Date
PARA WEEKLY CODING FOR HPV SCREENING
UPDATE For Users
Improving T he Businessof HealthCare Since 1985 January 31, 2018 NEWS FOR HEALTHCARE DECISION MAKERS
IN THIS ISSUE QUESTIONS & ANSWERS - Professional Reimbursement For Care Plan Oversight - 36600 And 31500 Denials - Compound Drug Billing - 99219 Denials - Signs And Symptoms For Pain Management NEW CHROME VERSION OF PDE & OTHER BROWSERS HYDRATION, IV INFUSIONS, INJECTIONS & VACCINE CHARGE PROCESS UPDATE: THERAPY CAP EXPIRATION PDE UPDATE: RAC TAB OP DATA
PARA COMPANY NEWS ABOUT PARA SERVICES CONTACT US
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The number of new or revised Med Learn (MLN Matters) articles released this week. All new and previous Med Learn articles can be viewed under the type "Med Learn", in the Advisor tab of the PARA Dat a Edit or . Click here.
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The number of new or revised Transmittals released this week. All new and previous Transmittals can be viewed under the type "Transmittals" in the Advisor tab of the PARA Dat a Edit or . Click here.
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FAST LINKS: Click on the link for special areas of interest: Page
Administration: Pages 1-53 HIM/Coding Staff: Pages 1-53 Providers: Pages 2,8,10,14 Pharmacy Services: Pages 9,49 Pain Management Services: Page 11
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PDE Users: Pages 12,31 Critical Access Hospitals: Pages 34,42 FQHC's: Pages 35,39,51 Hospice Services: Pages 33,41 Finance: Pages 37,43-48
© PARA Healt h Car e Fin an cial Ser vices CPT® is a r egist er ed t r adem ar k of t h e Am er ican M edical Associat ion
PARA Weekly Update: January 31, 2018
PROFESSIONAL REIMBURSEMENT FOR CARE OVERSIGHT
Question: How and what is required for a provider to be able to charge for Care Plan Oversight? Once the provider has signed and dated the Certification / Re-Certification, is this enough to support the charge G0180 and G0181? Answer: In the language of CMS, Medicare considers care plan oversight to be ?pre-and post-visit" work a bundled component of rendered evaluation and management (E/ M) services. However, care plan oversight is the one non-face-to-face that physicians can bill and receive reimbursement from Medicare. Most physicians chose not to charge for the service as Medicare makes the rules both complicated and very specific, i.e.; which provider can bill for the service, which beneficiaries are eligible to receive the services and which components actually ?make-up? the components make up care plan oversight. With this being said in the opening paragraph of this article, the answer to the question that started this article is ?No.? A physician just signing and dating a Certification/ Re-Certification is not enough to support charging for a Care Plan Oversight services. In the table below is a listing of requirements that will assist in determining if a provider is eligible to bill for Care Plan Oversight services. If you are able to meet all of the requirements in the table, a provider is eligible to bill: The physician cannot have a significant financial arrangement with the home health agency or hospice that is providing care to the patient The physician may not be an employee or medical director of the home health agency or hospice Only one (1) physician may bill Care Plan Oversight services per month Neither a physician who is billing for the end-stage renal disease services under a capitation arrangement nor a physician who is providing surgical follow-up in the global period may bill for Care Plan Oversight services The physician who bills for the Care Plan Oversight must be the same physician who signed the initial certification for the home health agency / Hospice The physician is required to have a face-to-face service with the patient within six (6) months of billing for the Care Plan Oversight The physician must have personally provided at least 30 minutes of service in one (1) calendar month The beneficiary must be receiving Medicare covered home health / hospice services during the period in which the Care Plan Oversight services are billed The beneficiary must require complex or multi-disciplinary care modalities requiring on-going physician involvement in the patient?s plan of care
Who can furnish CPO services? Services must be personally furnished by a physician or non-physician practitioner. CMS defines non-physician practitioner as a nurse practitioner (NP), clinical nurse specialist (CNS) or a physician assistant (PA). The non-physician practitioner is required to have a collaborative relationship with the physician who signed the initial home health agency / hospice plan of care. 2
PARA Weekly Update: January 31, 2018
PROFESSIONAL REIMBURSEMENT FOR CARE PLAN OVERSIGHT
CPO services must take at least 30 minutes in a calendar month to be billable. The services do not have to be rendered on the same day, but at the end of the month, to be billable they must add up to a total of 30 minutes. The physician or Non-physician practitioner must personally document the date, time spent and a brief description of the activities provided in the patient?s record. This documentation should be clearly defined in the medical record. The services should be billed to Medicare with the start date of the first month and an end date of the month?s final day. Codes for Care Plan Oversight services: The following codes can be used to report Care Plan Oversight service for Home Health / Hospice:
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PARA Weekly Update: January 31, 2018
PROFESSIONAL REIMBURSEMENT FOR CARE OVERSIGHT
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PARA Weekly Update: January 31, 2018
PROFESSIONAL REIMBURSEMENT FOR CARE PLAN OVERSIGHT
Not all insurers reimburse for Care Plan Oversight services, it is recommended providers confirm eligibility prior to billing for the services. Codes 99374 ? 99379 are usually reported for commercial insurance carriers, while the G0179 ? G0182 are used for Medicare reporting, there may be some commercial carriers that will accept both codes. What patients are eligible to receive CPO services: Patients are eligible for CPO services if they require: 1.Complex treatment 2.Under the care of multi-disciplinary teams 3.Under the care of a Medicare-approved home health agency / hospice
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PARA Weekly Update: January 31, 2018
PROFESSIONAL REIMBURSEMENT FOR CARE OVERSIGHT
Example: A family physician sees an elderly patient with diabetes, the patient lives alone and has non-healing skin ulcers. The patient is referred by the physician to a Medicare approved home health agency and the physician signs the initial plan of care. Over the course of the month, the physician coordinates the care with the nurse at the home health agency, arranges for treatment at a wound clinic and talks to the treating physician at the wound care clinic, reviews multiple laboratory testing results not related to an office visit or another E/ M service, and adjusts the patient?medications. The physician spends more than 30 minutes during the month performing these activities, documents the dates, times and services rendered. At the end of the month, the physician can bill G0181 Since Care Plan Oversight codes are ?timed codes? and as previously mentioned in this article, there are various components that Medicare has outlined, that can and cannot be used to determine if the provider has met the ?time criteria? to be able to charge for the services. This table may be able to help you sort out the component variables that can and cannot be ?counted? towards the Care Plan Oversight:
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PARA Weekly Update: January 31, 2018
PROFESSIONAL REIMBURSEMENT FOR CARE PLAN OVERSIGHT
Reference for this article: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
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PARA Weekly Update: January 31, 2018
36600 AND 31500 DENIALS
Question: We have been getting denials from our Medicaid products for CPT® 36600 stating that this is not a covered service per our contract, or it is included in payment of another service. When doing research we have found that CPT® 31500 and 36600 cannot be billed together without a modifier. We have also found that when billing a critical ER visit, CPT® 36600 is included. Our question is how should we be handling charging for CPT® 36600? Answer: First, Indiana Medicaid offers reimbursement for both 36600 and 31500:
There is a CCI edit indicating that 36600 is considered a component of 31500, endotracheal intubation, unless a modifier is appended to 36600 to attest that it was not performed solely to verify that the intubation was successful. If the arterial blood gas was drawn for reasons other than confirming the success of the intubation, the hospital may append modifier 59 or XU, unusual overlapping service, to 36600 to override the CCI edit.
It is most typical to report 36600 with an arterial blood gasses test. Our Claim Summary report, available when the user clicks on the CPT® Hyperlink after running the HCPCS report, indicates that hospitals report 36600 with the lab test 82803, arterial blood gasses on 64% of all claims with 36600, and with 82805, blood gasses with oxygen saturation, 34% of the time.
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PARA Weekly Update: January 31, 2018
COMPOUND DRUG BILLING
Question: What do other facilities do about commercially available compounded meds? Medicaid is rejecting the Succinylcholine we carry (100mg/ 5ml syringe compounded by Nephron) because the NDC is not listed (69374092005). It was suggested that I change the NDC to the manufactured product from which it was compounded from, however the description of the med administered will not match what is being billed ( succinylcholine 100mg/ 5ml single use syringe vs. succinylcholine 200mg/ 10ml multidose vial). As far as we know, this has not been an issue before now and we use several commercially available products and have for a few years. Answer: We have located billing instructions in effect for Indiana Medicaid, but they are unclear. Taking in the preponderance of the information found, we recommend reporting the NDC(s) that most closely matches the compounded drug(s). The following summarizes our research: 1. The PARA NDC database is populated for pharmacy items by First Data Bank; there is no data for NDC 69374092005. 2. We reviewed Indiana Medicaid billing instructions, and find it to be vague ? although it indicates that ?NDC?s included in the compound drug? are reimbursed. Here?s an excerpt from the Claim Submission and Processing document published on January 23, 2018: http://provider.indianamedicaid.com/media/155451 /claim%20submission%20and%20processing.pdf This manual mentions a special paper claim form forcompounded drugs ? however, it appears to be used for the IHCP pharmacy benefit ? in other words, I don?t think the compounded pharmacy claim form is for hospital use: We found some older instructions from 2007, but we also found a note that the ?policy regardingcompounded drugs? would change on 1/ 1/ 2008: http:/ / provider.indianamedicaid.com/ ihcp/ Bulletins/ BT200731.pdf An old 2007 Indiana Medicaid provider education Powerpoint deck offers this information ? but it says ?the policy regardingcompounded drugs will be changing on 1/ 1/ 2008?:
http://provider.indianamedicaid.com/media/28972/ndc% 20requirements%20for%20medical%20claims.pdf As you can see, we are unable to offer clear direction because the direction from Indiana Medicaid is not clear. It is possible thecompounder, Nephron, may have some advice. Here is a link and a snip from their contact page: https://www.nephronpharm.com/contact-us 9
PARA Weekly Update: January 31, 2018
99219 DENIALS
Question: We received a denial stating that the benefit has been reached for CPT® 99219 on one of our ICG claims. Our question is can we charge two days for CPT® 99219 if there is a different physician seeing the patient on each day? Answer: Though we are not familiar with the acronym ICG, there may be restrictions on covered services under that program. In terms of general professional fee billing practices, the patient?s coverage should not be billed for the initial day of observation care twice during the same stay, even if it represents two different providers on two different days within the stay. CPT® 99219 is for the initial observation care of the patient from the perspective of the patient, not the physician. Here is the full description of that code: 99219 - initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. usually, the problem(s) requiring admission to outpatient hospital "observation status" are of moderate severity. typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit. Professional fees for subsequent days of observation care, even if provided by a different physician, should be reported with 99224-99226. On the day of discharge from observation care, the attending provider should report 99217.
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PARA Weekly Update: January 31, 2018
SIGNS & SYMPTOMS FOR PAIN MANAGEMENT
Question: Should signs and symptoms such as pain in knee be coded when a definitive diagnosis is established but does not cover medical necessity of the pain management? Scenario: A patient is seen for bilateral Knee osteoarthritis and is experiencing severe pain in both knees.The physician performs a Total Knee Replacement and additionally performs post pain management for pain in bilateral knees.The osteoarthritis is the definitive diagnosis. Answer: Although the coding guidelines tell us not to code signs and symptoms that are integral to a disease process, when the objective of the procedure is pain management, the pain should be coded separately. The facility may add documentation of signs and symptoms, such as M25.561 or M25.562, provided that either the CRNA documents it or the surgeon has made mention of it in his dictation.
Medicare allows coding of signs and symptoms when required for medical necessity. Here?s an excerpt from Medicare?s narrative explaining medical necessity requirements for lab tests: https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/Downloads/lab1.pdf Federal Register 42 CFR Part 410 [CMS?3250?F] RIN 0938?AL03 Medicare Program; Negotiated Rulemaking: Coverage and Administrative Policies for Clinical Diagnostic Laboratory Services ?Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms or abnormal findings that substantiate the medical necessity for ordering the tests. ?
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PARA Weekly Update: January 31, 2018
NEW CHROME VERSION OF PDE & OTHER BROWSER FORMATS
We have been working on making the PARA Data Editor compatible with multiple web browsers so that everyone can have options when it comes to which browser to use, depending on resources or preferences. As of today, we are making available our PARA Data Editor Multiple Web Browser (Beta) Version to everyone with a proper PARA Data Editor Login. The Web Browsers that we are rolling out first with this version are Internet Explorer and Google Chrome. To all users who wish to use the Multiple Web Browser (Beta) Version, please be aware that this is a PRELIMINARY version meant to work out any errors and issues that it might exhibit. It is in the process of being updated to mirror the current production version of the PARA Data Editor. With your help, we will be able to narrow in on fixes throughout the PARA Data Editor Multiple Web Browser (Beta) Version to then ensure full functionality and to further expand to more Web Browsers. The PARA Data Editor Multiple Web Browser (Beta) Version can be accessed via the following link and using the appropriate login when prompted by the browser: https://www.para-hcfs.com/projects/pde_upgrade/pde_MultBrowser
Note new interface with options. 12
PARA Weekly Update: January 31, 2018
NEW CHROME VERSION OF PDE & OTHER BROWSER FORMATS
Once logged in, we would like for you to please be aware of a few key features to help us improve the PDE Multiple Browser (Beta) Version. First, please be aware of the change in look for the Multiple Browser (Beta) Version. We are attempting to update the look and feel of the PDE to be cleaner and user-friendly. Second, if you may have any questions, need help, would like to report an error or issue with the PDE Multiple Web Browser (Beta) Version, or anything else you may think of, click on the ?Contact Support? Link in the upper-right hand corner of the PDE:
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PARA Weekly Update: January 31, 2018
HYDRATION, IV INFUSIONS, INJECTIONS & VACCINE CHARGE PROCESS
There are a number of items to be considered when billing for the Nursing service to perform drug therapy. The charge process is divided into four specific groups of codes and processes: 1. Hydration and IV Therapy 2. Injections into IV lines and intramuscular (non-chemotherapy) 3. Vaccines 4. Chemotherapy Hydration and IV Therapy: Hydration and IV therapy are time based charges which have a first hour and a subsequent hour. The codes are as follows: 96360- Intravenous infusion, hydration; initial, 31 minutes to 1 hour 96361- Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure), the additional time has to be greater than 30 minutes 96365- Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour,16-60 minutes (less than 16 min = IVP) 96366- Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) 96367- Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure),16-60 minutes and a different drug 96368- Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure),once per encounter 96369- Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s),16-60 minutes 96370- Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure), must begreater than 30 minutes 96371- Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for primary procedure),once per encounter Hydration therapy must last longer than 30 minutes, to be considered for an initial 1st hour code. IV therapy less than 16 minutes is to be coded as an IV injection. Hydration less than 30 minutes is not a billable procedure. Establishing a heparin or saline lock for access or a slow drip of saline for access is not hydration or IV therapy.
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PARA Weekly Update: January 31, 2018
HYDRATION, IV INFUSIONS, INJECTIONS & VACCINE CHARGE PROCESS
Injections into IV lines are required to be classed into the following codes: 1. Initial injection med A (96374) 2. Additional subsequent injection, meds B ? Z (96375) 3. Additional subsequent injections med A (96376), there must be a period of more than 30 minutes that has to pass between injections of same drug. The codes used for IV injections are as follows: 96374- Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/ drug 96375- Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/ drug (List separately in addition to code for primary procedure) 96376- Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/ drug provided in a facility (List separately in addition to code for primary procedure) see time note above Intramuscular, subcutaneous and intra-arterial injections use the following codes: 96372- Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular 96373- Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intra-arterial
Vaccines are based on the number of injections and for Medicare the type of vaccine: 90471- Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/ toxoid) 90472- Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/ toxoid) (List separately in addition to code for primary procedure) G0008- ADMINISTRATION OF INFLUENZA VIRUS VACCINE G0009- ADMINISTRATION OF PNEUMOCOCCAL VACCINE G0010- ADMINISTRATION OF HEPATITIS B VACCINE ? not billable hospital outpatient Part B
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PARA Weekly Update: January 31, 2018
HYDRATION, IV INFUSIONS, INJECTIONS & VACCINE CHARGE PROCESS
General Rules: There can only be one ?initial? procedure, on a claim / encounter. The ranking to determine the initial procedure is as follows, the remaining procedures must be coded as additional or subsequent: 1. Chemotherapy services 2. 96365 ? IV therapy 1st hour 3. 96374 ? IV injection initial 4. Any other infusion/IV therapy code precedes a hydration code 5. 96360 ? Hydration 1st hour-this code used as ?initial? only if NO OTHER drug is administered as an infusion or IV therapy Establishing IV access is not hydration or IV therapy. Hydration procedures must have a diagnosis supporting the procedure, hydration substances include normal saline, D5W, and pre-packaged KCL. Initial IV therapy must last longer than 15 minutes, but if less than 16 minutes, the procedure should be charged as an IV injection. Drug administration charges are only reported on outpatient/ ambulatory care, emergency and observation patients, the service is not charged on inpatients. There are a number of different revenue codes which can be used to report these services; the basic guideline is to list the charge against the ?nursing station? providing the service. For the charge for an ?additional? hour of hydration or IV med therapy the service must last for more than 30 minutes into the additional hour. 0260- IV Therapy - General Classification 0450- Emergency Room - General Classification 0456- Emergency Room - Urgent Care 0510- Clinic - General Classification 0516- Clinic - Urgent Care Clinic 0761- Treatment or Observation Room - Treatment Room 0762- Treatment or Observation Room - Observation Room 0940- Other Therapeutic Services - General Classification
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PARA Weekly Update: January 31, 2018
HYDRATION, IV INFUSIONS, INJECTIONS & VACCINE CHARGE PROCESS
AMA CPTÂŽ instructs that ?If performed to facilitate the infusion or injection, the following services are included and are not reported separately? -1. Use of local anesthesia 2. IV start 3. Access to indwelling IV, subcutaneous catheter or port 4. Flush at conclusion of infusion 5. Standard tubing, syringes, and supplies For Declotting of a catheter or port, use 36593:
Chemotherapy-- Complex drugs and biologic agents are to be billed using the chemotherapy codes: 96401- Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic 96402- Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic 96405- Chemotherapy administration; intralesional, up to and including 7 lesions 96406- Chemotherapy administration; intralesional, more than 7 lesions 96409- Chemotherapy administration; intravenous, push technique, single or initial substance/ drug 96411- Chemotherapy administration; intravenous, push technique, each additional substance/ drug (List separately in addition to code for primary procedure) 96413- Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/ drug 96415- Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure)
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PARA Weekly Update: January 31, 2018
HYDRATION, IV INFUSIONS, INJECTIONS & VACCINE CHARGE PROCESS
96416- Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump [see also G0498 below] 96417- Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/ drug), up to 1 hour (List separately in addition to code for primary procedure) 96420- Chemotherapy administration, intra-arterial; push technique 96422- Chemotherapy administration, intra-arterial; infusion technique, up to 1 hour 96423- Chemotherapy administration, intra-arterial; infusion technique, each additional hour (List separately in addition to code for primary procedure) 96425- Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the use of a portable or implantable pump 96440- Chemotherapy administration into pleural cavity, requiring and including thoracentesis 96446- Chemotherapy administration into peritoneal cavity via indwelling port or catheter 96450- Chemotherapy administration, into CNS (eg, intrathecal), requiring and including spinal puncture 96549- Unlisted chemotherapy procedure G0498- Chemotherapy administration, intravenous infusion technique; initiation of infusion in the office/ clinic setting using office/ clinic pump/ supplies, with continuation of the infusion in the community setting (e.g., home, domiciliary, rest home or assisted living) using a portable pump provided by the office/ clinic, includes follow up office/ clinic visit at the conclusion of the infusion Many facilities report chemotherapy HCPCS 96416 when G0498 is more accurate.CMS instructs that when the infusion is initiated in a provider setting, and continued in the ?community setting?, the external infusion pump supplied for patient use is a component of the prolonged chemotherapy administration service, and the pump may not be billed as a separate DME claim to the DME MAC. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/SE1609.pdf
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PARA Weekly Update: January 31, 2018
HYDRATION, IV INFUSIONS, INJECTIONS & VACCINE CHARGE PROCESS
Under Medicare OPPS reimbursement, both the traditional prolonged chemotherapy CPTÂŽ, 96416, and G0498 are reimbursed at the same rate:
Chemotherapy Drugs-- The characteristics of chemotherapy drugs are described by both CPTÂŽ and CMS as ?non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of non-cancer diagnoses (e.g., cyclophosphamide for auto-immune conditions) or to substances such as monoclonal antibody agents, and other biologic response modifiers.?Most payors regard the J9000-J9999 range of drugs to be chemotherapy drugs. In addition, infliximab, rituximab, alemtuzumab, gemtuzumab, and trastuzumab are deemed by Medicare to be chemotherapy drugs. Drugs commonly considered to fall under the category of hormonal antineoplastics include leuprolide acetate and goserelin acetate. While chemotherapy drugs typically include the J9000-J9999 code set, many MACs and other payors will cover the following drugs as eligible for the chemotherapy administration code set: J0640- Leucovorin calcium, per 50 mg J0641- Levoleucovorin calcium, 05mg J1745- Injection infliximab, 10 mg Q3025- Injection, interferon beta-1a, 11 mcg for intramuscular use J2353- Octreotide, Depot Form for Intramuscular Injection 1 mg (Sandostatin LAR Depot)
A lengthy excerpt from the Medicare Claims Processing Manual regarding chemotherapy is provided at the end of this paper. Chemotherapy providers are advised to check Local Coverage Determinations published by the regional MAC for specific guidance on particular drugs.For instance, Noridian, the MAC for many Western states, provides the following guidance in its Local Coverage Article A52935 titled ?Chemotherapy Administration? (which is expected to be updated or retired 6/ 30/ 2016): 19
PARA Weekly Update: January 31, 2018
HYDRATION, IV INFUSIONS, INJECTIONS & VACCINE CHARGE PROCESS
?Medicare considers the use of the CHEMOTHERAPY administration codes to appropriately describe the parenteral administration of the following drugs ONLY: -
C9131 Injection, ado-trastuzumab emtansine, 1mg C9295 Injection, carfilzomib, 1mg J1745 Injection, infliximab, 10mg Q2017 Injection, teniposide, 50mg Q2049 Injection, doxorubicin hydrochloride, liposomal, imported Lipodox, 10mg Q2050 Injection, Doxorubicin hydrochloride, liposomal, not otherwise specified, 10mg Any non-GnRH drug/ compound listed in the current HCPCS section ?CHEMOTHERAPY DRUGS J9000-J9999?
?When GnRH and analogs (including but not limited to J9217) are used in the treatment of cancer, the drugs may be billed only with CPTÂŽ 96402 - CHEMOTHERAPY administration, subcutaneous or intramuscular; hormonal anti-neoplastic.? Direct supervision by a qualified healthcare professional and advanced practice training is typically required under state law for nursing staff providing the administration of chemotherapy drugs.A quote from AMA CPTÂŽ : ?See codes 96401 ? 96549 for the administration of chemotherapy or other highly complex drug or highly complex biologic agent services.These highly complex services require advanced practice training and competency for Staff who provide these services; special consideration for the preparation, dosage or disposal; and commonly, these services entail significant patient risk and frequent monitoring.Examples are frequent changes in the infusion rate, prolonged presence of nurse administering the solution for patient monitoring and infusion adjustments, and frequent conferring with the physician about these issues.?IV administration services leading up to the chemotherapy infusion and following the infusion,particularly hydration provided solely in support of chemotherapy treatment, have been included in the infusion code services and are not to be reported separately.? Not all drug administration which is performed in the chemotherapy department with or without another chemotherapy treatment is considered a chemotherapy service.The CMS Claims Processing Manual, Chapter 12, provides examples of non-chemotherapy administration services: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/ Downloads/clm104c12.pdf ?The administration of anti-anemia drugs and anti-emetic drugs by injection or infusion for cancer patients is not considered chemotherapy administration.?
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PARA Weekly Update: January 31, 2018
HYDRATION, IV INFUSIONS, INJECTIONS & VACCINE CHARGE PROCESS
General principles regarding chemotherapy administration coding follow: 1. Do not bill hydration when it is integral to the chemotherapy treatment. IV administration services leading up to the chemotherapy infusion and following the infusion, particularly hydration provided solely in support of chemotherapy, are not to be reported separately. 2. A subsequent non-chemotherapy infusion is reported with HCPCS code 96367 (additional sequential infusion, up to 1 hour).This code described the infusion of a second or subsequent non-chemotherapy drug after the initial drug infusion, regardless if the initial drug is chemotherapy or not. This must be a sequential infusion ? not a concurrent infusion. Sequential is defined as one after the other. Code 96367 is reported once per sequential infusion of the same non-chemotherapy substance. 3. A subsequent chemotherapy infusion which follows an initial chemotherapy infusion is reported with HCPCS code 96417 (Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/ drug), up to 1 hour (List separately in addition to code for primary procedure)). 4. A concurrent non-chemotherapy infusion is reported with HCPCS 96368. Concurrent is defined as being given at the same time. It is an add-on code and must be listed separately in addition to the code for the primary procedure. - A concurrent infusion is when multiple infusions are provided simultaneously through the same intravenous line. - Multiple substances mixed in one bag are considered to be one infusion. - The concurrent infusion code can only be billed once per day. - Code 96368 is used to report therapeutic/ diagnostic infusions only. It should not be used for chemotherapy infusions. 5. Concurrent chemotherapy-- There is no concurrent chemotherapy administration code, although some chemotherapeutic agents are given concurrently. In the usual circumstance where chemotherapy agents are mixed or given concurrently, report the unlisted chemotherapy administration code 96549, Unlisted chemotherapy procedure.The services described by sequential infusion codes require that the patient observations do not overlap.Multiple drugs given at the same session are considered to be sequential injections, rather than concurrent, and are reported with 96411 for IV push administration of additional non-chemotherapy drugs/ substances at the same session, and 96417 for IV infusion administration of additional non-chemotherapy drugs/ substances at the same session.
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PARA Weekly Update: January 31, 2018
HYDRATION, IV INFUSIONS, INJECTIONS & VACCINE CHARGE PROCESS
6. A port flush (code 96523) is reported when a patient comes into the office simply to have their port flushed with saline. This code should not be reported if any other service related to the port (i.e. lab draw or other infusion) is performed that day. 6. Time units are calculated based on how long the fluid is actually infusing into the patient. Time ends when the fluids have infused. Documentation within the medical record must substantiate start and stop times for the services billed.If the documentation does not provide a start and stop time, bill the injection code (96374 for non-chemotherapy drugs, or 96409 for chemotherapy drugs) instead. 6. Services such as the use of local anesthesia, IV start, access to indwelling IV (a subcutaneous catheter or port), a flush at the conclusion of an infusion, standard tubing, syringes and supplies are included in the payment for the drug administration service. These services should not be billed separately. 6. If the same drug is given in multiple pushes, only one unit can be billed, whether or not the drug is a chemotherapy or non-chemotherapy drug. Vaccines The codes associated with vaccine administration are as follows:
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PARA Weekly Update: January 31, 2018
HYDRATION, IV INFUSIONS, INJECTIONS & VACCINE CHARGE PROCESS
These codes are for the nursing service, the drug costs are to be attached to the product codes 90476 ? 90749:
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PARA Weekly Update: January 31, 2018
HYDRATION, IV INFUSIONS, INJECTIONS & VACCINE CHARGE PROCESS
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PARA Weekly Update: January 31, 2018
HYDRATION, IV INFUSIONS, INJECTIONS & VACCINE CHARGE PROCESS
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PARA Weekly Update: January 31, 2018
HYDRATION, IV INFUSIONS, INJECTIONS & VACCINE CHARGE PROCESS
*CMS 2013 OPPS CCI Manual excerpt regarding separate IV sites: http://www.cms.gov/Medicare/Coding/National CorrectCodInitEd/index.html?redirect =/nationalcorrectcodinited/
Excerpts from the CMS Claims Processing Manual, Chapter 12 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf 30.5 - Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions (Rev. 968. Issued: 05-26-06; Effective/ Implementation Dates: 06-26-06) A. General Codes for Chemotherapy administration and nonchemotherapy injections and infusions include the following three categories of codes in the American Medical Association?s Current Procedural Terminology (CPT® ): 1. Hydration; 2. Therapeutic, prophylactic, and diagnostic injections and infusions (excluding chemotherapy); and 3. Chemotherapy administration.
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HYDRATION, IV INFUSIONS, INJECTIONS & VACCINE CHARGE PROCESS
Physician work related to hydration, injection, and infusion services involves the affirmation of the treatment plan and the supervision (pursuant to incident to requirements) of nonphysician clinical staff. B. Hydration The hydration codes are used to report a hydration IV infusion which consists of a pre-packaged fluid and / or electrolytes (e.g. normal saline, D5-1/ 2 normal saline +30 mg EqKC1/ liter) but are not used to report infusion of drugs or other substances. C. Therapeutic, prophylactic, and diagnostic injections and infusions (excluding chemotherapy) A therapeutic, prophylactic, or diagnostic IV infusion or injection, other than hydration, is for the administration of substances/ drugs. The fluid used to administer the drug (s) is incidental hydration and is not separately payable. If performed to facilitate the infusion or injection or hydration, the following services and items are included and are not separately billable: 1. Use of local anesthesia; 2. IV start; 3. Access to indwelling IV, subcutaneous catheter or port; 4. Flush at conclusion of infusion; and 5. Standard tubing, syringes and supplies. Payment for the above is included in the payment for the chemotherapy administration or nonchemotherapy injection and infusion service. If a significant separately identifiable evaluation and management service is performed, the appropriate E & M code should be reported utilizing modifier 25 in addition to the chemotherapy administration or non-chemotherapy injection and infusion service. For an evaluation and management service provided on the same day, a different diagnosis is not required. The CPTÂŽ 2006 includes a parenthetical remark immediately following CPTÂŽ code 90772 (Therapeutic, prophylactic or diagnostic injection; (specify substance or drug); subcutaneous or intramuscular.) It states, ?Do not report 90772 for injections given without direct supervision. To report, use 99211.? This coding guideline does not apply to Medicare patients. If the RN, LPN or other auxiliary personnel furnishes the injection in the office and the physician is not present in the office to meet the supervision requirement, which is one of the requirements for coverage of an incident to service, then the injection is not covered. The physician would also not report 99211 as this would not be covered as an incident to service.
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HYDRATION, IV INFUSIONS, INJECTIONS & VACCINE CHARGE PROCESS
D. Chemotherapy Administration Chemotherapy administration codes apply to parenteral administration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of noncancer diagnoses (e.g., cyclophosphamide for auto-immune conditions) or to substances such as monoclonal antibody agents, and other biologic response modifiers. The following drugs are commonly considered to fall under the category of monoclonal antibodies: infliximab, rituximab, alemtuzumb, gemtuzumab, and trastuzumab. Drugs commonly considered to fall under the category of hormonal antineoplastics include leuprolide acetate and goserelin acetate. The drugs cited are not intended to be a complete list of drugs that may be administered using the chemotherapy administration codes. A/ B MACs (B) may provide additional guidance as to which drugs may be considered to be chemotherapy drugs under Medicare. The administration of anti-anemia drugs and anti-emetic drugs by injection or infusion for cancer patients is not considered chemotherapy administration. If performed to facilitate the chemotherapy infusion or injection, the following services and items are included and are not separately billable: 1. Use of local anesthesia; 2. IV access; 3. Access to indwelling IV, subcutaneous catheter or port; 4. Flush at conclusion of infusion; 5. Standard tubing, syringes and supplies; and 6. Preparation of chemotherapy agent(s). Payment for the above is included in the payment for the chemotherapy administration service. If a significant separately identifiable evaluation and management service is performed, the appropriate E & M code should be reported utilizing modifier 25 in addition to the chemotherapy code. For an evaluation and management service provided on the same day, a different diagnosis is not required. E. Coding Rules for Chemotherapy Administration and Nonchemotherapy Injections and Infusion Services Instruct physicians to follow the CPT® coding instructions to report chemotherapy administration and nonchemotherapy injections and infusion services with the exception listed in subsection C for CPT® code 90772. The physician should be aware of the following specific rules.When administering multiple infusions, injections or combinations, the physician should report only one ?initial? service code unless protocol requires that two separate IV sites must be used. The initial code is the code that best describes the key or primary reason for the encounter and should always be reported irrespective of the order in which the infusions or injections occur. If an injection or infusion is of a subsequent or concurrent nature, even if it is the first such service within that group of services, then a subsequent or concurrent code should be reported. For example, the first IV push given subsequent to an initial one-hour infusion is reported using a subsequent IV push code. The CPT ® includes a code for a concurrent infusion in addition to an intravenous infusion for therapy, prophylaxis or diagnosis. Allow only one concurrent infusion per patient per encounter. Do not allow 28
PARA Weekly Update: January 31, 2018
HYDRATION, IV INFUSIONS, INJECTIONS & VACCINE CHARGE PROCESS
payment for the concurrent infusion billed with modifier 59 unless it is provided during a second encounter on the same day with the patient and is documented in the medical record. For chemotherapy administration and therapeutic, prophylactic and diagnostic injections and infusions, an intravenous or intra-arterial push is defined as: 1.) an injection in which the healthcare professional is continuously present to administer the substance/ drug and observe the patient; or 2.) an infusion of 15 minutes or less. The physician may report the infusion code for ?each additional hour? only if the infusion interval is greater than 30 minutes beyond the 1 hour increment. For example if the patient receives an infusion of a single drug that lasts 1 hour and 45 minutes, the physician would report the ?initial? code up to 1 hour and the add-on code for the additional 45 minutes. Several chemotherapy administration and non-chemotherapy injection and infusion service codes have the following parenthetical descriptor included as a part of the CPT® code, ?List separately in addition to code for primary procedure.? Each of these codes has a physician fee schedule indicator of ?ZZZ? meaning this service is allowed if billed with another chemotherapy administration or nonchemotherapy injection and infusion service code. Do not interpret this parenthetical descriptor to mean that the add-on code can be billed only if it is listed with another drug administration primary code. For example, code 90761 will be ordinarily billed with code 90760. However, there may be instances when only the add-on code, 90761, is billed because an ?initial? code from another section in the drug administration codes, instead of 90760, is billed as the primary code. Pay for code 96523, ?Irrigation of implanted venous access device for drug delivery systems,? if it is the only service provided that day. If there is a visit or other chemotherapy administration or non-chemotherapy injection or infusion service provided on the same day, payment for 96523 is included in the payment for the other service. F. Chemotherapy Administration (or Nonchemotherapy Injection and Infusion) and Evaluation and Management Services Furnished on the Same DayFor services furnished on or after January 1, 2004, do not allow payment for CPT® code 99211, with or without modifier 25, if it is billed with a non-chemotherapy drug infusion code or a chemotherapy administration code. Apply this policy to code 99211 when it is billed with a diagnostic or therapeutic injection code on or after January 1, 2005. Physicians providing a chemotherapy administration service or a nonchemotherapy drug infusion service and evaluation and management services, other than CPT® code 99211, on the same day must bill in accordance with §30.6.6 using modifier 25. The A/ B MACs (B) pay for evaluation and management services provided on the same day as the chemotherapy administration services or a non-chemotherapy injection or infusion service if the evaluation and management service meets the requirements of section §30.6.6 even though the underlying codes do not have global periods. If a chemotherapy service and a significant separately identifiable evaluation and management service are provided on the same day, a different diagnosis is not required. In 2005, the Medicare physician fee schedule status database indicators for therapeutic and diagnostic injections were changed from T to A. Thus, beginning in 2005, the policy on evaluation and management services, other than 99211, that is applicable to a chemotherapy or a non-chemotherapy injection or infusion service applies equally to these codes. 29
PARA Weekly Update: January 31, 2018
ALERT: CY 2018 THERAPY CAP EXPIRATION
This article is a special alert to Rehabilitation service providers. In accordance with Section 5107 of the Deficit Reduction Act of 2005, the provisions require an exceptions process to the therapy caps for reasonable and medically necessary services. Services above the established therapy caps are identified at the claim levels using the KX modifier. This exceptions process has been previously extended though legislations steps. The provision expired as of December 31, 2017. Update status as of January 29, 2018: This alert is to let providers know that as of January 25, 2018, CMS will begin to release therapy claims being held since January 01, 2018. Beginning on January 31, 2018, CMS will begin to process the held claims based on the date of receipt, one day at a time. Simultaneously, CMS will hold all newly received therapy claims reporting the KX modifier and will implement a ?rolling hold? of 20 days. With this implementation, CMS is hoping to help minimize the number of claims requiring reprocessing and minimize the impact on beneficiaries, if the legislation should move forward and be enacted. PARA will be following this and will update clients as information is released https://www.cms.gov/Center/Provider-Type/All-Fee-For-Service-Providers-Center.html
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PARA Weekly Update: January 31, 2018
PDE UPDATE -- RAC TAB QUARTER 2 2017 OP DATA
PDE Updat e ? RAC Tab ? Qu ar t er 2 2017 OP Dat a Quarter 2 2017 Outpatient Standard Analytical File data has been received by PARA and is now being made available within the PDE. It is currently available within the RAC tab:
The data will soon be available within the Pricing Data tab as well all other areas that display Outpatient Peer Market information.Separate notices will be published within the PARA Weekly Update when the processing is completed.
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There were THREE new or revised Med Learn (MLN Matters) article released this week. All new and previous Med Learn articles can be viewed under the type ?Med Learn? in the Advisor tab of the PARA Data Editor (see example below.) To go to the full Med Learn document simply click on the screen shot or the link.
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The link to this Med Learn: MM10180
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The link to this Med Learn: MM10425
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The link to this Med Learn: MM10350
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PARA Weekly Update: January 31, 2018
There were 15 new or revised Transmittals released this week. All new and previous Transmittals can be viewed under the type Transmittals in the Advisor tab of the PARA Data Editor. To go to the full Transmittal document simply click on the screen shot or the link.
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The link to this Transmittal R2008OTN
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The link to this Transmittal R2022OTN
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The link to this Transmittal: R177SOMA
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The link to this Transmittal R2015OTN
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The link to this Transmittal: R2014OTN
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The link to this Transmittal R2013OTN
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The link to this Transmittal: R2012OTN
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The link to this Transmittal R2011OTN
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The link to this Transmittal: R2010OTN
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The link to this Transmittal R2016OTN
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The link to this Transmittal: R2017OTN
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The link to this Transmittal R2018OTN
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The link to this Transmittal: R2019OTN
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The link to this Transmittal R2021OTN
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The link to this Transmittal R239BP
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PARA Weekly Update: January 31, 2018
The PDE Editor Bulletin Board Tablet lists all articles added to the Bulletin Board
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