CMS Revises Billing for E/M with Superficial Treatment Delivery
CMS released MM11137 on February 22, 2019, to be implemented on March 25, 2019 and retroactive to January 1, 2019 CMS has revised billing for superficial radiation therapy. Physicians will now be able to bill an established patient evaluation and management (E/M) visit (99211, 99212 or 99213) only with CPT® code 77401 (superficial radiation treatment delivery) to account for the physician work associated with clinical treatment plan, treatment planning, physician management (when performed on the same date as the superficial radiation treatment delivery), device construction and physics consultation.
Medicare Administrative Contractors (MACs) will not search files for claims already paid or to retroactively pay claims, but MACs will adjust affected claims brought to their attention. This also means that providers will have to have the documentation of the E/M service already in the medical record as provided at the time of the superficial treatment delivery.
The full MedLearn Matters article can be found at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11137.pdf.
CMS Modifies Claims Processing Logic for Modifiers 59, XE, XS, XP, and XU
On February 15, 2019 CMS released MM11168, Modification of the MCS Claims Processing System for Modifiers 59, XE, XS, XP, and XU involving National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Column One and Column Two Codes, effective July 1, 2019.
The new modification allows for modifier 59, XE, XS, XP, and XU to be applied to the Column 1 or Column 2 code when billing the services identified within the NCCI PTP edits as allowing for a modifier to be applied to potentially bypass the edit. Currently and for all other edits, when a modifier is applicable it is only applied to the Column 2 code, no modifier is applied to the Column 1 code.
The exact reason for this modification is not explained by CMS, one idea is it could be due to incorrect reporting of modifiers, specifically 59 and the X modifiers, as these are used quite extensively. It is possible there is a lot of confusion related to applying modifiers and the volume of services billed with them is high resulting in high volume of denials when applied to the wrong code. By extending and allowing these particular modifiers to be applied to either code could offset the number of denials and additional work on both ends, payer and provider.
Noridian Healthcare Solutions Revises Chemotherapy Administration Article
Noridian Healthcare Solutions released an update to the Chemotherapy Administration Article (A52991) for both jurisdictions E and F, the changes are effective January 1, 2019, released on February 14, 2019. The changes to the Article are as follows:
Effective Date: January 1, 2019
Summary of Changes:
- Added the following J codes to the Infusions Chemotherapy section
- J0640 – leucovorin calcium to have IV chemo admin codes payable when given with 5-Fluoracil
- J2783 – rasburicase (Elitek®)
- J2820 – sargramostim (Leukine®)
- J9999 – (OPPS:C9399) for ElzonrisTM
- Q5109 – infliximab-qbtx (IxifiTM)
- Added J2820 sargramostim (Leukine®) as payable with 96401 if given for the treatment of cancer
- Added and deleted the following codes to the list of drugs payable with an external portable pump (G0498) as indicated in each Product Information sheet
- J9065 – cladribine,
- J9041 – bortezomib
- J9267 – Paclitaxel to be payable per the Product Information sheet
- J9371 – vincristine sulfate liposome (Oncovin, Vincasar PFS)
- Adrucil® listed with J9190 since it had been discontinued
ACR Asking Radiologists and Allied Professionals to Submit Ultrasound Invoices
CMS had proposed significant cuts to the Direct Practice Expense (PE) inputs for ultrasound equipment which was to go into effect January 1, 2019. This was delayed, but if the American College of Radiology (ACR) and Ultrasound Access Coalition (UAC) cannot support updated cost information of the supplies and equipment the ultrasound cuts could go into effect as early as CY 2020.
ACR is urging radiologists and allied professionals to assist by submitting invoices to the ACR that reflect the actual cost to purchase ultrasound equipment. CMS uses invoices of the actual costs for equipment when setting the relative value units (RVUs) such as practice expense. When the cost of equipment decreases or the data is limited in submission, this can affect the reimbursement for services under the Medicare Physician Fee Schedule (MPFS). If the cost of equipment decreases this tends to have a direct correlation to the reimbursement assigned to the CPT® codes assigned to the service utilizing the equipment. Invoices can be submitted to firstname.lastname@example.org.
Fiscal Year (FY) 2020 Hospital Wage Index
February 15, 2019 was the deadline this year for hospitals to submit to their Medicare Administrative Contractor (MAC) wage related information to assist in populating the Wage Index for the geographical area where hospital is located. The wage index is used to by CMS as a means of reflecting the relative wage level in a geographic area of the hospital compared to the national average hospital wage level.
The wage index is calculated and assigned to hospitals on the basis of the labor market area in which the hospital is located. Since 2005 the labor market areas are defined by the Core-Based Statistical Areas (CBSAs). The CBSAs are based on the county in which the hospital is located. The CBSA is then assigned a wage index value based on the cost reporting for the hospitals within the fiscal year calendar. Information was sent by the MACs for hospitals to submit the necessary data for CMS to calculate the FY 2020 wage indexes, these values are used for both inpatient and outpatient hospitals.
Healthcare Provider Taxonomy Codes (HPTCs) April 2019 Code Set Update
CMS released notification of updates to the Taxonomy Codes (HPTCs) effective July 1, 2019. Taxonomy codes are used for standardized classification of healthcare providers. The codes identify the specialty to which the provider is credentialed for and attributed to. In addition, when a provider is applying for a National Provider Identification (NPI) the healthcare provider must select a HPTC or description that most closes describes their specialty/classification. A provider may have more than one HPTC that applies or is close to what the provider considers their specialty, but each provider must select a primary HPTC.
The HPTCs are updated twice a year, April and October. The list of HPTCs are available at http://www.nucc.org/index.php/code-sets-mainmenu-41/provider-taxonomy-mainmenu-40. This website allows for review and/or download of new codes, modifications or copy of full set of codes. The updates effective July 1, 2019 include revisions to Behavioral Health & Social Service Providers and a new code for Allopathic & Osteopathic Physicians; Preventive Medicine, Addiction Medicine.
FDA Issues Thermography Warning
On February 25, 2019 the U.S. Food and Drug Administration (FDA) issued a warning that thermography devices should not be used as a standalone method for detecting, diagnosing or screening for breast cancer. “There is no valid scientific data to demonstrate that thermography devices, when used on their own or with another diagnostic test, are an effective screening tool for any medical condition including the early detection of breast cancer or other diseases and health conditions,” the FDA said in its statement. “Mammography … is the most effective breast cancer screening method and the only method proven to increase the chance of survival through earlier detection.”
In mid-February Good Morning America highlighted two patients whose cancers were missed by thermography, one of the women later died after believing per the exam results, she was “all clear.” The thermography devices have been seen by some as an alternative to diagnostic exams involving radiation or what may seem as invasive.
FDA cleared thermography devices to be used with another screening or diagnostic tool, not as a standalone. This is not the first warning issued by the FDA regarding thermography devices, warnings were issued in June 2011 and again in October 2017.
The FDA offers the following counsel to people receiving breast cancer screening:
- Be aware that thermography is not a substitute for regular mammograms and should not be used in place of mammography for breast cancer screening or diagnosis.
- Have regular mammograms according to screening guidelines or as recommended by your healthcare provider.
- Learn more about what to expect during a mammogram on theFDA’s Mammograms webpage.
- Follow your healthcare provider’s recommendations for additional steps to diagnose breast cancer such as a clinical breast exam, other breast imaging studies (such as breast ultrasound or MRI), or breast tissue biopsy.
February Coding Corner
Within this section, current topics will be the focus. In some cases, the Q&A could reflect common questions received by Revenue Cycle Inc. and in other cases, represent current issues encountered by Revenue Cycle Inc. professionals.
Question: During the 90-day post treatment period, are there any billable services, or only 99024?
Advice: It really does depend on what was performed during the 90-day global period following the completion of the external beam course. If there is a new area identified during the 90-day global period, then a new E/M could be billed for that new area with no management of the previous course and completed treatment. If the visit is to resume, continue or boost the same area that was just treated, this is still management of that area and the visit is not separately billable.
Question: In an IMRT patient where the Rad Onc has prescribed both gating and IGRT, are you allowed to bill both the imaging charge whether it be a CBCT or KV set as well as billing the daily gating charge?
Advice: Intrafraction tracking/gating is a form of IGRT. Only one imaging service is billable per session of treatment. Just as only one treatment delivery code is billable per treatment session even though multiple areas may be treated. Bill for the imaging that is the one if there was an issue with the treatment or the shifts/tracking that would be used as the standard for the treatment. Documentation is needed for all the imaging performed, but only one can be billed when appropriate.