Wednesday, September 28, 2016

Anesthesia Claims Modifiers


Physicians report the appropriate anesthesia modifier to denote whether the service was personally performed, medically directed, or medically supervised.

Specific anesthesia modifiers include:

AA - Anesthesia Services performed personally by the anesthesiologist;
AD - Medical Supervision by a physician; more than 4 concurrent anesthesia procedures;
G8 - Monitored anesthesia care (MAC) for deep complex complicated, or markedly invasive surgical procedures;
G9 - Monitored anesthesia care for patient who has a history of severe cardio-pulmonary condition;
QK - Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals;
QS - Monitored anesthesia care service;
QX - CRNA service; with medical direction by a physician;
QY - Medical direction of one certified registered nurse anesthetist by an anesthesiologist;
QZ - CRNA service: without medical direction by a physician; and
GC - these services have been performed by a resident under the direction of a teaching physician.

The GC modifier is reported by the teaching physician to indicate he/she rendered the service in compliance with the teaching physician requirements in §100.1.2. One of the payment modifiers must be used in conjunction with the GC modifier.

The QS modifier is for informational purposes. Providers must report actual anesthesia time on the claim.

The Part B Contractor must determine payment for anesthesia in accordance with these instructions. They must be able to determine the uniform base unit that is assigned to the anesthesia code and apply the appropriate reduction where the anesthesia procedure is medically directed. They must also be able to determine the number of anesthesia time units from actual anesthesia time reported on the claim. The Part B Contractor must multiply allowable units by the anesthesia-specific conversion factor used to determine fee schedule payment for the payment area.

Saturday, September 24, 2016

How to US Modifier V5 -V9 - ESRD modifiers

Dialysis adequacy, infection and vascular access reporting 

Effective for dates of service on and after July 1, 2010, renal dialysis facilities will require new quality data reporting for:

Dialysis adequacy.

Infection.

Vascular access.

Under the PPACA providers must submit claims as follows:

Claims with DOS prior to October 1, 2009 must follow the previous timely filing guideline.

Claims with DOS October 1, 2009 – December 31, 2009 must be filed by December 31, 2010.

Claims with DOS January 1, 2010, and forward must be filed within one calendar year of the DOS.

The new data reporting will allow the CMS to implement an accurate quality incentive payment for dialysis providers by January 1, 2012, as required by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) section 153c.

ALL end stage renal disease (ESRD) claims will require on the claim level:

o  Value code D5 – result of the last Kt/V reading
o  Occurrence code 51 – date of last Kt/V reading

No Kt/V test done –provider must attest that no test was performed by reporting the value code D5 with a 9.99 value and do not report the occurrence code date on the claim

ALL ESRD claims will require on the claim level:

o   Modifier V8 OR 
o  Modifier V9 

ALL ESRD hemodialysis claims will require for vascular access ESRD hemodialysis patients under Revenue code 821:

o  Modifier V5 
o  Modifier V6 
 o Modifier V7 

For additional information please visit;
http://www.cms.gov/MLNMattersArticles/downloads/MM6782.pdf

Tuesday, September 20, 2016

Modifier G7, AA, AB and AD - Usage Guide

Providers Billing on the CMS 1500 Claim Form

Use the appropriate procedure/diagnosis code from the list above and the most appropriate modifier from the list below:

G7 - Termination of pregnancy resulting from rape, incest, or certified by physian as life-threatening.

Providers Billing on the UB-04 Claim Form

Use the appropriate procedure/diagnosis code from those listed previously and the most appropriate condition code from the list below:

AA Abortion Due to Rape
AB Abortion Due to Incest
AD Abortion Due to Life Endangerment


In addition to the required coding, all claims must be submitted with the required documentation. Claims submitted for induced abortion-related services submitted
without the required documentation will be denied.

Induced Abortions to Save the Life of the Mother

Every reasonable effort to preserve the lives of the mother and unborn child must be made before performing an induced abortion. The services must be performed
in a licensed health care facility by a licensed practitioner, unless, in the judgment of the attending practitioner, a transfer to a licensed health care facility endangers the life of the pregnant woman and there is no licensed health care facility within a 30 mile radius of the place where the medical services are performed.


“To save the life of the mother” means:

The presence of a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, as determined by the attending practitioner, which represents a serious and substantial threat to the life of the pregnant woman if the pregnancy is allowed to
continue to term.

The presence of a psychiatric condition which represents a serious and substantial threat to the life of the pregnant woman if the pregnancy continues to term.
All claims for services related to induced abortions to save the life of the mother must be submitted with the following documentation:

** Name, address, and age of the pregnant woman
** Gestational age of the unborn child
** Description of the medical condition which necessitated the performance of the abortion
** Description of services performed
** Name of the facility in which services were performed
** Date services were rendered

And, at least one of the following forms with additional supporting documentation that confirms life-endangering circumstances:

** Hospital admission summary
** Hospital discharge summary
** Consultant findings and reports
** Laboratory results and findings
** Office visit notes
** Hospital progress notes

Friday, September 16, 2016

Usage of JW modifers

Change in policy regarding the use of the JW modifier for discarded Part B drugs and biologicals.

Effective January 1, 2017, providers are required to:

• Use the JW modifier for claims with unused drugs or biologicals from single use vials or single use packages that are appropriately discarded (except those provided under the Competitive Acquisition Program (CAP) for Part B drugs and biologicals) and

• Document the discarded drug or biological in the patient's medical record when  submitting claims with unused Part B drugs or biologicals from single use vials or single use packages that are appropriately discarded


The current policy allows MACs the discretion to determine whether to require the JW modifier for any claims with discarded drugs or biologicals, and the specific details regarding how the discarded drug or biological information should be documented.

Be aware in order to more effectively identify and monitor billing and payment for discarded drugs and biologicals, CMS is revising this policy to require the uniform use of the JW modifier for all claims with discarded Part B drugs and biologicals

Monday, September 12, 2016

CPT CODE 98960, 98961, 98962 - Not separately payable

Avoid claim errors for current procedural terminology codes 98960, 98961 and 98962

First Coast Service Options (First Coast) has recently seen a large number of Part A outpatient claim errors for current procedural terminology (CPT®) codes 98960, 98961 and 98962. Providers are reminded that professional services paid under the Medicare physician fee schedule (MPFS) for these codes are bundled or not valid for Medicare purposes. The Centers for Medicare & Medicaid Services (CMS) published relative values units (RVU) as a courtesy, since many private payers use this methodology when establishing their payment rates.

The CPT codes 98960, 98961 and 98962 are not separately billable services, and are either bundled into another service reported on the same day or are simply not covered. Do not report these codes to Medicare, unless required for secondary insurance.

• Verify the patient’s records to ensure you are billing the correct CPT® code
• Submit the charges as non-covered when a denial is required for the secondary payer

CPT® code definitions:

• 98960 -- education & training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient

• 98961 -- 2-4 patients

• 98962 -- 5-8 patients

Most read CPT modifiers