CorroHealth Weekly eJournal, May 3, 2023

j our nal e

Nuclear Medicine

CodesFor

Radioisoptes

COVID-19

Vaccines

FDA SimplifiesUse Of Bivalent mRNA

SETTING

Physical Therapist Professional Fees in the Hospital Setting

With few exceptions,most services that are rendered by PTs in the hospital setting are unable to be split into professional and technical fees. Either the professional fee may be billed, or the technical fee may be billed, but not both

To determine whether a HCPCSor CPT® code can be ?split billed?(reported by both the facility and the physician for services performed in the outpatient facility setting), PDEusers can refer to Medicare?s payment policy indicators displayed on the PARA Data Editor Professional Fee report on the Calculator tab:

PHYSICAL THERAPISTFEESIN THEHOSPITAL SETTING

"Incident -To" Billing In The Facilit y Set t ing

CMSdefines ?incident-to?services as those services that are furnished incident to physician professional services in the physician?s office (whether located in a separate office suite or within an institution) or in a patient?s home. The concept of ?incident-to?billing does not apply to services rendered in the facility setting The physician does not employ the PT; the hospital does, and the hospital is already receiving reimbursement for the PT?s services.

https://www cms gov/outreach-and-education/medicare-learning-networkmln/ mlnmattersarticles/downloads/se0441.pdf

PHYSICAL THERAPISTFEESIN THEHOSPITAL SETTING

EMG & Nerve Conduct ion St udies

Many Critical Access Hospitals have reported Medicare denials when billing a professional fee for EMG services rendered by a physical therapist who is employed by the hospital The codes in question are 95886, 95910, and 95911

In their denials, Medicare advises they will not pay 95886-26 on a professional fee claim with POS22 (outpatient hospital.)The acceptable POScodes are:

- 11 Office

- 15 ?Mobile Unit

- 20 ?Urgent Care Facility

- 32 ?Nursing Facility

- 49 ?Independent Clinic

Similarly, Medicare advises that CPT® 95910-26 is payable only when billed with one of the following POScodes:

- 11 ?Office

- 32 ?Nursing Facility

- 49 ?Independent Clinic

We note that POS22 ? Outpatient Hospital, is conspicuously absent from either list Medicare denials also indicate ?Modifier 26 is incorrect.?

PHYSICAL THERAPISTFEESIN THEHOSPITAL SETTING

Based on Medicare?s remarks, a qualified physical therapist in private practice (billing POS11 ? Office, for instance) could be reimbursed for the global or the professional component of these studies, but a physical t herapist w ho is w orking w it hin an out pat ient acut e care facilit y m ay not be paid a professional fee for t hese services.

Under Medicare?s cost-reimbursement methodology, a hospital is already fully reimbursed for the employment costs of physical therapists By billing a separate professional fee, the hospital is seeking reimbursement for a cost that is reimbursed through a different mechanism. For a CAH, the physical therapist?s employment costs are reimbursed under Medicare?s percent of-charges cost reimbursement methodology

Qualified physical therapists may be reimbursed by Medicare for furnishing these studies: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ PhysicianFeeSched/Diagnostic-Services-by-Physical-Therapists

Critical Access Hospitals are paid by Medicare on a cost-reimbursement basis, and the hospital?s cost report is used as the basis of the percent-of-charges reimbursement applied by Medicare to reimburse all covered facility fees. The cost report already includes the costs associated with its employed or contracted physical therapists

PHYSICAL THERAPISTFEESIN THEHOSPITAL SETTING

Any services the physical therapist performs at the hospital are therefore considered reimbursed within the percent of-charges method paid on hospital facility fees Therefore, the hospital cannot separately bill professional fees for physical therapists that are already reimbursed via the cost-based reimbursement on facility fees ? that would be double-dipping. Billing a professional fee for a physical therapist is different from billing a professional fee for an employed physician. CAHs cannot include the cost of ?Qualified Healthcare Professionals?that bill for direct patient care professional fees in the hospital cost report, which is the basis of the cost-based reimbursement for a CAH

The following section from Title 42 of the Code of Federal Regulations explains that Medicare?s cost-reimbursement for CAH facility fees does not include the cost of ?physician services or other professional services to CAH outpatients ?

https://www ecfr gov/current/title-42/chapter-IV/subchapter-B/part-413/subpartE/ section-413.70

Payment for outpatient services furnished by CAH?

(1)

General.

(i) Unless the CAH elects to be paid for services to its outpatients under the method specified in paragraph (b)(3) of this section, the amount of payment for outpatient services of a CAH is determined under paragraph (b)(2)of this section.

(ii) Except as specified in paragraph (b)(6) of this section, payment to a CAH for outpatient services does not include any costs of physician services orother professional services to CAH outpatients.

The Medicare cost report work sheet A-8-2 ensures that CAHs do not ?double dip?? it ensures that the hospital cost report does not include the costs relating to professional services that are paid separately by insurers and the Medicare Physician Fee Schedule.

CAHs must separate the time the physician spends performing separately billable professional services from the time the physician spends performing non-billable duties. The hospital cost report can include an allocation of the physician?s employment cost for only that portion that is not attributed to performing separately billable professional services.

PHYSICAL THERAPISTFEESIN THEHOSPITAL SETTING

While Medicare allows hospitals to allocate their costs, and separately report professional fees performed by physicians and non-physician practitioners like PAs and ARNPs, there is no evidence they will allow this same allocation for physical therapists.

This may be the most efficient approach, because the cost of the therapist would usually be 100%allocated to the cost report anyway. With the exception of these nerve conduction study interpretation codes, all other services that PTs perform in the hospital setting are reimbursed on facility fees

If 101%of the cost of the physical therapist is reimbursed via the cost report anyway, then it seems inefficient to go through the cost allocation procedure for a relatively small number of separately payable services ? the difference in overall reimbursement is unlikely to be worth the effort to carve the associated salary cost out of the cost report

Incidentally, we also surveyed our Medicare claims database for 2022 claims from other CAHs (Method II) which reported 95866, 95910, or 95911 with modifier 26 on their claims We found none were reported with the NPI of a physical therapist in the ?attending?field; all reported a physician neurologist or other physician/non-physician practitioner. There is no evidence that any CAH has billed or been paid by Medicare for a physical therapist reporting 95866-26, 95910-26, or 95911-26.

We recommend clients consult with their cost report accountant to verify whether they concur with our interpretation of the situation.

Addit ional Resources

For further information regarding charging and documenting physical therapy services in the hospital setting, please see the following PARA Papers available in the Advisor tab of the PDE:

Q&A ? Physical Therapy Documentation

?Incident-To?Billing in the Clinic and Hospital Settings

FDA Simplifies COVID-19 Vaccines

On April 18, 2023, the FDA authorized an amendment to the Emergency Use Authorization (EUA) for COVID-19 bivalent vaccines for all patients ages 6 months and older. Monovalent COVID-19 vaccines offered through Pfizer-BioNTech and Moderna are no longer authorized in the United States

Coronavirus (COVID-19) Update: FDA Authorizes Changes to Simplify Use of Bivalent mRNACOVID-19 Vaccines

The amended EUA provides the following information:

- Patients who had a monovalent COVID-19 vaccine only may receive one bivalent vaccine

- Unvaccinated patients may receive one bivalent vaccine

- Most patients who have already had one dose of bivalent are considered fully vaccinated at this time. The FDA may revise this decision after the FDA Advisory Committee meeting in June

Exceptions to this include:

- Patients aged 65 or older ? may receive an additional bivalent vaccine at least four months following the first

- Patients with immunocompromised conditions ? may receive an additional bivalent vaccine at least two months following the first with additional doses as determined by the healthcare provider The FDA states there are additional considerations for patients aged 6 months ? 4 years

The FDA offers additional recommendations for children ages 6 months through 5 years depending upon previous COVID-19 vaccination administrations

Coding For Nuclear Medicine

Radiopharmaceuticals

Int roduct ion

The process of assigning HCPCScodes and units for radioisotopes and imaging-related drugs for nuclear medicine services can be quite challenging. This is because there are often multiple codes available for the same substance depending on factors such as dosage and whether the drug is being used for therapeutic or diagnostic purposes Additionally, different payers may have different requirements, such as requesting a copy of the invoice or National Drug Code (NDC) for the substance. Furthermore, the codes and guidelines for imaging agents tend to change more frequently than those for imaging services.

Coding and Billing for Radiopharm aceut icals

Alphanumeric Level II HCPCScodes are utilized to invoice Medicare and other payers for pharmaceuticals and drugs Radiopharmaceuticals are measured in curies, which is a unit of radioactivity.

Some HCPCScodes for radiopharmaceuticals are defined in terms of millicuries (mCi), while others are defined in terms of microcuries (uCi) The kits used for the administration of radiopharmaceuticals, such as the Insta/Vent? system for lung scans, are included in the reimbursement for the study and are not reported separately.

While most radiopharmaceuticals are bundled into the charge for the radiology service, some expensive radiopharmaceuticals do carry separate reimbursement under Medicare?s hospital outpatient reimbursement methodology (OPPS). Drugs listed as status K or status G under OPPSare separately payable. For example, A9543 (Y-90/Zevalin) carries a substantial amount of additional reimbursement:

NUCLEARMEDICINERADIOPHARMACEUTICALS

Other HCPCSfor radiopharmaceuticals such as Pylarify® , QuadraMet® , Illucix® , Pluvicto? , Metastron, and Locametz® all also carry a significant amount of separate reimbursement when reported in addition to the radiology procedure code

NUCLEARMEDICINERADIOPHARMACEUTICALS

In most cases, submitting charges for contrast and radiopharmaceuticals will not result in additional Medicare reimbursement for an OPPSfacility or Critical Access Hospital.

However, it is still important to report the charge for the radiopharmaceutical for two reasons:

- Medicare bases APCreimbursement on cost data collected from hospital claims, and

- Some payers (like Medicaid) will reimburse contrast separately

Non-Highly Enriched Uranium Sources

Hospitals providing technetium Tc-99m labeled isotopes for nuclear medicine imaging services may be eligible for additional reimbursement if the isotope used in the procedure was obtained from a non-Highly Enriched Uranium (HEU) source. In order to encourage facilities to use non-HEU source isotopes, Medicare will pay an additional $10 per study dose if the add-on HCPCSQ9969 is reported in addition to the A95XXcode:

NUCLEARMEDICINERADIOPHARMACEUTICALS

In 2012, Medicare added HCPCScode Q9969 (Tc-99m from non-highly enriched uranium source, full cost recovery add-on, per study dose) to provide additional reimbursement for Tc-99 derived from a non-HEU source, which is more costly

The objective of the additional reimbursement is to eliminate domestic reliance on Tc-99m derived from nuclear reactors using Highly Enriched Uranium (HEU). CMSwill reimburse providers $10 per non-HEU derived Tc-99m dose in the hospital outpatient setting in addition to the payment for the imaging procedure

Hospitals report Q9969 once per dose, in addition to the Tc-99m code (such as A9541, for example.) The HCPCSQ9969 is reimbursed one time per study dose. For example, if separate doses of Tc-99m are provided for a study at rest study and a stress study, the hospital would report Q9969 x 2, in addition to the line item reporting the isotope itself

As long as the Tc-99m doses used can be certified by the hospital to be at least 95 percent derived from non-HEU sources, Q9969 may be reported in addition to the A95XXcode Hospitals should maintain documentation that the dose was derived from a non-HEU source by means of product invoices, patient dose labels, or tracking sheets that indicate that a dose was produced from non-HEU sources. Isotope purchasing managers should inquire if the Tc-99 manufacturer has labeled a generator or a dose attesting to it being derived from a non-HEU source

Questions about whether the Tc-99Mm was derived from a non-HEU source should be directed to the manufacturer or radiopharmaceutical supplier

Download the complete guide, along with more tables from the Para Data Editor (PDE) by clicking here

New Radiology Contrast Materials And Radiopharmaceuticals Crosswalk Available in Advisor Tab

Two new tools have recently been added to the Advisor tab in the PDE. Crosswalks to the appropriate HCPCS codes for radiologic contrast materials and radiopharmaceuticals and their corresponding CPT codes are now available

The crosswalks also provide information about the types of studies for which each drug is used, the associated NDCs, suggested revenue codes, CCI edits, MUEs, and more

In most cases, submitting charges for contrast and radiopharmaceuticals will not result in additional Medicare reimbursement for an OPPSfacility (Critical Access Hospitals are paid on a cost-reimbursement basis by Medicare.) However, it is still important to report the charge for the contrast agent or radiopharmaceutical for two reasons:

- Medicare bases APCreimbursement on cost data collected from hospital claims, and

- Some payers (like Medicaid) will reimburse contrast separately

Clients can access these tools via the Advisor Tab in the PDE:

Theprecedingmaterialsare for instructional purposesonly. Theinformation ispresented "as-is"and to thebest of CorroHealth'sknowledgeisaccurateat the timeof distribution. However, due to theever-changing legal/regulatorylandscape, thisinformation issubject to modification asstatutes, laws, regulations, and/or other updatesbecomeavailable. Nothingherein constitutes, isintended to constitute, or should berelied on as legal advice. CorroHealth expresslydisclaimsanyresponsibilityfor anydirect or consequential damagesrelated in anywayto anythingcontained in thematerials, which areprovided on an "as-is"basisand should be independentlyverified beforebeingapplied You expresslyaccept and agreeto thisabsoluteand unqualified disclaimer of liability. Theinformation in thisdocument isconfidential and proprietaryto CorroHealth and is intended onlyfor thenamed recipient. No part of thisdocument maybereproduced or distributed without expresspermission. Permission to reproduce or transmit in anyform or byanymeanselectronicor mechanical, includingpresenting, photocopying, recording, and broadcasting, or byanyinformation storageand retrieval system must beobtained in writingfrom CorroHealth. Request for permission should bedirected to Info@Corrohealth com.

PARA invit es you t o check out t he m lnconnect s page available from t he Cent ers For Medicare and Medicaid (CMS). It 's chock full of new s and inform at ion, t raining opport unit ies, event s and m ore! Each w eek PARA w ill bring you t he lat est new s and links t o available resources. Click each link for t he PDF!

Thursday, April 27, 2023

New s

- Hospital Price Transparency Enforcement Updates

- For the First Time, HHSIs Making Ownership Data for All Medicare-Certified Hospice and Home Health Agencies Publicly Available

- Behavioral Health Integration Services: Find Out What Medicare Covers & Who?s Eligible

Claim s, Pricers, & Codes

- HCPCSApplication Summaries & Coding Decisions: Drugs & Biologicals

Event s

- 2023 Quality Conference ? May 1?3

MLN Mat t ers®Art icles

- Home Health Claims: Telehealth Reporting

- Skilled Nursing Facility Prospective Payment System: Updates to Current Claims Editing

t r ans mit t al s

Therew ereTWELVEnew or revised Transmittalsreleased thisw eek.

To go to thefull Transmittal document simply click on thescreen shot or thelink.

TRANSMITTAL R11942CP

TRANSMITTAL R11997MSP

TRANSMITTAL R12006OTN

TRANSMITTAL R12002OTN

TRANSMITTAL R9R242I

TRANSMITTAL R12001OTN

TRANSMITTAL R11996MSP

TRANSMITTAL R12005OTN

TRANSMITTAL R12003CP

TRANSMITTAL R12000OTN

TRANSMITTAL R12011OTN

TRANSMITTAL R11999OTN

edl ear ns

Therew ere0 new or revised MedLearnsreleased thisw eek.

To go to thefull Transmittal document simply click on thescreen shot or thelink.

Theprecedingmaterialsare for instructional purposesonly. Theinformation ispresented "as-is"and to thebest of CorroHealth'sknowledgeisaccurateat thetimeof distribution. However, due to the ever-changinglegal/regulatory landscape, thisinformation issubject to modification asstatutes, laws, regulations, and/or other updatesbecome available. Nothingherein constitutes, isintended to constitute, or should berelied on aslegal advice. CorroHealth expresslydisclaimsanyresponsibilityfor anydirect or consequential damagesrelated in anywayto anything contained in thematerials, which areprovided on an "as-is"basisand should beindependentlyverified before beingapplied. You expresslyaccept and agree to thisabsoluteand unqualified disclaimer of liability. The information in thisdocument isconfidential and proprietaryto CorroHealth and isintended onlyfor thenamed recipient. No part of thisdocument maybereproduced or distributed without expresspermission. Permission to reproduceor transmit in anyform or byanymeanselectronicor mechanical, includingpresenting, photocopying, recording, and broadcasting, or byanyinformation storageand retrieval system must beobtained in writingfrom CorroHealth. Request for permission should bedirected to Info@Corrohealth.com.