Riverbend

Question From ACT

We are hearing that CMS did not intend to apply the “treating physicianâ€� requirement to the provider based sites and they will revise the language.  We are also hearing that other FI’s are stating the transmittal will be enforced as written.  We would like to hear RGBA’s interpretation and how this might impact off-site supervising physician arrangements.  Please advise whether hospitals need to have a physician on staff for face-to-face patient visits such as in the cardiac rehabilitation department.

Riverbend is interpreting Transmittal 82 (CR 5946) as written.  Cardiac rehabilitation departments have specific supervision regulations in the NCD that have not changed because of this transmittal.  If cardiac rehabilitation services are performed in a provider based outpatient department that is not located on the hospital premises, direct supervision is required. Riverbend has requested clarification of treating physician from CMS. (Posted 6/4/2008)

Please address Transmittal 82 (CR 5946) as it relates to therapeutic services provided “incident toâ€� a physician’s service in off-campus hospital departments with provider based status.  Until the transmittal was released, the supervision was met in these settings by utilizing a physician who was immediately available in an emergency and RGBA required us to have evidence of this (i.e. cardiac rehab departments).  The transmittal appears to overrule this long standing policy and suggest the supervision for therapeutic services in the off-campus department can only be provided by the treating physician.

Services that are provided "incident to" in a provider based outpatient department of the main facility are now required to have direct supervision by a treating physician.  Direct supervision means that the physican or appropriate non-physician practitioner must be in the outpatient department for the "incident to" services to be covered. (Posted 6/4/08)

We understand the Important Message from Medicare (CMS-R-193) applies to our hospital inpatients.  We also recognize that CMS provides some flexibility by allowing delivery of the IMM before admission (up to 7 days prior).  Is it permissible for an acute care hospital to present the initial IMM to Medicare patients presenting to the Emergency Room and those admitted to Observation status even though they are not inpatient status at the time of delivery?  Doing so ensures that the hospital does not inadvertently overlook deliver of the initial Notice after the registration process is completed.  All ED and Observation patients would be advised of their rights in the event their physician formally admits them as an inpatient.

It is permissable for the IMM to be given to patients in the ED or Observation, however, it cannot be delivered during an emergency.  If given more that 2 days (7 days before admission) before discharge a follow-up must be presented to the patient no more than 2 days before discharge and if on the date of discharge at least 4 hours before discharge so patient may consider their rights.(Posted 6/4/08)

Is it appropriate to report a distal protection device using the cardiovascular unlisted code of 93799 when used during a cardiovascular intervention?

No, because distal protection devices are included in procedures.

The FDA does not approve a stint without a distal protection device that goes along with that stint.  So just as in with the stint deployment device that's included with the stint, so is the distal protection device.  These devices also are included in angiograms and (PPA) procedures.  And you can also see that the language for the (ICD9) stinting procedures for carotid stinting procedures also includes the distal protection device in that language. (12/13/2007)

When a screening Prostate Specific Antigen (PSA) has been ordered, if the order includes a diagnosis that justifies a diagnostic test, is it acceptable to report a diagnostic (PSA) instead?

In the Medicare Benefits Policy Manual, Chapter 15, titled Covered Medical and Other Health Services, Section 80.6 includes the following information: The treating physician must order all diagnostic tests, and must use the result in the management of the beneficiary's specific medical problem.  A testing facility may not change the diagnostic test or perform an additional diagnostic test without an order.  Therefore if you have a screening test ordered, you must provide the screening and not a diagnostic test, because you do not have an order for one.  However, you can report that diagnostic – diagnosis code on the claim at the same time.

If you have a diagnostic (PSA) ordered, however the ordering physician only provides a screening diagnosis, in this case you should verify with that physician actually what they want ordered.  If the order is the diagnostic test, then you're going to have to clarify the diagnosis with the physician.  On the other hand, if you have a screening (PSA) ordered with no appropriate screening diagnosis, you still should verify with that physician.  If you have other documentation though and it contains something that supports medical necessity such as the patient's age and the reason for the screening when the patient really has no other signs or symptoms, then it might be appropriate for you to code the screening diagnosis code.

CMS recently published Transmittal 79, Change Request 5743: “Requirements for Ordering and Following Orders for Diagnostic Testsâ€�.  This change request provides the information needed for this question. (12/13/2007)

According to the NUBC guidelines, UB-04 form locator 70A through C, Patient's Reason for Visit, shoud be used for unscheduled outpatient visits. Is the Direct Data Entery (DDE) system in compliance with these guidelines?  Where does form locator 70 appear?

The DDE system is in compliance with the NUBC instructions and guidelines, and it is updated appropriately.  Also, data elements in the CMS uniform electronic billing specifications are consistent with the UB04 data set to the extent that one processing system can handle both. 

According to the outpatient code editor specifications 8.3, the diagnosis pointer is associated with form locator 70 A through C, form locator 67 and 67 A through Q, and states that the diagnosis codes apply to the whole claim and are not specific to the line item.  The first diagnosis is considered the patient's reason for the visit diagnosis, and the second diagnosis is considered the principle diagnosis.

The DDE claim is considered an electronic claim in this system.  And the UB04 changes were for hard copy submission only.  So there was no compliancy needed for DDE. It's considered an electronic claim, and it's processed accordingly in the system. (12/13/2007)

Will Riverbend look at Field Locator 69  since its going in the admitting diagnosis field to meet medical necessity on diagnostic outpatient testing as a reason the physician’s ordering the test?   

The system doesn’t look at this field but uses the medical records to determine medical necessity. If the coding without Field Locator 69 doesn’t support medical necessity you will have to appeal these claims for consideration. Riverbend will look into updating the system to look at that locator for medical necessity since this is referenced in the OCE specifications. (12/13/2007)

What drugs are separately billable and not included in the composite rate for a hospital based End Stage Renal Disease (ESRD) facility?

According to the CMS Internet Only Manual, Publication 100-4, Claims Processing Manual, Chapter 4 Outpatient ESRD Hospital Independent Facility and Physician Supplier Claims, Section 50.2, Drugs and Biologicals Included in the Composite Rate, certain drugs used in the dialysis procedure are covered under the facility composite rate, and may not be billed separately.  Drugs that are used as a substitute for any of these items, or are used to accomplish the same effect, are also included in the composite rate.  Self administered items are not covered under the Medicare program with the exception of EPO.

There is a paragraph in the Benefit Policy Manual, Publication 100-02, Chapter 11, Section 30.4.1., that includes separately billable drugs, and these include antibiotics, (Hinlatinux), anabolics, muscle relaxants, analgesics, sedatives, tranquilizers, and thrombolitics used to de-clot central venous catheters.  These may be billed by the facility if they are actually administered in the facility by the facility staff. (12/13/2007)

If a patient goes to an acute facility for 24 hours for an outpatient service during an inpatient rehabilitation stay to receive a pacemaker and then returns to the inpatient rehabilitation facility for the remainder of the stay, does the facility bill separate visits or do they combine the claims and bill all services on one claim?

In the Medicare Benefits Policy Manual, 100-2, Chapter 6, Section 110.3, states in all hospitals, every service provided to a hospital inpatient other than those listed must be treated as an inpatient hospital service to be paid under Part A, if Part A coverage is available and the beneficiary is entitled to Part A.

Exclusions to those services were the influenza, pneumococcal and Hepatitis B vaccine and their administration; the screening mammography, the screening PAP smear pelvic exam, colorectal screening, prostate screening, bone mass measurements and diabetes self management training services. (12/13/2007)

If the patient is in an acute hospital stay, left and was admitted into a Skilled Nursing Facility (SNF) for one day, then transferred back and admitted to the hospital as an inpatient, were they to combine claims or split the inpatient hospital claim? 

In Medicare Claims Processing Manual Publication 100-4, Chapter 3, Section 40.2.6, a beneficiary can not be an inpatient of two institutions at the same time. Since the patient was admitted as an inpatient in the SNF, the hospital would submit two separate claims for two separate DRG payments and the SNF submits a claim for one day. (12/13/2007)

Does the Medicare 24-Hour rule apply in the one-day SNF example listed in question number 5?

Per Medicare Claims Processing Manual Publication 100-4, Chapter 3, Section 40.2.5, when a patient is discharged/transferred from an acute care Prospective Payment System (PPS) hospital, and is readmitted to the same acute care PPS hospital on the same day for symptoms related to, or for evaluation and management of, the prior stay’s medical condition, hospitals shall adjust the original claim generated by the original stay by combining the original and subsequent stay onto a single claim. In the example given, the patient was transferred to a SNF and did not return on the same day so the claims would not be combined. (12/13/2007)

If a SNF patient is admitted under a Primary No Fault Insurance policy, and several days after the admission into the Medicare Part A stay, the primary exhausts the monetary benefit, are they to carry out a 90-day assessment that was began upon admission to be used through the end of the benefit period? 

There are two MSP scenarios when dealing with No Fault Insurance policies when primary to Medicare. One is if the primary policy pays for a certain set of days, and the other one is if the primary pays for a certain dollar amount.  If the primary payer reimburses a certain set of days, begin the patient’s assessments on the first covered day after the primary policy benefit days exhaust.

For the primary policy with a dollar limit, Medicare will be reimbursing and counting the patient days according to the MSP Pricer. To estimate the days Medicare will begin using and when assessments would begin, you will need to calculate the claim payment prior to submission or monitor what the primary is paying where you may get a good estimate of when benefits will pick up within the 8 days required for the 5 day assessment to receive the maximum reimbursement for the level of care you're providing your beneficiary. Eight days includes the five-day assessment with your three-day grace period. Keeping open communication with the primary payer will be vital to see how closely benefits are to exhaustion.

The Claims Processing Manual Publication 100-4, Chapter 6, Section 30.1, lists the assessment indicators; they're called “Special Payment Situationâ€� indicators, for the 5, 14, 30, 60 and 90-day assessments that you may have missed.  (12/13/2007)

How can I be sure that a line item on a chemotherapy claim for consolidated billing claims were rejected or processed correctly?

In the Medicare Claims Processing Manual Publication 100-04, Chapter 6, Section 20.3, chemotherapy administration codes are included in SNF PPS payments when performed alone or with other surgery, but they're excluded if they don't have the same line item date.  If the line item date on your claim is not the same as your chemotherapy services line item date, the claim will process but the code will process as a line item rejections. (12/13/2007)

Why did we get line item denials for barium swallows, CPT 74230 on many of the October claims billed while using the new five-digit code 797.20, one of the new five-digit code extensions of the old 787.2 code and were no medical records requested?

We determined that when the ICD-9 updates were loaded for the Local Coverage Determinations (LCD) the edits did not update appropriately.  These have been reviewed and now have been corrected.   Any claims that were denied must be appealed. (12/13/2007)

Is there a place to see what has been manually keyed into DDE on a given day?

There is no reporting for claims entered into Direct Data Entry since this is considered “real time� adjudication. A suggestion would be to go into claims summary (screen 12) and check status location (S/LOC) SB2500 where those claims will reside until the batch cycle runs that night. (12/13/2007)

Where can I go to see the last 3 checks dates and dollar amounts?

The last three checks generated are listed in the Direct Data Entry (DDE) system in screen 01 titled Inquiries and then selection FI titled Check History. (12/13/2007)

How do we get a problem submitting electronic claims with the NPI under a sole proprietor resolved?

There are extensive problems with Rural Health Intermediaries experiencing problems with clinics that are defined as a sole proprietor in regard to the clinical crosswalk. We’re having regular conversations with CMS they are working to correct the crosswalk process to get those NPIs on there. We are unable to resolve the issues until further assistance from CMS. They are aware of our urgency to correct this issue. (12/13/2007)

If procedures therapeutic simulation planning (77290) 3-D dimensional planning (77295) are performed on the same day and they have an (NCCI) there, then the services should not be billed together.  However, these procedures are not always performed on the same day, and based on medical necessity, the physician may come back a couple of days later upon review of the first studies and order the 3-D.  These procedures are being billed separately since they are performed on different dates of service and are being denied. Is this correct?

Riverbend is using internal criteria to review those claims since many times documentation of a simulation supports the service was done specifically to facilitate the 3-D images. The facility is paid for the simulation planning (77290) when paid for the 3-D simulation (77295) even if they were performed on a different date of service.

We are currently reviewing the policy on this but for now facilities will not be reimbursed for simulation planning (77290) since they are getting the whole payment under HCPCS 77295.   Riverbend will be publishing an article in the January 2008 Medicare Review Quarterly Round the Bend regarding 3-D simulation services. (12/13/2007)

If a physician of a Rural Health Clinic sees a patient in the clinic, and then is admitting the patient to the hospital for an inpatient stay on that day, can the office visit be billed?

The office visit for that day can be billed to the Fiscal Intermediary since the patient was seen in the clinic. If the physician sees the patient during the inpatient stay, the provider will bill the visit to the Part B Carrier. (12/13/2007)

Can a physician bill a RHC office visit when he/she sees their spouse that has Medicare?

Medicare does not allow reimbursement for services to immediate family members. (12/13/2007)

When is Riverbend going to update the DDE system to enable the provider to see all of the diagnosis codes that are on a UB-04? 

This has been an issue before the UB-04 was implemented because the electronic claim can hold more than nine diagnosis codes and six procedure codes as listed in DDE. Riverbend runs a standard system that is overseen by CMS which we call FISS. It is a FISS standard system, and at the time that the UB-04 was implemented, FISS was not instructed by CMS to expand the claim record, so at this point, there is no estimated time of resolution.  Once CMS makes the decision to expand the FSS claim system, then they will start programming it to expand and accept more coding than what is displayed at this point. (12/13/2007)

How do we submit a no-pay claim for SNF services when the patient is enrolled in an HMO if we do not have a Medicare HIC number?

Since a Medicare Beneficiary has to be enrolled in both Part A and Part B to enroll in a Medicare HMO replacement policy, you will have to obtain a copy of a their original Medicare card from the patient to bill the no-pay claims. (12/13/2007)

Are swing bed visits billed to Riverbend?

Yes swing bed visits are processed by Riverbend. (12/13/2007)

If a provider is having problems submitting their Medicare Secondary Payer (MSP) claims electronically can they send them hard copy?

You may send those claim hard copy temporarily while resolving the electronic issue. However, you can submit the claims through the DDE system and they will be processed under the 14 day payment floor guidelines as opposed to the 29 day payment floor for hard copy claims. (12/13/2007)

If a patient is covered by an employer who has less than 100 employees and the primary insurance retracted their payment stating Medicare is primary but the CWF still states that the other payer is primary, where do we go with information?

The provider is to contact the Coordination of Benefits Contractor at 800-999-1118 to have the CWF updated to show Medicare as the primary payer. The caller may want to be prepared to fax documentation to verify the employer has less than 100 employees. The following link refers to an MSP Fact Sheet with information facilities can incorporate in their offices to assist with Medicare Secondary Payers. (12/13/2007)

Are there modifiers beyond the normal to indicate outpatient lab work, such as specimen only services?

No. There are no modifiers to indicate specimen only services. Medicare claims Processing Manual, Chapter 16 pertains to laboratory services. Also see Change Request 5573 for the new date of service policy guidelines.

Do laboratory services go on another type of bill besides 141?

There are no special coding requirements for lab services. Please review Change Request 4208 for instructions on type of bill 14X for non-patient laboratory specimens.

The transmittal for the new UB-04 requirements state that a diagnosis code is not required for specimen lab work. Can you clarify?

Diagnosis codes are required on all Medicare claims to Riverbend. This example may apply to other payers.

Are the tests not subject ot medical necessity eidts?

Laboratory service claims are subject to medical necessity edits.

What documentation is required for the hospital to submit if we get an ADR?

The required documentation will depend on the edit the claim receives in the system and will be listed on the ADR. At the very least, you will have to provide Physician's orders and the lab results submitted for review.

Do we need to have a signed physician's order or is the printed electronic order sufficient since we usually have an electronic requisition ordering the test, the MD name, the diagnosis code, etc.?

This signature may be affixed electronically or manually to the orders.

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