The summary of events and newsworthy items for the month of August is provided in the following pages. In most instances, the link to the full document of information is provided. Any of the contents may be further discussed by reaching out to Revenue Cycle Coding Strategies LLC.
WPS Makes Changes to Mammogram Policy
Medicare Administrative Contractor (MAC), Wisconsin Physician Services (WPS) has made adjustments to the specialties allowed to provide supervision for mammograms.
Effective for claims processed on or after August 2, 2021, WPS will no longer pay for the technical, professional or global charges for mammograms if the supervision for the study is provided by Nurse Practitioners, Clinical Nurse Specialists, or Physician Assistants.
WPS has previously reimbursed mammogram studies when these provider types have supervised the study. However, citing Medicare’s requirement that a physician (MD/DO) be the one to perform the professional component and to supervise the technical aspect of the study, WPS will discontinue payment for mammograms when provided by the previously listed non-physician practitioners. Further information and a list of procedure codes affected by the change can be located here on the WPS website.
- Affected Procedure Codes:
- Medicare Benefit Policy Manual, Chapter 15, Section 280.3
- Medicare Claims Processing Manual, Chapter 18, Section 20
- National Coverage Determination 4
ICD-10-CM Updates and Changes for FY 2022
Fiscal Year (FY) 2022 will see a few significant updates and changes to ICD-10-CM for coding and reporting. Some of the changes and updates for coding and reporting are bulleted below with the changes bolded italicized; these go into effect October 1, 2021.
- Within the General Coding Guidelines, the Level of Detail in Coding was updated to include and emphasize the need for coding to the highest level of specificity.
Diagnosis codes are to be used and reported at their highest number of characters available and to the highest level of specificity documented in the medical record.
- A section emphasizing the importance of the correct code assignment was added to the guidelines for coding Laterality.
When laterality is not documented by the patient’s provider, code assignment for the affected side may be based on medical record documentation from other clinicians. If there is conflicting medical record documentation regarding the affected side, the patient’s attending provider should be queried for clarification. Codes for “unspecified” side should rarely be used, such as when the documentation in the record is insufficient to determine the affected side and it is not possible to obtain clarification.
- Within the Use of Sign/Symptom/Unspecified Codes section, the following has been added:
As stated in the introductory section of these official coding guidelines, a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.
- The following was added in Chapter 2: Neoplasms (C00-D49)
Bilateral Ovarian Cancer, Primary and Secondary New Codes
C56.3 – Malignant neoplasm of bilateral ovaries
C79.63 – Secondary malignant neoplasm of bilateral ovaries
- Chapter 21: Factors influencing health status and contact with health services (Z00-Z99) saw the following additions.
- Categories of Z Codes,
The reason for the encounter (for example, screening or counseling) should be sequenced first and the appropriate personal and/or family history code(s) should be assigned as additional diagnos(es).
Additionally, Chapter 21 saw the addition of the section Social Determinants of Health to include the correct order of coding, acceptable means in which to obtain this information, and the “Z” code categories where these health codes are.
CMS Plans to Rescind MFN Rule
The Most Favored Nation (MFN) Rule was executed by Executive Order in 2020 and was included in the November 2020 interim final rule. In the newest round of proposed rules, CMS is seeking comments on rescinding the 2020 interim final rule.
The MFN Rule was a model intended to lower prescription drug costs by requiring Medicare pay no more for a list of 50 specific drugs and biologicals than other developed nations. The mandatory MFN model would no longer reimburse for the specified drugs based on the average sales price (ASP) but instead would reimburse based on prices similar countries paid for the drugs. Additionally, the MFN model also planned to adjust the add-on payment for providers to a flat amount for each dose instead of a percentage of the drug’s cost.
The comment period allotted for the MFN interim final rule was called into question as it provided a very short period of time to allow comments to be submitted. The MFN rule was met with resistance from many different professional associations, pharmaceutical companies and physician groups. Some apposed cited the loss of revenue and reduced access to the specified drugs to beneficiaries, especially cancer patients. On the grounds this short comment period violated the Administrative Procedures Act (APA), the rule was temporarily prohibited from taking effect after being challenged in court. After reviewing the 1,166 comments made on the MFN interim final rule during the shortened comment period and the court’s injunction which highlighted findings regarding procedural issues with the MFN interim rule, the Centers for Medicare and Medicaid Services (CMS) issued a proposed recension to the MFN model on August 10, 2021, with a 60 day open comment period.
While the fate of the MFN Rule is in limbo, CMS highlights a current Executive Order that directs the Secretary of HHS to work to accomplish lower prescription drug and biological prices while improving beneficiary access to them. As addressed in the proposed rule: “HHS is exploring opportunities to promote value-based care for our beneficiaries; to address the high cost of Medicare Part B drugs, manufacturers’ pricing, and the resulting growth in Medicare Part B drug spending; and to modernize the Medicare program to improve the quality and cost of care for beneficiaries. We will continue to carefully consider the comments we received on the November 2020 interim final rule as we explore all options to incorporate value into payments for Medicare Part B drugs and improve beneficiaries’ access to evidence-based care.”
Guidance for Minimally Invasive Lung Cancer Treatments Issued
The Society of Interventional Radiology (SIR) has issued guidance for image-directed percutaneous ablation to treat multiple forms of lung cancer.
Endorsed by the Canadian Association for Interventional Radiology, the Cardiovascular and Interventional Radiology Society of Europe, and the Society of Interventional Oncology, recommendations were released for image-guided thermal ablation (IGTA) to treat Stage I non-small-cell lung cancer (NSCLC), recurrent NSCLC, and metastatic lung cancer. The recommendation documents were developed by a multidisciplinary team consisting of interventional radiologists, oncologists, thoracic surgeons and radiation oncologists after a comprehensive literature study, meta-analysis, retrospective cohort studies, and single-arm trials. SIR’s position statement outlines clinical practice guidelines, qualifying patients, treatment delivery, and follow-up care post-treatment. The published Quality Improvement Standards also provides indications, contraindications, procedural thresholds, procedural considerations, and postprocedural monitoring and follow up information for IGTA for NSCLC, recurrent lung cancer, and metastatic disease.
Check Out Your MACtivity
- Article for PET Scans for Onc Conditions (A58826)
- Anticipated Retirement 9.30.21
- Infliximab LCD (L33704)
- Infliximab LCA (A57653)
- Forms Catalog – Make sure you’re using the most up to date forms!
- Medical documentation and checklists
- New Website with crosswalk reference to find content on new site
August 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 Coding Strategies and in other cases, represent current issues encountered by Revenue Cycle Coding Strategies professionals.
Question: I am looking for clarification on how to code under the RO Model. My question is: Do we still report on a case all the codes as we would normally and add in the M codes. Do we sill report all the charges and add in the new HCPCS codes? Also, the additional modifiers GB and B1 is something new too?
Advice: There could potentially be three different claims submitted. A start-of episode claim, an end-of-episode claim and a encounter-like or No-Pay claim. The No-Pay claim will be separate and will include the RT services identified on the RO Model Packaged/Bunded HCPCS codes list within the given 90-day episode. CMS will use this data for the annual reconciliation and for Model evaluation and monitoring. The No-Pay claim will be submitted once the start-of-episode claim has been adjudicated. The B1 condition code and GB modifier are utilized to alert CMS the claim should be paid fee for service and not under the RO Model.
Question: We are wanting to verify the correct billing of Prolia – J0897. Does the first hour of infusion bill as a chemotherapy 96413 or a therapeutic 96372?
Advice: Prolia or Denosumab is an injection, not an infusion. You will need to verify if your payer wants you to use the therapeutic injection code 96372 or the chemo code 96401.
Question: Patient has metastasis to T9 being treated with 3-D & T4 being treated with IMRT. Both plans were run the same day. Can both plans be charged on the same day?
Advice: Only one plan is billable per date of service, regardless of the number of plans/treatment sites. If the plans are developed and therefore billed on separate dates of service, medical necessity would need to support developing the plans in that manner as billing on multiple dates without medical necessity support could be misconstrued by payers and auditors as an attempt to avoid edits. While only one plan is billable, the calculations (77300) and devices (77334 for 3-D and 77338 for IMRT) would be considered billable for all plans as documented and supported. As a reminder, there is an edit in place between codes 77338 and 77334 with the opportunity to apply a modifier to 77334 as supported and appropriate.