The summary of events and newsworthy items for the month of July is provided on 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.

Public Health Emergency Extended

Alex M. Azar II, Secretary of Health and Human Services (HHS) announced the renewal of the public health emergency (PHE) declared due to the Coronavirus Disease 2019 (COVID-19). The PHE was originally declared on January 31, 2020 and renewed on April 21, 2020.  The new extension went into effect on July 25, 2020 and will last for 90 days, making the new expiration date October 23, 2020. The extension of the PHE allows for the flexibilities implemented by CMS to help compensate for the ever-changing healthcare environment due to the pandemic to continue.

ASTRO Resolves Humana CT Image Guidance Denials

Earlier this year, Humana began denying cone beam CT image guidance, CPT® code 77014, when billed within 14 days of IMRT treatment planning, code 77301. ASTRO submitted an advocacy letter to Humana explaining the appropriateness in billing CT image guidance with IMRT treatment delivery within 14 days of the IMRT treatment planning code. Humana has agreed that the claims were incorrectly denied and will reprocess the claims.  Practices do not need to take any further action to have their incorrectly denied claims reprocessed. The ASTRO article regarding the resolution to this issue can be found here.

Neutral Payment Ruling for Clinic Visit by Appellate Court

In CY 2019 CMS finalized a site-neutral method for reimbursement for code G0463, Hospital outpatient clinic visit for assessment and management of a patient.  In any setting considered off-campus, more than 250 yards from the main buildings of the hospital, either excepted or nonexcepted, CMS set a site neutral rate.  This means in either off-campus location the reimbursement for code G0463 would be 40% of the on-campus outpatient reimbursement.  This rate change, phased in over 2 years, aligns with the Bipartisan Budget Act of 2015 which set the same reimbursement regulations for nonexcepted provider-based outpatient departments.

A lawsuit was filed by the American Hospital Association.  Many commenters felt the decision by the United States District Court for the District of Columbia on September 17, 2019, to vacate the portion of the CY 2020 Outpatient Prospective Payment System (OPPS) proposed rule related to the volume control method for clinic visits, did not support the decision by CMS to move forward with the second-year implementation in payment reduction.  CMS did file an appeal in late September 2019, but this motion to modify and request for stay was denied. 

CMS was working to ensure affected 2019 claims for clinic visits were paid in a manner consistent with the court’s order, but CMS did not agree it was appropriate to make a change to the second year of the two-year phase-in policy.  Within the CY 2020 final rule, CMS expressed their belief the Secretary does have the authority to make changes as a means of controlling unnecessary increases in the volume of outpatient department (OPD) services.  Specifically, the authority to remove potential reimbursement incentives or differences that may unnecessarily increase the volume of services provided based on location or setting.  By implementing a site-neutral payment policy for the clinic visit, CMS believed this appropriately and effectively will impact and adjust any unnecessary services or continued increase in services due to higher reimbursement in a particular setting.

On July 17, 2020 the United States Appellate Court for the District of Columbia unanimously ruled CMS was well within their rights to expand the site-neutral payment policy rule to include E/M services provided in all off-campus provider-based facilities.  This unanimous ruling indicates that CMS has the authority to make significant adjustments to payments when the agency believes payment policy is promoting excessive utilization or set at inappropriate payment levels.  Reimbursement in the hospital setting typically is higher than similar services reimbursed under the Medicare Physician Fee Schedule (MPFS).  This ruling could mean future rulemaking by CMS could outline other “site neutral” adjustments to more services where the reimbursement or payment method results in “unnecessary increases in the volume”. 

These changes are no longer only applicable to new provider-based departments opened after November 2, 2015 and outside 250 yards of the main buildings of the hospital.  Off-campus departments which were excepted, traditionally within the previous 35-mile radius prior to November 2, 2015, may now also be subjected to the same “site neutral” payment policies and no longer paid at the on-campus outpatient hospital rate.  This latest ruling can be appealed, but understanding of the potential impact moving forward is important.

Office of Inspector General Reviews Telehealth Flexibilities

The Office of Inspector General (OIG) will be conducting two concurrent reviews to examine the use of telehealth services for Medicare beneficiaries during the COVID-19 pandemic. In response to the public health emergency, CMS granted temporary telehealth flexibilities to Medicare beneficiaries to access a wider range of telehealth services without having to travel to health care facilities. The reviews the OIG will conduct will be in an effort to explore whether telehealth flexibilities should be extended beyond the public health emergency.  One review will examine the extent to which telehealth services are being used by Medicare beneficiaries along with the different types of providers and beneficiaries using telehealth services. The second review will focus on identifying program integrity risks with Medicare telehealth services to ensure appropriate use and reimbursement during COVID-19. The expected issue date of the reports is FY 2021.

CGS Retires Chemotherapy and Biologicals LCD, Replace with LCA

As of June 2020, CGS Administrators retired Local Coverage Determination (LCD) Chemotherapy and Biologicals (L34093).  CGS has replaced the LCD with the article entitled Off-Label Use of Anti-Cancer Drugs and Biologicals (A58113). CGS states that while there is no longer a policy in place with attached billing and coding articles, they will utilize the coverage indications as listed in the CMS Internet Only Manual (IOM) 100-02, Chapter 15, section 50.4.1 and 50.4.5.  CGS also has a recorded webinar from May 7, 2020 available for further education and guidance on Off-Label Use of Drugs and Biologicals for Anti-Cancer Chemotherapeutic Regimen.

Alternative Payment Model Program Leads to Reduced Volume of Imaging Services

Starting in 2013, Oregon changed its reimbursement of traditional primary care services for selected community health centers (CHSs) from a per visit to a per patient rate for the Medicaid program.  An analysis utilizing Oregon’s claims data found the payment reform was associated with a 42.4 percent relative reduction in price-weighted traditional primary care services, driven fully by decreased use of imaging services. The review of claims data included the price-weighted volume of care for five service areas including traditional primary care services, which encompassed imaging, tests, and procedures. Other services provided by CHCs carved out from the payment reform included emergency department visits, inpatient services, and other services of non-CHC providers.  Oregon’s initiative could provide valuable information for other states interested in using payment reform to advance the patient-centered medical home model for the Medicaid population.

ABN Form Renewal Approved

The Advance Beneficiary Notice of Noncoverage (ABN) form, CMS-R-131, along with form instructions have been approved by the Office of Management and Budget (OMB) for renewal.  Starting August 31, 2020, the use of the renewed form with the expiration date of June 30, 2023 will be mandatory. The ABN is issued by providers, physicians, practitioners, and suppliers to fee for service (FFS) Medicare beneficiaries in situations where Medicare payment is expected to be denied.  ABN forms are issued to Medicare beneficiaries in certain instances in order to transfer potential financial liability to the beneficiary. The ABN webpage has more information along with renewed forms and instructions, which can be located here.   

ATRO Updates SBRT Policy

Based on new evidence, ASTRO has issued an update to their stereotactic body radiation therapy (SBRT) policy regarding the recommendations for medical insurance coverage. The updated SBRT Model Policy provides guidance to payers on when using SBRT is appropriate and should be covered by health insurance. The policy now breaks down appropriate clinical indications of SBRT into two categories. The first category outlines clinical indications for primary malignant tumors and the second category includes secondary, metastatic, and recurrent tumors and tumors near previously irradiated volumes. Additionally, the policy highlights coverage considerations for spinal metastases and indications for coverage with evidence development (CED).  It is of note that ASTRO model policies are written for an insurance payer audience and differ from their practice guidelines.  Practice guidelines are written for the physicians and outline recommendations to optimize clinical care, and therefore do not serve as clinical guidelines.

Palmetto Reviews Drugs and Biologicals Denials

Citing the high cost of biologicals and the uptick in utilization, several drugs and biologicals were placed under review this option year by Palmetto GBA.  The drugs selected for review are the top drugs based on dollars at risk and CERT error rates.  Claiming the fourth spot on the CERT Improper Payment report, outpatient services has an improper payment of $299,661,709 and a projected improper error rate of 9.5 percent.  Pegfilgrastim (Neulasta®), Denosumab (Prolia®), and Bevacizumab (Avastin®) were the drugs ranked the highest on the list of total potential dollars at risk. There are currently four drugs under review and a potential for an additional four to be reviewed. Palmetto has released common denial codes as well as way to prevent denials of drugs and biologicals here.

Medicare Reimbursements for Diagnostic Imaging Decline Over Past Decade

A new study from the Journal of the American College of Radiology (JACR) has found that Medicare reimbursement for diagnostic imaging studies has steadily decreased between 2007 and 2019.  The study, released July 22, 2020, selected common radiology exams across multiple modalities, including CT, CTA, mammography, MRI, MRA, nuclear medicine, radiography, ultrasound, and bone densitometry.  Using the Physician Fee Schedule Look-Up Tool from CMS, individual CPT® codes were reviewed to evaluate reimbursement data. The findings indicate that, after adjusting for inflation, Medicare reimbursements have declined for all studies across all modalities. MRI saw the greatest mean decrease in reimbursement rates (-$52.08). Bone densitometry demonstrated the largest decrease in total percentage change (-70.5%), while the smallest mean decreases in both annual change and total percentage change were observed in Nuclear Medicine (-$0.32 and -4.28%, respectively). The JACR recommends further investigation to accurately model future radiology reimbursement trends. 

Read the JACR article here for additional information.

Interventional Radiologists Take on More Prominent Role During Outbreak

Interventional radiologists have stepped up to take on additional work during the coronavirus pandemic, according to experts. In an article published July 23, 2020 in the Journal of Vascular and Interventional Radiology (JVIR), subspecialty experts assert that interventional radiologists have accounted for a larger share of both procedural volume and gross charges at two academic medical centers in Chicago and Tucson, Arizona. While hospital-wide procedure volumes at these facilities have fallen significantly during the pandemic, interventional radiology (IR) has seen a much smaller decline. In Tucson, total gross procedural charges dropped by 40 percent year-over-year, while IR procedures saw a decline of just 20 percent.

“The data above demonstrate that, while other procedural services such as surgery, cardiac catheterization lab and endoscopy have suffered decreased procedural volume and changes, IR has filled the void,” Miken Patel, MD and Osman Ahmed, MD wrote.  The physicians asserted interventional radiologists have transitioned from performing primarily outpatient procedures and services to focusing on inpatients during the outbreak. Patel, Ahmed and their colleagues attribute this increase in IR services to two factors: efficacy in organizing workflows and availability to treat patients. The experts note that there has been an increase in consult requests which overlap with other specialties. Where other physicians have eschewed these consultations, interventional radiologists have stepped in to take on this additional work.  The team concludes that this flexibility has allowed for less interruption and more efficiency in patient care for the critically ill and has reduced some of the burden placed on healthcare systems during the pandemic.

Read the JVIR article here for additional information.

July 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: A patient had two 2-view chest x-rays done in the ER an hour apart. In the second report, it states this is a repeat study due to poor inspiration on the prior study. Is only one billable per the CCI manual?  “If imaging studies (e.g., radiographs, computerized tomography, computerized tomography, magnetic resonance imaging) are repeated during the course of a radiological encounter due to substandard quality or need for additional views, only one unit of service for the appropriate code may be reported.

Advice: If the Radiologist  cannot interpret a radiograph due to suboptimal  results in the radiograph, and the image is of no diagnostic value, and a repeat study is performed, then the first procedure is non-billable and the second radiograph is considered the only image taken. The provider usually advises the technologist of this and the image is destroyed/deleted from the PACS system. If however, the Radiologist uses the image because there is some information that is of value on the original radiograph and is used as part of his/her interpretation,  then then the repeat radiography will require either modifier -76 or -77 to identify a repeat study.

Question: Can a 77331 be billed for TDLs on 3D AND IMRT?

Advice: Billing for TLDs, code 77331, is not separately billable when utilized prior to or part of the development of the IMRT plan. The QA performed as part of the IMRT plan is intended to replace the need for special dosimetry and verification of dose. Per the Medicare Claims Processing Manual “Payment for the services identified by CPT codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the APC payment for CPT code 77301 (IMRT planning). These codes should not be reported in addition to CPT code 77301 when provided prior to or as part of the development of the IMRT plan.” Additionally, NCCI edits do not allow for 77331 to be billed on the same date as IMRT treatments. TLDs, 77331, could be billable with 3D plans but as a special service code should not be billed for every patient. While the service may be performed on all patients as st