DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services

Medicare Quarterly Provider Compliance Newsletter Guidance to Address Billing Errors

Updated Provider Index Now Available! See the Introduction section for more details Volume 3, Issue 4 - July 2013

ICN 908787/ July 2013 Table of Contents Comprehensive Error Rate Testing (CERT): Home Health Certification...... 1

CERT Finding: Glucose Monitoring Supplies...... 3

CERT Finding: Inpatient Psychiatric Facility Prospective Payment System (PPS)...... 5

Recovery Auditor Finding: Infusion Pump Denied/Accessories & Drug Codes Should Be Denied...... 7

Recovery Auditor Finding: Overutilization of Nebulizer Medications..... 8

Recovery Auditor Finding: Post-Acute Transfer - Underpayments...... 10

Recovery Auditor Finding: Co-Surgery Not Billed with Modifier 62..... 11

Recovery Auditor Finding: Pre-admission Diagnostic Testing Review...... 13

Recovery Auditor Finding: Duplicate Claims...... 15

Recovery Auditor Finding: Add-on HCPCS/CPT Codes Without Primary Codes...... 17

Recovery Auditor Finding: Dose versus Units Billed - Bevacizumab (HCPCS J9035) and Rituximab (HCPCS J9310)...... 19

Recovery Auditor Finding: Mohs Surgery Pathology Billed by Separate Provider...... 21

Recovery Auditor Finding: Cataract Removal, Part B Number of Units Incorrectly Billed...... 23

Recovery Auditor Finding: Pulmonary Procedures and Evaluation & Management Services...... 25

Archive of Previously-Issued Newsletters

This educational tool was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This educational tool was prepared as a service to the public and is not intended to grant rights or impose obligations. This educational tool may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. The Medicare Learning Network® (MLN), a registered trademark of CMS, is the brand name for official CMS educational products and information for Medicare Fee-For- Service Providers. For additional information, visit the MLN’s web page at http://go.cms.gov/MLNGenInfo on the CMS website. Your feedback is important to us and we use your suggestions to help us improve our educational products, services and activities and to develop products, services and activities that better meet your educational needs. To evaluate Medicare Learning Network® (MLN) products, services and activities you have participated in, received, or downloaded, please go to http://go.cms.gov/MLNProducts and click on the link called ‘MLN Opinion Page’ in the left-hand menu and follow the instructions. Please send your suggestions related to MLN product topics or formats to [email protected]. CPT only copyright 2012 American Medical Association. All rights reserved. ICD-9-CM Notice: The International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) is published by the United States Government. A CD-ROM, which may be purchased through the Government Printing Office, is the only official Federal government version of the ICD-9-CM. ICD-9-CM is an official Health Insurance Portability and Accountability Act standard. Introduction

The Medicare Fee-For-Service (FFS) program contains a number of payment systems, with a network of contractors that processes more than one billion claims each year, submitted by more than one million providers, including hospitals, physicians, Skilled Nursing Facilities, clinical laboratories, ambulance companies, and suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). These contractors, called “Medicare claims processing contractors,” process claims, make payments to health care providers in accordance with Medicare regulations, and educate providers on how to submit accurately coded claims that meet Medicare guidelines. Despite actions to prevent improper payments, such as pre-payment system edits and limited medical record reviews by the claims processing contractors, it is impossible to prevent all improper payments due to the large volume of claims.

The Centers for Medicare & Medicaid Services (CMS) issues the “Medicare Quarterly Provider Compliance Newsletter,” a Medicare Learning Network® (MLN) educational product, to help providers understand the major findings identified by Medicare Administrative Contractors (MACs), Recovery Auditors, Program Safeguard Contractors, Zone Program Integrity Contractors, the Comprehensive Error Rate Testing (CERT) review contractor and other governmental organizations, such as the Office of Inspector General. This is the fourth issue in the third year of the newsletter.

This issue includes 11 findings identified by Recovery Auditors and three items related to CERT findings. This educational tool is designed to help FFS providers, suppliers, and their billing staffs understand their claims submission problems and how to avoid certain billing errors and other improper activities when dealing with the Medicare FFS program. An archive of previously-issued newsletters is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNProducts/downloads//MedQtrlyCompNL_Archive.pdf on the CMS website.

This newsletter describes the problems, the issues that may occur as a result, the steps CMS has taken to make providers aware of the problems, and guidance on what providers need to do to avoid the issues. In addition, the newsletter refers providers to other documents for more detailed information wherever that may exist.

The findings addressed in this newsletter are listed in the Table of Contents and can be navigated to directly by “left-clicking” on the particular issue in the Table of Contents. A searchable index of keywords and phrases contained in both current and previous newsletters is available at http://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNProducts/downloads//MedQtrlyCompNL_ Index.pdf on the CMS website. In addition, a newly-enhanced index is now available that provides a listing of all Recovery Auditor and CERT Review Contractor findings from previous newsletters. The index is customized by specific provider types to help providers quickly find and learn about common billing and claim review issues that impact them directly. For more information, visit the newsletter archive at http:// www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNProducts/Downloads/MedQtrlyCompNL_Archive.pdf on the CMS website.

Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 III Comprehensive Error Rate Testing (CERT): Home Health Certification

Provider Types Affected: Home Health Providers, Physicians, and Non-Physician Practitioners

Background: The CERT Most insufficient documentation Examples of HH PPS Improper program’s reviews of Home Health errors for HH PPS result from claims Payments: Prospective Payment System (HH in which the clinical findings from PPS) claims have identified many the face-to-face encounter, details 1. This example shows that the improper payments. about these findings supporting the physician provided only a list of beneficiary’s homebound status, diagnoses. Requirements for Home Health or the need for skilled services are Mrs. Jones had a face-to-face Prospective Payment System: missing or inadequately documented. encounter with a physician for the As a condition for payment, the Some of the records reviewed purpose of certifying the beneficiary’s Affordable Care Act mandates that, contain very little clinical information eligibility for home health benefit. prior to certifying a beneficiary’s beyond simple lists of diagnoses, The face-to-face encounter record is eligibility for the home health recent injuries, or procedures. quoted below: benefit, the certifying physician Often, the need for skilled nursing is must document that he or she or an justified with only a diagnosis, such “The encounter with the patient was allowed non-physician practitioner as chronic obstructive pulmonary in whole, or in part, for the following (NPP) had a face-to-face encounter disease, osteoarthritis, or fracture of medical conditions, which is the with the beneficiary. The regulation the humerus. In some records, the primary reason for home health governing the face-to-face encounter beneficiary’s homebound status is care: osteoarthritis, dementia, requires the documentation to documented only by a notation such idiopathic scoliosis, osteoporosis, gait include “…an explanation of as “gait abnormality” or “taxing effort.” abnormality.” why the clinical findings of such encounter support that the patient As described in the regulation (i.e., No other clinical information was is homebound and in need of either 42 CFR 424.22(a)(1)(v)), such submitted. In order for the home intermittent skilled nursing services information is not sufficient; the face- health benefit to be covered by or therapy services.…” 1 to-face encounter documentation Medicare, documentation of the must explain why the findings from beneficiary’s face-to-face encounter Improper Payments by Type the encounter support the medical must include an explanation of of Error: The majority of HH necessity of the services ordered why the clinical findings of such PPS improper payments are due and the beneficiary’s homebound encounter support that the patient to insufficient documentation status. Also, the "Medicare Benefit is homebound and in need of either errors. Insufficient documentation Policy Manual" states that the intermittent skilled nursing services errors occur when the medical documentation must include a brief or therapy services. The claim was documentation submitted is narrative that “describes how the scored as an improper payment due inadequate to support payment for patient’s clinical condition as seen to an insufficient documentation error the services billed or when a specific during that encounter supports the because the certifying provider did documentation element that is patient’s homebound status and need not explain why the findings from the required as a condition of payment for skilled services.” 2 encounter supported the medical is missing. Examples of specific necessity of the services ordered or documentation elements include the the beneficiary’s homebound status. physician signature on an order, or a The use of general phrases such as form that is required to be completed “unable to leave home” and “leaving in its entirety. the home requires a considerable and taxing effort” are not sufficient to meet this requirement.

142 CFR 424.22(a)(1)(v) 2CMS Pub. 100-2, Ch.7, Section 30.5.1.1

1 Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 2. This example shows that the Medicare-Learning-Network- documentation lacked details MLN/MLNMattersArticles/ to support the beneficiary’s downloads/SE1219.pdf on the Did you know... homebound status. Centers for Medicare & Medicaid Mr. Smith’s physician completed a Services (CMS) website. face-to-face encounter form as part • 42 Code of Federal Regulations • Are you billing correctly for ordered/ (CFR) 424.22, “Requirements referred services? Will you be of the certification that Mr. Smith impacted when CMS turns on required home health benefits. The for home health services” is the edits for these services? See sentence below was the only mention available at http://www.gpo. MLN Matters® articles #SE1221, of Mr. Smith’s homebound status: gov/fdsys/pkg/CFR-2011- #SE1011, and the MLN fact sheets title42-vol3/pdf/CFR-2011- “Medicare Enrollment Guidelines “There exists a normal inability of title42-vol3-sec424-22.pdf on for Ordering/Referring Providers” patient to leave home; leaving the the Internet. and “The Basics of Medicare home requires a considerable and Enrollment for Physicians Who • The “Medicare Benefit Policy Infrequently Receive Medicare taxing effort.” Manual,” Chapter 7, Section Reimbursement” to learn what you 30.5.1.1 is available at http:// need to do. No other clinical information was www.cms.gov/Regulations- submitted. In order for the home • The Centers for Medicare & and-Guidance/Guidance/ health benefit to be covered by Medicaid Services has posted an Manuals/Downloads/ updated Medicare FFS Version Medicare, documentation of the bp102c07.pdf on the 5010 835 Health Care Claim beneficiary’s face-to-face encounter CMS website. Payment/Advice Companion must include an explanation of Guide to the Medicare FFS why the clinical findings of such Companion Guides web page. encounter support that the patient is homebound. The claim was scored as an improper payment due to an insufficient documentation error because the certifying individual did not explain why the findings from the encounter supported the beneficiary’s homebound status. The use of general phrases such as “unable to leave home” and “leaving the home requires a considerable and taxing effort” are not sufficient to meet this requirement.

Resources for Providers: • Providers who would like additional information about Medicare’s HH PPS can refer to MLN Matters® Article SE1219, “A Physician’s Guide to Medicare’s Home Health Certification, including the Face-to-Face Encounter,” available at http://www.cms. gov/Outreach-and-Education/

Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 2 Comprehensive Error Rate Testing (CERT): Glucose Monitoring Supplies

Provider Types Affected: Durable Medical Equipment (DME) Suppliers

Background: The CERT program’s necessary. Information used to • Physician’s notes showing reviews of claims for glucose justify continued medical need must periodic reviews of the monitoring supplies have consistently be timely for the date of service glucose monitoring orders yielded high improper payment under review. Suppliers must not within Medicare’s designated rates. Claims for glucose monitoring deliver refills without a refill request timeframes. supplies selected by CERT included from a beneficiary. Items delivered Other improper payments for the following items: without a valid, documented refill glucose monitoring supplies are request will be denied as not attributed to medical necessity • Current Procedural Terminology reasonable and necessary. errors. For example, improper (CPT) code A4253 (Blood payments occur because the Glucose/Reagent Strips); Suppliers must not dispense a quantity of supplies exceeding a beneficiary exceeds allowable • CPT A4256 (Normal, low and beneficiary's expected utilization. utilization limits by concurrently high calibrator solution/chips); Suppliers must stay attuned to receiving glucose monitoring • CPT A4258 (Spring-powered changed or atypical utilization supplies from multiple suppliers. device for lancet, each); and patterns on the part of their clients. Here is an example of an improper • CPT code A4259 (Lancets, per Suppliers must verify with the claim: A claim for blood glucose box of 100). ordering physicians that any changed test strips was submitted for a or atypical utilization is warranted. beneficiary who did not require Requirements for Glucose Regardless of utilization, a supplier insulin. The quantity of blood Monitoring Supplies: As a condition must not dispense more than a three glucose test strips ordered exceeded of Medicare coverage, the diabetic month quantity at a time. the utilization amounts covered by beneficiary’s medical record must Improper Payments by Type Medicare for non-insulin dependent contain sufficient documentation of of Error: Most of the improper diabetic beneficiaries. Clinical the beneficiary’s medical condition payments for glucose monitoring documentation was missing that to support the need for the type and supplies are due to insufficient supported the medical need for quantity of items ordered and for the documentation to support the glucose this quantity of blood glucose test frequency of use or replacement. monitoring supplies billed. Critical strips. In addition, no documentation Documentation must include such documentation that is often missing was submitted supporting that the elements as a physician’s order for from the submitted records included: treating physician had seen the the glucose monitoring supplies, beneficiary and evaluated diabetic evaluations demonstrating physician • The order for the glucose control within the six months prior oversight of the beneficiary, and the monitoring supplies, need for glucose monitoring supplies. stating the number of times per day the For Durable Medical Equipment, beneficiary is to test his Prosthetics, Orthotics, and Supplies or her glucose level; (DMEPOS) provided on a recurring and/or basis (i.e., refills), billing must be based on prospective, not • Physician’s notes retrospective use. In addition to showing the information that justifies the initial beneficiary’s diabetic provision of the supplies, there must condition and the need be information in the beneficiary's for glucose monitoring medical record to support that at the frequency billed; the item remains reasonable and and/or

3 Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 to ordering the blood glucose test strips. The claim was scored as an improper payment due to an “insufficient documentation error.” Resources for Providers: Did you know... Providers who would like additional information on avoiding improper The Medicare Learning Network® (MLN) recently issued payments for blood glucose self- a series of MLN Matters® Special Edition articles to provide education on OIG findings related to Recovery testing equipment and supplies for Audit issues. The articles include information about these Medicare beneficiaries can refer to issues and guidance health care professionals can use to these resources: avoid them in the future. For a complete listing of these articles and other articles designed to help health care • MLN Matters® Article SE1008 professionals understand common billing errors and avoid “Medicare Coverage of improper payments, go to http://www.cms.gov/Outreach- Blood Glucose Monitors and and-Education/Medicare-Learning-Network-MLN/ Testing Supplies,” available MLNProducts/Downloads/ProvCmpl_Articles.pdf on the CMS website. at http://www.cms.gov/ Outreach-and-Education/ Medicare-Learning-Network- MLN/MLNMattersArticles/ downloads/SE1008.pdf on the CMS website; and • Local Medicare Coverage Determinations, available at http://www.cms.gov/medicare- coverage-database/overview- and-quick-search.aspx on the CMS website.

Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 4 Comprehensive Error Rate Testing (CERT): Inpatient Psychiatric Facility Prospective Payment System (PPS)

Provider Types Affected: Hospitals

Background: The CERT program’s that the services were and continue Examples of Inpatient Psychiatric reviews of claims for inpatient to be required for treatment that Facility PPS Improper Payments psychiatric hospitalizations in could reasonably be expected to hospitals subject to the Inpatient improve the patient’s condition, or 1. Insufficient Documentation Psychiatric Facility Prospective for diagnostic study, and that the Error: A beneficiary presented Payment System (PPS) have patient continues to need daily active to the emergency department identified many improper treatment furnished directly by, or with the assistance of a mental payments. Claims for inpatient requiring the supervision of, inpatient health caseworker who had psychiatric hospitalizations psychiatric facility personnel. found him at home in bed. selected by CERT included claims The beneficiary stated that in both inpatient psychiatric Subsequent recertifications are he was depressed and had facilities and exempt psychiatric required at intervals to be determined not taken his medications for units of acute care hospitals. by the institution’s Utilization Review about a week. He had a history committee, but no less frequently of recurrent exacerbations of Requirements for Inpatient than every thirty days. a major depressive disorder, Psychiatric Facility: As a complicated by progressive condition of Medicare coverage, Improper Payments by Type of Parkinson's disease, congestive the beneficiary’s medical record Error: The majority of Inpatient heart failure (CHF), and chronic must contain physician certification Psychiatric Facility PPS improper obstructive pulmonary disease and recertification statements. In payments are due to insufficient (COPD). On presentation in addition to the standard requirements documentation errors. Insufficient the emergency department, relating to the medical necessity documentation errors occur when the his Global Assessment of of an inpatient admission, in these medical documentation submitted Functioning Scale (GAF) score institutions the admitting physician is inadequate to support payment deteriorated considerably is required to include a signed for the services billed or when a compared to his baseline statement in the beneficiary’s medical specific documentation element that GAF score. He was admitted record attesting that the admission is is required as a condition of payment as an inpatient to a Medicare appropriate. is missing. Examples of specific certified inpatient psychiatric documentation elements include the unit for reestablishment of The admission certification is physician signature on an order, or a his psychiatric medications required at the time of admission or form that is required to be completed and evaluation. In order to as soon thereafter as is reasonable in its entirety. Most insufficient be covered by Medicare, and practicable. It must state that documentation errors for Inpatient the beneficiary’s inpatient inpatient psychiatric services were Psychiatric Facility PPS result from psychiatric medical record must required: claims in which the required physician contain a physician certification. certification and recertification The claim was scored as an • For treatment that could statements are missing. Other improper payment due to an reasonably be expected to improper payments included such insufficient documentation improve the patient’s condition; errors as lack of medical necessity. error because the physician or Medical necessity errors occur when certification was missing from • For diagnostic study. adequate documentation is received the submitted documentation. to make an informed decision that If the beneficiary continues to require the services billed are not medically 2. Medically Unnecessary Service active inpatient psychiatric treatment, necessary based upon Medicare or Treatment Error: A beneficiary a physician must then recertify as coverage policies. was transferred from another of the 12th day of hospitalization hospital after treatment for

Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 5 alcohol withdrawal. On arrival, • Local Medicare Coverage the beneficiary had evidence Determinations, available at of mild withdrawal symptoms, http://www.cms.gov/medicare- and was stable. He had alcohol coverage-database/overview- dependence treatment in the and-quick-search.aspx on the past. Inpatient treatment was CMS website. not medically necessary for this episode. This claim was scored as a medically unnecessary service error because this beneficiary’s treatment could have been provided as outpatient services. Resources for Providers: • “Inpatient Psychiatric Facility PPS,” available at http://www. cms.gov/Medicare/Medicare- Fee-for-Service-Payment/ InpatientPsychFacilPPS/index. html on the CMS website; • 42 CFR 424.14, “Requirements for inpatient services of inpatient psychiatric facilities” (71 FR 37504, June 30, 2006) available at http://www.ecfr.gov/cgi- bin/text-idx?c=ecfr&tpl=/ ecfrbrowse/Title42/42cfr424_ main_02.tpl on the Internet; • “Medicare General Information, Eligibility, and Entitlement Manual,” Chapter 4, Section 10.9, “Physician Certification and Recertification of Services,” available at http:// Did you know... www.cms.gov/Regulations- The Medicare Learning Network® (MLN) has released a and-Guidance/Guidance/ new package of products designed to educate physicians Manuals/Downloads/ and other Medicare and Medicaid providers about medical ge101c04.pdf on the CMS identity theft and strategies for addressing it. These website; products include a web-based training course that is approved for Continuing Education (CE) and Continuing • “Medicare Benefit Policy Medical Education (CME) credit. For more information, visit Manual,” Chapter 2, Section the MLN Provider Compliance web page at http://www. 30.2.1, “Inpatient Psychiatric cms.gov/Outreach-and-Education/Medicare-Learning- Hospital Services,” available Network-MLN/MLNProducts/ProviderCompliance.html at http://www.cms.gov/ and click on the ‘Medicaid Program Integrity: Safeguarding Regulations-and-Guidance/ Your Medical Identity Educational Products’ link under ‘Downloads’ at the bottom of the page. Guidance/Manuals/ Downloads/bp102c02.pdf on the CMS website; and

6 Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 Recovery Audit Finding: Infusion Pump Denied/Accessories & Drug Codes Should Be Denied

Provider Types Affected: Durable Medical Equipment (DME)Suppliers

Problem Description: Medicare A4221. Per LCD 11570, supplies ✓✓The “Medicare National policy requires that when the are covered if the related pump is Coverage Determinations infusion pump claim is denied, covered. Therefore, the 3 units of Manual,” Chapter 1, Part 4, then the infusion accessories and A4221 are overpaid for September Coverage Determinations, infusion drugs are also denied. 30, 2007. Section 280.14, Infusion The Recovery Auditors conducted Pumps discusses coverage of an automated review of claims for Guidance on How Providers external infusion pumps, and infusion pumps, accessories and Can Avoid These Problems: is available at http://www. drugs. Of the claims reviewed, cms.gov/Regulations-and- a significant number of claims DME suppliers who submit claims Guidance/Guidance/Manuals/ had overpayments for billing of for infusions pumps need to know Downloads/ncd103c1_Part4. accessories and drugs associated the billing requirements for infusion pdf on the CMS website. with a denied infusion pump. accessories and drugs. You are encouraged to review the following Here are two examples of documents in the Local Coverage excess billings: Determinations section of the Medicare Coverage Database: Example 1: A 73 year-old male was denied an E0784 (Insulin external ✓✓“External Infusion Pumps” ambulatory infusion pump) on April addresses coverage indications, 5, 2007. The same patient was then limitations, and medical necessity, allowed 13 units of A4221 (supplies coding and general information. for maintenance of drug infusion Please find this document, catheter) and 30 units of K0552 updated 2/17/2013, posted by (supplies for external drug infusion your DME MAC (L11555, L2745, pump, syringe type cartridge) on L5044 or L11570), available at April 5, 2007. No paid claims exist http://www.cms.gov/medicare- for the E0784 within the same rental coverage-database/overview- month as the A4221 and K0552. and-quick-search.aspx on the Per Local Coverage Determination CMS website. (LCD) 11570, supplies are covered if the related pump is covered. ✓✓“External Infusion Pumps,” Therefore, the 13 units of A4221 policy article, effective 1/1/ 2013, and the 30 units of K0552 are discusses non-medical necessity overpaid for April 5, 2007. coverage and payment rules and coding guidelines. Please Example 2: A 63 year-old female find this document, updated was denied an E0784 (Insulin 3/15/2013, posted by your DME external ambulatory infusion pump) MAC (A20210, A47226, A19713, on September 7, 2007. The same or A19834), available at http:// patient was then allowed 3 units of www.cms.gov/medicare- A4221 (supplies for maintenance coverage-database/overview- of drug infusion catheter) on and-quick-search.aspx on the September 30, 2007. No paid CMS website. claims exist for the E0784 within the same rental month as the

Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 7 Recovery Audit Finding: Overutilization of Nebulizer Medications

Provider Types Affected: DME Suppliers

Problem Description: A table of Ipratropium Bromide, up to 0.5 mg., Guidance for Providers to the maximum units per month for administered through DME) on May Avoid Coding Errors: inhalation drugs to meet medical 21, 2012. The same patient was necessity is published in the Local then dispensed another 360 units of DME suppliers who submit claims Coverage Determination (LCD) for J7620 on June 11, 2012 and another for inhalation drugs need to know the Nebulizers. Claims billed for units that 360 units of J7620 on July 2, 2012. maximum units per month that may exceed the allowable amounts will be In total, the patient received 1080 be billed to meet medical necessity considered an overpayment. units of J7620 in three months. Per guidelines. You are encouraged to the LCD, patients are allowed 186 review the following documents in The Recovery Auditors conducted units of J7620 per one month refill the LCD section of the Medicare an automated review of claims period. Based on the number of units Coverage Database: for inhalation drugs and found a dispensed in June and July 2012, ✓“Nebulizers,” addresses significant number of claims had the excess units dispensed in May ✓ coverage indications, limitations, overpayments for billing of inhalation were not for use in the following and medical necessity, drugs in excess of the amounts two months. Therefore, 174 units accessories, inhalation drugs covered under medical necessity. of J7620 dispensed May 21, 2012 and solutions, including a table are overpaid. At the time of this The Recovery Auditors conducted representing the maximum service the policy in effect allowed for the review of claims for inhalation milligrams/month of inhalation delivery of refills no sooner than 10 drugs with the following J codes: drugs that are reasonable and days prior to the end of usage for the necessary for each nebulizer • J2545 PENTAMIDINE current product. ISETHIONATE; drug, and refill requirements. • J7605 ARFORMOTEROL; Example 2: A 60 year-old female Please find this document, was dispensed 1200 units of updated 3/15/2013, posted by • J7606 FORMOTEROL your DME MAC (L5007, L27226, FUMARATE; J7611 (Albuterol, inhalation solution, administered through L11499, or L11488), available at • J7608 ACETYLCYSTEINE; DME, concentrated form, 1 mg.) http://www.cms.gov/medicare- • J7611 ALBUTEROL; on February 14, 2012. The same coverage-database/overview- • J7612 LEVALBUTEROL; patient was dispensed 1200 units and-quick-search.aspx on the CMS website. Once at that site, • J7620 ALBUTEROL; of J7611 on March 19, 2012 and an additional 1200 units on April 20, enter the key word “nebulizers” • J7626 BUDESONIDE; 2012. In total, the patient received where requested and select • J7631 CROMOLYN SODIUM; 3600 units of J7611 in three months. the appropriate choice for • J7639 DORNASE ALFA; Per the LCD, patients are allowed Geographic Area/Region to view the applicable LCD. • J7644 IPRATROPIUM 465 units of J7611 per one month refill period. Based on the number of BROMIDE; and ✓“Nebulizers” - Policy Article - units dispensed in March and April ✓ • J7669 METAPROTERENOL Effective April 2013. Search for 2012, the excess units dispensed SULFATE. the article posted by your DME in February were not for use in the MAC (A24623, A47233, A24944, following two months. Therefore, 735 Here are two examples of A24944, or 24942), available at units of J7611 dispensed February excess billings: http://www.cms.gov/medicare- 14, 2012 are overpaid. At the time coverage-database/overview- Example 1: A 66 year-old male of this service, the policy in effect and-quick-search.aspx on the was dispensed 360 units of J7620 allowed for delivery of refills no CMS website. This document (Albuterol/Ipratropium Combination: sooner than 10 days prior to the end addresses coding information Albuterol, up to 2.5 mg., and of usage for the current product. and general information about

8 Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 documentation requirements, prescription requirements and medical record information, in addition to coverage indications, Did you know... limitations, and medical necessity, accessories, inhalation drugs and solutions, including a The Medicare Learning Network® (MLN) Product Ordering table representing the maximum System was recently upgraded to add new enhancements. You can now view an image of the product and access milligrams/month of inhalation its downloadable version, if available, before placing your drugs that are reasonable and order. To access a new or revised product available for necessary for each nebulizer order in hard copy format, go to MLN Products and click on drug, and refill requirements. “MLN Product Ordering Page” under “Related Links” at the bottom of the web page. ✓✓The “Medicare National Coverage Determinations Manual,” Chapter 1, Part 4, Coverage Determinations, Section 280.1 has a Durable Medical Equipment Reference List, and is available at http://www. cms.gov/Regulations-and- Guidance/Guidance/Manuals/ Downloads/ncd103c1_Part4. pdf on the CMS website.

Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 9 Recovery Audit Finding: Post-Acute Transfer - Underpayments

Provider Types Affected: Inpatient Hospital – Acute Care

Problem Description: The Recovery • This instruction offers ✓✓To avoid payment errors, please Auditors conducted an automated clarification as to what remind staff to code claims as review of inpatient claims with constitutes new and material transfers only if the beneficiary is qualifying Diagnosis-Related Groups evidence, as it relates to good discharged to another facility. (DRGs) that were identified with cause for reopening the claims. discharge disposition to an acute Justification for reopening these ✓✓Ensure that the discharge care inpatient facility (02), skilled claims was due to improper disposition to an acute care nursing facility (03), home health (06), payments found in the results of inpatient facility (02), skilled inpatient rehab facility (62), long-term the data analysis. nursing facility (03), home health (06), inpatient rehab facility (62), care facility (63), or psychiatric facility • Inpatient claims were identified long-term care facility (63), or (65). These inpatient claims fall under with discharge disposition to psychiatric facility (65) is correct, the Post Acute Care Transfer (PACT) an acute care inpatient facility so that you will receive correct policy and are reimbursed on per (02), skilled nursing facility (03), reimbursement. These discharge diem rate, up to full Medicare Severity home health (06), Inpatient rehab dispositions are reimbursed on Diagnosis Related Group (MS-DRG) facility (62), long-term care facility per diem rate, up to full MS-DRG code reimbursement. However, there (63), or psychiatric facility (65). is no identified claim submission from reimbursement. • These inpatient claims fall under the supposed receiving facility. the Post Acute Care Transfer ✓✓Review the full text of the Medicare Policy: Medicare allows policy and are reimbursed on Code of Federal Register, 42 its contractors to reopen claims for per diem rate, up to full MS-DRG CFR 412.4, Discharges and good cause when evidence from reimbursement. Transfers, available at http:// data analysis identifies errors or • However, there is no identified www.gpo.gov/fdsys/pkg/CFR- patterns of overutilization on the part claim submission from a 2004-title42-vol2/pdf/CFR- of a provider or supplier. This causes receiving facility. 2004-title42-vol2-sec412-4.pdf, the contractor to believe its initial which generally provides the Therefore, the inpatient claims determinations for the claims of the following: will be adjusted to receive the full provider or supplier were incorrect MS-DRG reimbursement. These as noted in the “Medicare Claims • Payment for discharges. The are underpayments in favor of the Processing Manual,” Chapter 3, hospital discharging an inpatient provider. Inpatient Hospital Billing, Sections is paid in full, . . . • Payment for transfers. Generally, 20.1.2.4, Transfers, and 40.2.4, Guidance on How Providers Inpatient Prospective Payment a hospital that transfers an Systems (IPPS) Transfers Between Can Avoid These Problems: inpatient . . . is paid a graduated per diem rate for each day of the Hospitals, available at http:// ✓Providers and their coders should ✓ patient’s stay in that hospital, not www.cms.gov/Regulations-and- review the “Medicare Claims to exceed the amount that would Guidance/Guidance/Manuals/ Processing Manual,” Chapter have been paid . . . if the patient Downloads/clm104c03.pdf on the 3, Inpatient Hospital Billing, had been discharged to another CMS website. Sections 20.1.2.4, Transfers, setting. Payment is graduated and 40.2.4, Inpatient Prospective The Code of Federal Regulations by paying twice the per diem Payment Systems (IPPS) (CFR) at 42 CFR Sections 405.980(b) amount for the first day of the Transfers Between Hospitals, and (c), and 405.986, states that stay and the per diem amount available at http://www. a contractor may reopen an initial for each subsequent day, up to cms.gov/Regulations-and- determination made on a claim the full DRG payment. (Edited for Guidance/Guidance/Manuals/ between 1 year and 4 years from the ease of reading. See full text at Downloads/clm104c03.pdf on date of the initial determination when the Web address cited above.) the CMS website. good cause exists.

10 Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 Recovery Audit Finding: Co-Surgery Not Billed with Modifier 62

Provider Types Affected: Physicians

Problem Description: The Under some circumstances, • Modifier 66: If a team of Recovery Auditors have identified the individual skills of two or surgeons (more than 2 surgeons significant payment errors because more surgeons are required to of different specialties) is required of failure to appropriately apply perform surgery on the same to perform a specific procedure, the co-surgeon modifier, used patient during the same operative each surgeon bills for the when two or more surgeons of session. This may be required procedure with a modifier “-66.” different specialties contribute because of the complex nature Field 25 of the MFSDB identifies to one operative session and of the procedure(s) and/or the certain services submitted with each separately submit claims patient’s condition. In these cases, a “-66” modifier which must to Medicare. They found many the additional physicians are not be sufficiently documented instances of improper payments acting as assistants-at-surgery. If to establish that a team was when two surgeons performed two surgeons (each in a different medically necessary. All claims surgery on the same patient, where specialty) are required to perform for team surgeons must contain one surgeon added the co-surgeon a specific procedure, each surgeon sufficient information to allow modifier 62 and the other did not. bills for the procedure with a pricing “by report.” When two different providers bill modifier 62. Co-surgery also refers the same CPT code, same patient to surgical procedures involving two If surgeons of different specialties and same date of service and one surgeons performing the parts of are each performing a different of the providers bills with modifier the procedure simultaneously, i.e., procedure (with different CPT 62, the other provider must also heart transplant. codes), neither co-surgery nor bill with modifier 62. Improper multiple surgery rules apply (even payments exist when two surgeons The following billing procedures if the procedures are performed perform surgery on the same apply when billing for a surgical through the same incision). If patient; one surgeon added the procedure or procedures that one of the surgeons performs co-surgeon modifier 62 and the required the use of two surgeons or multiple procedures, the multiple other did not. Note, however, that a team of surgeons: procedure rules apply to that modifier 62 may only be used when surgeon’s services. the co-surgeons are of different • Modifier 62: If two surgeons specialties and are working (each in a different specialty) are For co-surgeons (modifier 62), the together on the same procedure. required to perform a specific fee schedule amount applicable to procedure, each surgeon bills the payment for each co-surgeon is Medicare Policy: The “Medicare for the procedure with a modifier 62.5 percent of the global surgery Claims Processing Manual,” “-62.” Co-surgery also refers to fee schedule amount. Team surgery Chapter 12, Section 40.8, Claims surgical procedures involving (modifier 66) is paid for on a “By for Co-surgeons and Team two surgeons performing Report” basis. Surgeons, available at http:// the parts of the procedure www.cms.gov/Regulations-and- simultaneously, i.e., heart Case Examples from the Review transplant or bilateral knee Guidance/Guidance/Manuals/ EXAMPLE 1: A provider bills for Downloads/clm104c12.pdf on the replacements. Documentation of the medical necessity for CPT Code 61548, Hypophysectomy Centers for Medicare & Medicaid or excision of pituitary tumor, and Services (CMS) website, provides two surgeons is required for certain services identified in the billed with modifier 62, for a patient the following guidance: on date of service March 8, 2012. A Medicare Fee Schedule Data Base (MFSDB). different provider bills for the same service for the same patient on the same date of service because he/

11 Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 she was the co-surgeon, yet did not bill with the modifier 62. The second surgeon was overpaid for failing to properly apply modifier 62.

EXAMPLE 2: A provider bills for CPT Code 49652, Laparoscopy, Does your documentation support the Did you know... Surgical repair, ventral, umbilical, medical need for the service rendered? spigelian or epigastric hernia, and The documentation may include clinical evaluations, billed with modifier 62, for a patient physician evaluations, consultations, progress notes, on July 2, 2011. A different provider physician’s office records, hospital records, nursing home bills for the same service for the records, home health agency records, records from other same patient on the same date of healthcare professionals and test reports. It is maintained by the physician and/or provider. For more information, service because he/she was the please refer to the “Program Integrity Manual”, Pub 100- co-surgeon, yet did not bill with 08, Chapter 3, Section 3.2.3 A. modifier 62. The second surgeon was overpaid for failing to properly apply modifier 62.

In both of these examples, providers should append the appropriate modifier to the claim line when they are the co-surgeon, operating on the same beneficiary, on same date of surgery.

Guidance for Providers to Avoid Coding Errors:

✓✓You may read the “Medicare Claims Processing Manual,” Chapter 12, Section 40.8, Claims for Co-surgeons and Team Surgeons, available at http://www.cms.gov/ Regulations-and-Guidance/ Guidance/Manuals/Downloads/ clm104c12.pdf, which provides guidance on billing in cases of co-surgery.

✓✓You should review the “Global Surgery Fact Sheet,” available at http://www.cms.gov/ Outreach-and-Education/ Medicare-Learning-Network- MLN/MLNProducts/downloads/ GloballSurgery-ICN907166. pdf on the CMS website. This fact sheet describes the use of modifiers related to surgery.

Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 12 Recovery Audit Finding: Pre-admission Diagnostic Testing Review

Provider Types Affected: Inpatient Hospitals

Problem Description: The Recovery non-subsection (d) hospital) on a Wednesday, outpatient services Auditors identified pre-admission immediately preceding the provided by the hospital on Sunday, diagnostic testing services were date of admission are deemed Monday, Tuesday, or Wednesday being reimbursed in addition to related to the admission and, are included in the inpatient Part A reimbursement of the Inpatient therefore, must be billed with payment. Prospective Payment System (IPPS) the inpatient stay, unless the Hospital for services provided during services that are not diagnostic EXAMPLE 2: Outpatient claim the defined temporal window as a are unrelated to the inpatient was submitted for CPT codes source of overpayments. hospital claim (that is, the 36415 - Routine Venipuncture; preadmission services that are 80053 - Comprehensive Metabolic Medicare Policy: Diagnostic not diagnostic are clinically Panel; 83615 - Lactate (LD) (LDH) services (including clinical diagnostic distinct or independent from Enzyme; 85025 - Complete CBC w/ laboratory tests) provided to a the reason for the beneficiary’s Diff WBC; 86850 - RBC Antibody beneficiary by the admitting hospital, inpatient admission). Screen; 86900 - Blood typing ABO; or by an entity wholly owned or 86901 - Blood Typing RD (D); and operated by the admitting hospital (or Claims examples: 86923 - Compatibility Test for date of by another entity under arrangements service 3/15/2011, and patient was with the admitting hospital), within 3 EXAMPLE 1: An outpatient claim admitted to inpatient on the following days prior to and including the date was submitted for CPT codes 36415 day, 3/16/2011. . Admitting diagnostic of the beneficiary's admission are - Routine Venipuncture; 80053 - codes were 285.9 Anemia NOS and deemed to be inpatient services and Comprehensive Metabolic Panel; 162.8 Malignant Neoplasm Bronchus included in the inpatient payment, 86304 - Immunoassay, Tumor, CA or Lung NEC. unless there is no Part A Coverage. 125; 83725 - Assay of Magnesium; and 85025 - Complete CBC w/Diff Finding: When a beneficiary • The technical portion of all WBC for date of service 2/18/2011. receives outpatient hospital services, other than ambulance Patient was admitted to inpatient services during the day immediately and maintenance renal dialysis the same date of service, 2/18/2011. preceding the hospital admission, services that are not diagnostic, Admitting diagnostic codes were the outpatient hospital services are provided by the hospital (or an 183.0 Malignant Neoplasm treated as inpatient services if the entity wholly owned or operated Ovary and V58.11 Antineoplastic beneficiary has Part A coverage. by the hospital) on the date Chemotherapy and Immunotherapy. Hospitals and FIs apply this of a beneficiary’s inpatient provision only when the beneficiary admission are deemed related Finding: Diagnostic services is admitted to the hospital before to the admission and thus, must (including clinical diagnostic midnight of the day following receipt be included on the bill for the laboratory tests) provided to a of outpatient services. The day on inpatient stay. beneficiary by the admitting hospital, which the patient is formally admitted or by an entity wholly owned or • The technical portion of as an inpatient is counted as the first operated by the admitting hospital (or outpatient non-diagnostic inpatient day. When this provision by another entity under arrangements services, other than ambulance applies, services are included in with the admitting hospital), within 3 and maintenance renal dialysis the applicable PPS payment and days prior to and including the date services, provided by the not billed separately. When this of the beneficiary's admission are hospital (or an entity wholly provision applies to hospitals and deemed to be inpatient services and owned or wholly operated units excluded from the hospital included in the inpatient payment, by the hospital) on the first, PPS, services are shown on the bill unless there is no Part A coverage. second, and the third calendar and included in the Part A payment. For example, if a patient is admitted days (1 calendar day for a

13 Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 Guidance for Providers to ✓✓Critical access hospitals (CAHs) Avoid Coding Errors: are not subject to the 3-day (nor 1-day) DRG payment window. ✓Review the “Medicare Claims ✓ Did you know... Processing Manual,” Chapter 3 - ✓✓An entity is considered to be Inpatient Hospital Billing, Section “wholly owned or operated” by 40.3 - Outpatient Services the hospital if the hospital is the In order for Medicare to cover a power mobility device (PMD), the supplier Treated as Inpatient Services, sole owner or operator. A hospital need not exercise administrative must receive the written prescription available at http://www.cms.gov/ within 45 days of a face-to-face Regulations-and-Guidance/ control over a facility in order examination by the treating physician, Guidance/Manuals/Downloads/ to operate it. A hospital is or discharge from a hospital or clm104c03.pdf on the considered the sole operator nursing home, and before the PMD CMS website. of the facility if the hospital is delivered. The date of service on has exclusive responsibility for the claim must be the date the PMD device is furnished to the patient. A ✓✓This provision does not apply implementing facility policies to ambulance services and (i.e., conducting or overseeing PMD cannot be delivered based on a verbal order. If the supplier delivers maintenance renal dialysis the facilities routine operations), the item prior to receipt of a written services. Additionally, Part A regardless of whether it also has prescription, the PMD will be denied services furnished by skilled the authority to make the policies. as non-covered. nursing facilities, home health agencies, and hospices are For more details, please refer to excluded from the payment the Medicare Learning Network® fact sheet on this topic titled, window provisions. “Power Mobility Devices (PMDs): ✓ Complying with Documentation & ✓ For hospitals and units excluded Coverage Requirements.” from IPPS, this provision applies only to services furnished within one day prior to and including the date of the beneficiary’s admission. The hospitals and units that are excluded from IPPS are: psychiatric hospitals and units; inpatient rehabilitation facilities (IRF) and units; long- term care hospitals (LTCH); children’s hospitals; and cancer hospitals.

14 Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 Recovery Audit Finding: Duplicate Claims

Provider Types Affected: Outpatient Facilities

Problem Description: The Recovery 1. A provider received duplicate health care professional) Auditors conducted an automated payments of $87.45 on 4/13/12 or 77 (repeat procedure or review of claims that appear to and 5/5/12 for CPT 71020 service by another physician be duplicates. An issue may exist (Chest x-ray) with billed date of or other qualified health care when duplicate services are billed service of 3/29/12. Both claims professional) should be used and reimbursed under Medicare. were billed for same patient, to report the performance of Outpatient claims submitted by a same provider, and same date multiple diagnostic services on facility for the same service to a of service, same charge, same the same day if these were not particular individual on a specified CPT code, and same units, actually duplicate claims. date of service that was included without a modifier. The duplicate in a previously submitted claim will billing increased the subscriber’s ✓✓The following Healthcare be audited for duplicate payments. liability by $53.00. Common Procedure Coding System (HCPCS) and Current Exact duplicate data fields submitted 2. A provider received duplicate for outpatient facility claims including Procedural Terminology (CPT) payments of $64.19 on codes are involved: same member, same provider, 2/22/12 and 4/20/12 for CPT same dates of service, same types 77080 (Dual-energy X-ray of services, same place of service, ––HCPCS- A codes- Ambulance/ absorptiometry (DXA), Bone Transportation services same procedure codes, and same Density axial) with billed date of ––HCPCS- B&C codes-Enteral billed amount will be audited for service of 1/31/12. Both claims and Parenteral Therapy duplicate payments. There are were billed for the same patient, actually claims or claim lines that same provider, and same date ––HCPCS- D codes-Dental contain an item or service, or multiple of service, same charge, same Procedures instances of an item or service, CPT code, and same units, ––HCPCS-E codes- Durable for which Medicare payment may without a modifier. Medical Equipment be made. Correct coding rules ––HCPCS- G&H codes- applicable to all billers of health care Guidance for Providers to Temporary Procedures and claims encourage the appropriate Avoid Coding Errors: Professional Services & Mental use of condition codes or modifiers Health to identify claims that may appear to ✓Providers need to include the ✓ ––HCPCS codes-J Codes-Drugs be duplicates, but are in fact, not. The appropriate modifier when Administered Other Than Oral claims processing systems contain performing multiple diagnostic Method edits which identify duplicate claims services on the same day. and suspect duplicate claims. All Providers, coders, and billing ––HCPCS codes- L Codes- exact duplicate claims or claim lines staff should review the claims Orthotic Procedures are automatically denied or rejected submitted, and verify that if ––HCPCS codes-M-P Codes- (absent appropriate modifiers). subsequent claims are submitted Medical Services & Pathology/ for the same beneficiary, for Laboratory The following two scenarios the same date of service, with exemplify reasons for adjustments ––HCPCS codes-Q-R-S Codes- the same codes, but the claims the Recovery Auditors make in order Temporary Codes are verified to be different, then to align provider payments with ––HCPCS codes-V Codes-Vision appropriate modifiers be used. Medicare guidelines. Codes

✓✓Billing of modifier 76 (repeat ––CPT codes- Anesthesia-00100 procedure or service by the to 01999 same physician or other qualified

Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 15 ––CPT codes-Medicine-90281 to 99607 (excluding E/M 99201 to 99499) ––CPT codes-Path & Lab-80047 to 89356 Did you know... ––CPT codes-Radiology-70010 to 79999 ––CPT codes-Surgery-10021 to Although the final rule on the proposed ICD-10 deadline change has yet to be published, it is important to continue 69990 planning for the transition to ICD-10. The switch to the new code set will affect every aspect of how your organization Resources: provides care, but with adequate planning and preparation, you can ensure a smooth transition for your practice. Keep • Review MLN Matters® article Up to Date on ICD-10. Please visit the ICD-10 website for MM8121 about the Clarification the latest news and resources to help you prepare. of Detection of Duplicate Claims Section of the CMS Internet Only Manual, which is available at http://www.cms. gov/Outreach-and-Education/ Medicare-Learning-Network- MLN/MLNMattersArticles/ Downloads/MM8121.pdf on the CMS website. • Review the update to the “Medicare Claims Processing Manual,” Chapter 1, Section 120: “Detection of Duplicate Claims,” which is available at http://www. cms.gov/Regulations-and- Guidance/Guidance/Manuals/ downloads/clm104c01.pdf on the CMS website.

Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 16 Recovery Audit Finding: Add-on HCPCS/CPT Codes Without Primary Codes

Provider Types Affected: Outpatient Hospitals

Background: An add-on code is a Type II, or Type III, add-on code. physician of the same specialty HCPCS/CPT code that describes a 2. On the Medicare Physician Fee in his group practice is paid for service that, with one exception (see Schedule Database an add-on CPT code 99291 on the same the Exception paragraph below), is code generally has a global date of service. always performed in conjunction with surgery period of “ZZZ”. another primary service. An add-on Type II: A Type II add-on code does code is eligible for payment only if 3. In the American Medical not have a specific list of primary it is reported with an appropriate Association’s (AMA’s) CPT procedure codes. CR 7501 lists primary procedure performed by the Manual an add-on code is the Type II add-on codes without same practitioner on the same date designated by the symbol “+”. any primary procedure codes. of service. An add-on code is never The code descriptor of an add-on Claims processing contractors are eligible for payment if it is the only code generally includes phrases encouraged to develop their own procedure reported by a practitioner. such as “each additional” or “(List lists of primary procedure codes separately in addition to primary for this type of add-on codes. Like Exception: The “Medicare Claims procedure).” the Type I add-on codes, a Type II Processing Manual,” Chapter add-on code is eligible for payment 12, Section 30.6.12(I)) requires Types of Add-on Codes if an acceptable primary procedure a provider to report CPT code CMS has divided add-on codes code as determined by the claims 99292 (Critical care, evaluation into three groups to distinguish the processing contractor is also eligible and management of the critically payment policy for each group. for payment to the same practitioner ill or critically injured patient; each for the same patient on the same additional 30 minutes (List separately Type I : A Type I add-on code has date of service. in addition to code for primary a limited number of identifiable service)) without its primary code primary procedure codes. CR 7501 Type III: A Type III add-on code has CPT code 99291 (Critical care, lists the Type I add-on codes with some, but not all, specific primary evaluation and management of the their acceptable primary procedure procedure codes identified in the critically ill or critically injured patient; codes. A Type I add-on code, “CPT Manual”. CR7501 lists the Type first 30-74 minutes) if two or more with one exception, is eligible for III add-on codes with the primary physicians of the same specialty in payment if one of the listed primary procedure codes that are specifically a group practice provide critical care procedure codes is also eligible for identifiable. However, Medicare's services to the same patient on the payment to the same practitioner claims processing contractors same date of service. For the same for the same patient on the same are advised that these lists are date of service only one physician date of service. Claims processing not exclusive and there are other of the same specialty in the group contractors must adopt edits to acceptable primary procedure codes practice may report CPT code 99291 assure that Type I add-on codes are for add-on codes in this Type. Like with or without CPT code 99292, and never paid unless a listed primary the Type I add-on codes, a Type III the other physician(s) must report procedure code is also paid add-on code is eligible for payment if an acceptable primary procedure their critical care services with CPT • As indicated in "Medicare Claims code 99292. code as determined by the claims Processing Manual" (Chapter processing contractor is also eligible 12, Section 30.6.12(I)) and Identifying Add-on Codes: Add- for payment to the same practitioner on codes may be identified in three described in the “Background” for the same patient on the same ways: section of CR7501 and the date of service. “Exception” section above, CPT 1. The code is listed in Change code 99292 may be paid to a Rarely Medicare contractors may Request (CR) 7501 or physician who does not report allow, with appropriate submitted subsequent CRs as a Type I, CPT code 99291 if another documentation, either pre-pay, or on

17 Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 appeal, payment for a primary code primary procedure performed by and add-on code on two consecutive the same practitioner. An add- dates of service if the services are on code, with one exception, is appropriately related. never eligible for payment if it Did you know... is the only procedure reported Problem Description: Recovery by a practitioner. Providers are Auditors have found that some advised to use add-on codes with A Medicare overpayment is a providers are billing only the add-on a primary procedure code where payment made to a physician or codes without their respective primary appropriate. supplier that exceeds amounts codes resulting in overpayments. due and payable under Medicare Add-on codes billed without their ✓CMS will update the list of statute and regulations. Once the ✓ overpayment is determined, the primary codes are considered an add-on codes with their primary amount becomes a debt owed by the overpayment, with one exception procedure codes on an annual debtor to the Federal government. as previously explained in the basis before January 1 every Federal law requires CMS to Background Section above. year based on changes to the seek the recovery of all identified AMA’s CPT Manual. In addition overpayments. Example: A provider submitted a quarterly updates will be issued claim with CPT Code 26863 for 1 by CMS, as necessary, via a unit for date of service May 5, 2010 Change Request. without billing for the primary CPT Code 26862. Resources:

• Add-on CPT Code 26863 • Use of add-on codes as Description: Fuse/Graft part of the National Correct added joint – Arthrodesis, Coding Initiative (NCCI) is interphalangeal joint with or discussed in the "Medicare without internal fixation; with Claims Processing Manual" autograft, each additional joint. (Chapter 12, Section 30, which List separately in addition to is available at http://www. code for primary procedure. cms.gov/Regulations-and- • Primary CPT Code 26862 Guidance/Guidance/Manuals/ Description: Fusion/graft Downloads/clm104c12.pdf on of finger – Arthrodesis, the CMS website. interphalangeal joint, without • Change Request (CR) 7501 internal fixation; with autograft. (Transmittal 2636 dated January This is a parent CPT Code and 16, 2013) titled “National Correct can be reported with add-on Coding Initiative (NCCI) Add-On CPT Code 26863. Codes Replacement of Identical Letter, Dated December 19, Findings: Add-on codes billed 1996 with Subject Line, Correct without their primary codes are Coding Initiative Add-On (ZZZ) considered an overpayment. Codes – ACTION” is available Overpayment for add-on CPT Code at http://www.cms.gov/ 26863 was retracted as a billing error. Regulations-and-Guidance/ Guidance/Transmittals/ Guidance on How Providers Downloads/R2636CP.pdf on Can Avoid These Problems: the CMS website.

✓✓An add-on code, with one exception explained previously, is eligible for payment only if it is reported with an appropriate

Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 18 Recovery Audit Finding: Dose versus Units Billed - Bevacizumab (HCPCS J9035) and Rituximab (HCPCS J9310)

Provider Types Affected: Hospitals and Physicians

Problem Description: Recovery Findings: It is unlikely that a Guidance on How Providers Auditor reviews of medical records patient would receive 16,000 mg of Can Avoid These Problems identified errorsassociated with units Bevacizumab in one day, and when ✓ of a medication being administered the patient’s medical record was ✓ It is important that billing staff versus units of the medication billed. reviewed, it was noted that 160 units use the recurring (annual and It was found that improper payments should have been billed, and not quarterly) OPPS updates exist due to excessive units being 1600 units. because HCPCS codes billed for the following drugs: for drugs, biologicals, and Example 3: Rituximab Claim 1 radiopharmaceuticals can • Bevacizumab (HCPCS J9035 A provider billed HCPCS code J9310 undergo changes in their HCPCS (Injection, bevacizumab, 10 (Injection, rituximab, 100 mg) for code descriptors that are effective mg)), or C9257 (Injection, 71 units for date of service (DOS) each new Calendar Year (CY) bevacizumab, 0.25 mg), and October 27, 2009. Since HCPCS or quarter. In addition, several • Rituximab (HCPCS J9310 code J9310 has 1 unit equal to 100 temporary codes can be deleted (Injection, rituximab, 100 mg)). mg, receiving 71 units would mean and replaced with permanent that this patient received 7100 mg of HCPCS codes. Example 1: Bevacizumab Claim 1 Rituximab for that DOS. ✓ Recovery Auditors found that Findings: A patient receiving ✓ Providers are strongly a provider billed 1300 units of 7100mg of Rituximab seemed encouraged to report charges Bevacizumab (HCPCS J9035 abnormal, therefore, the patient’s for all drugs, biological and (Injection, bevacizumab, 10 mg). chart was requested. It was found radiopharmaceuticals, regardless Because 1 unit equals 10 mg, the that the patient only received 710 mg of whether the items are paid 1300 units would represent that and that an incorrect number units separately or packaged, using 13,000 mg of Bevacizumab was were billed. The correct number of the correct HCPCS codes for administered to the patient in units should have been 7.1 and not the items used. Hospitals should one day. 71. The 7.1 units was rounded up to bill for these products making certain that the reported units of Findings: It is unlikely that a 8 units. service of the reported HCPCS patient would receive 13,000 mg of Example 4: Rituximab Claim 2 Bevacizumab in one day. A review of code are consistent with the A provider billed HCPCS code J9310 quantity of a drug, biological the patient’s medical records verified (Injection, rituximab, 100 mg) for 100 that 1300 mg of Bevacizumab was or radiopharmaceutical that units for DOS April 29, 2010. Again, was actually administered to administered. Therefore, since 1 unit since HCPCS code J9310 has 1 unit equals 10 mg, the correct number the patient and billing for units equal to 100 mg, that would mean of service consistent with the of units that should have been billed that this patient received 10,000 mg was 130 units and not 1300 units. dosages contained in the long of Rituximab for that DOS. descriptors of the active HCPCS Example 2: Bevacizumab Claim 2 Findings: A patient receiving codes approved for that CY. On October 6, 2010, a provider 10,000 mg of Rituximab seemed ✓ billed HCPCS code J9035 (Injection, abnormal, and the patient’s chart ✓ Section 9343(g) of the Omnibus bevacizumab, 10 mg) for 1600 units. was requested. It was found that the Budget Reconciliation Act of Since HCPCS code J9035 has 1 unit patient only received 1000 mg and 1986, P.L. No. 99-509, requires equal to 10mg, that would mean that that an incorrect number of units hospitals to report claims for this patient received 16,000 mg of were billed. The number of units was outpatient services using HCPCS Bevacizumab in one day. adjusted down to 10 units to reflect codes. The “Medicare Claims the proper dosage amount given to Processing Manual,” Chapter the patient. 4, Section 20.4, states: “The

19 Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 definition of service units is the 46 on the Form CMS-1450) • The Office of Inspector General number of times the service or where HCPCS code reporting (OIG) Report titled “Review of procedure being reported was is required is the number of High-Dollar Payments for New performed.” times the service or procedure Mexico and Oklahoma Medicare being reported was performed. Part B Claims Processed by ✓✓Hospitals and providers are For example, the descriptor Pinnacle Business Solutions, reminded to ensure that units of for HCPCS code J9035 is Inc, for the Period January 1 drugs administered to patients “Injection, bevacizumab, 10 through December 31, 2006” are accurately reported in terms mg.” Therefore, when billing for (published April 2009), which is of the dosage specified in the full bevacizumab, HCPCS code available at http://oig.hhs.gov/ HCPCS code descriptor. That J9035, 1 unit represents 10mg oas/reports/region6/60800071. is, units should be reported in of bevacizumab. Likewise, the pdf on the Internet. multiples of the units included descriptor for HCPCS code • MLN Matters® Article in the HCPCS descriptor. If J9310 is “Injection, rituximab, 100 MM5718, which is available the description for the drug mg.” Therefore, when billing for at http://www.cms.gov/ code is 6 mg, and 6 mg of the rituximab, HCPCS code J9310, Outreach-and-Education/ drug was administered to the 1 unit represents 100mg of Medicare-Learning-Network- patient, the units billed should rituximab. Providers should verify MLN/MLNMattersArticles/ be 1. As another example, if the the milligrams given and convert downloads/MM5718.pdf on the description for the drug code is to the proper units for billing. CMS website. 50 mg, but 200 mg of the drug was administered to the patient, Resources: the units billed should be 4. • “Medicare Claims Processing Providers and hospitals should Manual,” Chapter 17 - Drugs not bill the units based on the and Biologicals, which is way the drug is packaged, stored, available at http://www. or stocked. That is, if the HCPCS cms.gov/Regulations-and- descriptor for the drug code Guidance/Guidance/Manuals/ specifies 1 mg and a 10 mg vial downloads/clm104c17.pdf on of the drug was administered to the CMS website; the patient, hospitals should bill 10 units, even though only 1 vial • MLN Matters® Article was administered. The HCPCS MM6857, which is available short descriptors are limited to 28 at at http://www.cms.gov/ characters, including spaces, so Outreach-and-Education/ short descriptors do not always Medicare-Learning-Network- capture the complete description MLN/MLNMattersArticles/ of the drug. Therefore, before downloads/MM6857.pdf on the submitting Medicare claims CMS website. for drugs and biologicals, it is • MLN Matters® Article extremely important to review the MM6323, which is available complete long descriptors for the at http://www.cms.gov/ applicable HCPCS codes. Outreach-and-Education/ Medicare-Learning-Network- ✓✓Providers should differentiate MLN/MLNMattersArticles/ between unit billing versus downloads/MM6323.pdf on the milligram billing on drugs. The CMS website. definition of service units (FL

Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 20 Recovery Audit Finding: Mohs Surgery Pathology Billed by Separate Provider

Provider Types Affected: Physicians

Problem Description: During an stage, up to 5 tissue blocks (list • 17315 – Mohs micrographic audit of the CPT codes associated separately in addition to code for technique, including removal of with Mohs Micrographic Surgery primary procedure) all gross tumor, surgical excision (MMS) across a several state region, • 17313 – Mohs micrographic of tissue specimens, mapping, auditors found instances in which the technique, including removal of color coding of specimens, preparation and/or interpretation of all gross tumor, surgical excision microscopic examination of the slides of tissue removed during of tissue specimens, mapping, specimens by the surgeon, and the procedures were performed by color coding of specimens, histopathologic preparation someone other than the surgeon, or microscopic examination of including routine stain(s) (eg, his or her employee. specimens by the surgeon, and hematoxylin and eosin, toluidine The following CPT codes were histopathologic preparation blue), each additional block after reviewed: including routine stain(s) (eg, the first 5 tissue blocks, any hematoxylin and eosin, toluidine stage (list separately in addition • 17311 – Mohs micrographic blue), of the trunk, arms, or legs; to code for primary procedure) technique, including removal of first stage, up to 5 tissue blocks Examples of Coding Errors: all gross tumor, surgical excision of tissue specimens, mapping, • 17314 – Mohs micrographic Below are two examples of errors color coding of specimens, technique, including removal of associated with MMS procedures. all gross tumor, surgical excision microscopic examination of A physician billed CPT of tissue specimens, mapping, Example 1: specimens by the surgeon, and Code 17311 (Mohs Micrographic color coding of specimens, histopathologic preparation Surgery), while on the same date of microscopic examination of including routine stain(s) (eg, service CPT Code 88305 (Surgical specimens by the surgeon, and hematoxylin and eosin, toluidine Pathology, gross and microscopic histopathologic preparation blue), head, neck, hands, examination) was also billed for the including routine stain(s) (eg, feet, genitalia, or any location preparation and interpretation of the hematoxylin and eosin, toluidine with surgery directly involving slides taken during the procedure, blue), of the trunk, arms, or legs; muscle, cartilage, bone, tendon, performed by someone other than each additional stage after the major nerves, or vessels; first the surgeon or his or her employee. stage, up to 5 tissue blocks first stage, up to 5 tissue blocks (list separately in addition to Auditor Finding: CPT Code 17311 • 17312 – Mohs micrographic code for primary procedure) was an overpaid claim. technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; each additional stage after the first

21 Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 Example 2: A physician billed CPT ✓✓Additionally, you should be notes should also contain the Code 17313 (Mohs Micrographic aware of Mohs Medicare location, number, and size of the Surgery) while on the same date of coverage limitations: 1) Only lesion(s), the number of stages service CPT Code 88305 (Surgical physicians (MD/DO) may performed, and the number of Pathology, gross and microscopic perform MMS; 2) The physician specimens per stage. examination) was also billed for performing MMS must be the preparation and interpretation specifically trained and highly ✓✓You must describe the histology of the slides during the procedure, skilled in MMS techniques and of the specimens taken in the performed by someone other than pathologic identification; and first stage. That description the surgeon or his or her employee. 3) As mentioned above, if the should include depth of invasion, surgeon performing the excision pathological pattern, cell Auditor Finding: CPT Code 17313 morphology, and, if present, was an overpaid claim. using MMS does not personally provide the histologic evaluation perineural invasion or presence Guidance on How Providers of the specimen(s), the CPT of scar tissue. For subsequent Can Avoid These Problems: codes for MMS cannot be used, stages, you may note that the rather the codes (11600-11646) pattern and morphology of ✓✓The physician performing for the standard excision of the tumor (if still seen) is as MMS serves both as surgeon malignant lesions should described for the first stage; or, and pathologist, performing be chosen. if differences are found, note the not only the excision but also changes. There is no need to the histologic evaluation of ✓✓If MMS on a single site cannot repeat the detailed description the specimens (to facilitate be completed on the same day documented for the first stage, this requirement, the surgical because the patient could not presuming that the description pathology CPT codes 88300- tolerate further surgery and would fit the tumor found on 88309 and 88331-88332 and the additional stages were subsequent stages. 88342 are bundled into the MMS completed the following day, codes, described above).  you must start with the primary Resources code (CPT code 17311) on day • You can review the entire Local ✓✓The majority of skin cancers can two. Computer edits will reject Coverage Determination (LCD) be managed by simple excision claims where a secondary code addressing MMS at http://www. or destruction techniques. The (e.g., CPT code 17312) is billed cms.gov/medicare-coverage- medical record of a patient without the primary code (e.g., database/details/lcd-details. undergoing MMS should clearly CPT code 17311) also appearing aspx?LCDId=28278&ContrI show that this procedure on same date of service, and the d=175&ver=33&ContrVer=1 was chosen because of the same claim. &CoverageSelection=Both& complexity (e.g. poorly defined ArticleType=All&PolicyType ✓Your documentation in the clinical borders, possible deep ✓ =Final&s=All&KeyWord=mo patient's medical record should invasion, prior irradiation), size hs&KeyWordLookUp=Title& support the medical necessity of or location (e.g. maximum KeyWordSearchType=And& this procedure and of the number conservation of tumor-free CptHcpcsCode=17311&typ and locations of the specimens tissue is important). Medicare e=lcd&page=results_index. taken. The operative notes and will consider reimbursement for asp&bc=gAAAABAAAAAA pathology documentation should MMS for accepted diagnoses AA%3d%3d& on the clearly show that the procedure and indications, which you must CMS website. document in the patient's medical was performed using accepted record as being appropriate MMS technique, in which for MMS and that MMS is the you acted in two integrated, most appropriate choice for the but distinct, capacities as treatment of a particular lesion. surgeon and pathologist. The

Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 22 Recovery Audit Finding: Cataract Removal, Part B Number of Units Incorrectly Billed

Provider Types Affected: Physicians and Non Physician Practitioners (NPP)

Background: Cataract removal procedure), manual or mechanical page found here http://www. can only occur once per eye for technique). Since these codes are cms.gov/Medicare/Coding/ the same date of service. This mutually exclusive of one another NationalCorrectCodInitEd/ issue identifies overpayments only one code should have been index.html on the CMS website. associated to outpatient hospital reimbursed. Per the “NCCI Policy providers billing more than one Manual,” CPT codes describing • CPT 66830 REMOVAL OF unit of cataract removal for the cataract extraction (66830-66984) SECONDARY MEMBRANOUS same eye. Additionally according are mutually exclusive of one CATARACT (OPACIFIED to the "National Correct Coding another. Only one code from this POSTERIOR LENS CAPSULE Initiative Policy Manual for Medicare CPT code range may be reported AND/OR ANTERIOR Services," Chapter 8, Section D #3, for an eye. Therefore, Medicare HYALOID) WITH CORNEO- cataract removal codes are mutually recivered payment for CPT SCLERAL SECTION, WITH exclusive of each other and can only code 66984. OR WITHOUT IRIDECTOMY be billed once for the same eye. (IRIDOCAPSULOTOMY, Example 2: For DOS 11/23/10, IRIDOCAPSULECTOMY) From the "National Correct Coding the provider billed and received Initiative Policy Manual for Medicare reimbursement for 2 units of • CPT 66840 REMOVAL OF Services", "CPT codes describing code 66984 66984 RT modifier LENS MATERIAL; ASPIRATION cataract extraction (66830-66984) (Extracapsular cataract removal TECHNIQUE, 1 OR MORE are mutually exclusive of one with insertion of intraocular lens STAGES another. Only one code from this prosthesis (1 stage procedure), • CPT 66850 REMOVAL CPT code range may be reported for manual or mechanical technique). OF LENS MATERIAL; an eye". Since cataract removal can only PHACOFRAGMENTATION occur once per eye, this would be an TECHNIQUE (MECHANICAL Problem Description: Recovery OR ULTRASONIC) (EG, Auditors discovered numerous overpayment. As a result, Medicare PHACOEMULSIFICATION), incorrect claims submissions would adjust the units down to 1 for WITH ASPIRATION related to cataract removal. The this claim line. most common cause of improper Guidance on How Providers • CPT 66852 REMOVAL OF LENS MATERIAL; PARS payments identified for these claim Can Avoid These Problems: types was incorrectly billing for PLANA APPROACH, WITH OR WITHOUT VITRECTOMY cataract removal. Cataract removal ✓✓When billing for cataract can only be billed one time per eye. surgery, care must be taken to • CPT 66920 REMOVAL Choose the code that reflects the not inadvertently bill for similar OF LENS MATERIAL; correct procedure used for removing cataract codes that have been INTRACAPSULAR the cataract. placed in the NCCI edit, and • CPT 66930 REMOVAL Example 1: For Date of Service stated to be mutually exclusive. OF LENS MATERIAL; (DOS) 10/20/09, the provider billed The applicable codes are listed INTRACAPSULAR, FOR and received reimbursement for below along with their definitions. DISLOCATED LENS code 66852 LT modifier (Removal of They can be found in the • CPT 66940 REMOVAL lens material; pars plana approach, “National Correct Coding Initiative OF LENS MATERIAL; with or without vitrectomy) and also Policy Manual for Medicare EXTRACAPSULAR (OTHER 66984 LT modifier (Extracapsular Services,” version 15.3. Chapter THAN 66840, 66850, 66852) 8, Section D, #3. This manual can cataract removal with insertion of • CPT 66982 EXTRACAPSULAR intraocular lens prosthesis (1 stage be downloaded from the National Correct coding Initiative Edits CATARACT REMOVAL WITH

23 Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 INSERTION OF INTRAOCULAR Resources: LENS PROSTHESIS • The “National Correct Coding (1-STAGE PROCEDURE), Initiative Policy Manual MANUAL OR MECHANICAL for Medicare Services” is TECHNIQUE (EG, IRRIGATION available from the “Downloads” AND ASPIRATION OR section of http://www.cms. PHACOEMULSIFICATION) gov/Medicare/Coding/ • CPT 66983 INTRACAPSULAR NationalCorrectCodInitEd/ CATARACT EXTRACTION index.html on the CMS website. WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE) • CPT 66984 EXTRACAPSULAR CATARACT REMOVAL WITH Did you know... INSERTION OF INTRAOCULAR LENS PROSTHESIS Want to stay connected about the latest new and revised (1 STAGE PROCEDURE), Medicare Learning Network® (MLN) products and services? MANUAL OR MECHANICAL Subscribe to the MLN Educational Products electronic mailing TECHNIQUE (EG, IRRIGATION list! For more information about the MLN and how to register for this service, visit http://www.cms.gov/MLNProducts/ AND ASPIRATION OR downloads/MLNProducts_listserv.pdf and start receiving PHACOEMULSIFICATION updates immediately! The above codes are mutually exclusive; one per eye per date of service may be used.

Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 24 Recovery Audit Finding: Pulmonary Procedures and Evaluation & Management Services

Provider Types Affected: Physicians and non-physician practitioners

Problem Description: The • CPT 99213 Office or other CPT code 99213 should not be billed Recovery Auditors conducted outpatient visit for the because a physician in attendance automated reviews of claims evaluation and management of for a pulmonary function study with Evaluation & Management an established patient, low to obtains a history and performs a (E&M) Services and Pulmonary moderate, 15 minutes of face physical examination related to the Diagnostic Procedures. They to face. pulmonary function testing. Thus, identified overpayments associated • Modifier 25: Significant, separate reporting of an evaluation with evaluation and management separately identifiable evaluation and management service is not services Current Procedural and management service by the appropriate. In this situation, modifier Terminology (CPT) 99211-99213 same physician on the same day 25 would need to be appended to billed without Modifier 25 on the of the procedure or other service. show if the service was separate and same date of service as a pulmonary identifiable. diagnostic procedure (94010-94799). Billing Considerations: 2. A provider billed CPT code Medicare Policy: If a physician • If a physician in attendance 94060 Breathing capacity test in attendance for a pulmonary for a pulmonary function study with no modifier for date of function study obtains a history and obtains a history and performs service February 12, 2011. performs a physical examination a physical examination related The same provider also billed related to the pulmonary function to the pulmonary function CPT code 99212 Office or testing, separate reporting of an testing, separate reporting of other outpatient visit for the evaluation and management service an evaluation and management evaluation and management of is not appropriate. If a significant, service is not appropriate. an established patient without separately identifiable E&M service • If a significant, separately any modifier. identifiable E & M service is is performed unrelated to the CPT code 99212 should not performed unrelated to the performance of the pulmonary be billed because a physician performance of the pulmonary function test, an E&M service may in attendance for a pulmonary function test, an E & M service be reported with modifier 25. function study obtains a history and may be reported with Modifier 25. Here are the definitions of CPT performs a physical examination 99211-13, E & M Services and • If the evaluation and related to the pulmonary function Modifier 25: management was not testing. Separate reporting of separately identifiable, then the • CPT99211 Office or other an evaluation and management E & M service should not be service is not appropriate. In this outpatient visit for the reimbursed separately. evaluation and management situation modifier 25 would need to be appended to show if the service of an established patient that Billing Examples: may not require the presence was separate and identifiable. 1. A provider billed CPT code of a physician. Usually the Use of CPT Modifier 25, 94010 Breathing capacity test presenting problem(s) are Significant Evaluation and with no modifier for date of minimal. Typically, 5 minutes are Management Service by Same service September 19, 2011. spent performing or supervising Physician on Date of Global The same provider also billed these services. Procedure: The “Medicare Claims CPT code 99213 Office or Processing Manual,” Section 30.6.6, • CPT 99212 Office or other other outpatient visit for the available at http://www.cms.gov/ outpatient visit for the evaluation and management of Regulations-and-Guidance/ evaluation and management an established patient without Guidance/Manuals/Downloads/ of an established patient, any modifier. which requires at least 2 of clm104c12.pdf requires that CPT 3 key components. Modifier 25 should only be used on

25 Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 4–July 2013 claims for E & M services, and only 25 should be appended. If when these services are provided the E & M services were not by the same physician (or same separately identifiable, then Did you know... qualified nonphysician practitioner) the E & M should not be to the same patient on the same reimbursed separately. day as another procedure or other Looking for the latest new and revised service. Medicare contractors pay ✓✓Review the “Global Surgery MLN Matters® articles? The Medicare for an E & M service provided on Fact Sheet,” available at http:// Learning Network® offers several www.cms.gov/Outreach-and- ways to search and quickly find the day of a procedure with a global articles of interest to you: fee period if the physician indicates Education/Medicare-Learning- that the service is for a significant, Network-MLN/MLNProducts/ MLN Matters® Search Engine: an separately identifiable E & M service downloads/GloballSurgery- advanced search feature that allows that is above and beyond the usual ICN907166.pdf for more you to search MLN Matters® articles pre- and post-operative work of the information and examples of from 2004 to the current year. billing for E & M services and procedure. Different diagnoses are : a list of when to append Modifier 25. MLN Matters® Index not required for reporting the E & common keywords and phrases M service on the same date as the contained within MLN Matters® procedure or other service. Modifier articles. Each index is organized 25 is added to the E & M code on by year with the ability to search by the claim. specific keywords and topics. Most indices link directly to the related Both the medically necessary E & article(s). For a list of available M service and the procedure must indices, visit the MLN Matters® be appropriately and sufficiently Articles web page and scroll down to documented by the physician or the ‘Downloads’ section. qualified nonphysician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim. Guidance for Providers to Avoid Coding Errors:

✓✓Review the “Medicare Claims Processing Manual,” Section 30.6.6, available at http://www. cms.gov/Regulations-and- Guidance/Guidance/Manuals/ Downloads/clm104c12.pdf, which requires that CPT Modifier 25 should only be used on claims for E & M services, and only when these services are provided by the same physician (or same qualified nonphysician practitioner) to the same patient on the same day as another procedure or other service. If the E & M services were truly separately identifiable, modifier

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