Ask the Contractor Teleconference
November 9,
2005
Topic: Billing Tips
Questions &
Answers
Question 1: For physical therapy re-evaluation 97002 and treatment on the same day, is it okay to use Modifier 59?
Answer 1:
Yes, the re-evaluation and treatment may
occur on the same date and it is okay to use the Modifier -59. Ensure that your
supporting documentation supports the fact that the services are
separately identifiable.
Question 2:
Can you provide a list of
all CPT, HCPCS codes that require Modifier -26 for billing.
Answer
2: Please refer to your fee schedule. The
codes that can be broken down into components will appear three times; one for
global, one with modifier -26, one with modifier TC. Also, refer to your CPT
descriptions as there are some codes that are professional components merely by
description. Example: 93000 is global, 93005 is the tracing only and 93010 is
the interpretation and report.
Question 3
: Regarding Nursing Facility
discharge codes 99315 and 99316, may the nursing discharge management
represented by these codes be performed on a day other than the actual discharge
?
Answer
3: No
Question 4:
Must the date that a nursing
facility discharge code is reported reflect the actual date of discharge?
Answer 4:
Yes
Question
5: How do I properly bill for
G0181? Do I list a “from” and “to” date?
Answer
5: Yes, you need a “from” and “to” date. The
first date your performed a service and the last date your performed the service
as you only bill CPO at the end of the month in which the services were
rendered. Care Plan Oversight (CPO) services may not be billed across the month
and should be billed as one unit of service. Item 23 should include the six
digit Medicare Provider I.D. number of the Home Health Agency or Hospice. For a
broader overview, see our educational article dated December 23,2004 @ file:///O:/medicarenhic/FY05-06/Feb/23/.
Question
6: Is it true that only
1 diagnosis will be looked at per detail line no matter how many are on the
claim form?
Answer
6: Claim
completion requirements instruct providers to reference one ICD-9 CM code per
line of service. But all diagnoses indicated in Item 21 are reviewed before the
claim is denied when necessary. The CMS instructions in Change Request 4097 to
Carriers regarding adjusting their software to accept up to eight diagnosis
codes instead of only four is not effective until October 1, 2006. ( We still
have a little bit of time to work on adjusting our system.) We will keep you
informed via our website.
Question
7: Regarding Nuclear Studies- Which
date of service is appropriate to bill when they have a study that is initiated
on one day but read and interpreted by a physician on a second day?
Answer
7: CMS' regulation does not address this issue of whether
the radiological group should utilize the date the service took place with the
patient or the date when it was completed by the radiologist, in other words,
the interpretation. As a group, you need to define one way or the
other. As a personal thought about this, it is better to use the date that
the patient was with you because at a later date, if other services are
performed, you don't want them to conflict and potentially hit CCI edit.
Question
8: Concerning Item 19 and
Physical Therapy services: I know that the patient doesn't have to see the
physician every 30 days; however, can they see the physician every 30 days and
if not, where do they get a plan of care from, do they have to fax it to the
doctor or how do they get that plan of care that everybody is talking about?
Answer
8:
If the
doctor is requiring the visit every 30 days to recertify the plan of care, then
his requirements do supersede Medicare's instructions. So you have to go
along with his requirements and the plan of care should contain, at
minimum, the diagnoses, long term treatment goals and type, amount duration and
frequency of therapy services .
Question
9: So, if for example, they
want to see the patients every 60 days, what do we do? We have that
documentation on file. How do I apply that documentation?
Answer
9: It is
not required that the doctor actually see the patient for your re-certification;
however, you must have a re-certification signed-off every 30 days
.
Question 10:
What is a re-certification?
Is that a prescription or a form? Where do I get the form, what do I do,
how do I provide the form?
Answer
10:
Recertification is the physician's/NPPs approval of the plan of care. You can
use any form as there is no specified format. The plan should contain at minimum
the diagnoses, long term treatment goals and type, amount duration and frequency
of therapy services .
Ensure that you receive a dated signature on the plan of
care every 30 days and that it is retained in the patient's file and available
upon request.
Question
11: Can they sign the
Evaluation, re-evaluation as the certification that is stipulating what
the treatment is for, the doctor's name and he signs off ?
Answer
11: Yes, as long as he signs and dates it and
it contains the required information.
Question
12: We are having trouble
with co-managed cataract surgery getting paid for the post-op care. We
take care of the co-management for 30 days, and, the optometrist takes over for
the remaining 60 days. Our claims are getting denied as duplicates because of
the same CPT code used for the surgery.
Answer 12:
Both of you should be using the Modifiers 54 and 55 to
indicate the co-management. The surgeon uses Modifier 54, and you will use
Modifier 55 for the post-op management. You will also need to include in Item 19
the date that you assumed care for the post-operative period. The surgeon
would need to indicate when they relinquished care for the post-op period.
Question
13: Then why are we still get
denied as duplicate claims?
Answer
13: Are
you sure that the other provider has not been paid and perhaps they forgot to
use the Modifier and were paid for the entire service? Because if they did not
bill correctly and they are paid for the entire service, then you would get a
duplicate.
Question 14:
Then, I do not need to apply the
Modifier 59?
Answer
14: No. You do not need Modifier 59. The only
Modifiers you should use for co-management of your cataract surgery are
Modifiers -54 and -55.
Question 15:
Can I bill them on the same claim
form?
Answer
15: Yes, and in Item 19 you must include the
dates that you saw the patients. Refer to our Surgery Billing Guide on our
website for a complete overview.
Question
16: Please clarify something
that was mentioned at the beginning of the seminar where Medicare is a Secondary
Payer. What did you say about
Answer
16: If Medicare is the primary insurance
company, then the word “NONE” should be indicated in Item 11. If Medicare is the
Secondary Insurance, then Items 11 a, b ,c should be completed with the primary
insurance company information as well as Items 4, 6 and 7 on the claim form.
Question
17: And what about
Answer
17:
Question 18:
Regarding the primary and secondary
procedures by a Urologist. The secondary procedure 52332 is not in the CCI
edit for the primary 52310 but they are paying on the secondary and not the
primary because the primary is bundled with the secondary, but not the other way
around?
Answer
18: Are you checking the mutually exclusive
codes as well? There's a column1 and a column 2 table and there's also the table
for mutually exclusive codes.
Question
19: I don't see that in the
CCI edit . Once again the primary code is 52310 and the secondary code is 52332
Answer
19: Per research of the mutually exclusive
table, procedure code 52332 is considered the major procedure and 52310 is
bundled into it .
Question 20:
When a patient is self referred,
what number should we enter in
Answer
20:
You can enter your physicians name and UPIN number and you should use the
patient requested Confirmatory Consultation Codes (99271- 99275) .
(Note:
For 2006 the Confirmatory Consultation Codes are deleted)
Question
21: How do we bill a CPT
77427?
Answer
21: Was your
question about the fractions crossing over into the next month or the next year?
We have a very extensive article out on the website. Click on our
Medicarenhic.com and under the educational articles, there is a one reference
sheet that has everything on it that you're asking about specifically.
Question
22: We have that
information/documentation but we are having problems with the claims processors
understanding that standard.
Answer 22
: Did you exercise your appeals rights and
what happened from there?
Question 23:
We were going to appeal it, but we
don't understand why they don't understand the guidelines because we should be
able to go to the website and find it also .
Answer
23: One of the things we continue to do is to
provide feedback to our claims examiners. Radiation therapy treatment is
something that is very confusing to them. We do provide feedback
continuously so that they are aware of what it means. If you do have
problems with basic claim processing, please let us know so that we can provide
that additional education to our claims examiners. You can call Customer
Service and they will provide that feedback to our claims area.
Another
area that we do have problems is hyperfractionation. Those areas are very
confusing to the public as well as to our claims examiners processing the
claims. Please continue to provide feedback to us so that we can make those
educational efforts.
Question
24: When we have two different
ICD-9 codes and only one line item, there will be a reference to both items 1
and 2, and on the next line item it is only referencing to diagnosis #2. Is it
proper to list “1,2” on one line item?
Answer
24: No it is not. You can only reference one ICD-9 per line
of service. The system is only going to pick up the first diagnosis indicator
you listed. If the code has a policy and we need to review for medical
necessity, we will go back and look at all the ICD-9 codes submitted in Item 21.
Question
25: So you don't look at “1,2” per
line item. You only look at the first one.
Answer 25:
Yes, that's all the system will pick up in
processing. However, if we need additional information to determine if
your service is payable, we will look at the other ICD-9 codes submitted in Item
21.
Question 26:
We just had an ALJ hearing for that
particular issue and the judge said he was going to send it back to have it
re-evaluated. Does that mean someone is going to look at that “1,2”
that was not processed in the beginning?
Answer 26:
Yes, but only for that particular
claim.
Question
27: I'm still confused about
Physical Therapy and Item 19. It is still unclear whether to put the
recertification date or not.
Answer 27:
Item 19 on the CMS 1500 form or the
electronic equivalent is reserved only for the last date the patient was
physically seen by the attending physician- whatever that date may be because it
is not required that they see the patients every 30 days to re-certify. You are
not to put a plan of care or a re-certification date in item 19.
Question 28:
We have not been putting our UPIN
number in
Answer
28: Item 19 requires the UPIN and the date last
seen. Currently, we are not editing that particular item on a prepayment
basis. But properly completing this
item certifies that the required physician certification/recertification is on
file and available upon request by the carrier.
Question
29: When we bill Modifier -22
electronically, we are getting paid but you are not asking for documentation to
review to see if it warrants a high level of reimbursement. Are we going
to need to appeal with the documentation?
Answer
29: Yes. If Modifier -22 comes in without
documentation to support the services, we will pay the fee schedule allowance
only. It's up to you to forward documentation to support the use of
Modifier -22.
Question
30: We will have to draft it
on paper to appeal it. Correct?
Answer
30: Yes , you will have to request an appeal in
writing with the documentation.
Question 31:
Can we initially drop these claims
on paper with the reports attached or will we be penalized for that?
Answer
31: You can send the claims to us on paper.
Question
32: We bill for a diagnostic
GI imaging procedure using a miscellaneous CPT code of 91299 as that procedure
does not have a designated CPT code. For the supporting documentation of
the sites we include the report and a fact sheet describing what the service is,
do I need to include a letter of medical necessity?
Answer
32: No, we're going to look at the report to
determine what the procedure is first of all and the Medical Necessity should be
documented by an ICD-9 code in Item 21.
Question 33:
Regarding Physical Therapy:
We're well aware that the initial certification needs to be signed by the
attending physician along with the re-certification every 30 days by the
attending physician. Do they need the signature of the attending physician
on the discharge documentation?
Answer
33: No, we do not
require the signature of the attending physician on the discharge
documentation. Make that part of your patient's file.
.
Question 34:
When the attending physician
writes a prescription for therapy, they might typically prescribe
two/three treatments a week for six weeks. When we have patients
that are unable to consistently go for six weeks, say, they come for two weeks,
something happens where they were not able to receive therapies for whatever
reason, are we constrained by the number of treatments that the attending
physician wrote on the prescription for the number of weeks, or is this
something that we work out with the attending physician?
Answer 34:
You have to work that out with the attending
physician. Anytime there is a break in the treatment or an illness, we
consider that as insignificant change and we're not looking for you to re-write
that in anyway.
Question
35: Did I hear you say that
the fee schedule will not be available on CD-Rom this year but will be available
on the website?
Answer
35: Yes. the 2006 Fee Schedule will not be on
the CD-Rom this year; but will be on the website http://www.medicarenhic.com/cal_prov/fee_sched.shtml
Question 36: When will that be available?
Answer
36: Thursday, November 10 th
Question
37: When someone comes for a
physical therapy with a prescription in hand from their doctor with low back
pain, they give the frequency number, the duration, the diagnosis, they give the
type of treatment they so choose, does that prescription itself count as a
certification of a Plan of Care or do we in fact do as we're currently doing and
send them a copy of our evaluation to have be signed and returned back to us?
Answer
37: If your system isn't broken, don't fix
it. Always stick with what works!
Question
38: What will be the impact
of the CCI for nursing home therapy homes and how can we assure that our systems
are compliant with the regulations effective January 1, 2006?
Answer 38:
The institutional therapy providers impacted by CCI
edits for the first time will include: SNF's, CORF's, OPT's, Home Health
Agencies (HHA). It appears most of the impact will be on PART A but here's a web
page you can refer to http://www.cms.hhs.gov/medlearn/cmsinit.aspfor
additional information.
2/23/06