the -59 modifier but notes that CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available. CMS will continue to recognize the -59 modifier in many instances but may selectively require a more specific - X{EPSU} modifier for billing certain codes at high risk for incorrect billing. Services denied based on NCCI edits may not be billed to Medicare beneficiaries, nor can a provider use an “Advanced Beneficiary Notice” (ABN) to seek payment from the patient since these denials are based on incorrect coding rather than medical necessity or a benefit exclusion. Hospitals, like physicians and other providers, must follow national correct coding policies. Though the NCCI edits were initially developed for processing professional claims, the NCCI edits are incorporated into the Outpatient Code Editor (OCE) used for processing outpatient hospital service claims, outpatient physical therapy and speech-language pathology services, skilled nursing facilities (SNFs), comprehensive outpatient rehabilitation facilities (CORFs), and home health agencies (HHAs). These are commonly referred to as the NCCI “Hospital” Version of CCI edits. Review the NCCI manual on CMS here: http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/nationalcorrectcodinited/
Since Medicare’s inception in 1966, private health care insurers have processed medical claims for Medicare beneficiaries. Originally these entities were known as Part A Fiscal Intermediaries (FI) and Part B carriers. In 2003 the Centers for Medicare & Medicaid Services (CMS) was directed via Section 911 of the Medicare Prescription Drug Improvement, and Modernization Act (MMA) of 2003 to replace the Part A FIs and Part B carriers with A/B Medicare Administrative Contractors (MACs) in accordance with the Federal Acquisition Regulation (FAR). A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries. CMS relies on a network of MACs to serve as the primary operational contact between the Medicare FFS program and the health care providers enrolled in the program. MACs are multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims. MACs perform many activities including: Process Medicare FFS claims Make and account for Medicare FFS payments Enroll providers in the Medicare FFS program Handle provider reimbursement services and audit institutional provider cost reports Handle redetermination requests (1st stage appeals process) Respond to provider inquiries Educate providers about Medicare FFS billing requirements Establish local coverage determinations (LCD’s) Review medical records for selected claims Coordinate with CMS and other FFS contractors Currently there are 12 A/B MACs and 4 DME MACs in the program that process Medicare FFS claims for nearly 70% of the total Medicare beneficiary population, or 37.5 million Medicare FFS beneficiaries. The MACs serve more than 1.5 million health care providers enrolled in the Medicare FFS program. Collectively, the MACs process more than 1.2 billion Medicare FFS claims annually, 210 million Part A claims and more than 1 billion Part B claims, and paid $367 billion in Medicare benefits. MAC A/B Jurisdiction Map (Dec 2015): Source: www.cms.gov
