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Q: What is HETS? How do I connect to this system?
A: The Healthcare Eligibility Transaction System (HETS) system is intended to allow release of eligibility data to Medicare providers or their authorized billing agents. Such information may not be disclosed to anyone other than the provider, supplier, or beneficiary for whom a claim is filed. Read More→
By Kimberly Anderwood Hoy, director of Medicare and compliance for HCPro, Inc.
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.
For hospitals, even though the GSP does not apply, modifier -79 has a payment impact on the multiple procedure reduction. It is used to override the multiple procedure reduction when procedures are provided in separate sessions and therefore not subject to the multiple procedure reduction policy. The result of applying modifier 79 is that both procedures will be paid at 100% of the payment rate, rather than being subject to the multiple procedure reduction that reduces all but the highest-paying procedure by 50%.
The instruction requires contractors to review modifier -79 claims and take appropriate action such as pre-payment edits or post-payment reviews. The instruction is being made as a result of an Office of Inspector General report on misuse of modifier -79. While the finding cited a particular physician’s misuse of modifier -79, modifier -79 was included in the OIG Work Plan for hospitals in 2006 and 2007.
Hospitals should review their use of modifier -79, ensuring that coders have been provided appropriate education on the use of modifier -79 and its impact on both the NCCI edits and the multiple procedure reduction. Proper application of modifier -79 requires that the coder understand not only the coding implications related to the NCCI, but also the payment implications related to the multiple procedure reduction.
Hospitals to report ZIP codes of outpatient service locations for certain services
On February 13, CMS issued clarifying instructions on the calculation of payment amounts for services paid to hospitals on the basis of the Medicare Physician Fee Schedule (MPFS), such as physical therapy, occupational therapy, speech language pathology, and mammograms. The instruction requires providers to report the ZIP code of outpatient service facility locations for off-site outpatient facilities. The location ZIP code will be used to calculate the appropriate local MPFS payment amount.
Effective date: October 1, 2007
Implementation date: July 6, 2009
CMS accepts National Drug Codes (NDCs) for drugs with no HCPCS assigned
On February 13, CMS issued instructions for submitting NDCs for drugs reported with C9399. HCPCS code C9399 is used for FDA approved drugs that do not yet have a product specific HCPCS code. The instruction also makes clear that contractors must accept decimal quantities for NDCs, although they may round those quantities for payment purposes.
Effective date: July 1, 2009
Implementation date: July 6, 2009
CMS issues corrections to the 2009 IPPS and OPPS wage indices
On February 13, CMS released corrections to the wage index for the fiscal year 2009 IPPS and the calendar year 2009 OPPS for certain hospitals requesting reversals of decisions made on their behalf by CMS and one provider with a typographical error in its reclassified CBSA.
Effective date: October 1, 2008
Implementation date: May 18, 2009
CMS announces changes to laboratory NCD edit software for April
On February 13, CMS released a transmittal communicating the changes it will make in April to the laboratory NCD edit software.
Effective date: April 1, 2009
Implementation date: April 6, 2009
CMS instructs contractors to strengthen safeguards against the abuse of modifier -79
On February 13, CMS released a transmittal instructing its contractors to review their safeguards against the misuse of modifier -79 and make any necessary changes.
Effective date: March 16, 2009
Implementation date: March 16, 2009
CMS clarifies enforcement of amended requirements for physician-owned hospitals and critical access hospital (CAH) disclosures to patients
On February 13, CMS issued a memo in which it clarifies its enforcement approach to certain changes in requirements, including revision to the physician-owned hospital disclosure requirements.
CMS issues decision memo for surgery for diabetes
On February 12, CMS issued a final decision memo in which it determined it would not make changes to National Coverage Determination (NCD) Manual section 100.8 (Intestinal Bypass Surgery) and section 100.11 (Gastric Balloon for Treatment of Obesity). Treatments for obesity alone remain non-covered.
CMS issues proposed decision memo for screening computed tomography colonography (CTC) for colorectal cancer
On February 11, CMS proposed to maintain noncoverage of CTC for colorectal cancer screening.
View the proposed decision memo.
OIG issues comparison of second-quarter 2008 average sales prices (ASP) and average manufacturer prices (AMP) for Medicare Part B prescription drugs
On February 11, the OIG released a report comparing second-quarter ASPs to AMPs for Medicare Part B prescription drugs and its impact on Medicare fourth-quarter reimbursement.
Q: When a patient presents with controlled diabetes that progresses to uncontrolled during a hospital stay, should we assign present on admission (POA) indicator N?
A: There is no Coding Clinic on this particular topic. However, you would presumably assign the POA indicator N because controlled diabetes is a combination code, and a portion of the code was not POA (i.e., the uncontrolled diabetes). Consider the following excerpt from the ICD-9 Official Guidelines for Coding and Reporting:
Assign “N” if any part of the combination code was not present on admission (e.g., obstructive chronic bronchitis with acute exacerbation and the exacerbation was not present on admission; gastric ulcer that does not start bleeding until after admission; asthma patient develops status asthmaticus after admission).
Editor’s note: Shannon E. McCall, RHIA, CCS, CPC-I, director of coding and HIM at HCPro, Inc. in Chesterfield, VA, answered this question that originally appeared in the February issue of Briefings on Coding Compliance Strategies.
On January 27, the National Center for Health Statistics published updated ICD-10 guidelines to replace its July 2007 guidelines. Although HIM directors can anticipate updates to this draft prior to implementation in 2013, they can use the guidelines to begin to train coders on the new system. Visit the Centers for Disease Control and Prevention Web site for more information.
Patients with cancer undergo many expensive treatments and tests and often find themselves bankrupt even if they have insurance, according to a new report.
The report, released by the Kaiser Family Foundation and the American Cancer Society followed 20 typical cancer patients. Of those patients, nine had insurance through an employer, one paid for employer coverage through COBRA, seven had individual insurance, two received coverage through a state high-risk insurance pool, and one became uninsured.
The study found that many of the patients became too sick to work, but were able to remain covered by their employer’s insurance up to 18 months by paying the full premium, although they found the added expense hard to bear. Other patients experienced delays in treatment caused by funding problems, debt, and stress about costs.
Medicare is the secondary payor when:
- The patient is 65 or older and the patient or the patient’s spouse is still employed and has insurance through that employer.
- The patient is under 65 and the patient or patient’s spouse is employed by an employer with 100 or more employees and has insurance through that employer.
- The claim is workers’ compensation.
- The claim is a Black Lung claim.
- The claim is a result of an accident and liability insurance is available.
- The claim is for ESRD and the patient is still in the 30-month coordination of benefits period.
Additional MSP tips:
- When Medicare is the secondary payor, the primary payor is #1 in the sequence of payors.
- Medicare is #2 in the sequence of payors when Medicare is the secondary payor.
- MSPs are to be completed on each registration to ensure proper billing.
Editor’s note: Dunn Memorial Hospital in Bedford, IN, uses these hints to help its patient access staff members successfully complete the Medicare Secondary Payer Questionnaire.
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