Rejected debridement claims should be
resubmitted
APCs Insider, August 23, 2013
Receiving a billing rejection can be frustrating, especially when you’re confident the
documentation supports the claim. In a recent case, the rejection may have been erroneous, and
affected providers are urged to resubmit those claims for payment.
CMS recently announced the rejection of outpatient hospital claims containing CPT® codes for
skilled nursing facility (SNF) consolidated billing (CB).
The rejected codes are:
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
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11042, debridement, subcutaneous tissue (includes epidermis and dermis, if performed);
first 20 sq cm or less
11043, debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous
tissue, if performed); first 20 sq cm or less
11044, debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle,
and/or fascia, if performed); first 20 sq cm or less
These rejections are occurring because the codes were not removed from the minor surgery
inclusion list in the 2013 SNF CB File for FI billing. CMS has instructed contractors to bypass
SNF CB common working file edits for outpatient hospital bill types 13x and 85x with dates of
service on or after January 1, 2013, when one or more of these CPT codes is present on the
hospital claim.
CMS recently added two new codes for payment of new brachytherapy sources for which source
codes have not yet been established:
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C2698, brachytherapy source, stranded, not otherwise specified, per source
C2699, brachytherapy source, non-stranded, not otherwise specified, per source
CMS will reimburse providers based on a rate equal to the lowest stranded or non-stranded
payment rate for such sources, respectively, on a per source basis.
Once CMS establishes a new HCPCS code for a new source, it will assign the new code to its
own APC, with the payment rate set based on external data and other relevant information, until
claims data are available for the standard OPPS rate-making methodology.
Updated Reason Codes for Medicare Conditional Payment Policy and Billing Procedures for Liability,
No-Fault, and Workers’ Compensation Medicare Secondary Payer Claims
See MLN Matters® Article #7355 for background on the clarification of Medicare Conditional Payment
Policy and Billing Procedures for Liability (L), No-Fault (NF), and Workers’ Compensation (WC) Medicare
Secondary Payer (MSP) Claims. Medicare Administrative Contractors/Fiscal Intermediaries (MACs/FIs)
have been directed to set reason codes 39071, 39072, and 39073 to suspend. In early October, the
following system changes will occur:
• Bypass claim level reason codes 39071, 39072, and 39073 for home health raps (322 and 332 types of
bills); and ensure these types of bills continue to receive an override of N and a non-pay code of Z.
• Cost avoid claims that receive reason codes 39071, 39072, and 39073 will be reprocessed through the
MSP drivers. Claims should cost avoid with the appropriate 34xxx MSP reason code, based on the MSP
info in CWF 03 trailer; to prevent looping to CWF.
• Modify the system to ensure condition code 15 applies to those claims meeting the criteria for
application.
Summary of Propsed rule
Payment of Drugs, Biologicals, and
Radiopharmaceuticals: For CY 2014,
proposed payment for the acquisition
and pharmacy overhead costs of
separately payable drugs and biologicals
that do not have pass-through status
would be set at the statutory default of
average sales price (ASP) plus 6 percent.
Packaging Proposals: The OPPS
packages payment for multiple
interrelated items and services into a
single payment to create incentives for
hospitals to furnish services in the most
efficient way by enabling hospitals to
manage their resources with maximum
flexibility, thereby encouraging longterm
cost containment. For 2014, we are
proposing to unconditionally package or
conditionally package the following
items and services and to add them to
the list of OPPS packaged items and
services in 42 CFR 419.2(b):
(1) Drugs, biologicals, and
radiopharmaceuticals that function as
supplies in a diagnostic test or
procedure;
(2) Drugs and biologicals that function
as supplies or devices in a surgical
procedure;
(3) Laboratory tests;
(4) Procedures described by add-on
codes;
(5) Ancillary services (status indicator
‘‘X’’);
(6) Diagnostic tests on the bypass list;
and
(7) Device removal procedures.
We refer readers to section II.A.3. of
this proposed rule for a complete
description of our 2014 packaging
proposals.
Establishing Comprehensive APCs:
In order to improve the accuracy and
transparency of our payment for certain
device-dependent services, for CY 2014,
we are proposing to create 29
comprehensive APCs to prospectively
pay for the most costly devicedependent
services. We are proposing to
define a comprehensive APC as a
classification for the provision of a
primary service and all adjunct services
provided to support the delivery of the
primary service. The comprehensive
APC would treat all individually
reported codes as representing
components of the comprehensive
service, resulting in a single prospective
payment based on the cost of all
individually reported codes that
represent the delivery of a primary
service as well as all adjunct services
provided to support that delivery. We
are proposing to make a single payment
for the comprehensive service based on
all charges on the claim, excluding only
charges for services that cannot be
covered by Medicare Part B or that are
not payable under the OPPS.
Payment of Hospital Outpatient
Visits: For CY 2014 we are proposing to
replace the current five levels of visit
codes for each clinic, Type A ED, and
Type B ED visits with three new
alphanumeric Level II HCPCS codes
representing a single level of payment
for the three types of visits, respectively.
We are proposing to assign the new
alphanumeric Level II HCPCS to newly
created APCs with CY 2014 OPPS
payment rates based on the total mean
costs of Level 1 through Level 5 visit
codes obtained from CY 2012 OPPS
claims data for each visit type.
Proposed OPPS Nonrecurring
Policy Changes: We note in this
proposed rule that we expect to allow
the enforcement instruction for the
supervision of outpatient therapeutic
services furnished in CAHs and small
rural hospitals to expire at the end of CY
2013. In addition, we are proposing to
amend the conditions of payment for
‘‘incident to’’ hospital or CAH
outpatient services (sometimes referred
to as hospital or CAH ‘‘therapeutic’’
services) to require that individuals
furnishing these services be in
compliance with State law.
Finally, we refer readers to the CY 2014
Medicare Physician Fee Schedule
(MPFS) proposed rule (CMS–1600–P) to
review Medicare’s proposal to apply the
therapy caps and related provisions
under section 1833(g) of the Act to
physical therapy (PT), speech-language
pathology (SLP) and occupational
therapy (OT) (‘‘therapy’’) services that
are furnished by a CAH, effective
January 1, 2014.
See page 17 of rule
Page 30 for observation
CMS Will Not Enforce Supervision Requirements for Outpatient
Therapeutic Services in Critical Access Hospitals and Certain Small
Rural Hospitals for CY 2013 (see downloads below)
Release Date: November 1, 2012
Release: CMS Extends Enforcement Instruction on Supervision Requirements for Outpatient
Therapeutic Services in Critical Access and Small Rural Hospitals for CY 2013
On March 15, 2010, the Centers for Medicare & Medicaid Services (CMS) instructed all of its
Medicare contractors not to evaluate or enforce the supervision requirements for therapeutic services
provided to outpatients in Critical Access Hospitals from January 1, 2010 to December 31, 2010,
until the Agency could revisit the supervision policy during the Calendar Year (CY) 2011
rulemaking cycle. While the Agency continued to develop its policy during the CY 2012 rulemaking
cycle regarding the supervision of these services, CMS extended this instruction through CY 2011
and expanded it to include small rural hospitals with 100 or fewer beds. For purposes of this notice,
CMS defines “small rural hospitals” as hospitals with 100 or fewer beds that are geographically
located in a rural area or that are paid under the hospital outpatient prospective payment system with
a rural wage index.
We extended this enforcement instruction to our contractors for another year, through CY 2012, to
allow time for the initiation of supervision reviews by the Advisory Panel on Hospital Outpatient
Payment (the Panel), which began in early 2012 and are continuing in accordance with the provisions
of the CY 2012 Outpatient Prospective Payment System/Ambulatory Surgical Center final rule (76
FR 74371). CMS is now extending this instruction an additional year through CY 2013. This
additional year, which will be the final year of the extension, will provide additional opportunities for
stakeholders to bring their issues to the Panel.
CMS continues to expect the hospitals covered under this notice to fulfill all other Medicare program
requirements when providing services to Medicare beneficiaries and when billing Medicare for those
services. While CMS is instructing contractors not to enforce the supervision requirements for
outpatient therapeutic services in these hospitals for CY 2010-2013, we continue to emphasize
quality and safety for services provided to all patients in these facilities
Bilateral procedures and MUEs
First Coast Service Options, Inc. (First Coast) Provider Contact Center has been receiving numerous inquiries
regarding medically unlikely edits (MUEs), anatomical modifiers (e.g., RT, LT, E1, E3, etc.) and the usage of modifier
50. The purpose of this article is to provide clarification on how modifier 50 should be billed.
Bilateral surgery is defined as a procedure performed on both sides of the body at the same operative session or on
the same day. This definition does not include procedures that are bilateral in nature or include the terms "bilateral" or
"unilateral/bilateral" in their descriptors.
When submitting claims for bilateral surgery, use modifier 50 with the procedure code. Claims for bilateral surgical
procedures should be billed on a single claim detail line with the appropriate procedure code and modifier 50 and one
(1) unit of service (UOS). Modifiers RT and LT should not be used when modifier 50 applies. When billing claims for
procedure codes that are bilateral in nature, regardless of whether these services are performed unilaterally or
bilaterally, providers should bill the surgical procedure code as a single claim detail line item without modifier 50.
To determine if a procedure should be billed with the modifier 50 as a bilateral procedure, providers may access the
Medicare Physician Fee Schedule (MPFS) look-up tool. Select MPFS, enter the date of service, locality and
procedure code. Once you select "Submit," the details of the procedure code will be revealed. Under the heading
"Modifier," select more. The "Bilateral Surgery" indicator will advise if a modifier 50 should be billed with the code.
Source: CMS Internet-only manual (IOM) Pub. 100-04 Medicare Claims Processing Manual, Chapter 4, Section
20.6.2; Chapter 23