This week’s note from the instructor is written by Debbie Mackaman, RHIA, CPCO, CCDS, regulatory specialist for HCPro.
CMS recently released Transmittal 585 adding language to Chapter 3 of the Medicare Program Integrity Manual. This chapter has gone through major changes in the last year or so and focuses on verifying billing and coding errors and the corrective actions that can be taken by CMS contractors. Section 22.214.171.124 - Coding Determinations has new language that should be of interest to all providers.
Effective May 4, 2015, MACs, Comprehensive Error Rate Testing (CERT) contractors, Supplemental Medical Review Contractor (SMRC), Recovery Auditors, and Zone Program Integrity Contractors (ZPICs) may up code or down code a claim in certain situations. However, this excludes determinations made by contractors based on whether or not the item or service is “reasonable and necessary” under current CMS policy. It also instructs contractors not to substitute the payment amount for a different amount when the determination is based on the item or service not being medically necessary under the circumstances.
When the medical record supports a higher or lower level procedure or diagnosis code, the MAC, SMRC, CERT, ZPIC and Recovery Auditor will not deny the entire claim and instead will change the code and adjust the payment. CMS policy will continue to take precedence over coding guidelines listed in the Current Procedural Terminology-4 (CPT-4), Coding Clinic for ICD-9, and Coding Clinic for HCPCS. However, all of the appropriate coding guidelines for the procedure or diagnosis code must be met in order for the contractor to make the change.
Although this new guidance applies to certain situations, CMS did not provide any details on what those situations are other than providing the following examples. The examples provided appear to be more clerical in nature or errors based on clear documentation. I have added additional information to show the potential payment impact based on the national payment amounts.
- CBC with differential (85025) was ordered and billed but CBC without differential (85027) was provided:
o 85025 = $10.58
o 85027 = $8.81
- CT chest with contrast (71260) was ordered and billed but CT chest without contrast (71250) was provided:
o 71260 = $240.92
o 71250 = $120.02
- DRG 193 was billed but the medical records supports DRG 195 (in the following example, wage index = 1.00 and no other payment adjustments made):
o DRG 193 Simple Pneumonia with MCC (1.4491) = $8,510.30
o DRG 194 Simple Pneumonia with CC (.9688) = $5,689.59
o DRG 195 Simple Pneumonia without CC/MCC (.7044) = $4,136.81
- ER E&M level 3 (99283) was billed but the medical record supports level 2 (99282):
o 99283 = $62.57
o 99282 = $41.48
o The example provided would most like apply to professional services as CMS permits hospitals to develop their own internal systems for assigning E/M levels for ED encounters.
The ability for a contractor to change the code and adjust the payment may or may not have an impact on reducing the number of appeals submitted by providers. In doing the math, the number of denials attributed to contractors will certainly decrease. Providers should watch for more information on the implementation of this change and how information will be provided on the Remittance Advice when these actions occur.
Note from the Instructor: CMS releases updated educational tool on coverage, billing and payment for preventive services
This week’s note from the instructor is written by Judith L. Kares, JD, regulatory specialist for HCPro.
In its April 2, 2015 MLN Connects Provider ENews, CMS released a revised “Preventive Services” Educational Tool (ICN 006559), which is now available in a user-friendly interactive format. This revised resource is designed to provide information on Medicare-covered preventive services, including related guidelines on coverage, billing and payment. Let us review the information available to those who utilize this new tool.
In the updated “Preventive Services” Educational Tool, CMS provides the following information on Medicare preventive services:
- Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes;
- International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes;
- Coverage requirements;
- Frequency limitations; and
- Beneficiary liability for each Medicare preventive service.
CMS also indicated which of the listed preventive services can be delivered via telehealth.
The updated tool contains relevant information for 26 preventive services, listed in alphabetical order, ranging from Alcohol Misuse Screening and Counseling to Ultrasound Screening for AAA.
Below is an example of the information available for one of the listed services:
Alcohol Misuse Screening and Counseling (Also referred to as the Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse)
G0442 – Annual alcohol misuse screening, 15 minutes
G0443 – Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
No specific diagnosis code
Contact local Medicare Administrative Contractor (MAC) for guidance
Who Is Covered
All Medicare beneficiaries are eligible for alcohol screening.
Medicare beneficiaries who screen positive (those who misuse alcohol but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence) are eligible for counseling if:
- They are competent and alert at the time that counseling is provided; and
- Counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting.
- Annually for G0442; or
- For those who screen positive, 4 times per year for G0443
- Copayment/coinsurance waived
- Deductible waived
CMS also provides additional guidance in the form of Frequently Asked Questions and a listing of related resources. The tool permits users to print individual or complete guidelines.
Assistance with limitation on liability and hospital outpatient notification process
In particular, this tool may aid hospitals with their outpatient notification process when limitation on liability (LOL) applies. LOL requires hospitals to notify beneficiaries when they believe certain outpatient services ordered by practitioners will not be covered under Medicare because those services:
- fail to meet Medicare’s medical necessity guidelines for the patient’s condition;
- are screening or preventive services subject to frequency limitations;
- are custodial in nature; or
- are experimental or for research purposes.
Many preventive services included in this educational tool are subject to frequency limitations, as well as other coverage requirements. Medicare only provides coverage for specific preventive services so long as those services are not provided more frequently than their respective frequency limitations and meet other applicable coverage guidelines.
For example, once a beneficiary has reached the age of 40, the frequency limitation for coverage of a screening mammography is 11 full months after the last covered screening mammography. If a beneficiary has a screening mammography in April 2015, she will not be eligible for another covered screening mammography until April 1, 2016.
When a hospital believes that certain services (including those subject to frequency limitations) will not be covered because LOL applies, it is required to notify the beneficiary prior to the performance of the service that the hospital will look to the beneficiary for payment if:
- he or she has the services performed; and
- Medicare denies payment.
The current form of required notification is the Advanced Beneficiary Notice of Noncoverage (ABN).
In this user-friendly interactive educational tool, CMS has pulled together relevant coverage information on preventive services, making it much easier for hospitals using this tool to implement an appropriate ABN process with respect to these services.
CMS email update subscriptions
If they have not already done so, hospitals are encouraged to subscribe to CMS email updates, including the MLN Connects Provider ENews, through the CMS.gov Email Updates web site. The site can be accessed through the “CMS Email Update Lists – Subscriber’s Main Page” link on HCPro’s links page. The MLN Connects Provider ENews is published every Thursday and contains valuable information on MLN national provider calls and events; CMS announcements; claims, pricer and code updates; and MLN educational products.
Note from the Instructor: Sustainable Growth Rate fix legislation and other hot topics from Medicare/Medicaid Payment Institute
This week’s note from the instructor is written by Kimberly Anderwood Hoy Baker, JD, regulatory specialist for HCPro.
Last week I had the pleasure of attending the American Health Lawyers Association Institute on Medicare and Medicaid Payment Issues in Baltimore, Maryland. It was announced on the first day that there were over 150 regulators from the OIG, CMS and HHS in attendance. I had the pleasure of personally speaking with Marc Hartstein, Twi Jackson, Tiffany Swygert, and Dan Schroder, all from CMS. They were all very receptive to audience questions and confirmed and clarified several recent items for me.
Although there were many informative sessions, there is one item I wanted to share that could directly affect some of your payments. Additionally, it may require action to verify you are receiving the correct payments not only from your MAC, but also anyone using the CMS PCPricer to set payment rates (e.g. Medicare Advantage plans). The FY2015 IPPS pricer issued to the MACs, as well as the PCPricer, has been incorrectly applying the rural wage index floor, which was just discovered by CMS last week.
The rural wage index floor applies when an area’s wage index is lower than the statewide rural wage index for their state. In that case, the wage index is brought up to the statewide rural average, which can have a potentially large impact on a provider’s payments. Application of the rural wage index floor has been increasing. For example, in California where I live, at least 16 metropolitan areas use the rural floor, including cities like LA and San Diego.
To determine if you are receiving the rural wage index floor, compare your wage index in Table 4A with the wage index for your state in Table 4B. If they match, your area has been brought up to the rural floor and you should verify you have been paid at that rate. You can actually use the PCPricer’s change data feature to change the wage index to the index published for you and compare that to the payments you are receiving. It is important you don’t just verify the wage index CBSA on the information screen for your provider because, as I understand the error, if your CBSA is correct it may be pulling the calculated wage index for that CBSA, rather than the rural floor as it should. If you find a discrepancy, you should bring it to the attention of your MAC or check their website about reprocessing of claims with this error. CMS indicated all these claims would have to be reprocessed.
One of the biggest topics of discussion was House bill H.R. 2 Medicare Access and CHIP Reauthorization Act of 2015, better known as the Sustainable Growth Rate (SGR) fix. Kimberly Brandt, who works with members of the US Senate Finance Committee, discussed various items included in the Senate version of the bill, as well as coordination between the House and Senate for passage of the bill before the negative payment rate adjustment of approximately 21% hits physicians April 1. The House did pass the bill on Thursday March 26; however, the Senate didn’t take action prior to leaving for a two week scheduled break on Friday. With the 14 day payment hold on claims, they would return just in time, on April 13, to allow the rates to be corrected before claims are paid for April 1 dates of service.
In addition to elimination of the SGR reduction, there are several provisions in the law that will affect hospitals. It extends the probe and educate audits on the 2-midnight rule, as well as the prohibition on RAC review of patient status, through the end of this fiscal year (September 30, 2015). But it’s not all good news for hospitals. One of the ways the increase to the doctors will be paid for is by spreading the documentation and coding adjustment return payment across six years in .5% increments beginning in 2018. Originally, the full 3.2% payment increase was to be added back to rates in 2018.
Another area that will see potentially limited increases in coming years to pay for the fix is the post-acute setting, including skilled nursing, home health, hospice, inpatient rehab hospitals, and long term acute care hospitals. Their market basket increase, essentially the rate of annual inflation in their rates, will be frozen at 1%, while the market basket typically exceeds 2 or 2.5%. There was discussion in one session of the conference that, based on some current proposals from the Medicare Payment Advisory Commission (MedPAC), this may in fact provide the post-acute setting more of an update than was recommended.
Other provisions included an extension of the Low Volume Hospital adjustment and the Medicare Dependent Hospital Adjustment. Unlike in prior years, when the adjustments were approved in single year increments, this bill actually extends them through the remainder of FY2015, as well as FY2016 and FY2017.
Likewise, the therapy caps and exception process, as it currently exists, also were extended through October 1, 2017. However, they did make a tweak to the manual review process. Currently, there is a manual review when therapy claims for a particular patient exceed $3,700. That process will now be directed at providers with high denial rates, questionable billing practices, newly enrolled providers, or for specific services that might be questionable.
Included in the bill was also a related bill that had previously been introduced called the Protecting the Integrity of Medicare Act (PIMA). This additional section of the bill directs the MACs to implement a new program called the Improper Payment Outreach and Education Program aimed at giving providers more information on the audit process, audits being done, and how to avoid the errors being identified. CMS will also be required to provide the MACs information to support their efforts.
One additional provision, oddly located in the PIMA, but potentially relating more to the SGR fix, is a prohibition on CMS implementing their plan to eliminate the 10 and 90 day global period in favor of a 0 day global period. This was big news when CMS announced it and would have caused significant difficulty and increased billing and costs for the professional provider community, so this is undoubtedly a welcome change for physicians.
Again, this bill has passed the house and a similar bill was pending in the Senate, and Kimberly Brandt indicated it would undoubtedly pass. Additionally, one of the other conference speakers, John Hellow, of Hooper, Lundy & Bookman, PC, stated that President Obama indicated he would sign the bill even if the length of the CHIP extension (the key difference between the House and Senate versions) is for the shorter timeframe in the House bill. He indicated this signals a presumably favorable treatment of the bill by House Democrats. We’ll keep you posted on the passage of this bill.
This week’s note from the instructor is written by Judith L. Kares, JD, regulatory specialist for HCPro.
CMS recently issued the April 2015 quarterly updates to the OPPS (Claims Processing Transmittal 3217) and the I/OCE (Claims Processing Transmittal 3218). Last week we focused on the discussion in the quarterly OPPS update regarding CMS’ decision to allow payment for certain preadmission inpatient only procedures bundled into a subsequent inpatient claim under the so-called three- (or one-) day window rules. This week we will review the other key changes set out in the April OPPS and I/OCE updates.
Summary of additional key OPPS and I/OCE changes
Addition of one new pass-through device category: Effective April 1, 2015, CMS has created one new pass-through device category identified by HCPCS code C2623. Reimbursement for C2623 is cost based, subject to an offset amount equal to the policy-packaged portion of the APC to which the procedure utilizing the device is assigned. The policy-packaged portion of the applicable APC payment is the portion of the payment that was designed to cover the predecessor device used with that procedure.
Addition of six new pass-through drugs and biologicals: Effective April 1, 2015, CMS has approved six new pass-through drugs/biologicals. These pass-throughs—C9445, C9448, C9449, C94502, C9451, and C9452—are reimbursed based upon average sales price (ASP) + 6%, updated on a quarterly basis. If ASP data is not yet available, reimbursement is based on wholesale average cost (WAC) + 6%. If WAC data is not yet available, reimbursement is based on 95% of average wholesale price (AWP); however, as soon as ASP data is available, ASP + 6% is the basis for payment.
Other changes to drugs and biologicals: CMSreleased updated April 1, 2015, ASP data, as well as retroactive ASP updates for certain prior quarters. In particular, hospitals should review these updates to determine whether to submit adjustment claims for prior quarters.
Effective April 1, 2015, CMS also made the following changes:
- Changed the status indicators (SIs) for the following two drugs:
o J0365—changed from SI of “K” to “E” (not recognized by Medicare)
o J7180—changed from SI of “N” to “K” (separately payable under OPPS)
Finally, CMS is correcting coinsurance (initially set at 20%) for the following two drugs, as set out below:
- For HCPCS code J7315, effective January 1, 2014, through March 31, 2015; and
- For HCPCS Code C9447, effective January 1, 2015, through March 31 2015
Implementation of the “PO” HCPCS modifier. In keeping with its finalized instructions in the CY 2015 OPPS final rule, CMS emphasized that the “PO” HCPCS modifier should be reported with every code for outpatient hospital services furnished in an off-campus hospital provider-based department (PBD), beginning with dates of services on and after January 1, 2016. In preparation, hospitals may begin voluntarily reporting this new modifier during CY 2015.
The “PO” modifier, however, should not be reported for remote locations of a hospital, satellite facilities of a hospital, or for services furnished in an emergency department. In response to an informal query regarding whether critical access hospitals (CAHs) are also subject to the mandatory reporting of the “PO” modifier, one CMS representative has indicated that CAHs are not required to do so. CAHs may want to seek further confirmation by contacting their MACs or raising this issue during an open door forum call.
Two billing clarifications. CMS also provided clarification on the following two services:
- Hospitals may report C2625 (Stent, non-coronary, temporary, with delivery system) when utilizing the Propel™ and Propel Mini™ drug eluting sinus implants by Intersect ENT; and
- Hospitals are reminded to report two claim lines when billing for cystoscopy procedures using Cysview® (hexaminolevulinate hydrochloride):
o One claim line with an appropriate cystoscopy procedure code; and
o A separate claim line with HCPCS code C9275 (Injection, Hexaminolevulinate Hydrochloride, 100 mg, per study dose)
I/OCE processing of inpatient-only procedure, subject to emergency exception. In the April 2015 I/OCE update, CMS clarified the processing of an inpatient-only procedure performed emergently in the outpatient setting in the following circumstances:
- The patient died prior to being admitted to the inpatient setting; and
- On the same date of service, the hospital performed another procedure (SI of “J1”) for the same patient that would otherwise qualify for payment under a comprehensive APC
In these circumstances, CMS stated the hospital should follow the rules applying to the emergency exception to the inpatient only rules. Under the inpatient-only rules, Medicare generally denies payment not only for the inpatient-only procedure performed in the outpatient setting, but for all other outpatient services performed for that patient on the same date of service, including those services otherwise payable under the OPPS.
The emergency exception applies when an inpatient-only procedure is performed emergently, but the patient dies before he or she can be admitted. Under this exception, Medicare will pay for a single inpatient-only procedure under APC 0375, and all other outpatient services performed for the patient on the same date of service are packaged. To trigger the applicability of the emergency exception, the hospital must attach the CA modifier to the inpatient-only procedure and report patient status code 20 (patient expired) in FL 17 on the UB-04.
In the April I/OCE update, CMS clarified by stating the emergency exception rules should be followed even when a procedure with a SI of “J1” is reported on the same claim with the same date of service as the inpatient-only procedure. The specified inpatient-only procedure APC (0375) will be assigned as the payable APC. The comprehensive APC procedure will be assigned to its comprehensive APC; however, the comprehensive APC will be packaged with SI = N, along with all other lines on the claim.
Additional resources on this topic
This note from the instructor is written by Debbie Mackaman, RHIA, CPCO, CCDS regulatory specialist for HCPro.
In a recent issue of the Medicare Insider, Kimberly Anderwood Hoy Baker, JD, regulatory specialist for HCPro, wrote about the implementation of Condition Code 53 (initial placement of a medical device provided as part of a clinical trial or free sample) for hospital outpatient claims when certain criteria have been met. Since then, we have received several questions about investigational devices so I thought I would take this time to generally review the CMS policy on Investigational Device Exemption (IDE) studies.
Medicare may cover certain FDA-approved investigational devices and related routine care items and services when the investigational device meets certain coverage criteria as posted on the CMS Coverage website. Once approved, the devices are placed in Category A or Category B which have specific billing requirements.
Category A Device
The “absolute risk” of this type of device has not been established and the FDA is unsure whether the device can be safe and effective based on its intended use. Medicare covers only routine care items and services furnished in this type of study, if CMS has determined that the Medicare coverage criteria are met.
Routine care items are items and services that are otherwise generally available to Medicare beneficiaries. This means that a benefit category exists, it is not statutorily excluded, and there is not a national non-coverage decision.
Under a Category A IDE study protocol, a hospital may only submit a claim for the routine care items and services. The device cannot be reported on the claim since the device itself is not eligible for payment under the Medicare program. Payment for the related routine care items may not exceed what Medicare would have paid for comparable items that are usually approved for standard of care.
Category B Device
The “incremental risk” of this type of device is known and it has been determined to be safe and effective. Medicare covers the device and routine care items and services furnished in this type of study if CMS has determined that the Medicare coverage criteria are met.
Providers must notify their MAC before submitting claims for Category B IDE services. Once the MAC notifies the provider that all required information for the IDE has been accepted, the provider may bill for the services. Payment for Category B IDE study devices and routine care items may not exceed what Medicare would have paid for comparable devices and routine care items generally approved by Medicare.
General Billing Guidance
When billing for Category A IDE routine items or Category B IDE device and related routine items, specific information must be included on the claim. Here is a brief summary.
For all hospital claims:
- Condition Code 30 (“non-research services provided to patients enrolled in a Qualified Clinical Trial”). Until further clarification is received, presumably both conditions codes 30 and 53 may be reported on the same outpatient claim when both criteria are met.
- Value Code D4 (clinical trial number assigned by NLM/NIH). The number reported with the value code amount is equal to the mandatory 8-digit clinical trial number as specified on the Medicare Coverage webpage or on clinicaltrials.gov.
- Charges are reported in the covered column when all applicable coverage criteria are met.
- ICD-9 code V70.7 (“examination of participant in clinical trial”) must be reported on the claim; when applicable, ICD-10 diagnosis code Z00.6 should be reported.
For hospital inpatient claims:
- Routine care costs incurred during an approved Category A or B IDE study may be billed on the claim when those items are considered to be otherwise generally available to Medicare beneficiaries.
- When the hospital incurred a cost for the Category B device, report the IDE number under revenue code 0624 (FDA investigational device) with charges in the covered column.
- When the hospital receives the Category B device without charge, the device should not be billed on the inpatient claim.
For hospital outpatient claims:
- For Category B IDE studies, report the IDE number under revenue code 0624.
- Report the Category B device HCPCS code under revenue code 0624, if one exists.
- Report Modifier -Q0 (“investigational clinical service provided in a clinical research study that is an approved clinical research study”) to identify all lines containing an investigational item/service.
- Routine care costs incurred during an approved Category A or B IDE study must be reported with Modifier -Q1 (“routine clinical service provided in a clinical research study that is an approved clinical research study”) to identify all lines containing routine services medically necessary for routine patient care or treatment of complications arising from a Medicare beneficiary’s participation in a Medicare-covered clinical trial.
- Bill the Category B device and Category A or B routine care items as covered charges.
Note from the instructor: CMS revises its billing and payment policies to permit certain preadmission inpatient-only procedures to be bundled into the subsequent inpatient admission
This week’s note from the instructor is written by Judith L. Kares, JD, regulatory specialist for HCPro.
In a surprising move, CMS issued Claims Processing Transmittal 3217 on Friday, March 13, changing its billing instructions to allow payment for certain preadmission inpatient only procedures bundled into a subsequent inpatient claim under the so-called three- (or one-) day window rules. This expansion of coverage applies to the following:
- all preadmission inpatient-only procedures performed on the date of admission; and
- all preadmission inpatient-only procedures performed during the relevant window (one or three day[s] preceding the date of admission) which would otherwise be deemed related to the inpatient stay.
For purposes of the preadmission bundling rules, a procedure is deemed to be related to the subsequent inpatient stay if it is clinically associated with the reason for a patient’s inpatient admission. The relevant preadmission window is three days for IPPS and Maryland hospitals and one-day for all non-IPPS hospitals, except for critical access hospitals (CAHs). CAHs are not subject to the preadmission bundling rules.
In Paragraph 5 of the narrative portion of the transmittal, CMS stated its change in policy, as follows:We are revising our billing instructions to allow payment for inpatient only procedures that are provided to a patient in the outpatient setting on the date of the inpatient admission or during the 3 calendar days (or 1 calendar day for a non-subsection (d) hospital) preceding the date of the inpatient admission that would otherwise be deemed related to the admission to be bundled into billing of the inpatient admission, according to our policy for the payment window for outpatient services treated as inpatient services. Effective April 1, 2015, inpatient only procedures that are provided to a patient in the outpatient setting on the date of the inpatient admission or during the 3 calendar days (or 1 calendar day for a non-subsection (d) hospital) preceding the date of the inpatient admission that would otherwise be deemed related to the admission, according to our policy for the payment window for outpatient services treated as inpatient services will be covered by CMS and are eligible to be bundled into the billing of the inpatient admission.” CMS also referred to related sections of the Medicare Claims Processing Manual (Chapter 4, §§ 10.12 and 180.7) that have been revised, accordingly, and included that revised language at the end of the transmittal. Interestingly, in revising the relevant manual sections, CMS did not add the positive language set out above. Instead, CMS simply deleted prior existing language that:
- denied payment for preadmission inpatient-only procedures provided to a patient during the relevant window, even if they would otherwise be deemed related to the reason for the admission; and
- required any such services to be billed on a separate non-covered, no pay TOB (0110), but not on the covered inpatient claim.
Presumably, these changes are at least in part designed to address the question often asked with respect to the situation where the patient comes into the outpatient setting to have a procedure performed that is not on the inpatient-only list. However, once there, an inpatient-only procedure is performed. In that case, is it sufficient if the hospital writes the inpatient order as soon as the procedure is completed? In the past, CMS has deferred the question to the MACs. This new policy would appear to more adequately respond to this question.
There are still a number of unanswered questions, however. Among others, one question raised by the change is whether compliance is permissive or mandatory. CMS stated it is changing its billing instructions “to allow payment” for certain preadmission inpatient-only procedures. Such procedures will be “eligible to be bundled into the inpatient claims.” Again, it is not clear whether compliance with these changes is permissive or mandatory, although it would certainly appear to be in a hospital’s best interests to comply.
One additional question is the treatment of other services performed in the outpatient setting on the same day as a preadmission inpatient-only procedure, whether diagnostic or non-diagnostic, related or unrelated. Under the general inpatient-only rules, all such services, even those otherwise covered and payable under the OPPS, are not covered when performed on the same day as an inpatient-only procedure. In other words: Are hospitals permitted, or required, to report such services on a subsequent inpatient claim, in accordance with otherwise applicable preadmission bundling rules?
Some of the answers may come when CMS releases the April 2015 quarterly update to the Integrated Outpatient Code Editor (IOCE) data files, instructions and specifications. Hospitals should certainly be on the lookout for these updates. Also, hospitals are encouraged to take advantage of open door forum call and other opportunities to bring related questions to the attention of the regulators. Continuation of limitations on inpatient-only services billed as outpatient services
Except as specifically provided in this recent change, it appears the billing and coverage limitations on inpatient-only services performed and billed as outpatient services will continue to apply, subject to the existing separate procedure and emergency exceptions set out in the relevant sections of the Medicare Claims Processing Manual, as revised.
Additional resources on this topic
April 2015 quarterly update to the IOCE Code Specifications (soon to be released)
Note from the Instructor: Review of hospital inpatient mental health services payable under the inpatient psychiatric facility prospective payment system (IPF PPS)This note from the instructor is written by Judith L. Kares, JD, regulatory specialist for HCPro.
This note is the third installment in a three-part series focusing on Medicare rules relating to hospital outpatient and inpatient mental health services (alternatively referred to as “psychiatric services”). In two earlier issues, we discussed non-partial hospitalization and partial hospitalization outpatient psychiatric services. This week we will review Medicare rules relating to coverage and payment for hospital inpatient psychiatric services payable under the IPF PPS.
The IPF PPS is the primary payment methodology for inpatient psychiatric services. Both psychiatric hospitals and psychiatric distinct part units (DPUs) of hospitals and CAHs may qualify as IPFs, so long as they meet applicable CMS certification requirements.
An IPF is an institution certified by Medicare as an inpatient psychiatric hospital, which is primarily engaged in providing psychiatric services, by or under the supervision of a psychiatrist, for the diagnosis and treatment of mentally ill patients. To be certified as an IPF, a psychiatric hospital must not only meet the conditions of participation for a hospital, but also the special conditions of participation for a psychiatric hospital.
A DPU may also meet IPF certification requirements so long as the DPU:
- Admits only patients who require active inpatient treatment for a psychiatric principal diagnosis;
- Furnishes psychological and social work services, psychiatric nursing, and therapeutic activities through qualified personnel; and
- Meets medical record and staffing standards similar to those specified in the special conditions of participation for psychiatric hospitals.
An inpatient psychiatric hospital or psychiatric DPU must meet the following requirements for their services to be covered under the IPF PPS:
- Certification and recertification requirements, including the following:
o Initial physician certification at the time of admission that inpatient psychiatric hospital services are medically necessary for treatment which can reasonably be expected to improve the patient’s condition or for diagnostic study; and
o Physician recertification after 12 days, and then at least every 30 days thereafter, that services furnished were intensive treatment services or for diagnostic study and continue to be medically necessary to improve the patient’s condition or for diagnostic study, including active treatment on a daily basis, directly by, or requiring the supervision of, inpatient psychiatric facility personnel;
- A psychiatric evaluation within 60 hours of admission;
- Active treatment reasonably expected to improve the patient’s condition or for diagnostic study;
- An individualized treatment or diagnostic plan, including substantiation of the diagnosis, short and long term goals, and treatment modalities; and
- Appropriate medical records that include development of assessment and diagnostic data, appropriate progress notes, and discharge plan or summary.
Federal Per Diem Base Rate.
Payment under theIPF PPS is based on a Federal per diem base rate, adjusted by patient and facility-specific adjustments, with additional separate payment for electroconvulsive therapy (ECT) treatments. For FY 2015, the Federal per diem base rate, prior to facility specific adjustments, is $728.31, and the ECT base rate is $313.55. Beginning in FY 2014, the otherwise applicable Federal per diem base rate and the ECT base rate is reduced by 2% for any IPF that fails to meet its quality reporting requirements under the Inpatient Psychiatric Facilities Quality Reporting (IPFQR) program.
To calculate the facility-specific per diem base rate for FY 2015, the IPF should do the following:
- Step 1: Multiply the unadjusted Federal per diem base rate by the labor related share of 69.294% to derive the labor portion of the Federal per diem base rate, and multiply that portion by the hospital’s wage index.
- Step 2: Multiply the unadjusted Federal per diem base rate by the non-labor related share of 30.706% to derive the non-labor portion of the Federal per diem base rate, and, if applicable, multiply that portion by the Cost of Living Adjustment (COLA) for hospitals in Alaska and Hawaii.
- Step 3: Add the labor related amount from Step 1 to the non-labor related amount from Step 2 to derive the total facility specific Federal per diem base rate.
An IPF may also qualify for one or more of the following patient-specific adjustments to its facility specific Federal per diem base rate:
- An MS-DRG adjustment, which is a percentage adjustment (up or down) to the facility’s Federal per diem base rate for cases grouping to a set of 17 designated psychiatric MS-DRGs;
- A comorbidity adjustment, which is an upward percentage adjustment to the facility’s Federal per diem base rate for cases with secondary diagnoses that fit into 17 specific comorbidity categories;
- An age adjustment, which is an upward percentage adjustment to the facility’s Federal per diem base rate for beneficiaries 45 years of age and older; and
- A variable per diem adjustment, which is a percentage adjustment (up or down) to the facility’s Federal per diem base rate based on the number of days the patient has been admitted to the facility to account for the higher costs at the initiation of an admission. (The adjustment decreases through day 21, and all days after day 21 of an admission receive the same .92 (92%) adjustment).
An IPF may also qualify for two additional facility specific adjustments to its facility-specific Federal per diem base rate:
- A rural location adjustment, which is a 17% upward adjustment for IPFs located in a rural area; and
- A teaching facility adjustment, which is an upward percentage adjustment, based on the number of interns and residents and the facility’s average daily census.
Separate Payment for ECT.
As noted above, under the IPF PPS, there is additional separate payment for ECT treatments, whether provided directly or under arrangements. For FY 2015, the ECT base rate is $313.55, subject to a 2% reduction for those IPFs that fail to meet their quality reporting requirements under the IPFQR. The ECT base rate is also subject to applicable wage index and COLA adjustments. The IPF should report ECT services, as follows:
- Revenue code 0901, with the units of ECT provided to the patient during the IPF stay; and
- ICD-9-CM procedure code 94.27 for ECT, with the date of the last ECT treatment received by the patient.
An outlier payment may also be available for unusually costly cases based on a Fixed Dollar Loss Threshold, which CMS updates each year. For FY 2015, the Fixed Dollar Loss Threshold is $8755.00. For more information on the eight-step outlier calculation process, see the Medicare Claims Processing Manual, Chapter 3 § 190.7.2.
In a future issue of the Medicare Insider, we will discuss some of the limitations on coverage of outpatient and inpatient hospital psychiatric services.
Additional resources on this topic
This note from the instructor is written by Kimberly Anderwood Hoy Baker, JD, regulatory specialist for HCPro.
I thought I would take the opportunity to review free and discounted device billing in this week’s note. The OIG continues to find issues in hospital specific reviews and hospitals have had difficulty complying with the requirements, including situations where the available codes are not adequate for clinical trials and free samples. In late January, CMS issued a transmittal announcing the implementation of Condition Code 53 to address this situation, but the confusion and difficulty will inevitably continue
The first and most difficult step is identifying the devices and cases that must be reported under CMS’ free and discounted device policy. CMS specifies the devices the policy applies to in Table 27 of the 2015 OPPS Final Rule (see table below) and their associated APCs are listed in Table 26 (see table below). The problem is that free and discounted devices come into the hospital in a variety of ways, including devices ordered for a specific patient to free samples that come in with physicians, outside the inventory control systems.
Nevertheless, the OIG and CMS have indicated in policy statements and audits that any savings the hospital receives when providing procedures should be passed on to the Medicare program. For hospitals, this means a robust compliance initiative to find these devices and discounts. Multiple departments have to work together, including staff in supply, surgery, accounts payable, coding and billing. The appropriate staff in these departments have to be aware and look out for discounts as well as samples and clinical trial items that qualify for the policy.
Once the devices are identified, they must be properly reported to ensure the payment to the hospital is adjusted appropriately. Payment under OPPS is generally made for the procedure and not the device, and generally determined by the reported codes rather than charges. Therefore, simply reporting the items with a zero charge will have no effect on the payment to the hospital.
CMS changed the policy for free and discounted devices in January 2014, causing some confusion around free samples and clinical trial. The guidelines since January 2014 require hospitals to report value code FD when they furnish a “new replacement device” received without cost or with a credit of 50% or more of the cost of the replacement device. When value code FD is reported, it must be accompanied by condition code 49 (Product Replacement within Product Lifecycle) or 50 (Product Replacement for Known Recall of a Product).
This guideline left hospitals unsure how to report free devices received as part of clinical trials or free samples, particularly when they are associated with initial placement of the device. It was clear under prior policy statements and OIG audits that hospitals needed to report that they received these devices for free, but the existing codes left no way to do that. If the provider reported the device code with zero dollars, they would still receive full payment unless they also reported value code FD with the amount of the credit. The problem is that value code FD requires an accompanying condition code and the two available condition codes do not apply.
Claims Processing Transmittal 3181 solves this problem – or it will, once the adoption of condition code 53 is effective July 1 and implemented in processing systems July 6. The effective date of a policy usually relates back to the date of service on which the affected item is provided. However, in this case the effective date relates to the date the claim for services is received. The accompanying revisions to the claims manual make it clear that the policy itself is retroactive to January 1, 2014.
What this means for providers is that if they have received free samples or devices in clinical trials, they will have to hold those claims until July. Further, they may have to search their records to make sure they identified all free samples and clinical trial devices furnished since January 1, 2014. Some of these claims may be beyond timely filing once the system can actually accept them in July. Providers may have to submit one of the new automated adjustment claim requests, which will be implemented in April.
When a provider submits a claim with value code FD and one of the applicable condition codes, the payment for the procedure is then reduced by the amount reported with FD. The reduction is limited to the device offset percentage for the procedure, which represents the amount of the APC payment CMS calculated represents the packaged devices for the procedure. The offset percentage is available on the Annual Policy Files website for 2015.
This new transmittal gives providers an opportunity to review their policies and procedures related to free and discounted devices to ensure they are catching them all and are reporting them correctly. Unfortunately, some claims will have to be held until July for billing, but at least at that time we will have clearer instructions and the correct codes available to bill these special situations that have been a frustration for providers up to this point.
Table 26: APCs that Require Value Code FD Reporting
APC APC Description
0039 Level III Neurostimulator & Related Procedures
0061 Level II Neurostimulator & Related Procedures
0064 Level III Treatment Fracture/Dislocation
0089 Level III Pacemaker and Similar Procedures
0090 Level II Pacemaker and Similar Procedures
0107 Level I ICD and Similar Procedures
0108 Level II ICD and Similar Procedures
0227 Implantation of Drug Infusion Device
0229 Level II Endovascular Procedures
0259 Level VII ENT Procedures
0293 Level IV Intraocular Procedures
0318 Level IV Neurostimulator & Related Procedures
0319 Level III Endovascular Procedures
0351 Level V Intraocular Procedures
0385 Level I Urogenital Procedures
0386 Level II Urogenital Procedures
0425 Level V Musculoskeletal Procedures Except Hand and Foot
0655 Level IV Pacemaker and Similar Procedures
Table 27 Devices that Require Value Code FD Reporting
HCPCS Code CY 2015 Short Descriptor
Code HCPCS Short Descriptor
C1721 AICD, dual chamber
C1722 AICD, single chamber
C1728 Cath, brachytx seed adm
C1764 Event recorder, cardiac
C1767 Generator, neurostim, imp
C1771 Rep dev, urinary, w/sling
C1772 Infusion pump, programmable
C1776 Joint device (implantable)
C1777 Lead, AICD, endo single coil
C1778 Lead, neurostimulator
C1779 Lead, pmkr, transvenous VDD
C1785 Pmkr, dual, rate-resp
C1786 Pmkr, single, rate-resp
C1789 Prosthesis, breast, imp
C1813 Prosthesis, penile, inflatab
C1815 Pros, urinary sph, imp
C1818 Integrated keratoprosthesis
C1820 Generator, neuro rechg bat sys
C1840 Lens, intraocular (telescopic)
C1881 Dialysis access system
C1882 AICD, other than sing/dual
C1891 Infusion pump, non-prog, perm
C1895 Lead, AICD, endo dual coil
C1896 Lead, AICD, non sing/dual
C1897 Lead, neurostim, test kit
C1898 Lead, pmkr, other than trans
C1899 Lead, pmkr/AICD combination
C1900 Lead coronary venous
C2619 Pmkr, dual, non rate-resp
C2620 Pmkr, single, non rate-resp
C2621 Pmkr, other than sing/dual
C2622 Prosthesis, penile, non-inf
C2626 Infusion pump, non-prog, temp
C2631 Rep dev, urinary, w/o sling
 Condition code 53: Initial placement of a medical device provided as part of a clinical trial or free sample – code is for outpatient claims that have received a device credit upon initial medical device placement in a clinical trial or a free sample.
 Value code FD: Credit Received from the Manufacturer for a Replaced Medical Device
Note from the instructor: Review of hospital partial hospitalization outpatient mental health services
This note from the instructor is written by Judith L. Kares, JD, regulatory specialist for HCPro.
This note is the second note in a three-part series focusing on Medicare rules relating to hospital outpatient and inpatient mental health services (alternatively referred to as “psychiatric services”). Last week we discussed non-partial hospitalization outpatient psychiatric services. This week we will review Medicare rules relating to coverage, coding, billing and payment for partial hospitalization outpatient psychiatric services.
Partial hospitalization services are outpatient psychiatric services provided under a structured program that provides intensive psychiatric care through active treatment. Partial hospitalization is more intense than outpatient day treatment, resembling a highly structured, short term hospital inpatient program.
In order to be covered, all outpatient mental health services, including partial hospitalization services, must be both incident to a physician’s services and reasonable and necessary. They also must meet the following criteria:
- Be provided under an individualized treatment plan, established by a physician;
- Be supervised and periodically evaluated by a physician to determine progress toward treatment goals; and
- Be for diagnostic study or be reasonably expected to improve the patient’s condition.
Partial hospitalization services are generally provided in lieu of hospitalization. That is, beneficiaries either have been discharged from inpatient psychiatric treatment, and partial hospitalization services are ordered in lieu of continued hospitalization, or they are considered to be at reasonable risk for inpatient hospitalization if they do not receive partial hospitalization services.
In order to be eligible for partial hospitalization, however, beneficiaries must meet certain additional requirements, set out below:
- Be under the care of a physician who certifies they need 20 hours per week of therapeutic services as evidenced by their care plan;
- Require a comprehensive, structured multimodal treatment requiring medical supervision and coordination provided under an individualized plan of care;
- Have a mental disorder which severely interferes with multiple areas of daily life, including social, vocational and/or educational functioning, generally of an acute nature;
- Generally, have an acute onset or decompensation of an Axis I mental disorder as defined in DMS IV;
- Be able to cognitively and emotionally participate in the active treatment process and be capable of tolerating the intensity of a partial hospitalization program (PHP);
- Not require 24 hour supervision and have an adequate support system to maintain themselves outside the PHP; and
- Not be an imminent danger to themselves or others.
Certain specific documentation requirements must also be met, including the following:
- An initial psychiatric evaluation and certification by a physician of the beneficiary’s diagnosis and psychiatric need for partial hospitalization and evidence the beneficiary would require inpatient psychiatric hospitalization if the PHP services were not provided;
- A recertification by day 18, and every 30 days thereafter, by a physician treating the patient that the beneficiary would require inpatient psychiatric hospitalization in the absence of the PHP services;
- An individualized active treatment plan prescribed and signed by a physician; and
- Progress notes documenting the services provided.
Coding and billing
Hospitals should report condition code 41 to indicate a claim for partial hospitalization services. Since there are no specific HCPCS codes for reporting partial hospitalization, hospitals must report the individual services that comprise partial hospitalization, using a defined set of HCPCS codes, along with specified revenue codes. The applicable mental health revenue codes are in the 090X (Behavioral Health Treatment/Services) and 091X (Behavioral Health Treatment/Services – Extension of 090x) series of codes.
Most PHP services have an SI of “P,” but some PHP services are also payable as non-partial hospitalization outpatient mental health services and have status indicator “Q3”. For the complete list of partial hospitalization HCPCS codes, see the 1/1/15 update to the Integrated Outpatient Code Editor Specifications (IOCE), Appendix P, Section B “Partial Hospitalization Services.” In that section, Medicare has set out two lists of HCPCS codes to identify mental health services which qualify for coverage and payment as partial hospitalization services:
- “List A,” which is a list of psychotherapy codes approved for partial hospitalization; and
- “List B,” which is a list of all codes approved for partial hospitalization.
Hospitals should report units of service based on the description of the HCPCS code being reported to ensure proper application of payment grouping and edits. If the HCPCS code does not have a defined time, hospitals should not bill for sessions of fewer than 45 minutes.
There are two APCs for per diem payment of partial hospitalization services provided in a hospital outpatient department.
- APC 0175 “Level I Partial Hospitalization for Hospital-based PHP” when a hospital provides at least three partial hospitalization services from List B, at least one of which is a psychotherapy service on List A.
- APC 0176 “Level II Partial Hospitalization for Hospital-based PHP” when a hospital provides at least four partial hospitalization services from List B, at least one of which is a psychotherapy service on List A.
For payment purposes, the APC is assigned to a List A service, and the status indicator for all other partial hospitalization services is changed to “N” for packaged. If fewer than three services from List B or no psychotherapy services from List A are provided, each line with a partial hospitalization service on the claim will be denied. (See IOCE Appendix C-a for a summary of the claims adjudication process for partial hospitalization services.)
In a future issue of the Medicare Insider we will complete our overview of hospital mental health services by focusing on inpatient psychiatric services.
Note from the instructor: Review of hospital non-partial hospitalization outpatient mental health services
This note from the instructor is written by Judith L. Kares, JD,regulatory specialist for HCPro.
In preparation for a custom Medicare Boot Camp-Hospital version course, I had an opportunity to review the Medicare rules relating to hospital outpatient and inpatient mental health services (alternatively referred to as “psychiatric services”). This week we will focus on non-partial hospitalization outpatient services. In future issues, we will turn our attention to partial hospitalization outpatient services and inpatient psychiatric services. In particular, we will review the Medicare rules relating to coverage, coding, billing and payment for these services.
In order to be covered, outpatient psychiatric services must be both incident to a physician’s services and reasonable and necessary and must meet the following additional requirements:
- The services must be provided under an individualized treatment plan, unless only a few brief services are furnished. The treatment plan should be established by a physician and include the type, amount, frequency and duration of services, the diagnoses being treated and the anticipated goals of treatment.
- The services must be supervised and periodically evaluated by a physician to determine the progress toward treatment goals.
- The services must be for diagnostic study or must be reasonably expected to improve the patient’s condition (designed to reduce or control the patient’s psychiatric symptoms so as to prevent relapse or hospitalization and improve or maintain the patient’s level of functioning).
As long as the patient continues to show improvement in accordance with his/her individualized treatment plan, and the frequency of services is within accepted norms of medical practice, there is no limit on the length of time services may be covered.
Coding and billing
There is considerable guidance on the coding and billing of outpatient and inpatient psychiatric services included in the relevant sections of the American Medical Association’s 2015 CPT Manual (the CPT Manual) and the 2015 HCPCS Level II Manual. HCPCS codes identifying psychiatric services are primarily included in the 90,000 series of CPT codes and in the HCPCS Level II “G” codes. In particular, the CPT Manual provides significant guidance with respect to the selection of specific codes to be reported, when certain combinations of codes may or may not be reported together, when certain codes should be used in lieu of other codes, etc.
In addition to the CPT and HCPCS Level II Manuals, the January 2015 update of the Integrated Outpatient Code Editor (IOCE) Specifications, Attachment A, (IOCE Specs) provides additional guidance, including Appendix C-b (Mental Health Logic) which describes the claims flow and billing process for non-partial hospitalization outpatient mental health services. In particular, the IOCE Specs warn hospitals to avoid the following pitfalls:
- If HCPCS code G0129 for occupational therapy as a component of a partial hospitalization program is billed on a non-partial hospitalization claim, the claim will be returned to the provider.
- If HCPCS code G0176 for activity therapy is billed on a non-partial hospitalization claim, the line item will be rejected and the remainder of the claim will be processed for payment.
- If HCPCS code G0177 for training and educational services related to a patient’s disabling mental health problem is billed without other mental health services on the same day, the claim will be returned to the provider.
In addition to reporting the applicable HCPCS code for the covered non-partial hospitalization outpatient services, hospitals should also report an appropriate revenue code. The mental health revenue codes are primarily in the 090X (Behavioral Health Treatment/Services) and 091X (Behavioral Health Treatment/Services – Extension of 090X) series of codes.
Covered non-partial hospitalization mental health services are paid under the OPPS, as are most hospital services payable under Part B. Separately payable services under the OPPS are assigned to ambulatory payment classifications (APCs), which are the basis for payment. Not all covered and payable services are separately payable, however. That is, there is generally a separate payment for a significant service, but the payment for other services that are an integral part of a separately payable service are often “packaged.” When a service is packaged, the payment for that service is included in the payment for the more significant service into which it is packaged. When “packaged,” a service is identified with status indicator “N.”
Most non-partial hospitalization services are identified with status indicator “S,” which identifies those codes as separately payable services when not payable as part of a “composite” payment. When certain criteria are met, however, those codes are paid under a single composite payment, rather than separately. A composite payment is designed to provide a single payment for certain combinations of HCPCS codes (which would otherwise each be separately payable) when the composite criteria are met. Services that are potentially payable as part of a composite payment are identified with status indicator “Q3” in Addendum B and Addendum M to the calendar year (CY) 2015 OPPS final rule.
During CY 2015, payment for hospital non-partial hospitalization outpatient psychiatric services is capped at the reimbursement for APC 0176 Level II Partial Hospitalization in a Hospital-based Partial Hospitalization Program (PHP). The national allowable for APC 0176 is $195.70.
The IOCE aggregates the separate payments for multiple outpatient mental health services (identified with status indicator “Q3” in Addenda B and M) provided on the same date of service. If the sum of the payment amounts for the individual mental health services is greater than the payment amount for APC 0176, the Mental Health Composite APC 0034 is assigned to the first listed mental health code and the status indicator for all other mental health codes subject to composite payment is changed to “N” packaged.
If, however, the sum of the payment amounts for the individual mental health services does not exceed the payment amount for APC 0176, the individual services are processed for payment under standard OPPS/IOCE payment logic. That is, they will each be identified with status indicator “S” and individually separately payable based on the individual APC to which they are assigned, as set out in Addendum B.
A Medicare patient received individual psychotherapy for 45 minutes (CPT code 90834, for which the national payment rate is $115.52) in a hospital outpatient provider based clinic, followed by one hour of face to face psychological testing with a technician (CPT code 96102, for which the national payment rate is $199.33). Assuming that both codes have a status indicator of “Q3” in Addendum B, what is the total amount the hospital can expect to receive for these services (ignoring any wage index adjustment)?
$195.70 for Composite Mental Health APC 0034–The payment for CPT code90834 is $115.52, the payment for CPT code 96102 is $199.33 for a total of $ 314.85, which exceeds the payment of $195.70 for APC 0176 Level II Partial Hospitalization in a Hospital-based PH. Therefore, the payment is made under the Mental Health Composite.