The Centers for Medicare & Medicaid Services (CMS) is changing the payment status indicator for CPT® code 90662 Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use from “E” (not paid under the Outpatient Prospective Payment System (OPPS)) to “L” (not paid under OPPS; paid at reasonable cost; not subject to deductible or co-insurance) in the October 2010 Integrated Outpatient Code Editor (IOCE).

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The Centers for Disease Control and Prevention’s (CDC’s) National Center for Health Statistics (NCHS) posted updates Aug. 5 to the ICD-9-CM Official Guidelines for Coding and Reporting. These guidelines for diagnosis coding are effective Oct. 1.

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Effective Nov. 6, physicians separately can report implantable tissue markers (HCPCS Level II A4648 Tissue marker, implantable, any type, each) and implantable radiation dosimeters (A4650 Implantable radiation dosimeter, each) in Medicare Part B claims.

To receive payment for these miscellaneous supplies, codes A4648 and A4650 must be billed in conjunction with one of the following CPT^® codes:

19499 Unlisted procedure, breast

32553 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous intra-thoracic, single or multiple

49411 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous intra-abdominal, intra-pelvic (except prostate), and/or retroperitoneum, single or multiple

55876 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple

If one of the above CPT® codes is not paid on the same claim (or in history) with the same date of service, payment will be denied.

No policy change has been made for hospitals paid under the Outpatient Prospective Payment System (OPPS), Inpatient Prospective Payment System (IPPS), or ambulatory surgical centers (ASCs) paid under the ASC Payment System. Current Medicare policy continues to instruct Medicare contractors not to separately reimburse claims for HCPCS Level II codes A4648 or A4650 to hospitals and ASCs paid under these payment systems.

Refer to the Centers for Medicare & Medicaid Services (CMS) Transmittal 745, Change Request (CR) 6968, issued Aug. 6, for further clarification of this physician payment policy in Pub. 100-20 of the Medicare Claims Processing Manual.

Effective Jan. 1, 2011, the Centers for Medicare & Medicaid Services (CMS) will establish durable medical equipment prosthesis, orthotics and supplies (DMEPOS) specialty code B5 for ocularists.

The American Society of Ocularists defines an ocularist as a “carefully trained technician skilled in the arts of fitting, shaping, and painting ocular prostheses.” In addition to creating ocular prostheses, the ocularist shows the patient how to handle and care for them, and provides long-term care through periodic examinations.

Patients who need to be referred to an ocularist usually fall into the following categories:

• Recent enucleation/evisceration
• Problems with an existing prosthesis
• Blind eyes requiring a scleral shell
• Congenital anophthalmia/microphthalmia

Patients with existing ocular prostheses often need to be referred to the ocularist for problems with either the surface condition of the prosthesis or problems with the fit of the prosthetic eye or scleral shell.

Services provided by the ocularist include:

• Cleaning
• Polishing
• Enlargement
• Reduction
• Replacement

Due to the requirements of most insurance policies, a written prescription from the referring physician or other appropriate eye care specialist often is required.

Palmetto GBA recently amended its Cataract Surgery Local Coverage Determinations (LCDs) to reflect a focus on the adult patient and a more complete description of functional status.

In response to comments the J1 Part A/B Medicare administrative contractor (MAC) received, the title of the final policy was amended to appropriately reflect the adult patient population. Palmetto GBA also removed the specific Snellen visual acuity threshold from the final LCD. The reporting requirement of the “best corrected” Snellen visual acuity remains, however. As does the expectation that the medical records supporting the cataract extraction identify the activity limitations (e.g., in self-care and mobility) and participation restrictions (e.g., in interpersonal interactions and relationships and community, social and civic life) are also reported.

These terms may be new to physicians, hospitals, and ambulatory surgical centers (ASCs) providing cataract surgery but are reflective of long-standing concepts included in such well-established instruments like the National Eye Institute’s Visual Functioning Questionnaire – 25 (VFQ – 25).

To provide guidance to physicians, hospitals, and ASCs on how best to communicate functional status for patients requiring cataract extraction, Palmetto GBA has incorporated the concepts of the International Classification of Functioning, Disability and Health (ICF) taxonomy into the final version of the LCD.

Below is a case scenario demonstrating the value of going beyond diagnosis by using the concepts of the ICF. Please note that while Palmetto GBA is encouraging physicians and hospitals providing cataract surgery to consider the conceptual framework of the ICF, Medicare does not require the reporting of the ICF codes. Read more »

Palmetto GBA, Medicare administrative contractor (MAC) for jurisdiction 1 (J1), recently reported that the Comprehensive Error Rate Testing (CERT) contractor reported an increase in errors for complete blood counts (CBC) and urinalysis (UA) laboratory services.

According to the CERT report, data indicate two types of common errors:

• Code selection errors
• Standard protocol use in place of patient-specific physician orders

Sample Errors

In an Aug. 18 online article, Palmetto GBA gives the following two examples of common errors:

Example 1: A physician orders a CBC with automated differential WBC count (CPT® 85025 Blood count complete (CBC), automated (Hgb, Hct, RC, WBC and platelet count) and automated differential WBC count) or without automated differential WBC count (85027 Blood count complete (CBC), automated (Hgb, Hct, RC, WBC and platelet count)). Based on internal criteria, the lab examines a blood smear for additional verification. The lab may not report CPT® 85008 Blood count; blood smear microscopic examination without manual differential WBC count for the exam of a blood smear to complete the ordered automated hemogram test (CPT® 85025 or 85027) because National Correct Coding Initiative (NCCI) guidelines indicate it is a bundled service.

Example 2: A physician orders an automated hemogram (CPT® 85027) and a manual differential WBC count (CPT® 85007 Blood count; blood smear microscopic examination with manual differential WBC count). Both codes may be reported; however, an automated hemogram with automated differential WBC count (85025) may not be reported with a manual differential WBC count (CPT® 85007) because this results in duplicate payment for the differential WBC count.

Code Selection

Only lab services ordered by the physician should be provided and billed. A physician’s written order must match the performed service, Palmetto GBA advises.

• Submit CPT® Codes 85014 Blood count; hematocrit (Hct) and 85018 Blood count; hemoglobin (Hgb) to report a hemoglobin and hematocrit level.
• Submit CPT® Code 85027 to report a CBC to measure hemoglobin, hematocrit, red blood cell, white blood cell, and platelet levels.
• Submit CPT® Code 85025 to report a CBC and differential white blood cell (WBC) count to measure the percentages of white blood cell types.

Remember: The medical record must document the medical indication for the ordered services, the specific order written by the physician and the test results of the ordered diagnostic tests.

Improper Protocols

Providers may not perform additional laboratory services based on internal standard or implied protocols, accord to the MAC. Medicare only covers patient-specific orders written by a physician. The following sample protocols are not covered Medicare services and may be subject to a recovery audit contractor (RAC) for corrective action.

• Physician’s written order for a hemoglobin and hematocrit prompts the lab to perform a CBC
• Physician’s written order for a CBC prompts the lab to perform a CBC with differential
• White cells or bacteria discovered in a physician ordered urine test prompts the lab to perform a urine culture without a physicians order

Reference: Chapter 10, NCCI Policy Manual, Volume 15.3

Source: Palmetto GBA

An Office of Inspector General (OIG) review suggests physicians correctly code the place of service (POS) in Medicare Part B claims only 10 percent of the time. This pattern of incorrectly coded claims for nonfacility services resulted in Medicare overpaying physicians an estimated $13.8 million in 2007, the OIG concludes in a July report.

Of the 100 services the OIG sampled, 90 of the services were coded as having been performed in a nonfacility location, when 60 of the services were actually performed in hospital outpatient departments and 30 were performed in ambulatory surgical centers (ASCs).

The OIG provides in the report this example of incorrect coding:

“A carrier paid a physician $374 for performing a spinal pain injection procedure coded as having been performed in his office. Our analysis showed that the physician actually performed this procedure in a hospital outpatient department and that a fiscal intermediary had reimbursed the hospital for the overhead portion of the service. If the claim had been coded correctly, the physician would have received a payment of $96, which would not have included overhead costs. As a result of the incorrect coding, the physician was overpaid $278.”

The OIG report recommends for the Centers for Medicare & Medicaid Services (CMS) to immediately reopen the claims associated with the 484,118 nonsampled services and work with the physicians who provided the services (and more than likely miscoded the POS) to recover any overpayments.

For complete details, read the OIG July 2010 report; and for POS codes and definitions, refer to CMS Pub. 100-04, Medicare Claims Processing Manual, chapter 26, section 10.5.

TrailBlazer Health has launched a new online tool designed to help providers determine how multiple services of the same code should be submitted to Medicare Part B.

The Multiple Services of the Same Code Interactive Decision Tree tool gives providers the billing instructions and information they need to make the appropriate decision for when modifier 76 Repeat procedure or service by same physician may be used and how to bill bilateral procedures.

The provider simply selects the answer that applies to the claim in question. Either a new question or instructions automatically displays based on the answer to the question. Also based on the answers to questions, the provider may be led to the Modifier Code Search tool, which provides descriptions and guidelines for commonly used modifiers used in Medicare claims filing.

Medicare Part B physician payments for transforaminal epidural injection services increased from $57 million in 2003 to $141 million in 2007, according to a recent review conducted by the Office of Inspector General (OIG). That amounts to a 150 percent increase.

A gain in popularity of this magnitude prompted the OIG to conduct a review of this pain management service. In the review, the OIG states that roughly 34 percent of 433 sampled claims for transforaminal epidural injection services performed in 2007 did not meet Medicare requirements. The OIG estimates approximately $43 million in improper payments.

Physicians should prepare themselves for added contractor scrutiny of these types of pain management claims.

Transforaminal epidural injections are a type of interventional pain management technique used to diagnose or treat pain. There are two primary codes used to bill a single injection in the cervical/thoracic or lumbar/sacral area of the spine, and each primary code has an associated add-on code for use when injections are provided at multiple spinal levels. These codes are:

Physician payments vary based on the place of service (office vs. ambulatory surgical center (ASC) or outpatient department) and also the modifiers billed. For example, bilateral transforaminal epidural injections, which are performed on both the right and left side of a vertabrel level should be billed using modifier 50. The use of this modifier would increase payment to 150 percent of the base rate.

According to the OIG, “The reviewer found primarily that physicians improperly used add-on codes and bilateral modifiers.”

Medicare covers transforaminal epidural injections that are reasonable and necessary, which are those used in the diagnosis or treatment of illness or to improve the functioning of a malformed body part. To ensure payment, physicians must:

• Properly document medical care to support the service; and
• use uniform procedure codes to report all services.

Documentation should include a description of the service provided, with details such as location and frequency of injections, as well as outcomes that support subsequent injections. Diagnosis codes also must support medical necessity. Most contractors with local coverage determinations (LCDs) in place for transforaminal epidural injections also require the use of radiographic guidance (such as live X-rays), prohibit multiple pain management services on the same day, and limit frequency.

In response, the Centers for Medicare & Medicaid Services (CMS) says it intends to strengthen program safeguards, which may include medical reviews and system edits.

Read the OIG’s August review for complete details.

Recent guidance from Palmetto GBA Medicare sets a good example of why it is so important for coders to pay careful attention to code descriptions and documentation.

The Part B Medicare administrative contractor (MAC) for jurisdiction 1 sites a coder’s question:

“Due to an adverse reaction to Rituximab, an infusion scheduled for over one hour was discontinued after 10 minutes. The physician conducted an examination and returned the patient to the care of the nurse for an additional hour of monitoring. Can we be reimbursed for the entire hour?”

“If we bill the administration as a push, or add CPT modifier 52 (reduced service) or 53 (discontinued service) to the infusion code, we will receive lower reimbursement.”

Palmetto advises the coder as follows:

“Since the intent was for an infusion, CPT code 96413 (chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) would be more appropriate than billing as a push. The definition of CPT code 96413 states ‘up to one hour;’ therefore, the use of CPT modifier 52 or 53 would not be mandatory, especially with the additional time spent monitoring the patient after the infusion was stopped. Please note that documentation in the medical record of all time spent with the patient is critical. Use of CPT modifier 52 or 53 may result in reduced reimbursement, depending on the documentation submitted with the claim.”