Riverbend

Questions from Workshops

Is alcohol counseling, where we are assisting patients off the drug, covered under the RHC benefit?

This is not defined in the CMS Manual as a covered RHC service. Only psychiatric one-on-one therapy services are defined as covered therapy/counseling services when performed by a clinical psychologist, or clinical social worker during which an RHC/FQHC service is rendered. (03/18/2008)

Why would a denied claim, that was overturned by Maximus, deny other charges that were not initially denied?

The claim may have returned due to a coding edit. It may have then been appended with a code and the claim was actually denied in clinical audit, because the code was not appropriate. Also, the code may not have been appended and then additional information was added to the appeals process for the CAH. These would need to be reviewed on a claim by claim basis. (03/18/2008)

Is there a place where all edits or reason codes are listed? How do we know if a claim is going to RTP versus reject and deny?

There is a Reason Code tool on our website at www.rgbagov.com/tools and also by depressing F1 in the Direct Data Entry System within the claim. These can also be found on www.wpc-edi.com. RTP'd claims are considered a "face of the claim" error or consistency error. Those claims are returned and this gives the provider the ability to correct the errors. All others will reject and have to be re-billed or adjusted. They may also medically deny and have to be appealed through medical review. (03/18/2008)

Will the Medicare outpatient code editor ever review the diagnosis codes in the 3 'reason for visit' fields on the UB-04, to look for diagnosis codes that are listed in the LCD/NCD to support medical necessity?

Per the OCE specifications, diagnosis codes apply to the whole claim and are not specific to a line item (left justified, blank filled). The first listed diagnosis is considered 'patient’s reason for visit dx'. The second diagnosis is considered 'principal dx’. For Automated Medical Review, Riverbend utilizes an Expert Claims Processing System (ECPS), which is an independent automated system designed to make certain decisions for identified claims using pre-determined criteria as outlined by CMS guidelines. For Medical Review purposes, EPCS events are generated from Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs). If you have billed a diagnosis code in the first diagnosis field and it was rejected through our automated edits, this will need to be researched further for resolution. (03/18/2008)

We have a patient within the ER, who went straight from the ER to the cardiac cath lab. From the cardiac cath lab, they de-compensated, put in an assist device, which is inpatient only, and was transferred from the lab to another facility, which has an open heart unit. We submitted the claim with modifier CA on the inpatient only claims to receive payment. Regulation from Medicare states there is coverage when the patient dies during or after the procedure before being admitted, or when the patient survives the procedure and is transferred following the procedure. Can you advise when the patient didn’t expire?

CMS Manual System DHHS Pub 100-04 Medicare Claims Processing CMS Transmittal 784 Date: DECEMBER 16, 2005 Change Request 4238 SUBJECT: January 2006 Outpatient Prospective Payment System Code Editor (OPPS OCE) Specifications Version 7.0 Page 9 “For outpatients who undergo inpatient-only procedures on an emergency basis and who expire before they can be admitted to the hospital, a specified APC payment is made to the provider as reimbursement for all services on that day. The presence of modifier –CA on the inpatient-only procedure line assigns the specified payment APC and associated status and payment indicator to the line. The packaging flag is turned on for all other lines on that day. Payment is only allowed for one procedure with modifier -CA. If multiple inpatient-only procedures are submitted with the modifier –CA, the claim is returned to the provider. If modifier CA is submitted with an inpatient-only procedure for a patient who did not expire (patient status code is not 20), the claim is returned to the provider. ”Medicare Claims Processing Manual Chapter 4 - Part B Hospital (Including Inpatient Hospital Part B and OPPS) 20.6.7 - CA Modifier (Rev. 1, 10-03-03) Definition: Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission. (03/18/2008)

Can Rural Health Clinics bill allergy injections for patients? Would flu shots and pneumonia shots would be exempt?

RGBA will reimburse for allergy injections if included with a face to face encounter. Since a physician is not required to administer, they can not be billed as an encounter.  Face to face may be either 30 days prior to or 30 days after the injection.  Yes, flu and pneumonia shots remain non billable, and should be sent with your year end cost report.  The reason they are not billed on a UB04 is because they’re not subject to deductibles and co-insurance.  (03/18/2008)

What codes are suggested by Riverbend to use for wheelchair positioning when field intervention is required to identify the need for individual residents for the positioning with specific diagnosis?

There is actually no benefit for the code. Riverbend does not interpret the code for wheelchair positioning;  We interpret that code as educational only, with use for the code if you are providing some education to a patient that will be actually using the wheelchair, how they propel the wheelchair, for example. You can not use it for evaluations to order the patient a wheelchair, positioning the patient, ordering additional wedges, or those types of equipment. These are not payable through Medicare if a therapy is not required to position the patient into the wheelchair.  There is an article we have published in the Medical Review Quarterly regarding our policy on the wheelchair management code. (03/18/2008)

Why are EMG claims returning with code 95961, which is EMG-F2 extremities, that are coded 95903, nerve conduction/motor wave form? The claim is billed with seven units since there are seven nerves being tested on two extremities. The code 95903, nerve conduction amplitude of latency, motor nerve with F wave study is being used.

The EMG codes do have MUE edits and can only be reported at that maximum (noted in Appendix J of the CPT book).  If you have separate locations, such as the upper extremities and lower extremities, and different diagnoses, you should report each separate location as one line item with that appropriate number of studies provided.  If the same study is provided at both locations, you will need to append the modifier 59 to the second line item with the same CPT code. Carpal Tunnel syndrome (one upper extremity), CPT code 95903 X 3 (for three nerve conduction studies performed) Tarsal Tunnel syndrome (one lower extremity), CPT code 95903 – 59 X 4 (for four nerve conduction studies performed) (03/18/2008)

 

We need to know how we are to file the Self Administrated Drug charges.  Are these charges the responsibility of the patient?  If so how do facilities file them (under what revenue code?) so that the charges reflect the patient’s responsibility on our remits? 

Per IOM 100-1 Benefit Policy Manual, Chapter 15, Section 50.5, Medicare Part B does not cover drugs that are usually self-administered by the patient unless the statute provides for such coverage. These drugs billed as non-covered charges under revenue code 0637 and are statutorily excluded and should be considered non-covered charges on the claim and the remittance. (03/18/2008)

We have been unable to get claims paid due to non-matching NPI information.  The claims are being accepted by Blue Cross but are being rejected by Riverbend when they receive them from Blue Cross. Will it be possible to get an interim payment until it is resolved?

Per Medi 3040-07, as of 01/01/08, Providers, except DMEPOS suppliers, are no longer required to submit to the Medicare contractor a copy of the NPI notification received from the National Plan and Provider Enumeration System (NPPES), unless requested to do so by the contractor. Similarly, if the provider, except DMEPOS supplier, obtained the NPI via the Electronic File Interchange (EFI) mechanism, the provider need not submit a copy of the notification received from the EFI Organization (EFIO), unless requested to do so by the contractor. If paper documentation of a provider’s NPI is requested by the contractor, the contractor may accept a copy of the provider’s NPI Registry’s Details Page in lieu of a copy of the NPI notification. No payment can be made without resolution to the NPI data. (03/18/2008)

What is the status of the Highmark contract?  Is it still being disputed?  If so when can we expect an answer?

Please go to www.cms.hhs.gov/MedicareContractingReform/ for information on MAC bids and their status. On October 24, 2007, CMS awarded the contract for the Jurisdiction 12 (J12) A/B MAC to Highmark Medicare Services, Inc. (HMS).  J12 includes the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania.  On November 5, 2007, Palmetto GBA filed a protest against the award with the Government Accountability Office (GAO).  CMS notified GAO that the agency will be taking corrective action on certain aspects of the award decision.  The result of this corrective action is that the original protest has been dismissed by GAO.  The awarded contract (to HMS) is under a stay of performance until the agency completes its corrective action.  The corrective action is underway and CMS will update the MCR website upon completion of the corrective action. (03/18/2008)

Per Medlearn Matter SE0801 regarding Discharge Status Codes, states the new code 09 "Admitted as Inpatient to this Hospital" is only for use on Medicare outpatient claims and applies only to those Medicare outpatient services that begin greater than three days prior to an admission. What circumstances would you use that code on an outpatient claim?

Medlearn Matters Article SE0801 titled “Clarification of patient status 09” applies to those Medicare outpatient services that begin greater than the three days prior to an admission.  If the patient came in for outpatient services five days before they had an admission, then append this code to the claims. (03/18/2008)

 

When will you accept NPI only claims for testing?  We need a bulletin stating you will accept claims before the “go live” date of 5/23/2008 for testing so our Billing Vendors can remove their edits to require the legacy Provider Transaction Access Number (PTAN).

We will accept NPI only claims for testing. We have an Announcement on our website advising providers what to do if their NPI is not processing. We suggest you send a small batch of one or two claims for NPI testing to make sure they process correctly before sending all of your claims in this format. Please contact Ecommerce at 423-535-5717 for assistance with claims batch submission issues. (03/18/2008)

How long does a provider have to do an MDS correction? Is the timeframe different for an “over” billing correction as it is for an “under” billing correction? Are you allowed to change the ARD date if the MDS was transmitted but not billed yet? Are you allowed to change the ARD if the MDS was billed already?

Per RAI Manual CH 2, A Significant Correction of a Prior Full assessment (SCPA) must be completed within 14 days of the identification of the error. Per CH 5 of the RAI Manual, amendments may be made to the electronic record for any item during the encoding period, provided the amended response refers to the same observation period. Any discrepancies must be corrected in the computer file during the 7-day encoding period. (03/18/2008)

When a Critiacl Access Hospital (CAH) hospital transfers (from the ER, same day) a patient to a hospital that owns the CAH would the 72-hour or any other rule apply to the hospital that owned the CAH for blending purposes and would the CAH then not bill for the services received at the CAH? OR Since the 72-hr rule does not apply to CAHs would that be true in any and all transferred CAH cases to the hospital that owned them.

Per IOM 100-4, CH 3 Inpatient Hospital Billing, Section 40.3(B) states "Diagnostic services (including clinical diagnostic laboratory tests) provided to a beneficiary by the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital (or by another entity under arrangements with the admitting hospital), within 3 days prior to and including the date of the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment, unless there is no Part A coverage.However, Section 30.1.1 states "CAHs are exempt from the 1- and 3-day window provisions, services rendered by a CAH to a beneficiary who is an outpatient prior to that beneficiary’s admission to the CAH as an inpatient, are not bundled on the inpatient bill. Outpatient CAH services must be billed as such and on a separate bill (85x TOB) from inpatient services. Outpatient services rendered on the date of admission to an inpatient setting are still billed and paid separately as outpatient services in a CAH. (03/18/2008)

If a patient is readmitted within 30 days to the same hospital with the same condition, does the claim "automatically" need to be combined?

Per IOM 100-4, CH 3 Inpatient Hospital Billing, 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. Per section 40.2.6 states "Where a patient on leave of absence from a non-PPS hospital who was shown as "Still Patient" (patient status code 30, FL 22) on an interim bill; has not returned within 60 days, including the day leave began, or has been admitted to another institution at any time during the leave of absence, submit an adjusted bill. The hospital shows the day the patient left the hospital as the date of discharge. (A beneficiary cannot be an inpatient of two institutions at the same time.) Acute Inpatient PPS hospital stays do not have an "interrupted stay" policy but are considered Leave of Absences and should be billed per the above instructions. Per Section 190.7.1 for Inpatient Psychiatric Facilities, an interrupted stay is where a patient is discharged from an IPF and is readmitted to the same or another IPF before midnight on the third consecutive day following discharge from the original IPF stay. Section 190.10.7 provides specifics for billing the IPF interrupted stay. For the Interrupted stay policy for LTCH PPS, please see section 150.9.1.2. For IRF PPS, please see section 140.2.3. (03/18/2008)

 

Some users are bumped completely out of the system when they are in the T location fixing claims and F9 the system takes the user out completely and they have to put your Provider Transaction Access Number (PTAN) in again and it then brings you to the first page even if you may have been on page 6.

This is as a result of the transition to Companion Data Center (CDC) as announced by Riverbend in Medi-letter 2959-07 dated 2007-08-06 (03/18/2008)

 

Where can I get the basic training or reference material for no-pay billing in writing?

Please see IOM 100-4, CH 6 SNF Inpatient Part A Billing, Section 40.8 titled "Billing in Benefits Exhaust and No-Payment Situations" on the CMS website at www.cms.hhs.gov. This will include definitions, an outline and a Quick Reference Chart. There are also specifics to billing no-pays on this website in the EducationCenter. (03/18/2008)

 

Where can Riverbend Webinars be accessed after the presentation has taken place? How soon after the presentation is the PowerPoint available for facilities to access?

The Webinar material is made available to the provider community in the Education Center at www.rgbagov.com within 5-7 business days from the day it is completed. (03/18/2008)

How would we be able to research the number of allowable units for any given procedure code should we wish to research this when claims are returned to the provider (RTP’d)?

Medically unlikely edits (MUEs), are not published by CMS at this time. We do not have a file that can be read to see what the edits are.  We receive a file that is in computer language, and cannot be converted to readable text.   However if your claim is Returned because the units do not coincide with the long descriptor of the HCPCS/CPT code, then you should review the complete descriptor of the code published in the HCPCS book or CPT book to see the long descriptor which would include applicable one unit equivalents.  These long descriptors should be used to calculate the appropriate units for drug and/or service. (03/18/2008)

 

When must readmissions to the same hospital facility within 24 - 72 hours be combined?

Per IOM 100-4, CH 3 Inpatient Hospital Billing, 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. Per section 40.2.6 states "Where a patient on leave of absence from a non-PPS hospital who was shown as "Still Patient" (patient status code 30, FL 22) on an interim bill; (1) has not returned within 60 days, including the day leave began, or (2) has been admitted to another institution at any time during the leave of absence, submit an adjusted bill. The hospital shows the day the patient left the hospital as the date of discharge. (A beneficiary cannot be an inpatient of two institutions at the same time.) Acute Inpatient PPS hospital stays do not have an "interrupted stay" policy but are considered Leave of Absences and should be billed per the above instructions. Per Section 190.7.1 for Inpatient Psychiatric Facilities, an interrupted stay is where a patient is discharged from an IPF and is readmitted to the same or another IPF before midnight on the third consecutive day following discharge from the original IPF stay. Section 190.10.7 provides specifics for billing the IPF interrupted stay. For the Interrupted stay policy for LTCH PPS, please see section 150.9.1.2. For IRF PPS, please see section 140.2.3. (03/18/2008)

 

Is it still appropriate to code the first diagnosis as preoperative with reasons for the operation as well as the underlining conditions the patient may have when billing for preoperative consultations and regular physicals for rural patient?

The provider should append the appropriate diagnosis code for the pre-op services. The 2nd diagnosis would probably include the reason for the preoperative service. (03/18/2008)        

When a patient presents with a physical but the chronic conditions were also addressed, do we code the V700 plus HTN and IDDM or just the chronic condition?

The routine physical is considered a statutorily exclusion.  If other "covered services" were also discussed and evaluated during the face to face encounter, a separate billing to Riverbend should be submitted to obtain payment for the "covered" services that were performed. If possible, do not submit both claims on the same date, or within the same batch. (03/18/2008)   

Would you please review skilled care guidelines for a free standing rural health clinic when a provider examines a SNF patient in a hospital SNF bed and nursing home SNF bed. Can you provide clarification on whether these are billed to Part A Riverbend, Part B or directly to hospice?

If a patient is in a SNF Part A stay (no matter the location) you may bill the visit as an RHC encounter to Riverbend.  For Hospice patients, you will need to append a 07 Condition code to your claim. (03/18/2008)

 

When our provider sees a hospice patient at the clinic, hospital hospice bed, nursing home or home, does the guidelines specify if a provider is the hospice medical director? We were previously told all hospice patients seen at the clinic go to Riverbend regardless if related to terminal condition or not. Are the inpatient hospice claims to go to Part B or can the hospice be billed? Where do we bill nursing home hospice patients or home hospice patients when our provider goes to their location?

If the hospice patient is seen in the RHC, the services are billed to Riverbend with a 07 condition code. This ONLY applies to RHC providers due to the reimbursement method Medicare provides for those services.  RHCs do not have the option of billing services provided during RHC hours to Part A or Part B unless the Medicare guidelines specify the billing of those services.  All covered RHC services performed during RHC hours (at the Clinic, NH, or Patients "Home") are billed to RGBA along with the face to face encounter, with the exception of the Technical Components, and Lab charges.  Technical and Laboratory services are to be billed to the Part B Carrier. (03/18/2008)

 

Can outpatient services be done while patient is in a rehabilitation stay if the facilities are owned by the same company but have separate Provider Transaction Access Numbers (PTAN)? Example: Wound care services that are offered to patients in rehab – Can the doctor bill for consultations and services?

Per IOM 110-4, CH 5, Section 10, Payment for rehabilitation services provided to Part A inpatients of hospitals or SNFs are included in the respective PPS rate”. If you are referring to Outpatient Services that are considered inpatient based on a 3-day payment window, IRF PPS providers are not subject to the 3-day payment window (72-hour rule) for preadmission services, but are subject to the 1-day payment window (24-hour rule) for preadmission services. For this regulation IOM 100-4, CH 3 Inpatient Hospital Billing states "An entity is considered to be "wholly owned or operated" by the hospital if the hospital is the sole owner or operator. A hospital need not exercise administrative control over a facility in order to operate it." In this case, the outpatient services would be included in this other facility since its considered "wholly owned" by the hospital. (03/18/2008)

 

Can a radiologist performing outpatient diagnostic services at a hospital change or supplement the test originally ordered by the treating physician without obtaining an order from the treating physician? The Conditions of Participation do not appear to directly address this. 42 CFR 482.26 (b) (4) indicates that "services must be provided only on the order of practitioners with clinical privileges or, consistent with State Law, of other practitioners authorized by the medical staff and the governing body to order the services."

Riverbend’s interpretation of this subject has not changed. Riverbend maintains the policy that all hospital services must be medically necessary and be ordered by the patients treating physician who has knowledge of the patient’s illness and/or the patient’s medical history to make informed medical decisions regarding the appropriate services to be provided.   Any treating physician, including a radiologist, may order tests.  Medical necessity does not extend to interpreting physicians since they lack both the clinical information and more importantly, the doctor patient relationship.  For example, any radiologist who sees a patient, obtains any necessary history and supplemental physical findings, informs the patient of the tests, risks, benefits, costs, obtains the explicit or tacit consent of the patient, and assumes medico-legal liability for follow-up will be considered to be a treating or consulting physician and may order medically necessary tests.  Absent this doctor-patient relationship, the physician will be considered to be an interpreting physician and tests will be considered not medically necessary. (03/18/2008)

 

What are the instructions for submitting no-pay/information only claims to record cost report days for beneficiaries who have chosen Medicare Advantage plans and who are also SSI eligible.

Please see Transmittal 1311, Change Request (CR) 5647 for extensive details on capturing the Medicare Advantage days. This CR instructs all non-teaching hospitals (including IPPS, IRFP PPS, AND LTCH PPS) to bill covered claims with condition code 04 and teaching hospitals to bill as usual with condition codes 69 and 04. For SNF billing you can review Transmittals 1290 and 1394, as well as Change Requests 5653 and 5840 that include submitting covered claims with condition code 04. (03/18/2008)

How do we bill claims for patients with open Workers Compensation and Liability records when the services provided are not related to them?

The provider should submit a claim as Medicare Primary with occurrence code 05 and the “From” date of the claim as well as remarks stating the reason for the patient's visit. See our MSP helpful tips for further instructions. (03/18/2008)

How do we bill when a patient is admitted into the hospital for 7 days and under hospice care for the first 3 days but the last 4 days are Medicare’s responsibility?

Per IOM 100-2, CH 9, Coverage of Hospice Services under Hospital Insurance, Section 20.2, states “Upon revoking the election of Medicare coverage of hospice for a particular election period, an individual resumes Medicare coverage of the benefits waived when hospice care was elected. If a patient is enrolled in hospice upon admission to the hospital, and the patient's hospice revocation becomes effective prior to discharge, the hospital claim to Riverbend GBA must indicate the first day of traditional Medicare as both the admission and "from" date on the UB-04. (03/18/2008)

 

According to the CMS instructions laid out in Transmittal 1252 CR 5583, dated 05/25/07, on the UB-04, when we submit benefits exhaust bills, we indicate the skilled level of care the individual is receiving by a 213 bill type, and that they are still residing on the certified portion of the facility by a 30 in FL 17. When an individual has exhausted their 100-day benefit and remains in the Medicare certified portion of the facility at a non-skilled level of care, a no-pay bill is submitted that is indicated by a type of bill 210 with a 30 in FL 17. In this case, would the individual who is no longer receiving a skilled level of care while residing in the Medicare certified portion of the facility for 60 days, renew the 100-day benefit since the individual would have had 60 days at a non-skilled level of care?

The Transmittal 1252 Change Request 5583 is regarding corrections to no-pays for Medicare Advantage patients, the SNF Spell of Illness Quick Reference chart as well as the 210 no pay bills that overlapped the 22X part B bills. Per IOM 100-4, CH 6 SNF Inpatient Part A Billing, Section 40.8: In addition, SNF providers must submit no-payment bills for beneficiaries that have previously received Medicare-covered care and subsequently dropped to a non-covered level of care but continue to reside in a Medicare-certified area of the facility. It goes on to state "This applies even when a resident receives the therapy during a non-covered stay in which the beneficiary who is not eligible for Part A extended care benefit still resides in an institution (or part thereof) that is Medicare-certified as a SNF." It lists under #2, "SNF providers shall submit no-payment claims for beneficiaries that previously dropped to non-skilled care and continue to reside in the Medicare-certified area of the facility using the following options." AND "In these cases, the provider must only submit the final discharge bill that may span multiple months but must be as often as necessary to meet timely filing guidelines”. The timely filing guidelines would not arise if the situation stated in the question were accurate. There is also no mention of only a 60 day no-pay claim. The SNF Spell of Illness Quick Reference Chart states as well that for patients that are "Not Medicare Skilled" to "Do not submit claim if pt came in non-skilled. Otherwise, submit no-pay claim w/ discharge status code when patient leaves the certified area."  (03/18/2008)

We have been using modifier QR for billing certain CT/PET studies that are being performed and approved through the National Oncological Pet Registry. Change Request 5805 advised that effective January 1, 2008, modifier Q0 should be used instead of QR to show that the exam is part of a Medicare specified study through the NOPR. The change request further advises that while this change is effective January 1, 2008, it must be implemented by contractors by April 7, 2008; and providers were advised to check with their contractors to see exactly when they were implementing the change. Please advise if you have already implemented this change, or if not, when you expect to do so.

With the implementation date is 04/07/08, the system changes will not be in place to allow the new modifiers until 04/07/08. If the new modifiers are used now, the claims will not process. Please check with the pet registry for their modifier requirements. (03/18/2008)

 

Is there an appropriate code to describe accessing an implanted port to draw blood for lab work when the laboratory studies are the only service the patient receives on an outpatient visit? Patients with venofibrosis due to long term illnesses may have difficulty or an impossibility to stick for blood, and therefore, they may have an implantable port that is accessed for the blood sample. Has CMS established an appropriate outpatient code and payment for accessing a port for blood sampling purposes only. What CMP/HCPCS code, in addition to the lab codes, would be correctly applicable and payable under OPPS for obtaining the blood sample from the port?

For CY 2008 AMA created three new codes that pertain to this question.  These were developed to capture broader methods of collection or declotting. Code 36591 is “Collection of blood specimen from a completely implantable venous access device”.  Under OPPS this code has a status indicator of Q which means when medically necessary it may be paid when reported with no status "S" or status "T" services. It will be packaged into payable services on the same date with a status "S" or "T".   Code 36592 is “Collection of blood specimen using established central or peripheral catheter, venous, not otherwise specified”.  For OPPS this code has a status indicator of "N" and therefore will always be packaged into other payable services.   CMS has given instructions in the 2007 OPPS final rule stating that services that are packaged should be reported on claims even if they are the only service reported and no payment is made to the provider.  It is not appropriate to report a low level E&M code for this service as no E&M service took place. The third new code is CPT 36593 “Declotting by thrombolytic agent of implanted vascular access device or catheter”. For OPPS this code has been assigned a status indicator of "T" and when medically necessary will be payable under APC 676 at the rate of $158.11. (03/18/2008)

What is the cut off date for accepting provider/legacy numbers as well as NPI numbers?

Claims with only legacy identifiers in the primary provider fields were rejected as of March 1, 2008. If the claim contains a legacy identifier in any field, it will be rejected as of May 23, 2008. (03/18/2008)

We have claims that are being scanned incorrectly.  Some will go fine, but others are shifting the dollar amount for the primary payments (Box 39 on the UB04) making the paid amount incorrect.  E.g., Primary paid $52.00; Riverbend will process as primary paying $5.20 instead.  What can be done on Riverbend’s side to be consistent?

This issue was related to “misreads” with the old software. It had been tuned to get accurate reads on as many claims as possible, but there were some that would be printed a bit too far left or right and the charge fields would be read incorrectly. In December we implemented new technology that greatly improved the read accuracy in the OCR system.  If this issue happens again we need to be notified as soon as possible by way of Customer Service. (03/18/2008)

Who do we contact when we get different answers from Customer Service Representatives?

We would like to emphasize that responses are tailored to the questions asked. However, if you receive conflicting information from one of our Service Representatives at Riverbend, please ask to be referred to the Team Leader or Supervisor. This is, and has been our policy at Riverbend.  The Service Representatives are aware that callers have that option, and should not be offended by the request.  If the caller does not take that action, we have no way of knowing that the situation occurred, and can not provide training when appropriate.  We do, however, need to be made aware at the time of the occurrence, so the appropriate action can be taken.  (03/18/2008)

What happens when we have a paid inpatient claim and there has been a DX/DRG correction by our coding department and it is past the 60 day time limit for corrections? Do we do an adjustment online to indicate that a correction was made or appeal with medical records to prove what changes were made? If we do not adjust or appeal, would it be a strike against us if we were to be audited and DX or DRG does not match what was submitted?

Per IOM 100-04, CH 3 Inpatient Hospital Billing, Section 50.1: When a bill is submitted and the hospital of the FI discovers an error, the hospital submits an adjustment request if the error is a change in the days, blood deductible, inpatient cash deductible, servicing provider, discharge status in a PPS hospital, diagnosis codes or procedure codes that impact the assigned DRG code or outlier payment amount. It states the provider submits most adjustment requests as debits, using bill type XX8. CMS assumes you will be cancelling and rebilling the claims. Please note that any re-billed claim will be subject to the timely filing guidelines. However, if you choose to adjust the claim using a type of bill XX7, per Section 50.2, "if an adjustment the provider initiates results in a change to a higher weighted DRG, the FI edits the adjustment request to insure it was submitted within 60 days of the date of the remittance for the claim to be adjusted. If it is, the FI processes the claim for payment. If the remittance date is more than 60 days prior to the receipt date of the adjustment request and results in a change to a lower weighted DRG, the FI processes the claim for payment." (03/18/2008)

When a patient is admitted to a Skilled Nursing Facility under a Medicare Advantage policy, the physician certifications are started (admission, 14 day, 30 day, and etc).  If a patient is admitted originally under a Medicare Advantage product and then elects to return to traditional Medicare coverage, does the SNF continue on the same cert schedule?  For example, if the admission, 14 day and first 30 day cert were done while under Medicare Advantage, when the patient switches to traditional Medicare will the SNF continue with another 30 day cert when it is time to do so or does the SNF start the cycle all over again when the patient switches to traditional Medicare?

Per the Medicare Per IOM 100-4, CH 6 SNF Inpatient Part A Billing, Section 30.1: In some situations, beneficiaries may change their payer source after admission, but fail to notify the provider in a timely manner, e.g., dis-enrollment from an MA, dis-enrollment from a hospice, change in a Medicare payer status from secondary to primary, etc. In these cases, the provider may not have completed the RAI assessments needed for Medicare billing. New AI codes were established for these special payment situations.  The RAI Manual, CH 2 The Assessment Schedule for the RIA, states "In most cases, the first day of Medicare Part A eligibility is also the date of admission. However, there are situations where the Medicare beneficiary may only become eligible for Part A services at a later date." and  "When the Medicare Part A benefits resume, the Medicare schedule starts again with a 5-Day assessment, MDS Item AA8b = 1. The original date of entry (AB1) is retained. The beneficiary should be assessed to determine if there was a significant change in status. An SCSA could be completed with either the Medicare 5-Day or 14-Day assessment. (03/18/2008)

 

 

Has the requirement for the KX modifier been withdrawn or recalled for institutions and are providers required to determine medical necessity?

Please see the Medicare Claims Processing Manual Chapter 5, Section 10.2, Subsection C. 1. Exceptions to Therapy Caps - "Beginning January 1, 2007, there is no manual process for exceptions. All services that require exceptions to caps shall be processed using the automatic process. All requests for exception are in the form of a KX modifier added to claim lines. (See subsection C6 for use of the KX modifier.) Deletion of the manual process for exceptions increases the responsibility of the provider/supplier for determining and documenting that services are appropriate for use of the automatic exception process." (5/1/2007)

With Neulasta, should we use malignancy diagnosis and V58XX or should we use 288.0 for prophylactic to stop.

The ICD-9-CM codes were updated 9/4/06 to include changes for 2007. Code 288.0 was expanded to include five digits and the acceptable codes have been included in Riverbends LCD 13239. Review the new expanded codes acceptable for this LCD. The primary reason for the encounter should be the diagnosis used on your outpatient claims. (5/1/2007)

Is there a time limit for administering Aranesp after chemotherapy is stopped?

Aranesp is an erythropoetin analog and subject to all the conditions and limitation in LCD L1942 as well as subject to all the conditions and limitation of LCD 1938 (Epoetin Alfa) because the Epoetin LCD is the parent (controlling) LCD. The EPO LCD states EPO will be presumed to be necessary during an entire course of chemotherapy even if goals are met. However, EPO coverage will stop three months after cancer chemotherapy is discontinued even if those goals are met. Therefore, erythropoietin analogs will be subject to the same three month limitation. (5/1/2007)

When is certification required for ambulance transport?

We should not be asking for certifications for emergency transport.  The certification are only required if that is the only means of transport for the patient as a result of their condition and that means the physician is certifying that any other means of transport for the patient would not be appropriate. (5/1/2007)

What guidelines should be followed for documentation orders for Neulasta?

LCD 13239 does state the ASCO guidelines remain the de facto standard of unless specifically superceeded. The ASCO has updated their recommendations in 2005 for hematopoietic colony stimulating factors and these are considered the standard unless the Riverbend LCD specifically states otherwise. (5/1/2007)

Will a port flush on same date as other procedure be packaged, or only on same claim with other procedures?

CPT/HCPCS code 96523 (irrigation of implanted venous access device) is a "special" packaged code and will be packaged when reported on the same claim with other procedures on the same date of service. For CY 2007 a new category of "Special Packaged Codes" has been created. These codes will be paid separately when the codes appear on a claim with no separately payable OPPS services also reported on the same date of service. In all other circumstances the "special" packaged codes would be treated as packaged services. (5/1/2007)

Can you bill Type B codes for a designated area only open 8 hours per day? This space is maintained within a Type A licensed ED?

Yes, according to CMS Frequently Asked Questions regarding Emergency Department designation Type A or Type B. Question 5 states: "There is a separately identifiable area or part of a provider-based emergency department that closes at 10pm every evening, but is not integrated into the larger emergency department for the rest of the night. Under OPPS, is the entire emergency department treated as a Type B emergency departement, or just the section that closes at 10pm? Answer #5" Under Opps, it may be appropriate for a Type A emergency department to "carve out" portions of the emergency department that are not available 24 hours a day, where visits would be more appropriately billed with Type B emergency department codes. In that case, the "carve out" portion of the emergency department would bill Type B emergency department codes, while the other parts of the emergency department would bill Type A emergency department codes. Question #6: Under Opps, does a separately identifiable area refer to a physically separately identifiable area, or an area that is separately identifiable because of the process used to triage and/or treat patients? Answer #6: Separate identifiable area or part of a facility refers purely to physical location, rather than process used to triage and treat patients." http://www.cms.hhs.gov/HospitalOutpatientPPS/downloads/OPPS_Q&A.pdf (9/12/2007)

Please Clarify PEG tube "skilled service" since Peg tube feedings are considered under the list of skilled nursing services at what point does skilled tube feedings no longer be considered skilled?

It is true that a PEG tube can skill a patient for admission to a SNF. However, as with any condition of the patient, a facility should continously assess the patients continued need for skilled care. Debbie Coke has recently prepared an article that we will be publishing to our Web site discussing the continued skilled care for PEG tubes. Enteral feeding is considered to be a direct skilled nursing service to a patient if it comprises at least 26 percent of daily calorie requirements and provides at least 501 milliliters of fluid per day. However, this service alone will not support the patient receiving skilled nursing services indefinitely. The article will be published in May 2007. (5/1/2007)

We have codes that would be approved by our part B carrier for certain diagnoses; can these codes be added to Riverbend's LCD?

Use the LCD reconsideration process from the Riverbend website to request changes in any LCD.  (9/12/2007)