Jurisdictions J and M Part B Ask the Contractor Teleconference Questions and Answers: August 10, 2021, Electronic Data Interchange and Claims

Published 08/30/2021

Presubmitted Questions
All questions submitted on the Palmetto GBA Ask the Contractor Teleconference Submit a Question form are held until the scheduled ACT call and answered on the call. Because the ACT call is open to all providers, questions regarding individual claim situations are not able to be addressed in this open forum.

Question: Does a Medicare Secondary Payer (MSP) questionnaire form need to be completed by the patient on every single visit? A patient could be seen three to four times a month. 

Answer: Medicare law and regulations require all entities that bill Medicare for items or services to decide whether Medicare is the primary payer for those items or services before submitting a claim to Medicare. (See Section 1862(b)(2) of the Social Security Act and regulations at 42 CFR 489.20g.) Completing the Centers for Medicare & Medicaid Services (CMS) questionnaire greatly increases the likelihood that the primary payer is billed correctly. Verifying MSP information means confirming that the information previously furnished about the presence or absence of another payer that may be primary to Medicare is correct, clear and complete, and that no changes have occurred. 

Following the initial collection, the MSP information should be verified once every 90 days or before the next billing cycle of identical services (SE12002, PDF).

Question: I am looking for diagnosis guidelines for CPT code 93880. There is not a current policy regarding diagnosis. We are continuously getting smart edits, and each claim has to be touched when there is no national or local coverage policy or coverage article that provides ICD-10 diagnosis codes.

Answer: CMS issues National Coverage Determinations (NCDs) that specify whether certain items, services, procedures or technologies are reasonable and necessary under §1862(a) (1) (A) of the Act. In the absence of an NCD, Medicare contractors are responsible for determining whether services are reasonable and necessary. If no local coverage determination (LCD) exists for a particular item or service, the MACs, CERT, Recovery Auditors and ZPICs shall consider an item or service to be reasonable and necessary if the item or service meets the following criteria:

  • It is safe and effective
  • It is not experimental or investigational
  • It is appropriate, including the duration and frequency in terms of whether the service or item is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the beneficiary's condition or to improve the function of a malformed body member
    • Furnished in a setting appropriate to the beneficiary's medical needs and condition
    • Ordered and furnished by qualified personnel
    • One that meets, but does not exceed, the beneficiary's medical need

There are several exceptions, but in the absence of an NCD or LCD a provider must maintain documentation to support the medical necessity of the service for the individual patient and make that documentation available for any review entity.

There is no Smart Edit in place for this code. The provider was contacted individually and asked to provide further clarification regarding the edit message they were receiving so it can be determined if the edit is from the provider’s billing or software company. 

Question: We have six orthopedists and one of our physician assistants received denial for CPT code 27500, closed treatment of femur fracture with remark CO170; payment denied when performed/billed by this type of provider. Why? A physician assistant is licensed to perform this service in North Carolina. Can we appeal these denials? 

Answer: Although North Carolina state law allows a physician assistant (PA) to perform the procedure, this procedure is outside of the usual training of a PA, so evidence of specific training in the procedure needs to be submitted for the individual PA. This is usually done at the appeals level, but it can be done with the original claim. Providers have 120 days to appeal a claim denial and regardless of the submission of a question to an individual department within Palmetto GBA, the provider should exercise their appeal rights within the mandated time frame even when waiting on a response to their inquiry. 

Question: We have a provider who administers dexamethasone for various indications. The order is for "dexamethasone sodium phosphate 4 mg/ml injection solution: mix 4 mg in water and have the patient drink it." The clinic staff is billing HCPCS code J8540 (oral dexamethasone, 0.25 mg) rather than HCPCS code J1100 (injection, dexamethasone sodium phosphate, 1 mg). Which J-code is correct for this situation?

Answer: Since the drug is being given orally and is intended and specifically developed for injectable purposes, we believe the correct code to be used would be the J1100 code. If denied due to an oral route or administration, you would have appeal rights at which time you could provide more documentation to support the medical necessity of the oral administration of this specific drug. You should include in the narrative portion of your claim “oral admin and the NCDs #.” The NCD number will coincide with the injectable drug being given and the J code billed.

Question: Flu season is only a few months away. I would like to have updated guidelines for billing telehealth CPT codes. 

Answer: Palmetto GBA’s Emergency and Disaster Instructions page gives details about the COVID-19 public health emergency (PHE) waivers and flexibilities and provides a link to the CMS COVID-19 web page. Additionally, the CMS MLN Matters article MM12071 (PDF), “Summary of Policies in the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List,” provides the details you are requesting. 

CMS has approved some additional services that can be provided as telehealth due to the public health emergency. There is a link to a List of Telehealth Services that can be provided during the public health emergency. The list also includes those telehealth services that are approved to be provided via audio-only technology. 

Any new or updated instructions from CMS will be included on the Palmetto GBA Emergency and Disaster Instructions web page and included in our email updates.

Question: What is the place-of-service code to be used for telehealth services, and do we need to add CPT modifier 95? 

Answer: When billing professional claims for all telehealth services with dates of services on or after March 1, 2020, and for the duration of the PHE, bill with:

  • Place of service (POS) equal to what it would have been had the service been furnished in-person
  • CPT Modifier 95, indicating that the service rendered was performed via telehealth

Question: Is it acceptable to use CPT modifier 95/telehealth CPT code for audio-only, or just the audio-visual service? 

Answer: During the PHE, CMS has instructed providers to use the CPT modifier 95 when rendering telehealth services. When billing professional claims for non-traditional telehealth services with dates of service on or after March 1, 2020, and for the duration of the PHE, bill with the POS equal to what it would have been in the absence of a PHE, along with a CPT modifier 95, indicating that the service rendered was actually performed via telehealth. If the service is on the List of Telehealth Services (including those services approved during the PHE to be rendered by audio-only communication), providers should bill using the instructions above. 

Question: With the retirement of the NCD for FDG PET infection and inflammation, is this now reimbursed for those patients with painful and possibly infected prostheses, fever of unknown origin, inflammatory conditions such as sarcoidosis? 

Answer: National Coverage Determination 220.6.16 was retired, and CMS noted the following: 

Indications and Limitations of Coverage: Effective January 1, 2021, CMS determined that no national coverage determination was appropriate at the time for the FDG PET for inflammation and infection. In the absence of an NCD, coverage determinations are made by the Medicare administrative contractors. At this time, Palmetto GBA does not have a local coverage determination for that service. Therefore, as we previously indicated, coverage is based on the medical necessity of the service for the individual patient. Providers should maintain documentation in the medical record and make it available for review if requested. 

Question: In a non-provider-based billing clinic, where the nursing staff are performing blood draws for POC labs that the clinic will be processing on site, and billing on the Urgent Care claim, is it appropriate to charge the venipuncture along with the lab charge?

Answer: Yes, as long as the nursing staff are not employees of a provider-based billing clinic.  And as with the physician’s personal professional services, the patient’s financial liability for the “incident to” services or supplies are to the physician (or other legal entity) billing and receiving payment for the services or supplies. Therefore, the “incident to” services or supplies must represent an expense incurred by the either the physician or the legal entity billing for the services or supplies. Medicare Benefit Policy Manual (cms.gov) 100-2, Chapter 15 (PDF), section 60 and subsequent incident to sections.

Question: If a patient is being treated by an Advanced Practice Provider (APP) but they need to have medical nutrition therapy (MNT) services ordered, what should the provider do? MNT cannot be ordered by an APP, but it is the AAP who is "treating" the patient. Can a supervising M.D. order the MNT for the APP? 

Answer: The CMS Preventive Service tool for Medical Nutrition Therapy (MNT) states, “a referral from their treating physician” is required. An APP would not be able to refer the patient for Medicare-covered MNT services. If the APP is performing a service that was performed and billed as “incident to,” the following apply: 

  • In part, to qualify as "incident to," the service must be part of a patient's normal course of treatment during which a physician personally performed the initial service and remains actively involved in the course of treatment. The treating physician would then be the M.D. who performed the initial service and referred the patient for the MNT services. 

In the Social Security Act §1861 (ssa.gov) 1861 (r)(1), the term “physician,” when used in connection with the performance of any function or action, means a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the state in which he performs such function or action (including a physician within the meaning of section 1101(a)(7)).

References

Open Question and Answer Period

Question: I know if the requirements for CPT code 99221 (initial hospital) are not met, CMS has instructed that providers may use the subsequent hospital visit code 99223. Does that same principle apply for observation coding? Meaning, if the documentation doesn't support CPT code 99218 initial observation state, can we down code those CPT code 99225 subsequent observation stay?

Answer: CMS has not indicated that the same rule for hospital inpatient admissions is extended to observation services. It would not be appropriate for Palmetto GBA to provide guidance that may mistakenly be applied when we do not know the specifics of an individual patient situation. The individual patient documentation would need to meet the requirements for any of the observation (CPT codes 99218–99220 when the observation care is for less than eight hours on the same calendar day) and we just don’t know the specifics to be able to answer this. The provider would need to determine if the requirements for any of the applicable observation codes were met and documented before billing the service. In addition to the specific CPT code requirements for any service billed, you would need to review the CMS Internet Only Manual, Chapter 12 (PDF), Sections 30.68, 30.69 and subsequent sections and apply those guidelines to your specific patient situation and documentation. 

Question: Can we bill TCM as the primary care doctor during the global period for a surgical service provided by another provider? Our provider would not be providing surgical follow-up but would be addressing all of the other problems the patient has. 

Answer (post-call note): Physicians that are billing services with global periods of 010 and 090 days may not bill Transitional Care Management (TCM) services. If another physician, not part of the group that rendered the surgical procedure (10–90 global days), meets all of the TCM criteria and is not duplicating any of the postoperative care that should be provided by the surgeon as part of the global period, TCM services may be billed. It would be expected that documentation would support that the TCM services were not duplicative of the required surgical postoperative care that is the responsibility of the surgeon. 

Question: If a patient is inpatient because of COVID-19, we are putting CS HCPCS modifier on our E/M claims. Exactly what does that do that prevents the patient from receiving a bill?

Answer: On March 18, 2020, The Families First Coronavirus Response Act was signed into law. Section 102, “Waiving Cost Sharing Under the Medicare Program for Certain Visits Relating to Testing for COVID-19,” requires Medicare Part B to cover beneficiary cost-sharing for provider visits during which a COVID-19 diagnostic test is administered or ordered. If the inpatient visit was not a visit to determine the need for a COVID test or if a COVID test was not performed, the CS HCPCS modifier should not be appended and cost-sharing (deductible and coinsurance) should not be waived. 

Closing Remarks 

We encourage providers to use the Palmetto GBA interactive voice response system (IVR) and the eServices portal for claim status, eligibility, submission of simple claim re-openings, and your first level of appeal. Remember, when you submit your first level of appeal through eServices, you are also able to track that appeal. 

Palmetto GBA also has a very large set of tools that were created to help the provider community. We have heard from providers that they appreciate tools that allow them to locate things and perform tasks themselves. We certainly try to create those tools for that purpose. Please explore all that are currently available. 

We have an interactive voice response (IVR) call flow chart that will give you the steps to accessing information using the IVR system. The IVR Conversion Tool helps you convert those alpha numeric MBI and PTAN numbers for entry into the IVR. 

References

When calling the provider call center, we recommend that you have all necessary information at hand. You will need your tax ID, NPI, PTAN and, if you are asking about a patient, you will need their first name, last name, Medicare beneficiary identifier, date of birth, and sex. We often must wait for providers to gather that information once connected to a customer service representative (CSR). Waiting for a provider to gather the necessary information ties up the CSRs from assisting other providers. 

Palmetto GBA will be hosting the 2021 Virtual MACtoberfest on October 19–21, 2021. Mark your calendar and watch for notification of session topics and how to register.

Make sure your provider enrollment information is up to date in the provider enrollment chain and ownership system (PECOS). The Comprehensive Error Rate Testing (CERT) contractor and/or Palmetto GBA often need to contact a provider for documentation and often are unable to reach the provider to obtain what is needed because phone numbers are invalid or only a main hospital phone number is listed for an individual provider. 

If you have received a request from the Comprehensive Error Rate Testing review contractor, you will have received a bar coded cover letter with that request. Be sure to respond timely with complete, legible and authenticated documentation to support every service on the claim being reviewed. The cover letter should be included in your submission of records. 

If you would like to add a point of contact specifically for CERT reviews, you can call the CERT review contractor (888–779–7477) and add a point of contact to be used for an individual request that you are responding to. You can get more information on how to do that on our website under our CERT page. 

Palmetto GBA is participating in two “improving beneficiary care deficits” innovation initiatives: annual depressing screening and intensive behavioral therapy for cardiovascular disease. A teleconference is typically held monthly for these initiatives. Our goal is to help providers understand when these preventive services are covered and to help them recognize that this is perhaps missed revenue and patient care opportunities. These services are Medicare-covered preventive services. Some providers find reviewing their office structure allows them to identify opportunities to identify patients eligible for these preventive services and when appropriate, que your provider that the patient is eligible for the service. 

Please be sure you have signed up for Palmetto GBA Email Updates. This is the fastest way for you to receive important information from Palmetto GBA. 

References

The next Ask the Contractor Teleconference is scheduled for November 9, 2021.


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