Wednesday, November 23, 2016

Surgery Modifier code list

Modifiers Pertaining to Surgery or Services within the Global Period Modifiers assure that the carrier will give  consideration to the special circumstances that may affect payment. Omitting modifiers may result in payment denials. If a review is requested on a denied service, the appropriate modifier must be included with the review. A description of the service will not be sufficient to change the original claim decision. Use of the modifiers in this section applies to both major procedures with a 90-day postoperative period and minor procedures with a 10-day postoperative period (and/or a zero day postoperative period in the case of CPT modifiers 22 and 25.

CPT Modifier 22 – Unusual Procedural Services

When the service(s) provided is greater than that usually required for the listed procedure,  it may be identified by adding CPT modifier 22 to the usual procedure number.


CPT Modifier 24 – Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period

The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the CPT modifier 24 to the appropriate level of E/M service.



CPT Modifier 25 – Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the  Procedure or Other Service




CPT Modifier 50 – Bilateral Procedure

Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session must be identified by adding the CPT modifier 50 to the appropriate five-digit code.

Note: To prevent duplicate denials, surgical procedures billed bilaterally must be reported using the surgical code and the 50 CPT modifier billed on one detail.

CPT Modifier 51 – Multiple Procedures

When multiple procedures, other than Evaluation and Management Services, are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the CPT modifier 51 to the additional procedure or service code(s).

Note: This modifier must not be appended to designated "add-on" codes. CPT Modifier 52 – Reduced Services

Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of the CPT modifier 52 signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service.

Note: For hospital outpatient reporting of a previously scheduled procedure and/or service that is partially reduced or cancelled as a result of extenuating  circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see CPT modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use).


* Use of this modifier requires additional documentation such as an operative report and a concise statement specifying how the service differs from the usual.

* This information must be indicated in the appropriate documentation record for electronic claims or sent via FAX. It may also be attached to the  CMS-1500 claim form for paper claims.

* Failure to submit this documentation appropriately may result in services rejected as unprocessable.

CPT Modifier 53 – Discontinued Procedure

Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance must be reported by adding the CPT modifier 53 to the code reported by the physician for the discontinued procedure.

Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the  operating suite.

* For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see CPT modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use).

* Use of this modifier requires additional documentation such as a statement indicating why it was medically necessary to discontinue the procedure.

* The statement must be indicated in the appropriate documentation record for electronic claims. If paper claims are submitted, the statement must appear on an attachment to the CMS-1500 claim form.

* Failure to submit this documentation appropriately may result in services rejected as unprocessable.

CPT Modifier 54 – Surgical Care Only

When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services must be identified by adding the CPT modifier 54 to the usual procedure number. CPT Modifier 55 – Postoperative Management Only When one physician performs the postoperative management and another physician performs the surgical procedure, the postoperative component must be identified by adding the CPT modifier 55 to the usual procedure number.

Use of this modifier requires additional documentation and includes both the number of days postoperative care is provided, and the assumed or relinquished dates of the postoperative care.

* The number of postoperative days and the assumed or relinquished dates must be indicated in the appropriate documentation record for electronic claims.

1. For paper claims, the number of postoperative days must be indicated in Item 24g and the assumed or relinquished dates must be indicated in Item 19 of the CMS-1500 claim form.

2. Failure to submit this documentation appropriately may result in the services rejected as unprocessable.

* Claims for postoperative management only should also show the surgery as the procedure code and the date of the surgery as the date of service and the number of postoperative days the patient was seen.

CPT Modifier 56 – Preoperative Management Only

When one physician performs the preoperative care and evaluation and other physician performs the surgical procedure, the preoperative component must be identified by adding the CPT modifier 56 to the usual procedure number.

CPT Modifier 57 – Decision for Surgery 

An evaluation and management service that resulted in the initial decision to perform the surgery must be identified by adding the CPT modifier 57 to the appropriate level of E/M service.

CPT Modifier 58 – Staged or Related Procedure or Service by the Same Physician during the Postoperative Period

The physician may need to indicate that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure; or c) for the therapy following a diagnostic surgical procedure. This circumstance must be reported by adding the CPT modifier 58 to the staged or related procedure.

Note: This modifier is not used to report the treatment of a problem that requires a return to the operating room. See CPT modifier 78.




Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. CPT modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances.

* This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician.

* When another modifier is appropriate it should be used rather than CPT modifier 59.

CPT Modifier 62 – Two Surgeons

When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon must report his/her distinct operative work by adding the CPT modifier 62 to the single definitive procedure
code.

* Each surgeon must report the co-surgery once using the same procedure code.

* If additional procedure(s), including add-on procedure(s), are performed during the same surgical session, separate code(s) may be reported without the CPT modifier 62 added.

Note: If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the CPT modifier 80 or CPT modifier 81 added, as appropriate.



CPT Modifier 66 – Surgical Team 

Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel, and various types of complex equipment) are carried out under the "surgical team" concept.

* Such circumstances must be identified by each participating physician with the addition of the CPT modifier 66 to the basic procedure number used for reporting services.

CPT Modifier 76 – Repeat Procedure by Same Physician The physician may need to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance must be reported by adding the CPT modifier 76 to the repeated procedure/service.


CPT Modifier 77 - Repeat Procedure by Another Physician

The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This situation must be reported by adding CPT modifier 77 to the repeated procedure/service.

78 Return to the Operating Room for a Related Procedure During the Postoperative Period

The physician may need to indic te that another procedure was performed during the postoperative period of the initial rocedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it must be reported by adding the CPT modifier 78 to the related procedure.

* For repeat procedures on the same day, see CPT modifier 76.

CPT Modifier 79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period

The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance must be reported by using the CPT modifier 79. For repeat procedures on the same day, see CPT modifier 76.


CPT Modifier 80 – Assistant Surgeon

Surgical assistant services may be identified by adding the CPT modifier 80 to the usual procedure number(s).

* Additional documentation required with this modifier includes a statement that no qualified resident was available to perform the service, or a statement indicating that no exceptional medical circumstances exist, or a statement indicating the primary surgeon has an across the board policy of never involving residents in the preoperative, operative or postoperative
care of his/her patients.

1. If one of the above is not provided, the name and address of the hospital where the services were furnished must be indicated. * The statement must be submitted in the appropriate documentation record for electronic claims and on an attachment to the CMS-1500 claim form for paper claims.

2. The name and address of the hospital where services were furnished must be indicated in the appropriate documentation
record for electronic claims and in Item 32 of the CMS-1500 claim form for paper claims.

3. Failure to submit this documentation appropriately may result in services rejected as unprocessable.

CPT Modifier 81 – Minimum Assistant Surgeon

Minimum surgical assistant services are identified by adding the CPT modifier 81 to the usual procedure number.

* Additional documentation is required with this modifier and includes a statement that no qualified resident was available to perform the service, or a statement indicating that no exceptional medical circumstances exist, or a statement indicating the primary surgeon has an across the board policy of never involving residents in the preoperative, operative or postoperative care of his/her patients.

1. If one of the above is not provided, the name and address of the hospital where the services were furnished must be indicated.

* The statement must be submitted in the appropriate documentation record for electronic claims and on an attachment to the CMS-1500 claim form for paper claims.

2. The name and address of the hospital where services were furnished must be indicated in the appropriate documentation
record for electronic claims or in Item 32 of the CMS-1500 claim form for paper claims.

3. Failure to submit this documentation appropriately may result in services rejected as unprocessable.

CPT Modifier 82 Assistant Surgeon (When Qualified Resident Surgeon is not Available)

The unavailability of a qualified resident surgeon is a prerequisite for use of CPT modifier 82 appended to the usual procedure code number(s).


CPT Modifier 99 – Multiple Modifiers

Under certain circumstances, two or more modifiers may be necessary to completely delineate a service. In such situations, CPT modifier 99 must be added to the basic procedure, and other applicable modifiers must be listed as part of the description of the service.

HCPCS Modifier AS – Assistant At Surgery

Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery are identified by adding the HCPCS modifier AS to the usual procedure code number.

* Additional documentation is required with this modifier and includes a statement that no qualified resident was available to perform the service, or a statement indicating that no exceptional medical circumstances exist, or a statement indicating the primary surgeon has an across the board policy of never involving residents in the preoperative, operative or postoperative care of his/her patients.

1. If one of the above is not provided, the name and address of the hospital where the services were furnished must be indicated.


* The statement must be submitted in the appropriate documentation record for electronic claims or on an attachment to the CMS-1500 claim form for paper claims.

1. The name and address of the hospital where services were furnished must be indicated in the appropriate documentation
record for electronic claims or in Item 32 of the CMS-1500 c aim form for paper claims.

2. Failure to submit this documentation appropriately may result in services rejected as unprocessable.



Wednesday, November 16, 2016

Severity/Complexity Modifiers CH, CI , CJ , CK , CL AND CM , CN

Severity/Complexity Modifiers

For each nonpayable functional G-code, one of the modifiers listed below must be used to report the severity/complexity for that functional limitation.

Modifier                         Impairment Limitation Restriction

CH

0 percent impaired, limited or restricted

CI

At least 1 percent but less than 20 percent impaired, limited or restricted

CJ

At least 20 percent but less than 40 percent impaired, limited or restricted

CK

At least 40 percent but less than 60 percent impaired, limited or restricted

CL

At least 60 percent but less than 80 percent impaired, limited or restricted

CM

At least 80 percent but less than 100 percent impaired, limited or restricted

CN

100 percent impaired, limited or restricted


The severity modifiers reflect the beneficiary’s percentage of functional impairment as determined by the clinician furnishing the therapy services.



G. Required Reporting of Functional G-codes and Severity Modifiers

The functional G-codes and severity modifiers listed above are used in the required reporting on therapy claims at certain specified points during therapy episodes of care. Claims containing these functional G-codes must also contain another billable and separately payable (non-bundled) service. Only one functional limitation shall be reported at a given time for each related therapy plan of care (POC).


Functional reporting using the G-codes and corresponding severity modifiers is required reporting on specified therapy claims. Specifically, they are required on claims:

• At the outset of a therapy episode of care (i.e., on the claim for the date of service (DOS) of the initial therapy service);

• At least once every 10 treatment days, which corresponds with the progress reporting period;

• When an evaluative procedure, including a re-evaluative one, ( HCPCS/CPT codes 92521, 92522, 92523, 92524, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97001, 97002, 97003, 97004) is furnished and billed;

• At the time of discharge from the therapy episode of care–(i.e., on the date services related to the discharge [progress] report are furnished); and

• At the time reporting of a particular functional limitation is ended in cases where the need for further therapy is
necessary.

• At the time reporting is begun for a new or different functional limitation within the same episode of care (i.e., after the reporting of the prior functional limitation is ended)

Functional reporting is required on claims throughout the entire episode of care. When the beneficiary has reached his or her goal or progress has been maximized on the initially selected functional limitation, but the need for treatment continues, reporting is required for a second functional limitation using another set of G-codes. In these situations two or more functional limitations will be reported for a beneficiary during the therapy episode of care. Thus, reporting on more than one functional limitation may be required for some beneficiaries but not simultaneously.


When the beneficiary stops coming to therapy prior to discharge, the clinician should report the functional information on the last claim. If the clinician is unaware that the beneficiary is not returning for therapy until after the last claim is submitted, the clinician cannot report the discharge status.


When functional reporting is required on a claim for therapy services, two G-codes will generally be required.


Two exceptions exist:

1. Therapy services under more than one therapy POC-- Claims may contain more than two nonpayable functional G-codes when in cases where a beneficiary receives therapy services under multiple POCs (PT, OT, and/or SLP) from the same therapy provider.


2. One-Time Therapy Visit-- When a beneficiary is seen and future therapy services are either not medically indicated or are going to be furnished by another provider, the clinician reports on the claim for the DOS of the visit, all three G-codes in the appropriate code set (current status, goal status and discharge status), along with corresponding severity modifiers.


Each reported functional G-code must also contain the following line of service information:

• Functional severity modifier

• Therapy modifier indicating the related discipline/POC -- GP, GO or GN -- for PT, OT, and SLP services, respectively

• Date of the related therapy service

• Nominal charge, e.g., a penny, for institutional claims submitted to the A/B MACs (A). For professional claims, a zero charge is acceptable for the service line. If provider billing software requires an amount for professional claims, a nominal charge, e.g., a penny, may be included.


NOTE: The KX modifier is not required on the claim line for nonpayable G-codes, but would be required with the procedure code for medically necessary therapy services furnished once the beneficiary’s annual cap has been reached.

Saturday, November 12, 2016

Therapy payment caps and exception process

The Financial Limitation Legislation

A. Legislation on Limitations

The dollar amount of the limitations (caps) on outpatient therapy services is established by statute. The updated amount of the caps is released annually via Recurring Update Notifications and posted on the CMS Website www.cms.gov/TherapyServices, on contractor Websites, and on each beneficiary’s Medicare Summary Notice. Medicare contractors shall publish the financial limitation amount in educational articles. It is also available at 1-800-Medicare.

Section 4541(a)(2) of the Balanced Budget Act (BBA) (P.L. 105-33) of 1997, which added §1834(k)(5) to the Act, required payment under a prospective payment system (PPS) for outpatient rehabilitation services (except those furnished by or under arrangements with a hospital). Outpatient rehabilitation services include the following services:

• Physical therapy

• Speech-language pathology; and

• Occupational therapy.

Section 4541(c) of the BBA required application of financial limitations to all outpatient rehabilitation services (except those furnished by or under arrangements with a hospital). In 1999, an annual per beneficiary limit of $1,500 was applied, including all outpatient physical therapy services and speech-language pathology services. A separate limit applied to all occupational therapy services. The limits were based on incurred expenses and included applicable deductible and coinsurance.


The BBA provided that the limits be indexed by the Medicare Economic Index (MEI) each year beginning in 2002.

Since the limitations apply to outpatient services, they do not apply to skilled nursing facility (SNF) residents in a covered Part A stay, including patients occupying swing beds. Rehabilitation services are included within the global Part A per diem payment that the SNF receives under the prospective payment system (PPS) for the covered stay. Also, limitations do not apply to any therapy services covered under prospective payment systems for home health or inpatient hospitals, including critical access hospitals.

The limitation is based on therapy services the Medicare beneficiary receives, not the type of practitioner who provides the service. Physical therapists, speech-language pathologists, and occupational therapists, as well as physicians and certain nonphysician practitioners, could render a therapy service.


B. Moratoria and Exceptions for Therapy Claims

Since the creation of therapy caps, Congress has enacted several moratoria. The Deficit Reduction Act of 2005 directed CMS to develop exceptions to therapy caps for calendar year 2006 and the exceptions have been extended periodically. The cap exception for therapy services billed by outpatient hospitals was part of the original legislation and applies as long as caps are in effect. Exceptions to caps based on the medical necessity of the service are in effect only when Congress legislates the exceptions.


Application of Financial Limitations


(Additions, deletions or changes to the therapy code list are updated via a Recurring Update Notification)

Financial limitations on outpatient therapy services, as described above, began for therapy services rendered on or after on January 1, 2006. References and polices relevant to the exceptions process in this chapter apply only when exceptions to therapy caps are in effect. For dates of service before October 1, 2012, limits apply to outpatient Part B therapy services furnished in all settings except outpatient hospitals, including hospital emergency departments. These excluded hospital services are reported on types of bill 12x or 13x, or 85x. Effective for dates of service on or after October 1, 2012, the limits also apply to outpatient Part B therapy services furnished in outpatient hospitals other than CAHs and hospitals in Maryland. During this period, only type of bill 12x claims with a CMS certification number in the CAH range, type of bill 12x and 13x claims with a CMS certification number beginning with the State code for Maryland, and type of bill 85x claims are excluded. Effective for dates of service on or after January 1, 2014, the limits also apply to CAHs. Effective for dates of service on or after January 1, 2016, the limits also apply to hospitals in Maryland.


Contractors apply the financial limitations to the MPFS amount (or the amount charged if it is smaller) for therapy services for each beneficiary.

As with any Medicare payment, beneficiaries pay the coinsurance (20 percent) and any deductible that may apply. Medicare will pay the remaining 80 percent of the limit after the deductible is met. These amounts will change each calendar year.

Medicare shall apply these financial limitations in order, according to the dates when the claims were received. When limitations apply, the Common Working File (CWF) tracks the limits. Shared system maintainers are not responsible for tracking the dollar amounts of incurred expenses of rehabilitation services for each therapy limit.

In processing claims where Medicare is the secondary payer, the shared system takes the lowest secondary payment amount from MSPPAY and sends this amount on to CWF as the amount applied to therapy limits.



 Exceptions to Therapy Caps – General

The following policies concerning exceptions to caps due to medical necessity apply only when the exceptions process is in effect. Except for the requirement to use the KX modifier, the guidance in this section concerning medical necessity applies as well to services provided before caps are reached.

Provider and supplier information concerning exceptions is in this chapter and in Pub. 100-02, Chapter 15, section 220.3. Exceptions shall be identified by a modifier on the claim and supported by documentation.


The beneficiary may qualify for use of the cap exceptions process at any time during the episode when documented medically necessary services exceed caps. All covered and medically necessary services qualify for exceptions to caps. All requests for exception are in the form of a KX modifier added to claim lines. (See subsection D. for use of the KX modifier.)

Use of the exception process does not exempt services from manual or other medical review processes as described in Pub. 100-08. Rather, atypical use of the exception process may invite contractor scrutiny, for example, when the KX modifier is applied to all services on claims that are below the therapy caps or when the KX modifier is used for all beneficiaries of a therapy provider. To substantiate the medical necessity of the therapy services, document in the medical record (see Pub. 100-02, chapter 15, sections 220.2, 220.3, and 230).

The KX modifier, described in subsection D., is added to claim lines to indicate that the clinician attests that services at and above the therapy caps are medically necessary and justification is documented in the medical record.



 Exceptions Process


An exception may be made when the patient’s condition is justified by documentation indicating that the beneficiary requires continued skilled therapy, i.e., therapy beyond the amount payable under the therapy cap, to achieve their prior functional status or maximum expected functional status within a reasonable amount of time.

No special documentation is submitted to the contractor for exceptions. The clinician is responsible for consulting guidance in the Medicare manuals and in the professional literature to determine if the beneficiary may qualify for the exception because documentation justifies medically necessary services above the caps. The clinician’s opinion is not binding on the Medicare contractor who makes the final determination concerning whether the claim is payable.

Documentation justifying the services shall be submitted in response to any Additional Documentation Request (ADR) for claims that are selected for medical review. Follow the documentation requirements in Pub. 100-02, chapter 15, section 220.3. If medical records are requested for review, clinicians may include, at their discretion, a summary that specifically addresses the justification for therapy cap exception.

In making a decision about whether to utilize the exception, clinicians shall consider, for example, whether services are appropriate to-- he patient’s condition, including the diagnosis, complexities, and severity;

The services provided, including their type, frequency, and duration;

The interaction of current active conditions and complexities that directly and significantly influence the treatment such that it causes services to exceed caps.

In addition, the following should be considered before using the exception process:

1. Exceptions for Evaluation Services

Evaluation. The CMS will except therapy evaluations from caps after the therapy caps are reached when evaluation is necessary, e.g., to determine if the current status of the beneficiary requires therapy services. For example, the following CPT codes for evaluation procedures may be appropriate:

92521, 92522, 92523, 92524, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97001, 97002, 97003, 97004.

These codes will continue to be reported as outpatient therapy procedures as listed in the Annual Therapy Update for the current year at: http://www.cms.gov/TherapyServices/05_Annual_Therapy_Update.asp#TopOfPage.


They are not diagnostic tests. Definitions of evaluations and documentation are found in Pub. 100-02, chapter 15, sections 220 and 230.

Other Services. There are a number of sources that suggest the amount of certain services that may be typical, either per service, per episode, per condition, or per discipline. For example, see the CSC - Therapy Cap Report, 3/21/2008, and CSC – Therapy Edits Tables 4/14/2008 at www.cms.hhs.gov/TherapyServices (Studies and Reports), or more recent utilization reports. Professional literature and guidelines from professional associations also provide a basis on which to estimate whether the type, frequency, and intensity of services are appropriate to an individual. Clinicians and contractors should utilize available evidence related to the patient’s condition to justify provision of medically necessary services to individual beneficiaries, especially when they exceed caps. Contractors shall not limit medically necessary services that are justified by scientific research applicable to the beneficiary. Neither contractors nor clinicians shall utilize professional literature and scientific reports to justify payment for continued services after an individual’s goals have been met earlier than is typical. Conversely, professional literature and scientific reports shall not be used as justification to deny payment to patients whose needs are greater than is typical or when the patient’s condition is not represented by the literature.


2. Exceptions for Medically Necessary Services

Clinicians may utilize the process for exception for any diagnosis or condition for which they can justify services exceeding the cap. Regardless of the diagnosis or condition, the patient must also meet other requirements for coverage.

Bill the most relevant diagnosis. As always, when billing for therapy services, the diagnosis code that best relates to the reason for the treatment shall be on the claim, unless there is a compelling reason to report another diagnosis code. For example, when a patient with diabetes is being treated with therapy for gait training due to amputation, the preferred diagnosis is abnormality of gait (which characterizes the treatment). Where it is possible in accordance with State and local laws and the contractors’ local coverage determinations, avoid using vague or general diagnoses. When a claim includes several types of services, or where the physician/NPP must supply the diagnosis, it may not be possible to use the most relevant therapy diagnosis code in the primary position. In that case, the relevant diagnosis code should, if possible, be on the claim in another position.


Codes representing the medical condition that caused the treatment are used when there is no code representing the treatment. Complicating conditions are preferably used in non-primary positions on the claim and are billed in the primary position only in the rare circumstance that there is no more relevant code.

The condition or complexity that caused treatment to exceed caps must be related to the therapy goals and must either be the condition that is being treated or a complexity that directly and significantly impacts the rate of recovery of the condition being treated such that it is appropriate to exceed the caps. Documentation for an exception should indicate how the complexity (or combination of complexities) directly and significantly affects treatment for a therapy condition.

If the contractor has determined that certain codes do not characterize patients who require medically necessary services, providers/suppliers may not use those codes, but must utilize a billable diagnosis code allowed by their contractor to describe the patient’s condition. Contractors shall not apply therapy caps to services based on the patient’s condition, but only on the medical necessity of the service for the condition. If a service would be payable before the cap is reached and is still medically necessary after the cap is reached, that service is excepted.


Contact your contractor for interpretation if you are not sure that a service is applicable for exception.

It is very important to recognize that most conditions would not ordinarily result in services exceeding the cap. Use the KX modifier only in cases where the condition of the individual patient is such that services are APPROPRIATELY provided in an episode that exceeds the cap. Routine use of the KX modifier for all patients with these conditions will likely show up on data analysis as aberrant and invite inquiry. Be sure that documentation is sufficiently detailed to support the use of the modifier.

In justifying exceptions for therapy caps, clinicians and contractors should not only consider the medical diagnoses and medical complications that might directly and significantly influence the amount of treatment required. Other variables (such as the availability of a caregiver at home) that affect appropriate treatment shall also be considered. Factors that influence the need for treatment should be supportable by published research, clinical guidelines from professional sources, and/or clinical or common sense. See Pub. 100-02, chapter 15, section 220.3 for information related to documentation of the evaluation, and section 220.2 on medical necessity for some factors that complicate treatment.


NOTE: The patient’s lack of access to outpatient hospital therapy services alone, when outpatient hospital therapy services are excluded from the limitation, does not justify excepted services. Residents of skilled nursing facilities prevented by consolidated billing from accessing hospital services, debilitated patients for whom transportation to the hospital is a physical hardship, or lack of therapy services at hospitals in the beneficiary’s county may or may not qualify as justification for continued services above the caps. The patient’s condition and complexities might justify extended services, but their location does not. For dates of service on or after October 1, 2012, therapy services furnished in an outpatient hospital are not excluded from the limitation.






By appending the KX modifier, the provider is attesting that the services billed:

Are reasonable and necessary services that require the skills of a therapist; (See Pub. 100-02, chapter 15, section 220.2); and Are justified by appropriate documentation in the medical record, (See Pub. 100-02, chapter 15, section 220.3); and
Qualify for an exception using the automatic process exception.


If this attestation is determined to be inaccurate, the provider/supplier is subject to sanctions resulting from providing inaccurate information on a claim.

When the KX modifier is appended to a therapy HCPCS code, the contractor will override the CWF system reject for services that exceed the caps and pay the claim if it is otherwise payable.

Providers and suppliers shall continue to append correct coding initiative (CCI) HCPCS modifiers under current instructions.

If a claim is submitted without KX modifiers and the cap is exceeded, those services will be denied. In cases where appending the KX modifier would have been appropriate, contractors may reopen and/or adjust the claim, if it is brought to their attention.

Services billed after the cap has been exceeded which are not eligible for exceptions may be billed for the purpose of obtaining a denial using condition code 21.




Therapy Cap Manual Review Threshold

Beginning calendar year 2012, there shall be two total therapy service thresholds of $3700 per year: one annual threshold each for

(1) Occupational therapy services.

(2) Physical therapy services and speech-language pathology services combined.

Services shall accrue annually toward the thresholds beginning with claims with dates of service on and after January 1, 2012. The thresholds shall apply to both services showing the KX modifier and those without the modifier. Contractors shall apply the thresholds to claims exceeding it by suspending the claim for manual review.

Summary

The Balanced Budget Act of 1997 applies annual financial limitations for outpatient therapy services for Medicare Part B. These limitations are also referred to as “therapy caps.” The therapy caps are updated each year based on the Medicare economic index.

Providers of outpatient therapy services are required to submit the KX modifier on their therapy claims, when an exception to the cap is requested for medically necessary services. Section 202 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) extended the therapy cap exceptions process through December 31, 2017. As a reminder, excessive use of the KX modifier including routine use of the modifier prior to reaching the cap limits may indicate abusive billing.
Change request 9865 establishes that outpatient therapy caps for 2017 will be $1980 for physical therapy and speech-language therapy combined, and for occupational therapy.

Wednesday, November 9, 2016

Critical Access Hospital modifiers AK, GF, SB, AH and AE

Payment to the CAH for each outpatient visit (reassigned billing) will be the sum of the following:

• For facility services, not including physician or other practitioner services, payment will be based on 101 percent of the reasonable costs of the services. List the facility service(s) rendered to outpatients using the appropriate revenue code. The A/B MAC will pay 101 percent of the reasonable costs for the outpatient services less applicable Part B deductible and coinsurance amounts, plus:

• Show the professional services separately, along with the appropriate HCPCS code (physician or other practitioner) in one of the following revenue codes - 096X, 097X, or 098X.

The A/B MAC (A) uses the Medicare Physician Fee Schedule (MPFS) amounts to pay for all the physician/nonphysician practitioner services rendered in a CAH that elected the optional method. Payment is based on the lesser of the actual charge or the facility-specific MPFS amount less deductible and coinsurance times 1.15; and

•AK - Service rendered in a CAH by a non-participating physician

For a non-participating physician service, a CAH must place modifier AK on the claim. Payment is based on the lesser of the actual charge or a reduced fee schedule amount of 95 percent. Payment is calculated as follows:

• [(facility-specific MPFS amount times the non-participating physician reduction (0.95) minus (deductible and coinsurance] times 1.15.

•GF - Services rendered by a nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA)

GF - Services rendered in a CAH by a nurse practitioner (NP), clinical nurse specialist (CNS), certified registered nurse (CRN) or physician assistant (PA). (The “GF” modifier is not to be used for CRNA services. If a claim is received and it has the “GF” modifier for certified registered nurse anesthetist (CRNA) services, the claim is returned to the provider.) Also, while this national “GF” modifier includes CRNs, there is no benefit under Medicare law that authorizes payment to CRNs for their services. Accordingly, if a claim is received and it has the “GF” modifier for CRN services, no Medicare payment should be made.

Services billed with the “GF” modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 85 percent. Payment is calculated as follows:

• [(facility-specific MPFS amount times the nonphysician practitioner services reduction (0.85) minus (deductible and coinsurance)] times 1.15.

•SB - Services rendered in a CAH by a certified nurse-midwife

For dates of service prior to January 1, 2011, certified nurse-midwife services billed with the “SB” modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 65 percent. Payment is calculated as follows:
For dates of service on or after January 1, 2011, Medicare covers the services of a certified nurse-midwife. The “SB” modifier is used to bill for the services and payment is based on the lesser of the actual charge or 100 percent of the MPFS. MPFS Payment is calculated as follows:

• [(facility-specific MPFS amount) minus (deductible and coinsurance)] times 1.15.

• AH - Services rendered in a CAH by a clinical psychologist

Payment for the services of a clinical psychologist is based on the lesser of the actual charge or 100 percent of the MPFS. Payment is calculated as follows:

• [(facility-specific MPFS amount) minus (deductible and coinsurance)] times 1.15.

• AE - Services rendered in a CAH by a nutrition professional/registered dietitian.

Services billed with the “AE” modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 85 percent. Payment is calculated as follows:

• [(facility-specific MPFS amount times the registered dietitian reduction (0.85) minus (deductible and coinsurance)] times 1.15.

Outpatient services, including ASC type services, rendered in an all-inclusive rate provider should be billed using the 85X type of bill (TOB). Non-patient laboratory specimens are billed on TOB 14X.

MPFS rates contained in the HHH abstract file are used for payment of all physician/professional services rendered in a CAH that has elected the optional method. If a HCPCS code has a facility rate and a non-facility rate, the facility rate is paid. See Chapter 23 of Pub. 100-04, section 50.1 for the record layout for the HHH abstract file.

Tuesday, October 25, 2016

CPT code 99173, 99174 , 99183, 99199

Procedure code and Description

99173 Screening test of visual acuity, quantitative, bilateral.

99174 Instrument-based ocular screening

99199 - Unlisted special service, procedure or report


99183 – Physician attendance and supervision of hyperbaric oxygen therapy, per session.


Visual Function and Acuity Screening Services


When a preventive medicine code and a visual screening service (99172, 99173) is provided for the same patient by the same physician or other health care professional on the same date of service, the visual function and acuity screening service is eligible for separate reimbursement.

Billing Guide for 99173, 99174


Visual function screening (99172) and visual acuity screening (99173) are included in (and not separately reimbursed from) Preventive Medicine Services for members age 22 years or over. Code 99172 is included in Preventive Services for members  under age 22 years as well.

Q: Why is 99173 (screening test of visual acuity) not separately reimbursable when billed with a Preventive Medicine code?

A: Oxford considers vision screening using an eye chart to be integral to a Preventive Medicine examination in the same way that measurements of height, weight and blood pressure are integral to a Preventive Medicine examination. Therefore, vision screening using an eye chart is not reimbursed separately from  a Preventive Medicine examination.

Will vision screenings be separately allowed with Evaluation and Management (E/M) or Preventive Medicine codes?

A: No, vision CPT code 99173 (screening test of visual acuity, quantitative, bilateral) is intended to be done within the same session as an E/M or Preventive Medicine service and is not separately reimbursed, in accordance with CMS.

Covered ICD codes

 V20.2 Routine infant or child health check

* To report code 99173, you must employ graduate visual acuity stimuli that allow a quantitative estimate of visual acuity (eg, Snellen chart).

* Code 99174 is reported for instrument-based ocular screening for esotropia, exotropia, anisometropia, cataracts, ptosis, hyperopia, and myopia.

* When acuity (99173) or instrument-based ocular screening (99174) is measured as part of a general ophthalmologic service or an E/M service of the eye (eg, for an eye-related problem or symptom), it is considered part of the diagnostic examination of the office or other outpatient service code (99201–99215) and is not reported separately.

* Other identifiable services unrelated to the screening test provided at the same time are reported separately (eg, preventive medicine services).

* Failed vision screenings will most likely result in a follow-up office visit (eg, 99212–99215) linked to the diagnosis code for the reason for the failure (eg, 367.1 [myopia]); when a specific code cannot be identified, report 368.8 (other specified visual disturbance).


Definitions: 99199 - Unlisted special service, procedure or report

SH - Second concurrently administered infusion therapy

SJ - Third or more concurrently administered infusion therapy

Nursing Services

Code home IV nursing visits lasting up to two hours using CPT code 99601. Report each additional hour beyond the initial two with 99602 with the appropriate number of units.

When provided in the infusion suite of a home infusion agency, code  each nursing visit lasting up to two hours using CPT code 99199, with a narrative description. Report each additional hour beyond the initial two with 99199-52 with the appropriate number of units, in accordance with the NHIA (National Home Infusion Association) recommendations for billing


A health care provider may not require prepayment for communication concerning return to work planning, but may bill a reasonable fee for communication with any party to the claim except the employee. The health care provider may charge an insurer for communication for return to work planning using code 99199 on an itemized bill. The fee is not subject to a fee reduction. Counseling the employee about return to work is considered part of an office visit charge.

Supplementary Reports

The employer, insurer, employee, or department may request information about the nature and extent of an injury without using the HCPR or RWA. A written response to requests for information not required on the HCPR or RWA from the health care provider is considered a supplementary report. A health care provider is not required to respond to a request for  supplementary information nor is there a time limit for a response. The health care provider may charge a reasonable fee for
providing supplementary information. The charge for the supplementary report is listed using CPT code 99199 on an itemized bill and is not subject to a fee reduction



General Guide for Procedure 99183

1. CPT Code 99183 describes the physician work (presence and supervision) involved in this service. Documentation should support this.

2. Use CPT-4 code 99183 to describe both the initial and the subsequent treatments.

3. If the therapy is continued for more than two months, documentation of medical necessity must accompany the claim and it will be reviewed on a case-by-case basis.

4. CPT code 99183 applies to Non-Outpatient Prospective Payment System (Non-OPPS) providers only.

5. HPPS code C1300 applies to Part A OPPS providers only.

6. Claims for HBO of the treatment of diabetic wounds of the lower extremity require documentation of dual diagnoses. An ICD-9-CM code from either the 250.70-250.73 range or the 250.80-250.83 range (representing a diabetes-related problem) plus one of the following ICD-9-CM codes: 707.10, 707.11, 707.12, 707.13, 707.14, 707.15, or 707.19 (representing a lower extremity wound) must be reported. Claims for diabetic wounds without dual diagnoses do not meet utilization guidelines described in this coding and billing document and will be considered medically unnecessary and will be denied.

7. Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

8. Title XVIII of the Social Security Act, section 1862(a)(1)(A) only allows coverage and payment for those services that are considered to be medically reasonable and necessary.

Thus, chest x-rays, routine laboratory tests, routing EKGs, routine specialty consultations, other screening tests, or other testing driven by protocol are not covered.

9. Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

A provider noted the LCD has HCPCS code C1300, which is a Part A code, but is missing CPT code 99183, for Part B use.

Response:

The list of CPT codes has been corrected to include CPT code 99183.

CPT/HCPCS Codes

C1300 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval

99183 Physician attendance and supervision of hyperbaric oxygen therapy, per session CPT code 99183 is included in this policy


Comments:

A biller asked for clarification on whether a Physician Assistant or Nurse Practitioner can supervise patients for Hyperbaric Oxygen Therapy under the direction of their  supervising hyperbaric physician. The PA or NP will have met all requirements expected of the physician with documented dive experience.

Response:

No, the CPT 2010 Code Book defines this service (CPT 99183) as "Physician attendance and supervision of hyperbaric oxygen therapy, per session." This is distinct from most CPT codes since they do not use the term "physician" in their definitions. This restrictive definition of this service precludes a physician assistant or nurse practitioner from performing this service.

Medicare Payments

Medicare allowed charges of approximately $76 million dollars ($47 million paid) for HBO2 in 1998 for 15,687 beneficiaries. Outpatient reimbursement was $35 million for 6,734 beneficiaries, physicians received $18 million for 7,282 beneficiaries, approximately  $19 million was associated with a hospital stay for 8,916 beneficiaries, and nearly $5 million was allowed as part of a skilled nursing facility stay for 1,408 beneficiaries.5 HBO2 treatments generally involve a facility charge and often a charge by a physician for supervision. Procedure code 99183 is billed for physician supervision and revenue center 413 includes facility charges for HBO2. Facility reimbursement is typically included as part of the prospective payment’s diagnosis related group (DRG) payment if provided during an inpatient hospital stay or cost-based if provided by an outpatient department. Physician reimbursement is based on a fee schedule and was approximately $140 in 1998. In contrast, cost-based outpatient reimbursement varies considerably from hospital to hospital.

Cost-based reimbursement is currently being replaced with a prospective payment system for these services.

Medicare Payment Data

We identified all Medicare beneficiaries with hyperbaric treatments paid by Medicare between 1995 and 1998. Identification of a hyperbaric procedure was based on the American Medical Association’s (AMA) CPT code 99183 (hyperbaric oxygen treatment) or facility revenue center code 413 (hyperbaric). We then extracted all payments maintained in HCFA’s National Claims History (NCH), whether paid by a carrier (physician claims) or an intermediary (hospital inpatient, hospital outpatient, or skilled nursing facility claims). This data was then utilized in sample selection, provider profiling, and trending (among states and over years).

Some Providers did not provide sufficient documentation to justify Medicare

reimbursement

Billing errors and inadequate documentation account for 9 percent of beneficiaries treated with HBO2. In most cases, sufficient documentation was simply not provided. An on-site review at one of the hospitals failing to provide records resulted in recoupment action and a referral for a fraud investigation. While treatments may have been provided, the facility was unable to provide the intermediary with adequate documentation (e.g., treatment logs) in nearly all of the cases requested. In addition to documentation problems, three charts in the sample were counted as inappropriate because they billed Medicare for topical hyperbaric oxygen therapy - a procedure explicitly excluded in the reimbursement guidelines. Five charts used the 99183 code or the revenue center 413 for related  procedures other than HBO2 (e.g., basic wound care). Medical records for three charts showed that the beneficiary for whom claims were received was never treated with hyperbarics. The remainder of this group (12 charts) provided documentation, but it was not sufficient to complete the reviews.

HCPCS Coding for OIVIT


HCPCS code G9147, effective with the April IOCE and MPFSDB updates, is to be used on claims with dates of service on and after December 23, 2009, billing for non-covered OIVIT and any services comprising an OIVIT regimen.

NOTE: HCPCS codes 99199 or 94681(with or without diabetes related conditions 250.00-250.93) are not to be used on claims billing for non-covered OIVIT and any services comprising an OIVIT regimen when furnished pursuant to an OIVIT regimen. Claims billing for HCPCS codes 99199 and 94681 for non-covered OIVIT are to be returned to provider/returned as unprocessable.



 Medicare Summary Notices (MSN), Reason Codes, and Remark Codes


Contractors shall return non-covered OIVIT claims billed with HCPCS 99199 to provider/return as unprocessable.

The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.

Group Code: CO
CARC: 16
RARC: MA66, N56
MSN: N/A

Contractors shall return non-covered OIVIT claims billed with HCPCS 94681 with or without diabetes-related conditions 250-00-250.93 to provider/return as unprocessable.

The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.

Group Code: CO
CARC: 16
RARC: MA66, N56
MSN: N/A

Contractors shall deny claims for non-covered OIVIT and any services comprising an OIVIT regimen billed with HCPCS code G9147.

The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.

Group Code: CO
CARC: 96
RARC: N386
MSN: 16.10

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