Application of critical care Correct Coding Initiative (CCI) edits to hospitals

Effective January 1, 2009, the CCI edits for evaluation and management (E&M), including critical care, apply to hospitals. Two prior-existing frequently asked questions (FAQ) have been updated to reflect these changes. The updated FAQs are FAQ 8813 and FAQ 2392. Prior to January 1, 2009, not all CCI edits that applied to physician services also applied to comparable hospital services. In particular, those CCI edits that applied to physician E&M services (including critical care) were not incorporated into the Outpatient Code Editor (OCE) for application to hospital E&M services. [more]

Locality adjustment for Medicare Physician Fee Schedule-based payments

CMS issued Transmittal 1681 February 13, 2009, related to locality adjustment for payments made to hospitals derived from the Medicare Physician Fee Schedule (MPFS). The MPFS is used as the basis to determine payment amounts for several types of services, for instance physical therapy, speech language pathology, and occupational therapy. These payments will now be based on the MPFS amount for the ZIP code where the actual service facility is located rather than the main facility’s ZIP code. [more]

CMS increases its scrutiny of modifier -79 for multiple procedures

Last week, CMS published a One Time Notification related to modifier -79 (Unrelated Procedure or Service by the Same Physician During the Postoperative Period) and the global surgical package (GSP). The GSP is a feature of Medicare’s payment system for physicians and so at first blush this transmittal would appear not to apply to hospital providers. However, CMS’ business requirements apply to both carriers (who traditionally process physician claims) and fiscal Intermediaries (who traditionally process hospital claims), indicating that CMS is concerned about modifier -79 usage in both settings. [more]

Listen to the January 15 Hospital Open Door Forum

CMS’ regular Open Door Forum conference calls are a useful source of updates and clarifications, and an important line of communication between the agency and its industry. Check out the latest Hospital Open Door Forum, which CMS held January 25, 2009. This particular call includes an extensive discussion (during the Q&A) of CMS’ recent clarifications on physician supervision under “incident to” (begins around 30:15 of the audio clip).

Do you dial into CMS’ Open Door Forum calls regularly? Try a free trial to MedicareFind and gain access to transcripts and audio of these meetings.

Important CY 2009 OPPS status indicator changes

SIs “N,” “Q1,” Q2,” and “Q3”
In CY 2008, CMS greatly expanded the number of packaged items and services payable under the Outpatient Prospective Payment System (OPPS). More than 300 items and services that had formerly been separately payable became packaged, at least in certain circumstances. CMS is continuing this trend in CY 2009. Presently, there are four status indicators (SI) that identify packaged items and services: “N,” “Q1,” “Q2,” and “Q3.” Addendum D1 to the CY 2009 OPPS final rule defines SI “N” as identifying items and services that are paid under the OPPS; however, there is no separate payment for them. Instead, payment is included in the payment for other items and services. Think of those services as “never” being separately payable.

There are a number of other items and services that are “sometimes packaged” and “sometimes separately payable.”  In 2008, all of the “sometimes packaged” items and services were identified with the “Q” SI. These “Q” SI codes were then further divided into three subcategories, which established the criteria for determining whether they would be packaged or separately payable in particular circumstances. Those three subcategories were as follows: [more]

Watch for missing drug injection and infusion NCCI edits

As many of you know, CMS maintains two sets of NCCI edits: one for hospitals and one for physicians. The hospital version of the edits is one quarter behind the physician version. This can cause significant compliance issues for hospitals.

CPT and HCPCS codes are generally updated January 1 of each year. However, because the NCCI edits for hospitals are one quarter behind, the edits that apply to hospitals during the first quarter of a year are the edits for the fourth quarter of the prior year. This would mean that any new codes, adopted January 1, would not be included in the edits for the first quarter. This is especially problematic this year because of the new renumbered drug infusion and injection codes, which are subject to many bundling edits. [more]

Prepare for approaching ABN deadline

Medicare has been going through a number of transitions recently. One of these transitions relates to the appropriate form of notice when certain providers, including hospitals and physicians, believe that the outpatient services ordered by the patient’s physician fall under the limitation on liability provisions of the Social Security Act. Under these provisions, the provider must provide advance written notice to the beneficiary (or his or her representative) prior to the performance of the services in order to be able to bill the beneficiary for those services if Medicare denies coverage. [more]

Strategies for your ICD-10 implementation plan

Last week, HHS announced October 1, 2013, as the final implementation date for ICD-10-CM/PCS. ICD-10 was adopted for all diagnosis coding and for inpatient procedure coding. Also adopted were the standards changing the electronic claim format to accommodate the expanded ICD-10 codes.

For providers who have not begun preparing for ICD-10, this is a wake up call to start preparations. Not only will coders need to be retrained in the new coding system, but many other systems will have to be updated to accommodate this change. Providers will need to work with virtually all of their software vendors to implement this change. One of the most difficult parts of the transition, as we have experienced with the NPI, is not our own preparations, but awaiting CMS guidance on changes to their systems and policies. [more]

Where to go to get your laboratory NCD information

This week, CMS published the laboratory Medicare National Coverage Determinations Coding Policy Manual and Change Report, containing medical necessity edits for 23 common diagnostic laboratory tests. CMS published a transmittal earlier in December announcing these changes, and the policies also appear in the Internet-only Medicare National Coverage Determinations Manual (NCD Manual). However, the best reference is the Policy Manual and Change Report. [more]

NP/PA supervision in provider-based departments

Happy holidays everyone! I thought I would write a bit about physician supervision. One of the clarifications that I have discussed with many people recently is related to nurse practitioners (NP) or physician assistants (PA). CMS clarified that NPs/PAs may not provide the physician supervision in provider-based departments. This fact was not a surprise to most, but the impact for NP/PA rendered services should be considered. [more]