New NCCI manual
Another change that providers should be aware of initially slipped past unnoticed. With all the other changes, CMS published a
new version of the NCCI Policy Manual for Medicare Services, effective January 1, 2012. The manual is downloadable as a zip
file of several PDFs of individual chapters at this website.
In Chapter 1 of that manual, titled “General Correct Coding Policies”, they note that modifiers 76 (“Repeat Procedure or Service
by the Same Physician or Other Qualified Health Care Professional”) and 77 (“Repeat Procedure or Service by Another
Physician or Other Qualified Health Care Professional”) do not bypass the NCCI edits. In looking at the 2010 version of the
manual, this statement is not new, however, it is in contrast to FAQ 3739, last updated April of 2011, that included these two
modifiers in a list of modifiers that did override NCCI edits. Interestingly, the apparently incorrect FAQ was removed from the
CMS website at some point in the last year rather than being updated with the new information.
Although modifiers 76 and 77 no longer appear to bypass NCCI edits, modifiers 78 (“Unplanned Return to the
Operating/Procedure Room…for a Related Procedure in the Post-Operative Procedure”) and 79 (“Unrelated Procedure or Service
by the Same Physician During the Post-Operative Period”) are still listed. These two modifiers have a dual use for hospitals paid
under the OPPS. They bypass NCCI edits, but they also turn off the multiple procedure reduction logic which is not applicable if
the two procedures were provided in separate surgical encounters on the same day.
For hospitals, modifier 59 (“Distinct Procedure Services”) seems to be used as a default modifier for multiple surgical
procedures, particularly in separate departments or encounters. Modifier 59 bypasses NCCI edits but it does not turn off the
multiple procedures reduction and therefore it is not the best modifier if the two procedures occurred in separate surgical
sessions. If modifier 79 is used when the services occur in separate encounters, it will not only turn off the NCCI edit allowing
both codes to be paid, as does modifier 59, but it also allows the two codes to be paid at 100% per the applicable multiple
procedure reduction policy.
For example, a patient presents to a provider based clinic for a small mole removal (11400) and later that day presents to the
emergency department with a wound requiring repair of subcutaneous tissue (12031). There is an NCCI edit bundling 12031 into
11400 and therefore if these two codes are billed on the same claim they will hit an edit and only the mole removal (11400) will
be paid at $309.46. If modifier 59 is applied to 12031 indicating the wound repair is separate from the mole removal, the mole
removal (11400) will be paid at $309.46 and the wound repair (12031) will be paid at $113.90. The wound repair is paid at half
the applicable rate because of the multiple procedure reduction. However if modifier 79 is used, the procedures will both be paid
at 100% (i.e., $309.46 for the mole removal (11400) and $227.80 for the wound repair (12031)) as is appropriate under the
multiple procedure reduction policy because these two procedures were performed in separate surgical encounters.
There may be some concern with using modifier 79 because of the term “same physician” in the description. In relationship to
CPT codes, CMS states in section 20.2 Chapter 4 of the Medicare Claims Processing Manual:
“the usage of the term ‘physician’ does not restrict the reporting of the code…to physicians only, but applies to all practitioners,
hospitals, providers or suppliers eligible to bill the relevant CPT codes”.
Additionally, use of modifier 79 for unrelated procedures or services ‘by the same hospital’ in the post-operative period is
consistent with correct payment under the multiple procedure reduction policy, which allows for 100% payment when two
procedures occur in separate surgical encounters.
http://www.cms.gov/NationalCorrectCodInitEd/01_overview.asp#TopOfPage
Billing Preadmission Services Window Policy When Inpatient
Hospital Stay Is Denied
Providers have asked for clarification if services rendered for outpatient preadmission prior to an
inpatient admission that had been reported on the inpatient claim can be billed separately if the inpatient
stay is denied for medical necessity. The inpatient claim could be denied due to a prepayment edit,
Comprehensive Error Rate Testing (CERT) review, Recovery Auditor (RA) review, or Medical Review
(MR) Department review just to name a few.
The Provider Outreach & Education Department is clarifying that when a Part A payment cannot be
made on an inpatient claim, the preadmission services window policy (also known as the three-day
window) does not apply. When this policy does not apply, the outpatient preadmission services, if any,
may be billed, as usual, on a type of bill (TOB) 13X.
As a reminder the preadmission services window policy, for inpatient prospective payment system
(IPPS) hospitals, applies to outpatient preadmission services rendered within three days prior to and on
the date of the inpatient admission and for non-IPPS hospitals, applies to outpatient preadmission
services rendered within one day prior to and on the date of the inpatient admission.
Therefore, if the inpatient claim is medically denied (TOB 110), then outpatient services of any type
(including emergency room services, ambulatory surgery, etc.), if such services were rendered, that had
been reported on the inpatient claim based on the preadmission services window policy can be billed
separately, as usual, on a 13X TOB. This includes outpatient services of any type rendered on the same
day as the day of admission, as long as such services were rendered prior to the beneficiary’s formal
admission as an inpatient.
It should be noted that the applicable ancillary services rendered during the inpatient stay may be billed
on a 12X TOB. The 12X TOB should not include any outpatient services rendered prior to admission, if
any such services were rendered.
All claim(s) must be filed within the timely filing guidelines. Please share this information with the
necessary staff at your facility and update any procedures or policies as needed.
References
Preadmission Services Window Policy – The Centers for Medicare & Medicaid Services (CMS) InternetOnly Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 40.3 and
Chapter 4, Section 10.12. (1 MB)
Ancillary Services for 12X TOB – CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 6,
Section 10 and Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 240. (1 MB)
Note: Providers under the Part A to Part B Rebilling Demonstration are exempt from the process listed
Resolved – Reason Code 31313 – Change to the Release of
Indicator Field
An issue was previously identified with the “Release of Indicator” field for Institutional
Electronic Data Interchange (EDI) claims submitted in version 5010A2. The problem mainly
affected electronic claims that were submitted with a primary payer other than Medicare. These
claims were auto-populating a value of “N” instead of “Y” or left a blank in the Release of
Information (RI) field for the Payer ID field. This caused the Primary Payer Name submitted on
the electronic claim not to map to the Fiscal Intermediary Shared System (FISS) claim screen,
page 4 (MAP1034), causing claims to Return to Provider (RTP) under Reason Code 31313. A
fix was installed in FISS on Monday, March 5, 2012.
National Government Services, Inc.
Corporate Communications
10 Things We Don't Know About Looming Readmission Penalties
1.
How will hospitals be compared?
Hospitals with greater than expected risk adjusted readmission rates between July 1, 2008 and June 30,
2011 will be penalized in the first round.
But what groups of hospitals would constitute a fair comparison? Or those within a similar region or state or
similar size? Or those with similar patient populations such as safety net or rural hospitals? Or will each
hospital be measured with all others across the country?
This is important because there are vast regional differences in readmission rates across the country,
according to CMS's
Medicare Hospital Quality Chartbook for 2011.
CMS has indicated it intends to compare every hospital's readmission rates with the rest of the nation's, but
some hospital officials hope for reconsideration.
2.
2. Will CMS adjust for hospital size or socioeconomic status?
The risk adjustment formula to-date adjusts for some disease co-morbidities such as age, but does not
correct for hospitals with patients who are more likely to be low-income, poorly educated, or have little
access to primary care physicians, pharmacies and healthy food. It does not take into account race.
Some hospital leaders have argued vociferously that the formula is therefore biased against hospitals
grappling with tougher populations.
In its FY 2012 rule last August, CMS explained it would not adjust for such factors as English language
proficiency or socioeconomic status, saying that poorer scores could be due to "differences in the quality of
healthcare received by groups of patients with varying race/language and socioeconomic status."
If there were such a correction, poor quality care for patients in "certain racial and ethnic groups may be
obscured," the agency said, and "may suggest that hospitals with a high proportion of minority patients are held
to a different standard of quality than hospitals treating fewer minority patients."
Nancy Foster, Vice President for Quality and Patient Safety Policy for the American Hospital Association, says
many hospitals strongly disagree.
"What we're assessing here is supposed to be the performance of the hospital in doing what it can to prevent
readmission. And when you confound that by not adjusting for community factors, then what you end up
doing is penalizing hospitals for things that are clearly outside their control.
"I would agree that if we were assessing the impact of low socioeconomic status or communities without
adequate primary care physicians, we want to hold that up and make sure that our measures doesn't adjust for
that, but that's not what we're assessing here. We are supposed to simply be assessing hospital performance."
CMS promises to keep an open mind, and "will monitor" whether the program "has a disparate impact on
hospitals that care for large numbers of disadvantaged patients. If such an impact is found, we will consider
whether additional program modifications would be appropriate."
3. What is the "index hospitalization"?
What is the definition of the index hospitalization that starts the 30-day clock ticking?
Foster asks, "Is it the first one you come across in a year? Or, is it an admission to a critical access hospital that then
warrants further admission to a general acute care hospital? Those are the sorts of questions we hope they'll
answer."
4. What unrelated readmissions might be excluded?
In general, CMS will impose a penalty if a hospital has greater-than-expected risk-adjusted readmissions regardless
of the reason for the readmission. If a heart attack patient falls at home after discharge and must be readmitted,
perhaps the hospital might have first inspected the home for a fall risk.
However, some readmissions could be justifiably unrelated, and even typically required as a standard of care.
So far, however, CMS has noted it would not count as a readmission the case of a heart attack patient who is
subsequently scheduled for a heart bypass procedure within 30 days, since that would be a typical occurrence.
However, CMS has not named any "typically scheduled" exclusions for pneumonia or a heart failure. But neither has
it closed the door on the possibility.
5. How much will Medicare save?
The law will result in gradually increasing savings to the Medicare program, totaling $7.1 billion over the next seven
years, according to the Congressional Budget Office.
But will penalized hospitals lose the maximum 1% of base DRG, or will there be thresholds, for example, .5%?
So far, Foster interprets the penalty as one that includes the hospital's number of risk-adjusted readmissions factored
with its expected number and the hospital's base payment for that diagnosis, calculated with a complex formula set
forth by the ACA.
However, CMS still must clarify terms in the formula, such as base operating DRG, ratio, and floor adjustment
factors.
6. How will each condition be weighted?
Will readmission rates for each condition be weighted equally? The answer could be pivotal, because heart attack
patients are much less likely to be readmitted than patients with heart failure or pneumonia and they incur
readmission care costs that are one-fourth what is spent to treat heart failure or pneumonia readmissions, according
to a 2007 Medicare Payment Advisory Commission (MedPAC) report.
CMS intends to clarify its definition of "aggregate payments for excess readmissions."
7. What is an "Applicable Hospital"?
CMS intends to define this term. For example, might an admission that results in a readmission to a cancer hospital
be excluded?
8. What is the appeal process?
CMS is considering what aspects of readmission rates sent to hospitals for review prior to public release might be
correctable, and will clarify its review and process.
9. What future conditions will be added?
Four additional diagnoses account for 11.7% of all preventable readmissions, about 133,000 a year, according to a
2007 MedPAC report. They are:


chronic obstructive pulmonary disease
coronary artery bypass grafts


percutaneous coronary angioplasties, and
"other" vascular surgeries
The ACA specifies these four categories and others the HHS secretary deems appropriate may be added by FY2015.
CMS is expected to signal which ones top their list.
10. How will CMS prevent hospitals from gaming the system?
CMS acknowledges the possibility that some hospitals might try various tactics to avoid excess readmission penalties,
such as changing diagnostic codes to avoid identifying patients with AMI, heart failure, pneumonia, "systematic
shifting, diversion or delays in care," might put pressure on emergency room staff not to admit patients within the
30-day window.
And although CMS has promised to monitor such practices to "minimize any unintended consequences" it has not
explained how frequently or with what tools it intends to do so.
Cheryl Clark is a senior editor and California correspondent for HealthLeaders Media Online. She can be reached at
cclark@healthleadersmedia.com. Follow Cheryl Clark on Twitter
***2012 eRx Payment Adjustment Update***
CMS continues to receive inquiries about the Medicare Electronic Prescribing (eRx) Incentive Program
and the 2012 eRx payment adjustment. This message seeks to clarify the issues CMS has heard from
physicians and other healthcare professionals.
Statutory Authority/Background
CMS is required to adjust the payments of eligible professionals who are not successful electronic
prescribers beginning in 2012. This requirement is outlined in Section 132 of the Medicare Improvements
for Patients and Providers Act of 2008 (MIPPA).
CMS listed the requirements for being a successful e-prescriber for purposes of avoiding the 2012
payment adjustment in the 2011 Physician Fee Schedule final rule. In February 2012, all eligible
professionals who did not meet these requirements were sent a letter notifying them of this fact.
Significant Hardship Exemption Requests
In response to stakeholder feedback, CMS also published a standalone eRx rule on Tue Sep 6, 2011, to
provide additional circumstances under which eligible professionals would qualify for hardship
exemptions. Eligible professionals initially had until Tue Nov 1, 2011, to submit a request for a hardship
exemption for the 2012 eRx payment adjustment via the newly-created Quality Reporting Communication
Support Page; this deadline was later extended to Tue Nov 8, 2011. CMS finished its review of these
requests in February 2012 and continues to notify requestors via email whether their request was
approved or denied.
Questions and Concerns
Although there is no appeal or review process established for the eRx Incentive Program and payment
adjustment, CMS encourages eligible professionals with questions or concerns about the eRx payment
adjustment and hardship exemption requests to contact the QualityNet Help Desk. Through the
QualityNet Help Desk, CMS is working with eligible professionals and CMS-selected group practices that
have questions about eRx payment adjustments and/or hardship exemption decisions. CMS is handling
all hardship exemption requests and any questions or concerns on a case-by-case basis. Contact the
QualityNet Help Desk if you have issues relating to the eRx payment adjustment and/or the rationale for
denial of your hardship exemption request.
The QualityNet Help Desk can be reached Mon – Fri, 7am-7pm CMT, at 866-288-8912 or
QNetSupport@sdps.org.
2013 & 2014 eRx Payment Adjustment
Please note that payment adjustments under the eRx Incentive Program run until 2014. For information
on how to avoid the 2013 and 2014 eRx payment adjustments, please visit the Electronic Prescribing
Incentive Program webpage and review MLN Matters Article #SE1206.
____________________________________________________________
Dear Medicare Part A and B Providers,
NEWS FROM CMS
** Information Regarding the Billing and Payment for Administration of
PROVENGE®
The Centers for Medicare & Medicaid Services (CMS) had, on Fri Jan 6, 2012, reissued CR 7431,
Transmittal 2380, for autologous cellular immunotherapy (PROVENGE®) treatment of metastatic prostate
cancer with clarification regarding payment for the administration of PROVENGE and allowing for
separate payment for the cost of administration. However, there is an issue in the Medicare claims
processing system that is causing claims for administration of PROVENGE® not to be paid separately
from PROVENGE®. The Current Procedural Terminology (CPT) code 96365 is bundled when billed with
Healthcare Common Procedure Coding (HCPCS) code Q2043. Providers of PROVENGE® may be
affected by this situation.
To correct this problem, CMS will update current editing to allow CPT code 96365 to be paid separately
when HCPCS code Q2043 is present on claims with dates of service on and after Fri July 1, 2011. CMS
has instructed Medicare contractors to adjust claims for dates of service on and after Fri July 1 containing
CPT code 96365 that were denied and not paid due to the bundle editing, when brought to their attention.
Providers may, beginning Sun Apr 1, request contractors to adjust claims for administration of
PROVENGE® that were denied for this reason.
~~~~~~~~~~
Medicare Redesigns Claims and Benefits Statement **
As part of National Consumer Protection Week, the CMS Acting Administrator, Marilyn Tavenner,
announced the redesign of the statement that informs Medicare beneficiaries about their claims for
Medicare services and benefits. The redesigned statement, known as the Medicare Summary Notice
(MSN), will be available online and, starting in 2013, mailed out quarterly to beneficiaries.
This MSN redesign is part of a new initiative – “Your Medicare Information: Clearer, Simpler, At Your
Fingertips” – which aims to make Medicare information clearer, more accessible, and easier for
beneficiaries and their caregivers to understand. CMS will take additional actions this year to make
information about benefits, providers, and claims more accessible and easier to understand for seniors
and people with disabilities who have Medicare. This MSN redesign reflects more than 18 months of
research and feedback from beneficiaries to provide enhanced customer service and respond to
suggestions and input.
To see a side-by-side comparison of the former and redesigned MSNs, please visit
http://www.CMS.gov/apps/files/msn_changes.pdf.
Starting later this week, the redesigned MSN will be available to beneficiaries on www.MyMedicare.gov,
Medicare’s secure online service for personalized information regarding Medicare benefits and services;
in early 2013, paper copies of the redesigned MSN will start to replace the current version being mailed.
The full text of this excerpted CMS press release (issued Wed Mar 7) can be found at
http://www.CMS.gov/apps/media/press/release.asp?Counter=4298.
Web site for Medical necessity
http://www.cms.gov/Medicare/Coverage/CoverageGenInfo/index.html?redirect=/CoverageGenInfo/04_LabNCDs.asp
CMS to resolve incorrect claims processing issue for 12X and 13X bill
types
On February 24, CMS sent out an update informing providers that it has identified a Medicare
claims processing issue that has been causing hospital outpatient services rendered in an
institutional setting to be processed incorrectly. Specifically, the notice provided guidance on
claims inappropriately overlapping when billed with a 12X or 13X type of bill with the same
date of service.
CMS had previously issued guidance in Transmittal R2386CP, which clarified that providers
could separately bill outpatient services rendered prior to a non-covered inpatient admission. It
also states that the dividing line for services billed on the inpatient and outpatient claims is the
inpatient order, and that services “prior to the point of admission” are to be billed as outpatient
services with a 13X bill type. This includes services in the outpatient and emergency
departments.