Tuesday, March 9, 2021

CPT code J1439, L34093, J0887, Q9976

Required Billing and Coding


J Code Product Indications

J1439 Injection, ferric carboxymaltose, 1 mg 

L34093 (Chemotherapy and Biologicals)

J0887 - Injection, Epoetin Beta (For ESRD On Dialysis), 1 microgram

Q9976 - Injection ferric pyrophosphate citrate solution; 0.1 mg of iron



INDICATIONS


Injectafer® (ferric carboxymaltose injection) is indicated for the treatment of iron deficiency anemia (IDA) in adult patients who have intolerance to oral iron or have had unsatisfactory response to oral iron, or who have non-dialysis dependent chronic kidney disease.


WARNINGS AND PRECAUTIONS


Symptomatic hypophosphatemia requiring clinical intervention has been reported in patients at risk of low serum phosphate in the postmarketing setting. These cases have occurred mostly after repeated exposure to Injectafer in patients with no reported history of renal impairment. Possible risk factors for hypophosphatemia include a history of gastrointestinal disorders associated with malabsorption of fat-soluble vitamins or phosphate, concurrent or prior use of medications that affect proximal renal tubular function, hyperparathyroidism, vitamin D deficiency and malnutrition. In most cases, hypophosphatemia resolved within three months.

Monitor serum phosphate levels in patients at risk for low serum phosphate who require a repeat course of treatment.

Serious hypersensitivity reactions, including anaphylactic-type reactions, some of which have been life-threatening and fatal, have been reported in patients receiving Injectafer. Patients may present with shock, clinically significant hypotension, loss of consciousness, and/or collapse. Monitor patients for signs and symptoms of hypersensitivity during and after Injectafer administration for at least 30 minutes and until clinically stable following completion of the infusion. Only administer Injectafer when personnel and therapies are immediately available for the treatment of serious hypersensitivity reactions. In clinical trials, serious anaphylactic/anaphylactoid reactions were reported in 0.1% (2/1775) of subjects receiving Injectafer. Other serious or severe adverse reactions potentially associated with hypersensitivity which included, but were not limited to, pruritus, rash, urticaria, wheezing, or hypotension were reported in 1.5% (26/1775) of these subjects.


Billing and coding


Important information related to Injectafer reimbursement Proper billing and coding can help ensure eligible patients receive the proper program support. The following codes may be helpful to facilitate Injectafer reimbursement. The completion and submission of coverage-related documentation are the responsibility of the patient and healthcare provider.


Injectafer® (ferric carboxymaltose injection) is indicated for the treatment of IDA in adult patients:


• who have intolerance to or have had unsatisfactory response to oral iron or

• who have non-dialysis dependent chronic kidney disease


Product-Specific Billing Code

HCPCS J1439 Injection, ferric carboxymaltose 1 mg


Overview

Iron is a critical structural component of hemoglobin, a key protein found in normal red blood cells (RBCs) which transport oxygen. Without this important building block, anemic patients experience difficulty in restoring adequate, healthy RBCs that improve hematocrit levels. Iron deficiency is a common condition in end stage renal disease (ESRD) patients undergoing hemodialysis. Clinical management of iron deficiency involves treating patients with iron replacement products while they undergo hemodialysis. The available evidence suggests that the mode of intravenous administration is perhaps the most effective treatment for iron deficiency in hemodialysis patients. Unlike oral iron products, which must be absorbed through the GI tract, IV iron products are infused directly into the bloodstream in a

form that is readily available to the bone marrow for RBC synthesis, resulting in an earlier correction of iron deficiency and anemia.

Coverage also includes the medically necessary and reasonable use of parenteral iron preparations in non-dialysis related clinical conditions.


Guidelines


Medicare covers Sodium Ferric Gluconate Complex in Sucrose Injection as a first line treatment of Iron Deficiency Anemia when furnished intravenously to patients undergoing chronic hemodialysis who are receiving supplemental erythropoietin therapy.


Medicare also covers Iron Sucrose Injection as a first line treatment of Iron Deficiency Anemia when furnished intravenously to patients undergoing chronic hemodialysis who are receiving supplemental erythropoietin therapy.


Coverage also includes for parenteral iron in iron deficiency anemia:


• For patients with iron deficiency anemia who do not respond to oral iron supplementation due to malabsorption disorders or patients who have documented intolerance to oral iron supplementation.


• For anemia related to chronic kidney disease.


• Initial treatment of absolute iron deficiency in patients receiving myelosuppressive chemotherapy who have asymptomatic anemia and risk factors for the development of symptomatic anemia requiring transfusion.


For the pregnant beneficiary when iron stores are depleted such that the mother and/or the fetus are at risk of adverse outcomes and oral iron replenishment is either not tolerated or the anemia is of such severity as to require more immediate replenishment. Additionally, use in the peripartum period may be indicated when intra/post-partum hemorrhage is severe and by administering parenteral iron a transfusion may be avoided. This indication does not replace the strong consideration for transfusions when the hemorrhage is potentially life threatening.


APPLICABLE CODES


The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or

guarantee claim payment. Other Policies and Guidelines may apply.


PURPOSE

The Medicare Advantage Policy Guideline documents are generally used to support UnitedHealthcare Medicare Advantage claims processing activities and facilitate providers’ submission of accurate claims for the specified services. The document can be used as a guide to help determine applicable:


• Medicare coding or billing requirements, and/or

• Medical necessity coverage guidelines; including documentation requirements.

UnitedHealthcare follows Medicare guidelines such as LCDs, NCDs, and other Medicare manuals for the purposes of determining coverage. It is expected providers retain or have access to appropriate documentation when requested to support coverage. Please utilize the links in the References section below to view the Medicare source materials used to develop this resource document. This document is not a replacement for the Medicare source materials that outline Medicare coverage requirements. Where there is a conflict between this document and Medicare source materials, the Medicare source materials will apply.



A. Background: Section 153(b) of the Medicare Improvements for Patients and Providers Act (MIPPA) required the implementation of an ESRD PPS effective January 1, 2011. The ESRD PPS provides a single payment to ESRD facilities that covers all of the resources used in furnishing an outpatient dialysis treatment. The ESRD PPS includes consolidated billing requirements for limited Part B services included in the ESRD facility’s bundled payment. The Centers for Medicare & Medicaid Services (CMS) periodically update the lists of items and services that are subject to Part B consolidated billing (CB) and are therefore no longer separately payable when provided to ESRD beneficiaries by providers other than ESRD facilities.


The ESRD PPS provides outlier payments, if applicable, for high cost patients due to unusual variations in the type or amount of medically necessary care.

B. Policy: This change request (CR) provides instructions for new codes added to the Healthcare Common Procedure Coding System (HCPCS) file for anemia management and therefore will be added to the list of items and services subject to the ESRD PPS consolidated billing (CB) requirements.


1. J0887 - Injection, Epoetin Beta (For ESRD On Dialysis), 1 microgram

2. J1439 - Injection, ferric carboxymaltose, 1mg

3. Q9976 - Injection ferric pyrophosphate citrate solution; 0.1 mg of iron



Anemia management is a category of drugs and biologicals that are always considered to be used for the treatment of ESRD. ESRD facilities will not receive separate payment for J0887, J1439, or Q9976 with or without the AY modifier and the claims shall process the line item as covered with no separate payment under the ESRD PPS.

Q9976 is administered via dialysate. Therefore, when billing for Q9976, it should be accompanied by the JE modifier as discussed in CR 8256 issued April 26, 2013.

In accordance with 42 CFR 413.237(a)(1), HCPCS J0887, J1439, and Q9976 are considered to be eligible outlier services and will be included in the outlier calculation when CMS provides a fee amount on the Average Sales Price fee schedule.


There is a new HCPCS J0888 for epoetin beta for non-ESRD use. This code will not be permitted on the ESRD type of bill 072x.


Lastly, Q2047 was terminated effective January 1, 2013 and is therefore no longer subject to the ESRD PPS consolidated billing requirements. In addition, J0890 is a recalled drug and should not be furnished to  ESRD patients, therefore effective July 1, 2015, we are removing this code from the list of items and services that are subject to consolidated billing requirements.


Friday, December 25, 2020

Initial observation code CPT 99217, 99218, 99219, 99220

 CPT code and descriptions


99217 Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.])


99218 Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; Aetailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of low severity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit.


99219 Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit.


99220 Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of high severity. Typically 70 minutes are spent at the bedside and on the patient's hospital floor or unit.



Observation care Background


Observation care is a well-defined set of specific, clinically appropriate services, which include:


• Ongoing short term treatment,

• Assessment,

• Reassessment


These are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.


Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge.


In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours.


In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as a inpatient can be made in less than 48 hours, usually in less than 24 hours.


Q: Can Observation Care codes 99217 and codes 99218-99220 be reported on the same date of service?


A: No. CPT codes 99234-99236 should be reported for patients who are admitted to and discharged from observation status on the same calendar date for a minimum of 8 hours but less than 24. An initial Observation Care code (99218-99220) should be reported for patients admitted and discharged from observation status for less than 8 hours on the same calendar date. CPT code 99217 can only be reported for a patient discharged on a different calendar date.




Initial Observation Care (CPT code range 99218-99220)


• Included in Initial Observation Care:

- Initiation of observation status

- Supervision of the care plan for observation

- Performance of periodic reassessments


• When a patient receives observation care for less than 8 hours on the same calendar date, the Initial Observation Care, from CPT code range 99218 – 99220, shall be reported by the physician.


• When a patient is admitted for observation care and then is discharged on a different calendar date, the physician shall report Initial Observation Care,

from CPT code range 99218 – 99220, and CPT observation care discharge CPT code 99217.


• To report services provided to patient who is admitted to the hospital after receiving hospital observation care services on the same date, see initial

hospital care notes in the American Medical Association (AMA) Current Procedural Terminology (CPT) Publication.




• To report hospital admission on a date subsequent to the date of observation status, use appropriate initial hospital care codes (CPT 99221 – 99223)


• Observation status that is initiated in the course of an encounter in another site of service (eg. hospital emergency department, office, nursing facility) all E/M services provided by the supervising physician or other qualified health care professional in conjunction with initiating “observation status” are considered part of the initial observation care when performed on the same date.


- The level of service reported should include the services related to initiating “observation status” provided in the other sites of service as well as in the observation setting


• On the rare occasion when a patient remains in observation care for 3 days, the physician shall report an initial observation care code (99218-99220) for the first day of observation care, a subsequent observation care code (99224-99226) for the second day of observation care, and an observation care discharge CPT code 99217 for the observation care on the discharge date.


• Admitted and discharges from observation or inpatient status on the same date report CPT codes 99234-99236 as appropriate; do NOT report observation discharge in conjunction with a hospital admission.


• These codes may NOT be utilized for post-operative recovery if the procedure is considered part of the surgical “package.”



Policy Overview


Initial Observation Care CPT® codes 99218-99220 and Subsequent Observation Care CPT codes 99224-99226 are used to report evaluation and management (E/M) services provided to new or established patients designated as "observation status" in a hospital.


Observation Care Discharge Day Management CPT Code 99217 is used to report all services provided to a patient discharged from outpatient hospital “observation status” if the discharge is on a date other than the initial date of “observation status”.


Observation or Inpatient Hospital Care (including admission and discharge) CPT codes 99234-99236 are used to report observation or initial hospital services for a patient that is admitted and discharged on the same date of service. Inpatient Hospital Discharge Day Management CPT Codes 99238 and 99239 are used to report all discharge day management services for the hospital inpatient when discharge is on a date other than the initial date of admission.

Saturday, August 22, 2020

CPT code 93000, 93040, 93041, 93042, 93010 - ECG and EKG codes

 CPT® Code Procedure Description  


93000 Electrocardiogram Routine ECG with at least 12 leads; with interpretation and report  

93005 Electrocardiogram Routine ECG with at least 12 leads; tracing only, without interpretation and report  

93010 Electrocardiogram Routine ECG with at least 12 leads; interpretation and report only  

93040 Rhythm ECG One to three leads; with interpretation and report  

93041 Rhythm ECG One to three leads; tracing only, without interpretation and report  

93042 Rhythm ECG One to three leads; interpretation and report only


CPT Manual Instructions for Reporting Electrocardiographic Recording


• Codes 93040-93042 are appropriate when an order for the test is triggered by an event, the rhythm strip is used to help diagnose the presence or absence of an arrhythmia, and a report is generated.

• There must be a specific order for an electrocardiogram or rhythm strip followed by a separate, signed, written, and retrievable report.

• It is not appropriate to use these codes for reviewing telemetry monitor strips taken  from a monitoring system.

• The need for an electrocardiogram or rhythm strip should be supported by  documentation in the patient medical record.


Bundled Services per CPT Manual

• Do not report 93040-93042 when performing 93279-93289, 93291-93296, or  93298-93299

Report proper ICD-10-CM diagnosis codes to support the medical necessity for the use of an ECG. ICD-10-CM codes and/or ranges are provided below to help with your decision process.


Definitions

Codes 70010-79999, 93000-93010, and 0178T-0180T are used for reporting radiology procedures.


Modifiers:

-26 Professional Component

-76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care  Professional

-77 Repeat Procedure by Another Physician or Other Qualified Health Care  Professional

-ET Emergency services


Policy Statement

Medical Imaging and Electrocardiogram (ECG/EKG) Interpretation

Payment will be made for only one interpretation of any given x-ray, CT, MRI, ultrasound or ECG/EKG. Subsequent interpretations or readings by another physician (indicated by the -77 modifier) will not be covered. A re-interpretation by another physician is considered an integral part of the primary physician's medical care.


However, if the patient's condition warrants an immediate interpretation of an imaging study (emergency treatment -ET modifier), payment may be made to the attending or admitting physician even when a hospital staff physician also performs an imaging study interpretation.



OTHER CONSIDERATIONS

• Include documentation in the patient’s records to indicate medical necessity for a separate service.

• Confirm that proper ICD-10-CM diagnosis codes are reported to justify medical necessity of ECG monitoring.

• When appropriate, a modifier may be reported and support documentation should be provided with the claim.

• Some payers may have specific requirements for using certain codes, including prior authorization, restricted medical diagnoses or specialty provider types.

 


Indications and Limitations of Coverage

Nationally Covered Indications

The following indications are covered nationally unless otherwise indicated:

** Computer analysis of EKGs when furnished in a setting and under the circumstances required for coverage of other EKG services.

** EKG services rendered by an independent diagnostic testing facility (IDTF), including physician review and interpretation. Separate physician services are not covered unless he/she is the patient's attending or consulting physician.

** Emergency EKGs (i.e., when the patient is or may be experiencing a life threatening event) performed as a laboratory or diagnostic service by a portable x-ray supplier only when a physician is in attendance at the time the service is performed or immediately thereafter.

** Home EKG services with documentation of medical necessity.

** Transtelephonic EKG transmissions (effective March 1, 1980) as a diagnostic service for the indications described

below, when performed with equipment meeting the standards described below, subject to the limitations and conditions specified below. Coverage is further limited to the amounts payable with respect to the physician's service in interpreting the results of such transmissions, including charges for rental of the equipment. The device used by the beneficiary is part of a total diagnostic system and is not considered DME separately. Covered uses are to:

o Detect, characterize, and document symptomatic transient arrhythmias;

o Initiate, revise, or discontinue arrhythmic drug therapy; or,

o Carry out early post-hospital monitoring of patients discharged after myocardial infarction (MI); (only if 24- hour coverage is provided, see below).


Certain uses other than those specified above may be covered if, in the judgment of UnitedHealthcare, such use is medically necessary.


Additionally, the transmitting devices must meet at least the following criteria:

** They must be capable of transmitting EKG Leads, I, II, or III; and,

** The tracing must be sufficiently comparable to a conventional EKG.


24-hour attended coverage used as early post-hospital monitoring of patients discharged after MI is only covered if provision is made for such 24-hour attended coverage in the manner described here: 24-hour attended coverage means there must be, at a monitoring site or central data center, an EKG technician or other non-physician, receiving calls and/or EKG data; tape recording devices do not meet this requirement. Further, such technicians should have immediate, 24-hour access to a physician to review transmitted data and make clinical decisions regarding the patient. The technician should also be instructed as to when and how to contact available facilities to assist the patient in case of emergencies.


ICD-10-CM Description

ICD-10-CM Code/ Range

Abnormalities of heart beat R00.0-R00.9

Angina pectoris 120.0-120.9

Atherosclerotic heart disease I25.10-I25.119

Atrioventricular and left bundle-branch block 144.0-144.7

Cardiac arrest I46.2-I46.9

Cardiac murmurs and other cardiac sounds R01.0-R01.2

Cardiomyopathy I42.0-I42.9

Cardiomyopathy in diseases classified elsewhere I43

Essential (primary) hypertension I10

Gangrene, not elsewhere classified I96

Hypertensive heart disease I11.0-I11.9

Multiple valve diseases I08.0-I08.9

Old myocardial infarction I25.2

Other acute ischemic heart diseases I24.0-I24.9

Other cardiac arrhythmias I49.0-I49.9

Other conduction disorders I45.0-145.9

Other pulmonary heart diseases I27.0-I27.9

Pain in chest R07.1-R07.9

Rheumatic aortic valve diseases I06.0-I06.9

Rheumatic mitral valve diseases I05.0-I05.9

ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction I21.0-I21.4

Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction I22.0-I22.9


Friday, July 24, 2020

CPT G0108, G0109 and MODIFIER GQ


HCPCS Code Description

G0108 Diabetes outpatient self-management training services, individual, per 30 minutes

G0109 Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes

Modifier Description

GQ Via asynchronous telecommunications system

Place of Service Description

02 Telehealth: The location where health services and health related services are provided or received, through a telecommunication system.

PURPOSE

The Medicare Advantage Policy Guideline documents are generally used to support UnitedHealthcare Medicare Advantage claims processing activities and facilitate providers’ submission of accurate claims for the specified services.


Certified Providers

A designated certified provider bills for DSMT provided by an accredited DSMT program. C ertified providers must submit a copy of their accreditation certificate to the contractor. The statute states that a “certified provider” is a physician or other individual or entity designated by the Secretary that, in addition to providing outpatient selfmanagement training services, provides other items  and services for which payment may be made under title XVIII,

and meets certain quality standards. The CMS is designating all providers and suppliers that bill Medicare for other individual services such as hospital outpatient departments, renal dialysis facilities, physicians and durable medical equipment suppliers as certified. All suppliers/providers who may bill for other Medicare services or items and who represent a DSMT program that is accredited as meeting quality standards can bill and receive payment for the entire DSMT program. Registered dietitians are eligible to bill on behalf of an entire DSMT program, as long as the provider has obtained a Medicare provider number. A dietitian may not be the sole provider of the DSMT service. There is an exception for rural areas. In a rural area, an individual who is qualified as a registered dietitian and as a certified diabetic educator who is currently certified by an organization approved by CMS may furnish training and is deemed to meet the multidisciplinary team requirement. C ertified providers may be asked to submit updated accreditation documents at any time or to submit outcome data to an organization designated by CMS.

Frequency of Training

The initial year for DSMT is the 12 month period following the initial date. Medicare will cover initial training that meets the following conditions:
• Is furnished to a beneficiary who has not previously received initial or follow-up training under HCPCS codes G0108 or G0109;
• Is furnished within a continuous 12-month period;
• Does not exceed a total of 10 hours (the 10 hours of training can be done in any combination of 1/2 hour increments);
• With the exception of 1 hour of individual training, training is usually furnished in a group setting, which can contain other patients besides Medicare beneficiaries, and;
• One hour of individual training may be used for any part of the training including insulin training.

Follow-Up Training

Medicare covers follow-up training under the following conditions:
• No more than 2 hours individual or group training per beneficiary per year;
• Group training consists of 2 to 20 individuals who need not all be Medicare beneficiaries;
• Follow-up training for subsequent years is based on a 12 month calendar after completion of the full 10 hours of initial training;
• Follow-up training is furnished in increments of no less than one-half hour; and
• The physician (or qualified non-physician practitioner) treating the beneficiary must document in the beneficiary's medical record that the beneficiary is a diabetic.

Coverage Requirements for Individual Training

Medicare covers training on an individual basis for a Medicare beneficiary under any of the following conditions:

• No group session is available within 2 months of the date the training is ordered;
• The beneficiary’s physician (or qualified non-physician practitioner) documents in the beneficiary’s medical record that the beneficiary has special needs resulting from conditions, such as severe vision, hearing or language limitations or other such special conditions as identified by the treating physician or non-physician practitioner, that will hinder effective participation in a group training session; or
• The physician orders additional insulin training.
• The need for individual training must be identified by the physician or non-physician practitioner in the referral.


Telehealth

Individual and group DSMT services may be paid as a Medicare telehealth service. Before 03-11-2016, this manual provision required that 1 hour of the 10 hour DSMT benefit’s initial training must be furnished in-person to allow for effective injection training. Because injection training is not always clinically indicated, we are revising this provision to permit all 10 hours of the initial training and the two (2) hours of annual follow-up training to be furnished via telehealth in those cases when injection training is not applicable. The in-person injection training, when provided, may be furnished through either individual or group DSMT services. By reporting place of service (POS) 02 or the –GT or –GQ modifier with HCPCS code G0108 (Diabetes outpatient self-management training services, individual, per 30 minutes) or G0109 (Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes), the distant site practitioner attests that the beneficiary has received or will receive 1 hour of in-person DSMT services for purposes of injection training when it is indicated during the year following the initial DSMT service or any calendar year’s 2 hours of follow-up training.

As specified in the Medicare Benefit Policy Manual, chapter 15, section 300.2, individual DSMT services may be furnished by a physician, individual, and group DMST services may be furnished by a physician, other individual, or entity that furnishes other items or services for which direct Medicare payment may be made and that submits necessary documentation to, and is accredited by, a national accreditation organization approved by CMS. However, consistent with the statutory requirements of section 1834(m)(1) of the Act, as provided in 42 C FR 410.78(b)(1) and (b)(2) and stated in section 190.6 of this chapter, Medicare telehealth services, including individual and group DSMT services furnished as a telehealth service, could only be furnished by a licensed PA, NP, CNS, CNM , clinical psychologist, clinical social worker, or registered dietitian or nutrition professional, as applicable.

For Medicare payment to occur, interactive audio and video telecommunications must be used, permitting real-time communication between the distant site physician or practitioner and the Medicare beneficiary. As a condition of payment, the patient must be present and participating in the telehealth visit.

DMEPOS Suppliers

The DMEPOS suppliers are reimbursed for diabetes training through local carriers. In order to file claims for DSMT, a DMEPOS supplier must be enrolled in the Medicare program with the National Supplier Clearinghouse (NSC ). The supplier must also meet the quality standards of a CMS-approved national accreditation organization as stated above. DMEPOS suppliers must obtain a provider number from the local carrier in order to bill for DSMT.

The carrier requires the appropriate completed form, along with an accreditation certificate as part of the provider application process. After it has been determined that the quality standards are met, a billing number is assigned to the supplier. Once a supplier has received a National Provider Identification (NPI) number, the supplier can begin receiving reimbursement for this service.


Diabetes Education

Yes. In order for a client to participate in the diabetes education program, a licensed primary health care provider must refer the client to a program for diabetes education. Hospitals must be approved by the Washington State Department of Health (DOH) as a diabetes education provider.

For diabetes education services provided in a hospital outpatient setting, the provider must:
• Bill using revenue code 0942.
• Provide a minimum of 30 minutes of education/management per session.

Note: Services provided in an outpatient hospital department or hospital-based clinic must be billed on a UB-04 claim form. Services provided in a non-hospital based clinic or a physician’s office must be billed on a CMS-1500 claim form.

Note: The agency requires authorized hospital outpatient diabetes education programs to bill with revenue code 0942. Claims submitted using HCPCS codes G0108 and G0109 will be denied.

Denial reasons

Providers should be aware that MACs will return claims if you append demo code 85, and:

• You are not on the CEC participant provider list with a telehealth record type; or
• DOS “from date” is prior to your telehealth effective date, or
• DOS “from date” is after your telehealth termination date, or
• The DOS “from date” is prior to the beneficiary’s effective date; or
• The DOS “from date” is after the beneficiary’s termination date, or
• The DOS “from date” is more than 90 days after the beneficiary’s termination date; or
• The beneficiary was not aligned to the same ESCO with which you are participating, as identifi ed by ESCO ID; or
• The claim is for Part A and the TOB is other than 12X, 13X, 22X, 23X, 71X, 72X, 76X, 77X, and 85X,
• Other, non-telehealth services are billed on the same claim. In these cases, none of the services on the claim are processed.

In returning Part B claims, your MAC will use the following messaging:
• Claims Adjustment Reason Code (CARC) 16: (Claim/service lacks information or has submission/billing error(s) which is needed for adjudication) and
• Remittance Advice Remark Code (RARC) N763 (The demonstration code is not appropriate for this claim; resubmit without a demonstration code.)
• Group Code: CO (Contractual Obligation)



Saturday, March 28, 2020

Hospital Acquired conditions (HAC) CATAGORIES AND billing guidelines

Overview
Hospital Acquired Conditions (HAC) are serious conditions that patients get during an inpatient hospital stay. If hospitals follow proper procedures, patients are less likely to get these conditions. UnitedHealthcare Medicare Advantage doesn't pay for any of these conditions, and patients can't be billed for them, if acquired while in the hospital. UnitedHealthcare Medicare Advantage will only pay for these conditions if they were present on admission to the hospital.

Effective October 1, 2015, the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Version 33 Hospital Acquired Condition (HAC) list replaced the ICD-9-CM Version 32 HAC list.

HAC Categories:

01- Foreign Object Retained Following Surgery
02- Air Embolism
03- Blood Incompatibility
04- Stage III and IV Pressure Ulcers
05- Falls and Trauma
06- Catheter-Associated Urinary Tract Infection (UTI)
07- Vascular Catheter-Associated Infection
08- Surgical Site Infection (SSI) –Mediastinitis Following Coronary Artery Bypass Graft (CABG)
09- Manifestations of Poor Glycemic Control
10- Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) With Total Knee or Hip Replacement
11- Surgical Site Infection (SSI) Following Bariatric Surgery for Obesity
12- Surgical Site Infection (SSI) Following Certain Orthopedic Procedures of Spine, Neck, Shoulder or Elbow
13- Surgical Site Infection (SSI) Following Cardiac Implantable Electronic Device (CIED) Procedures
14- Iatrogenic Pneumothorax w/ Venous Catheterization

Present on Admission Guidelines

To group diagnoses into the proper Diagnosis-related group (DRG), CMS needs to capture a Present on Admission (POA) Indicator for all claims involving inpatient admissions to general acute care hospitals. Collection of POA indicator data is necessary to identify which conditions were acquired during hospitalization for the HAC payment provision as well as for broader public health uses of Medicare data. Use the UB-04 Data Specifications Manual and the ICD-10-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the POA indicator for each "principal" diagnosis and "other" diagnoses codes reported on claim forms UB-04 and 837 Institutional.


The POA Indicator guidelines are not intended to provide guidance on when a condition should be coded, rather to provide guidance on how to apply the POA Indicator to the final set of diagnosis codes that have been assigned in accordance with Sections I, II, and III of the official coding guidelines. Subsequent to the assignment of the ICD-10-CM codes, the POA Indicator should be assigned to all diagnoses that have been coded.

A joint effort between the health care provider and the coder is essential to achieve accurate and complete documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Medical record documentation from any qualified health care practitioner who is legally accountable for establishing the patient's diagnosis.

The provider, a provider's billing office, third party billing agents and anyone else involved in the transmission of this data shall insure that any re-sequencing of diagnosis codes prior to transmission to CMS also includes a re-sequencing of the POA Indicators


General POA Reporting Requirements

** POA indicator reporting is mandatory for all claims involving inpatient admissions to general acute care hospitals or other facilities.

** POA is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA.

** A POA Indicator must be assigned to principal and secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) and the external cause of injury codes. CMS does not require a POA Indicator for an external cause of injury code unless it is being reported as an "other diagnosis."

** Issues related to inconsistent, missing, conflicting, or unclear documentation must be resolved by the provider.

** If a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current official coding guidelines, then the POA Indicator would not be reported.

 CMS POA Indicator Reporting Options, Description, and Payment Indicator Description Medicare Payment
Y Diagnosis was present at time of inpatient admission. Payment is made for condition when an HAC is present
N Diagnosis was not present at time of inpatient admission. No payment is made for condition when an HAC is present
U Documentation insufficient to determine if condition was present at the time of inpatient admission. No payment is made for condition when an HAC is present
W Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission. Payment is made for condition when an HAC is present
1 Unreported/Not used. Exempt from POA reporting. This code is the equivalent of a blank on the UB-04, it was determined that blanks were undesirable when submitting this data via the 4010A.

NOTE: The number “1” POA Indicator should not be applied to any codes on the HAC list.  Exempt from POA reporting


Paper Claims

On the UB-04, the POA indicator is the eighth digit of Field Locator (FL) 67, Principal Diagnosis, and the eighth digit of each of the Secondary Diagnosis fields, FL 67 A-Q. In other words, report the applicable POA indicator (Y, N, U, or W) for the principal and any secondary diagnoses and include this as the eighth digit; leave this field blank if the diagnosis is exempt from POA reporting.

Electronic Claims

Submit the POA indicator on the 837I in the appropriate Health Care Information Codes segment as directed by the “UB04 Data Specifications Manual.


Reimbursement Guidelines

For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present.

The Present on Admission Indicator Reporting provision applies only to IPPS hospitals. CMS also required hospitals to report POA information for both primary and secondary diagnoses when submitting claims for discharges on or after October 1, 2007.


Q: Do the POA and HAC programs apply to outpatient or ambulatory surgery services?
A: No, this program is only for inpatient acute care admissions.

Q: If the POA indicator is not on the claim, will the claim be returned?
A: Beginning with claims with discharges on or after October 1, 2008, if hospitals do not report a valid POA code for each diagnosis on the claim, the claim will be returned to the hospital for correct submission of POA information

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