General
The following FAQs were retired in January 2008.
- Why would I no longer see lab charges showing up on my 130 supplemental lab report?
- CORFs provide social services (revenue code 550) but cannot get paid and cannot get any help. Please advise how we should bill for these services.
- Where can we get information about the 1.5% bonus for efforts on outcome reports? It’s been written about by the APTA but we cannot find anything on Highmark’s website.
- Do both the treatment and medical diagnosis codes, listed on the LCD, need to be reported on the claim?
- It was stated that a primary diagnosis and a treatment code should be on the claim. Is the primary or patient condition code required or recommended to be included on the claim?
- If my claim denies, can we adjust to change a diagnosis code?
- How do you get to the claim summary screen from the main menu? How long do the claims stay on the claim summary screen?
- Do we use the original evaluation date or the re-evaluation date when billing our claims?
- Do we use the therapist date or the physician’s date when billing occurrence codes 17, 28 or 29?
- Do we bill Medicare for a re-evaluation at the time of discharge?
- Do CCI edits reject or deny?
- What is ocular photodynamic therapy (OPT)?
- What are the coverage guidelines for OPT?
- What changes has CMS made to the NCD expanding the coverage of OPT with verteporfin?
- What documentation is required to show evidence of progression of the CNV lesions?
- Is OPT with verteporfin still covered for CNV lesions that occupy >50% of the entire lesion?
- Are there any noncovered indications for OPT with verteporfin to treat AMD?
- What are the billing instructions for OPT with verteporfin?
- What is meant by the term elective sterilization?
- What services related to sterilization are Not Covered by Medicare?
- What section of the law addresses the non covered conditions for sterilization?
- What section of the law addresses the non covered conditions for sterilization?
- What documentation should be submitted with sterilization claims?
- Can V codes be used as primary diagnoses?
- For Medicare B residents, would other provider visits (NP, podiatrist, psychologist, etc.) cover the 30-day requirement visit and be able to bill for Medicare B services?
- Is the separate Dysphagia Medical Work-up form necessary?
- We have had ongoing issues related to Partial Benefit Exhaust billing. Can you shed any light on this subject?
- What is Highmark Medicare Services' position on timed and untimed codes for speech? In other words, will SLP still be able to bill timed codes such as 97110 Therapeutic Activities, 97532 Cognitive Skills 1-on-1, 97535 Self Care Management?
- If an OMRA is completed early, when does the payment change? Are there any default days?
- Is care and management of chronic stasis ulcers considered a skilled service?
- Please provide detail on submitting and documenting mutually exclusive codes, and any training materials for staff on documenting and CCI edits.
- If I receive exception approval for 15 treatment days, must they be taken consecutively? Does each discipline count as a treatment day?
- Why do I need to submit medical records for a manual exception approval? Why can't I just put a KX modifier on the claim?
- In reference to rehabilitation therapy time, is the time spent evaluating the beneficiary counted?
- What is necessary when submitting medical record documentation for an Additional Documentation Request (ADR)?
- What documents should be submitted by a Skilled Nursing Facility (SNF) in response to a Medical Review Additional Development Request (ADR)?
- Our software vendors have developed code to produce no-pay bills for monthly periods. Can we keep submitting no-pay (no skilled care) bills monthly or do we have to wait until discharge?
- Will claims continue to suspend in SMNCOV and require a manual claims processor to push thru or will the process become automatic?
- What are the indications for using Pamidronate Disodium?
- How does Pamidronate work?
- What is the correct way to code Pamidronate Disodium?66
- How are units of Pamidronate calculated, and could you provide an example of the correct billing of Pamidronate?
- Where can I find additional information on the codes for Pamidronate Disodium?
- How are the results of a T score interpreted?
- What other indications may be considered for administration of Pamidronate Disodium?
- Can Pamidronate Disodium be used for the diagnosis of osteogenesis imperfecta in pediatric patient?
- Is the diagnosis of hypercalcemia (ICD-9-CM 275.42) sufficient to support payment for Pamidronate Disodium?
- What alpha-numeric HCPCS codes are valid for leuprolide acetate administered during chemotherapy for prostate cancer?
- How is the number of units billed determined?
- What documentation should be submitted for review when medical necessity may be questioned?
- What documentation must be submitted to support the neurological diagnosis for which IVIG treatment was initiated?
- What HCPCS codes should be used to bill for intravenous immune globulin (IVIG)?
- How should the patient's progress be documented to confirm that continued treatment is necessary?
- Is laboratory monitoring necessary to guide IVIG therapy necessary?
- Can the patient be maintained on the same dose of IVIG indefinitely?
- What documentation should be included when an Additional Development Request (ADR) form is received from Highmark Medicare Services?
- If the service is provided more than once a month, how should IVIG be billed?
- What is ECP and what does it mean?
- When does Medicare cover this service?
- How long is the usual course of therapy?
- What documentation is requested on the Additional Development Request (ADR) for this service?
- How will we know when these new codes are available for use?
- What is routine foot care?
- When is routine foot care eligible for reimbursement?
- What other conditions must be met for routine foot care services to be covered when the procedure presents a hazard to the beneficiary?
- What systemic conditions might justify coverage for routine foot care?
- When is an Evaluation and Management service eligible for payment in relation to routine foot care?
- What documentation should be submitted for review when medical necessity may be questioned?
- When is the treatment of mycotic nails considered routine and not covered for an ambulatory patient?
- When is the treatment of mycotic nails for nonambulatory patients covered?
- Is the treatment of warts on the foot covered under Medicare?
- Does Medicare offer a covered benefit for dental services?
- What defines "structures directly supporting the teeth"?
- Are providers required to receive a dental services claim denial from Medicare before they submit the claim to supplemental coverage or a secondary payer, i.e., group health insurer?
- Does this action also apply to inpatient dental hospital services or other dental services covered by Medicare?
- How does Medicare define excluded dental services under the Medicare benefit?
- What other dental services are covered under the Medicare benefit?
- What are structures contiguous to the jaw?
- Does the place of service, e.g., inpatient vs. outpatient, have any bearing on the coverage or exclusion of dental services?
- If a physician indicates the need for preoperative testing for a dental extraction due to dental caries, would the preoperative testing be covered?
- Does Medicare offer a covered benefit for diagnostic audiology testing?
- Are evaluations of chronic hearing loss covered?
- What is a qualified audiologist?
- Is a physician referral required for coverage of diagnostic audiology testing?
- What happens if a beneficiary undergoes diagnostic audiology testing without physician involvement or referral?
- What documentation is required to submit an audiology claim?
- What documentation is required to submit vestibular testing claims?
- What is the most common reason for denial of claims for diagnostic audiology testing?
- What diagnosis (ICD-9-CM) codes may be entered (and supported by documentation) when EPO (Q4054 and Q4055) is submitted on an ESRD claim?
- With regards to electronic billing, what will I use in July 2007?
- We report 90871 for intravenous infusion for therapy/diagnosis, administered by a physician or under direct supervision of a physician, each additional hour, up to eight (8) hours. Must we complete a full hour to report this code?
- We are billing for inpatient medical education (IME) and receiving reason code U5234? Is this a systems problem? If so, when will it be corrected?
- When billing for infusion therapy other than chemotherapy with the new codes (i.e., 90780), why are our claims being returned with reason codes 31422 or 31432?
- If an Inpatient Rehabiliation Facility is not yet effective for CMGs, can they bill with the necessary HIPPS Code?
- Is the moratorium on the financial limitation for outpatient rehabiliation service still in effect?
- What are the Therapy Caps?
- When should I submit documentation for a “manual request” of a therapy cap exception?
- What documentation is necessary to submit with an ADR request?
- What determines the rehab RUG levels?
Why would I no longer see lab charges showing up on my 130 supplemental lab report?
As a result of changes that were made within the PS&R system in January 2003, all lab fee services are being directed to the 135 report instead of the 130 lab report.
Date Posted: 06/09/2003, Date Reviewed/Revised: 01/28/2008
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Pub 100-2, Chapter 12, Section 40
40.7 - Social Services
Social services are covered CORF services if they are part of a comprehensive coordinated skilled rehabilitation program, included in the plan of treatment established and signed by the referring physician, and performed in conjunction with core CORF services. Social services must contribute to the improvement of the individual’s condition. Such services include:
- Assessment of the social and emotional factors related to the patient’s illness, need for care, response to treatment, and adjustment to care in the CORF'S
- Assessment of the relationship of the patient’s medical and nursing requirements to his or her home situation, financial resources, and the community resources available upon discharge from the CORF; and
- Counseling and referral for casework assistance in resolving problems in these areas
Date Posted: 04/04/2007, Date Reviewed/Revised: 01/20/2008
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The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that the 2007 Physician Quality Reporting Initiative (PQRI) webpage is now available.
PQRI establishes a financial incentive for eligible professionals to participate in a voluntary quality reporting program. Eligible professionals who successfully report a designated set of quality measures on claims for dates of service from July 1 to December 31, 2007, may earn a bonus payment, subject to a cap, of 1.5% of total allowed charges for covered Medicare physician fee schedule services.
For more information on 2007 PQRI, visit the CMS website (www.cms.hhs.gov/PQRI/)
Date Posted: 04/04/2007, Date Reviewed/Revised: 01/20/2008
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All diagnosis codes that apply to the patient should be reported on the claim.
Date Posted: 04/04/2007, Date Reviewed/Revised: 01/20/2008
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All diagnosis codes that apply to the patient should be reported on the claim.
Date Posted: 04/04/2007, Date Reviewed/Revised: 01/20/2008
If my claim denies, can we adjust to change a diagnosis code?
You cannot adjust denied claims (status location, D B9997). You would have to request an appeal.
Date Posted: 04/04/2007, Date Reviewed/Revised: 01/20/2008
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Main menu 01, claim summary screen, option 56. Claims remain here until finalized.
Date Posted: 04/04/2007, Date Reviewed/Revised: 01/20/2008
Do we use the original evaluation date or the re-evaluation date when billing our claims?
If you are referring to occurrence codes 17, 29 and 30, The date associated with occurrence codes 17, 29 & 30 is the date the plan of care was last reviewed.
Date Posted: 04/04/2007, Date Reviewed/Revised: 01/20/2008
Do we use the therapist date or the physician’s date when billing occurrence codes 17, 28 or 29?
The date associated with occurrence codes 17, 29 & 30 is the date the plan of care was last reviewed.
Date Posted: 04/04/2007, Date Reviewed/Revised: 01/20/2008
Do we bill Medicare for a re-evaluation at the time of discharge?
A re-evaluation may be appropriate prior to planned discharge for the purposes of determining whether goals have been met, or for the use of the physician or the treatment setting at which treatment will be continued. (Reference: CMS Pub 100-02, Ch 15, 220.3 C)
Date Posted: 04/04/2007, Date Reviewed/Revised: 01/20/2008
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CCI edits may either reject or return.
Date Posted: 04/04/2007, Date Reviewed/Revised: 01/20/2008
What is ocular photodynamic therapy (OPT)?
Ocular photodynamic therapy is a medical procedure which involves the infusion of a light activated (photosensitive) drug that is chemically designed to have a unique affinity for diseased tissue. It is used in the treatment of age-related macular degeneration (AMD), a common eye disease among the elderly and the leading cause of blindness in adults over the age of 50.
Date Posted: 06/22/2004, Date Reviewed/Revised: 01/20/2008
What are the coverage guidelines for OPT?
OPT is only covered when used in conjunction with verteporfin, an intravenous lipophilic photosensitive drug for patients with a diagnosis of neovascular age-related macular degeneration (AMD) and incident to a physician’s service.
Date Posted: 06/22/2004, Date Reviewed/Revised: 01/20/2008
What changes has CMS made to the NCD expanding the coverage of OPT with verteporfin?
After a thorough review and reconsideration, CMS has made a determination that the evidence is adequate to conclude that OPT with verteporfin is reasonable and necessary for treating AMD in two additional clinical instances:
- Subfoveal occult with no classic choroidal neovascularization (CNV) with AMD, and
- Subfoveal minimally classic CNV (where the CNV area occupies <50% of the area of the entire lesion) associated with AMD.
The above 2 indications are considered reasonable and necessary only when:
- The lesions are small (4 disk areas or less in size) at the time of initial treatment or within the 3 months prior to initial treatment, and,
- The lesions have shown evidence of progression within the 3 months prior to initial treatment.
Date Posted: 06/22/2004, Date Reviewed/Revised: 01/20/2008
What documentation is required to show evidence of progression of the CNV lesions?
Documentation of the progression of the CNV lesions should include evidence of the deterioration of visual acuity (at least 5 letters on a standard eye examination chart); lesion growth (an increase in at least 1 disk area; or the appearance of blood associated with the lesion.
Date Posted: 06/22/2004, Date Reviewed/Revised: 01/20/2008
Is OPT with verteporfin still covered for CNV lesions that occupy >50% of the entire lesion?
Yes, OPT with verteporfin continues to be approved for patients with a diagnosis of neovascular AMD with predominately classic subfoveal (CNV) lesions (where the area of classic CNV occupies = 50% of the area of the entire lesion) at the initial visit as determined by a fluorescein angiogram.
Note: This diagnosis must be determined by a fluorescein angiogram at the initial visit. Also, there are no requirements regarding visual acuity, lesion size, and number of re-treatments when treating predominantly classic lesion patients However, a fluorescein angiogram in subsequent, follow-up visits prior to treatment is required.
Date Posted: 06/22/2004, Date Reviewed/Revised: 01/20/2008
Are there any noncovered indications for OPT with verteporfin to treat AMD?
Yes. The following AMD-related uses of OPT with verteporfin not already addressed in the NCD will continue to be noncovered. These indications include, but are not limited to:
- Juxtafoveal or extrafoveal CNV lesions (lesions outside the fovea),
- Inability to obtain a fluorescein angiogram,
- Atrophic or “dry” AMD.
Note: OPT with verteporfin for other ocular indications, such as pathologic myopia or presumed ocular histoplasmosis syndrome, continue to be eligible for local coverage determinations through individual contractor discretion.
Date Posted: 06/22/2004, Date Reviewed/Revised: 01/20/2008
What are the billing instructions for OPT with verteporfin?
For photodynamic therapy use the appropriate CPT code:
CPT code 67221 (includes intravenous infusion), or
CPT code 67225, second eye, at single session (list separately in addition to code for primary eye treatment)
HCPCS code J3396, injection, verteporfin, 0.1 mg; billed with revenue code 0636 (requires detailed coding). HCPC code J3396 should be used for services on or after January 1, 2005.Date Posted: 06/22/2004, Date Reviewed/Revised: 01/20/2008
What is meant by the term elective sterilization?
A planned surgical procedure resulting in the inability to reproduce.
Date Posted: 05/13/2004, Date Reviewed/Revised: 01/20/2008
What services related to sterilization are Not Covered by Medicare?
Services that are not covered for sterilization include:
- Elective hysterectomy, tubal ligation, and vasectomy procedures if the reason is sterilization.
- Sterilization that is performed only as a measure to prevent the possible development of, or effect on, a mental condition should that individual become pregnant is not covered.
- Sterilization that is performed because a physician believes another pregnancy would endanger the overall general health of the woman is not covered.
- Sterilization of a mentally retarded person where the purpose is to prevent conception, rather than the treatment of an illness or injury is not covered.
Date Posted: 05/13/2004, Date Reviewed/Revised: 01/20/2008
What section of the law addresses the non covered conditions for sterilization?
The basis for the coverage or noncoverage of these services is found in Sec.1862 (a)(1) of the Act, under “Exclusions from Coverage” which states that no payment may be made for items and services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Date Posted: 05/13/2004, Date Reviewed/Revised: 01/22/2008
What section of the law addresses the non covered conditions for sterilization?
The basis for the coverage or noncoverage of these services is found in Sec.1862 (a)(1) of the Act, under “Exclusions from Coverage” which states that no payment may be made for items and services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Date Posted: 05/13/2004, Date Reviewed/Revised: 01/20/2008
What documentation should be submitted with sterilization claims?
The medical record is expected to include documentation of a pathology report that describes the pathological findings to support the medical necessity of the surgery for reasons other than sterilization. Medicare will deny claims when evidence is not present to support the medical necessity of the procedure.
Date Posted: 05/13/2004, Date Reviewed/Revised: 01/20/2008
Can V codes be used as primary diagnoses?
In many circumstances, V codes should be used only as a secondary diagnosis code and should not be selected for use as the primary diagnosis code. The ICD-9-CM provides these V codes to deal with encounters for circumstances other than disease/injury. V codes may be used in 3 circumstances:
- When a well person encounters health services for some specific reason (e.g., health screening, immunizations, lab tests)
- When a person w/a chronic condition encounters health care system for specific aftercare (e.g., dialysis)
- When circumstances influence a person's health status but are not an illness or injury (e.g., person w/artificial heart valve)
In circumstances #2 and #3, V codes should be used only as a secondary code and should not be selected as the primary code. However, V-codes may be used as the principal diagnosis code to identify services related to aftercare and rehabilitation therapy. Providers should use additional code(s) to identify underlying medical condition(s) when V-codes are used as the primary diagnosis.
Date Posted: 04/21/2006, Date Reviewed/Revised: 01/29/2008
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Section 1861(r) of the Social Security Act defines a physician (for Medicare purposes) as “The term ‘physician’, when used in connection with the performance of any function or action, means (1) a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he performs such function or action (including a physician within the meaning of section 1101(a)(7))”
Date Posted: 04/21/2006, Date Reviewed/Revised: 01/29/2008
Is the separate Dysphagia Medical Work-up form necessary?
The Centers for Medicare and Medicaid Services does not require the Dysphagia Medical Work Up Form to be used.
Date Posted: 04/21/2006, Date Reviewed/Revised: 01/29/2008
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Partial benefit exhaust claims should be billed as separate claims. Covered days and non-covered days should be billed separately.
Date Posted: 04/21/2006, Date Reviewed/Revised: 01/29/2008
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Billing any two codes for a therapy procedure requiring one-on-one patient contact is not permitted. Refer to the Part B Billing Scenarios for PTs and OTs, Section 1, “Billing – CPT Codes not Permitted” located on the CMS website at: http://cms.hhs.gov/therapyservices/
Date Posted: 04/21/2006, Date Reviewed/Revised: 01/29/2008
If an OMRA is completed early, when does the payment change? Are there any default days?
For Part A billing, the RUG III Payment rate may be adjusted on the ARD of a nonscheduled assessment.
Date Posted: 04/21/2006, Date Reviewed/Revised: 01/29/2008
Is care and management of chronic stasis ulcers considered a skilled service?
The patient must meet all skilled care requirements as stated under question 15.
Date Posted: 04/21/2006, Date Reviewed/Revised: 01/29/2008
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Refer to CCI edits for detail on submitting and documenting mutually exclusive codes. We have a power point presentation that was used as part of a teleconference for CCI edits that you may request from your education specialist.
Date Posted: 04/21/2006, Date Reviewed/Revised: 01/29/2008
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Treatment days should be used as medically appropriate for that beneficiary’s specific treatment plan. For example, if 15 treatment days of medically necessary therapy are approved, the patient would follow the plan of care which specifies the patient receive therapy treatment three days a week for five weeks. If the patient has services in the morning, leaves and returns in the afternoon for more services, those services all done on the same date apply to one treatment day of approved treatment.
Date Posted: 04/21/2006, Date Reviewed/Revised: 01/29/2008
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Transmittal 855, dated February 15, 2006, gives a list of acceptable ICD-9 codes that qualify for the automatic therapy cap exception. The contractor will be tracking the use of the KX modifier for appropriateness. If it has been determined that a facility is inappropriately utilizing the KX modifier, further auditing may be conducted at your facility for inquiry purposes.
Date Posted: 04/21/2006, Date Reviewed/Revised: 01/29/2008
In reference to rehabilitation therapy time, is the time spent evaluating the beneficiary counted?
“Whether the time spent evaluating the beneficiary is counted depends on whether it is the formal initial evaluation or an evaluation performed after the course of therapy has begun. The time it takes to perform the formal initial evaluation and develop the treatment goals and the plan of treatment may not be counted as minutes of therapy received by the beneficiary. However, a reevaluation – that is, a hands-on examination of the beneficiary and not simply an update to the documentation and revision of the care plan – that is performed once a therapy regimen is underway (for example, evaluating goal achievement as part of the therapy session) may be counted as minutes of therapy received.”
(Reference: Federal Register/Vol. 64, No. 146/Friday, July 30, 1999/Rules and Regulations, p. 41661)
The Federal Register Online : http://www.access.gpo.gov/nara/index.html
Date Posted: 06/25/2003, Date Reviewed/Revised: 01/29/2008
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The following medical record documentation should be submitted when responding to an additional development request (ADR).
- Hospital discharge summary or hospital or SNF transfer sheet
- History and physical
- Physician signed orders and physician progress notes
- Signed and dated certification or recertification for skilled care
- All nurses notes, therapy plan(s) of treatment, therapy evaulations, therapy minutes, therapy notes and progress notes from 30 days prior to the assessment reference date or since admission for each Rug III code billed and through the dates of service
- Medication, treatment, and wound care records, dietician notes
- Signed Medicare MDS for each of the RUG III codes billed
- If this is an adjusted claim and the HIPPS was changed due to an error on a prior claim, submit documentation for the reason for the correction
It is important to note that each RUG III code billed must be supported by the information within the medical record. Therefore, you will need to submit medical record documentation to support the MDS "look back" period for each code billed. For example, the dates of service on a claim are May 1 through May 9, admission date was April 26, and the 5 day MDS has the assessment reference date of April 30. The RUG III code billed is RHA01 for 9 days. The information to support this code would include the information from the admission date of April 30 through the dates of service on the claim, which is May 1 through May 9.
Supportive information can be found on the following web: link: http://www.cms.hhs.gov/NursingHomeQualityInits/20_NHQIMDS20.ASP.
Date Posted: 02/03/2006, Date Reviewed/Revised: 01/29/2008
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SNF providers should submit all documents listed in the ADR as well as any other supporting documentation, including, but not limited to physician’s orders, history and physical, MDS, progress notes, nurses’ notes, therapy orders, plan of care, certifications, and treatment notes.
Date Posted: 02/03/2006, Date Reviewed/Revised: 01/29/2008
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You may continue to submit no payment bills monthly, you do not have to wait until discharge.
Date Posted: 10/03/2006, Date Reviewed/Revised: 01/29/2008
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Yes, claims will continue to suspend in SMNCOV.
Date Posted: 10/03/2006, Date Reviewed/Revised: 01/29/2008
What are the indications for using Pamidronate Disodium?
Aredia or (Pamidronate Disodium) is indicated for the treatment of moderate or severe hypercalcemia associated with malignancy, with or without bone metastases; Paget’s disease; Osteolytic Bone Metastases of Breast Cancer; or Osteolytic Lesions of Multiple Myeloma.
For very select cases, Pamidronate Disodium may also be indicated for disabling osteoporosis and will be covered if the patient has all of the following:
- Severely disabling osteoporosis;
- T-score less than or equal to -2.5;
- Documentation of compression fractures of the axial skeleton, or peripheral fractures;
- Pain and difficulty with Activities of Daily Living (ADL’s), secondary to osteoporosis;
- Allergic to shellfish and/or salmon derivatives or has tried to use calcitonin without improvement; or has a contraindication to the use of calcitonin; or
- Intolerance to two or more antiresorptive agents or has tried for 12 months oral biphosphonates without documented improvement;
- Has a severely deteriorated condition and osteoporosis is so significant that a trial of oral biphosphonates is not medically warranted
Date Posted: 04/20/2006, Date Reviewed/Revised: 01/09/2008
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Pamidronate is a bone resorption inhibitor, which blocks the dissolution of calcium phosphate in bone or inhibits osteoclast activity.
Date Posted: 04/20/2006, Date Reviewed/Revised: 01/09/2008
What is the correct way to code Pamidronate Disodium?66
J2430 is for injection of Pamidronate Disodium per 30 mg.
Date Posted: 04/20/2006, Date Reviewed/Revised: 01/09/2008
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Pamidronate Disodium should be billed using the correct HCPC code and the current number of units should be entered for the prescribed dose. For example: the physician orders 90 mg of Aredia (Pamidronate Disodium) to be administered. The correct HCPC code is J2430 and the correct number of units is determined by the physician’s order. The calculation for this example follows:
90 mg divided by 30 mg = 3 units. (1 unit = 30mg)
Date Posted: 06/19/2007, Date Reviewed/Revised: 01/09/2008
Where can I find additional information on the codes for Pamidronate Disodium?
The coding description for Pamidronate Disodium can be found in the 2006 HCPCS Level II manual. Additional information can also be found in Highmark Medicare Services’ Local Coverage Determination (LCD) on Pamidronate Disodium.Date Posted: 04/20/2006, Date Reviewed/Revised: 01/09/2008
How are the results of a T score interpreted?
Positive integers are whole numbers greater than zero for example: 1, 2, 3, etc. Negative integers are the opposites of these whole numbers for example: -1, -2, -3, etc. 0 (zero) is neither positive nor negative. A number line, (see below), is labeled with integers in increasing order from left to right and goes in both directions. For any two different places on this line the integer on the right is greater than the integer of the left. When looking at a T score, 0.0 usually represents a normal healthy bone density and a T score of below –2.5 indicates osteoporosis. A T-score correlating with the diagnosis of osteoporosis should be less than or equal to –2.5;
-3.0, -2.5, -2.0, -1.0, 0.0, +1.0, +2.0, +2.5, +3.0
Date Posted: 04/20/2006, Date Reviewed/Revised: 01/09/2008
What other indications may be considered for administration of Pamidronate Disodium?
Pamidronate Disodium may be considered for very select individuals who have low bone density or osteopenia. Osteopenia is defined as hip bone mineral density measurement (BMD) that is between 1 - 2.5 standard deviations below the young adult female mean (T-score less than -1 and greater than –2.5). In order for osteopenia to be considered for coverage, the following selection criteria must be met and documented:
- The diagnosis must be made by a central DEXA scan measurement with a T-score less than -1 and greater than -2.5;
- The patient has intolerance to two or more antiresorptive agents or has had a 12 month trial of oral biphosphonates without documented improvement; and
- The patient must have the associated risk factors for fracture.
Date Posted: 04/20/2006, Date Reviewed/Revised: 01/09/2008
Can Pamidronate Disodium be used for the diagnosis of osteogenesis imperfecta in pediatric patient?
Yes. Pamidronate may also be indicated for the treatment of osteogenesis imperfecta in pediatric patients.
Date Posted: 04/20/2006, Date Reviewed/Revised: 01/09/2008
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No. Pamidronate Disodium for hypercalcemia that is not associated with malignancy or the other approved diagnosis will be denied. The provider must use the diagnosis, or other approved diagnoses which reflects the reason for use of Pamidronate. The codes used are to be carried out to the highest level of specificity and selected from the ICD-9-CM code book and appropriate to the year in which the service is rendered for the claim submitted.
Date Posted: 04/20/2006, Date Reviewed/Revised: 01/09/2008
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J9217-Leuprolide acetate (for depot suspension), 7.5 mg
J9218-Leuprolide acetate, per 1 mg
J9219-Leuprolide acetate implant, 65 mg
Date Posted: 02/12/2003, Date Reviewed/Revised: 01/10/2008
How is the number of units billed determined?
The definition of the HCPCS code specifies the lowest common denomination of the amount of the dosage. Hospitals utilize the units field as a multiplier to arrive at the dosage amount. For example, J9217 describes a dosage of 7.5 mg. For a total dosage of 22.5 mg, hospitals show 3 in the units field.
Date Posted: 03/12/2003, Date Reviewed/Revised: 01/10/2008
What documentation should be submitted for review when medical necessity may be questioned?
Most accurate and specific diagnosis code(s) must be submitted on the claim. The patient’s medical record should indicate the specific signs/symptoms, level of functional impairment, and other clinical data supporting the diagnosis code(s) used. Physician documentation of the indications for Leuprolide acetate should be noted in the record along with the response to treatment. The medical record must be available to the intermediary upon request.
Date Posted: 03/12/2003, Date Reviewed/Revised: 01/10/2008
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When initiating IVIG to treat neurological disorders, the diagnosis of the disorder must be unequivocal. There must be clinical evidence to support the diagnosis. Such evidence may include:
- biopsy(muscle-nerve) when necessary to support the diagnosis;
- quantitative clinical examinations;
- electrophysiological motor-sensory nerve conductions (EMG);
- CSF studies; and
- other ancillary tests such as serum immunoprotein.
Date Posted: 04/21/2003, Date Reviewed/Revised: 01/09/2008
What HCPCS codes should be used to bill for intravenous immune globulin (IVIG)?
NOTE THE CHANGE: Effective for services after January 1, 2006, HCPCS codes Q9941-Q9944 will no longer be paid by Medicare.
These codes will be replaced with HCPCS codes J1566 and J1567 for dates of service on or after January 1, 2006.
- J1566 - INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G., POWDER), 500 MG.
- J1567 - INJECTION, IMME GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG.
HCPC Coding Changes Effective July 1, 2007 for Immune Globulin
Effective for claims with dates of service on or after July 1, 2007, Health Care Procedure Code System (HCPC) code J1567 (injection, immune Globulin, intravenous, non-lyophilized (e.g. liquid), 500 mg) will no longer be payable for Medicare. In it's place, the following HCPCS codes will be payable, effective July 1, 2007:
HCPCS Code Short Description Long Description Q4087 Octagam Injection Injection, immune globulin (Octagam), intravenous, non lyophilized (e.g. liquid), 500 mg Q4088 Gammagard Liquid Injection Injection, immune globulin (Gammagard Liquid), intravenous, non-lyophilized (e.g. liquid), 500mg Q4091 Flebogamma Injection Injection, immune globulin (Flebogamma). intavenous, non-lyophilized (e.g. liquid), 500mg
Q4092 Gammunex Injection Injection, immune globulin (Gamunex), intravenous, non-lyophilized (e.g liquid), 500 mg Q4089 Rhophylac Injection Injection, Rho(D) immune globulin (human, (Rhophylac), intramuscular or intravenous, 100 iu Q4090 HepaGam B injection Injection, hepatitis B immune globulin (HepaGam B), intramuscular, 0.5 ml. NOTE: HepaGam B when given intravenously should be billed using an appropriate Not Otherwise Classified (NOC) code in the absence of a specific HCPC.
Reference: CMS Change Request 5635 - Dated June 1, 2007
Date Posted: 04/21/2003, Date Reviewed/Revised: 01/09/2008
How should the patient's progress be documented to confirm that continued treatment is necessary?
Once treatment is initiated, it is expected that the patient's progress will be meticulously documented in the medical record. If there is initial improvement by the second course of treatment, and continued treatment is necessary, then objective clinical assessment to monitor progress is required. Objective monitoring may use any accepted clinical method such as the MRC scale, Rankin score, ADL scores and/or objective findings of physical exam.. The documentation of the number of relapses for Multiple Sclerosis may be used. Subjective improvement alone is insufficient to continue IVIG.
Date Posted: 04/21/2003, Date Reviewed/Revised: 01/09/2008
Is laboratory monitoring necessary to guide IVIG therapy necessary?
No. Clinical monitoring takes clear precedence over laboratory monitoring. If clinical improvement is evident, then laboratory monitoring solely to guide therapy is not necessary.
Date Posted: 04/21/2003, Date Reviewed/Revised: 01/09/2008
Can the patient be maintained on the same dose of IVIG indefinitely?
No, there must be an attempt to wean the initial dosage when improvement has occurred. There must be an attempt to stop the IVIG infusion if improvement is sustained with dosage reduction. If withholding or decreasing IVIG therapy is inappropriate for the purpose of assessing response to therapy, then the record is expected to include documentation discussing why therapy cannot be withheld or decreased. If clinical improvement does not occur with IVIG, then the medication should discontinued.
Date Posted: 04/21/2003, Date Reviewed/Revised: 01/09/2008
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The following physician documentation should be submitted to Highmark Medicare Services when an ADR is received:
- physicians' orders
- the results of any tests used to diagnose the neurological or musculoskeletal disease for which IVIG was initiated (muscle-nerve biopsy, electrophysiological motor-sensory nerve conductions (EMG), CSF studies and any other ancillary tests such as serum immunoprotein);
- objective clinical assessment including functional status at the time of diagnosis and/or at the time IVIG was initiated;
- specific signs and symptoms, level of functional impairment and clinical data including laboratory test results supporting the diagnosis code(s) used for the date of service of the claim that is submitted for payment;
- the choice of IVIG over other treatments;
- the results of all testing/services rendered;
- the patient's response to the treatments;
- the medication administration form;
- previous treatment failures, when applicable;
- any attempt to stop IVIG treatment if improvement is sustained with a reduction in dosage. If withholding or decreasing IVIG therapy is inappropriate, the record is expected to include documentation as to why therapy cannot be withheld or decreased;
- the need for continued therapy using objective clinical assessments such as the MRC scale, Rankin score or ADL scores;
- the rationale for continued therapy, at the dose and frequency administered, after the first 90 days and at least every six months thereafter; and
- itemized bill.
Date Posted: 06/08/2007, Date Reviewed/Revised: 01/09/2008
If the service is provided more than once a month, how should IVIG be billed?
Administration of IVIG treatments is not considered a repetitive service and therefore does not have to be billed on a monthly basis. However, it is suggested that IVIG be billed monthly or at the conclusion of treatment to reduce paperwork.
It is suggested that if providers bill on a monthly basis, the provider need only submit one (1) packet of complete documentation for all dates of service within that month. This also increases efficiency and decreases cost for the provider.
Date Posted: 06/08/2007, Date Reviewed/Revised: 01/09/2008
What is ECP and what does it mean?
ECP stands for External Counterpulsation which is used for severe angina. ECP, commonly referred to as enhanced external counterpulsation, is a non-invasive outpatient treatment for coronary artery disease refractory to medical and /or surgical therapy.
Date Posted: 08/16/2004, Date Reviewed/Revised: 01/10/2008
When does Medicare cover this service?
Under the guidelines set forth by CMS, Medicare covers the use of this device to treat stable angina pectoris, since only that use has developed sufficient evidence to demonstrate its medical effectiveness. Other uses of this device and similar devices remain non-covered. In addition, the non-coverage of the hydraulic version of this type of device remains in force.
Coverage is also provided for the Use of ECP for beneficiaries who have diagnosed disabling angina (Class III or Class IV, Canadian Cardiovascular Society Classification or equivalent classification) who, in the opinion of a cardiologist or cardiothoracic surgeon, are not readily amenable to surgical intervention, such as PTCA or cardiac bypass.
Date Posted: 08/16/2004, Date Reviewed/Revised: 01/10/2008
How long is the usual course of therapy?
A full course of therapy usually consists of 35 one-hour treatments, which may be offered once or twice daily, usually 5 days per week.
Date Posted: 08/16/2004, Date Reviewed/Revised: 01/10/2008
What documentation is requested on the Additional Development Request (ADR) for this service?
The provider should send the following information:
- Physician’s order
- History, physical and evaluation by a cardiologist or cardiothoracic surgeon
- Documentation to support that the patient was not amenable to PTCA or coronary bypass surgery (i.e. their condition is inoperable, coronary artery is not readily amenable to such procedures, they are an excessive risk)
- Clinical documentation supporting the diagnosis for which ECP is rendered, including:
- Level of functional impairment
- Specific signs and symptoms
- List of current medications
- Reports of all testing
- Itemized bill
Date Posted: 08/16/2004, Date Reviewed/Revised: 01/10/2008
How will we know when these new codes are available for use?
CMS will notify the public through their listserv when the proposed guidelines become available. To subscribe to this listserv, please go to the following CMS Web site and follow the directions to the OPPS listserv: http://www.cms.hhs.gov/apps/mailinglists/
Date Posted: 10/11/2005, Date Reviewed/Revised: 01/29/2008
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Routine foot care includes the cutting or removal of corns or calluses; the trimming, cutting, clipping, or debriding of nails; and other hygienic and preventive maintenance care in the realm of self-care, such as cleaning and soaking the feet, the use of skin creams to maintain skin tone of both ambulatory and bedfast patients, and any services performed in the absence of localized illness, injury or symptoms involving the foot.
Date Posted: 12/17/2003, Date Reviewed/Revised: 01/10/2008
When is routine foot care eligible for reimbursement?
Routine foot care is eligible for Medicare reimbursement when:
- Systemic conditions such as metabolic, neurologic or peripheral vascular disease result in severe circulatory embarrassment or areas of diminished sensation in the individual’s legs or feet.
- The evidence documents that non-professional performance of routine foot care would be hazardous for the patient because of an underlying systemic disease/condition.
- Services ordinarily considered to be routine may be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of ulcers, wounds, or infections.
Date Posted: 12/17/2003, Date Reviewed/Revised: 01/10/2008
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If a procedure presents a hazard to the beneficiary, it is not considered routine when he/she is under the care of a doctor of medicine or osteopathy for a metabolic disease, such as diabetes mellitus, or for other conditions that have resulted in circulatory embarrassment of areas of desensitization in the legs or feet.
Date Posted: 12/17/2003, Date Reviewed/Revised: 01/10/2008
What systemic conditions might justify coverage for routine foot care?
The following metabolic, neurologic, and peripheral vascular diseases most commonly represent the underlying conditions that might justify coverage for routine foot care. This is not intended to be a comprehensive list. When the patient's condition is one of those designated by the asterisk (*), routine procedures are covered only if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition.
- Diabetes mellitus*
- Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)
- Buerger's disease (thromboangiitis obliterans)
- Chronic trhombophlebitis*
- Peripheral neuropathies involving the feet-
- Associated with malnutrition and vitamin deficiency *
- Malnutrician (general, pellagra)
- Alcoholism
- Malabsorption (celiac disease, tropical sprue)
- Pernicious anemia
- Associated with carcinoma *
- Associated with diabetes mellitus*
- Associated with drugs and toxins*
- Associated with multiple sclerosis*
- Associated with uremia (chronic renal disease)*
- Associates with traumatic injury
- Associated with traumatic leprosy or neurosyphilis
- Associated with hereditary disorders
- Hereditary sensory radicular neuropathy
- Angiokeratoma corporis diffusum (Fabry's)
- Amyloid neuropathy
- Associated with malnutrition and vitamin deficiency *
When is an Evaluation and Management service eligible for payment in relation to routine foot care?
Medical care provided on the same day as routine foot care by the same doctor for the same condition is not eligible for payment except if it is the initial E&M service performed to diagnose the patient’s condition or if the E&M service is a significant separately identifiable service. In this case, the modifier 25 must be reported with the E&M service and the medical records must clearly document the E&M service.
Date Posted: 12/17/2003, Date Reviewed/Revised: 01/10/2008
What documentation should be submitted for review when medical necessity may be questioned?
Services for which medical necessity may be questioned should be documented with additional clinical evidence. This evidence may include office records, physician notes or diagnoses characterizing the patient’s physical status as being of such an acute or severe nature that more frequent services are indicated. In the case of mycotic nails, the medical record should contain a description of the nails that requires debridement. In the absence of a systemic condition in these patients, documentation of the marked limitation of ambulation or in the case of non-ambulatory patients, that the condition is likely to result in significant medical complications in the absence of such treatment.
Date Posted: 12/17/2003, Date Reviewed/Revised: 01/10/2008
When is the treatment of mycotic nails considered routine and not covered for an ambulatory patient?
Any treatment of a fungal (mycotic) infection of the toenail for an ambulatory patient is considered routine and not covered in the absence of the documentation by the physician attending the patient’s mycotic condition of the (1) clinical evidence of mycosis of the toenail, and (2) the patient has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.
Date Posted: 12/17/2003, Date Reviewed/Revised: 01/10/2008
When is the treatment of mycotic nails for nonambulatory patients covered?
The treatment of mycotic nails for nonambulatory patient is covered only when the physician attending the patient’s mycotic condition documents that (1) there is clinical evidence of mycosis of the toenail, and (2) the patient suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.
Date Posted: 12/17/2003, Date Reviewed/Revised: 01/10/2008
Is the treatment of warts on the foot covered under Medicare?
The treatment of warts (including plantar warts) on the foot is covered to the same extent as services provided for the treatment of warts located elsewhere on the body.
Date Posted: 12/17/2003, Date Reviewed/Revised: 01/10/2008
Does Medicare offer a covered benefit for dental services?
Under section 1862(a)(12) of the Social Security Act, Medicare does not provide coverage of most dental services. Items and services provided “… in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth…” are not covered.
Date Posted: 06/22/2004, Date Reviewed/Revised: 01/10/2008
What defines "structures directly supporting the teeth"?
The structures that directly support the teeth are the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum, and alveolar process.
Date Posted: 06/22/2004, Date Reviewed/Revised: 01/10/2008
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Effective February 8, 2004, under section 950 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (the Act), a group health plan providing supplemental or secondary coverage to Medicare beneficiaries cannot require providers to obtain a claim denial from Medicare, for outpatient dental services that are not covered by Medicare, before paying the claim.
Date Posted: 06/22/2004, Date Reviewed/Revised: 01/10/2008
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A group health plan may continue to require a claim determination under this Act in cases involving or appearing to involve inpatient dental hospital services or dental services expressly covered by Medicare. (Payment may be made under Part A for these services.)
Date Posted: 06/22/2004, Date Reviewed/Revised: 01/10/2008
How does Medicare define excluded dental services under the Medicare benefit?
When an excluded service is the primary procedure involved, it is not covered regardless of its complexity or difficulty. The following examples are not covered:
- The extraction of an impacted tooth;
- An alveoloplasty (the surgical improvement of the shape and condition of the alveolar process) and a frenectomy when either of these procedures is performed in connection with an excluded service; e.g., the preparation of the mouth for dentures.
- The removal of the torus palatinus (a bony protuberance of the hard palate) could be a covered service. However, with rare exception, this surgery is performed in connection with an excluded service, i.e., the preparation of the mouth for dentures. Under such circumstances, this service is not covered.
Date Posted: 06/22/2004, Date Reviewed/Revised: 01/10/2008
What other dental services are covered under the Medicare benefit?
When reasonable and medically necessary, payment may be made for:
- Surgery related to the jaw or any structure contiguous to the jaw;
- The reduction of any fracture of the jaw or any facial bone, including dental splints or other appliances used for this purpose;
- Reconstruction of a ridge performed as a result of and at the same time as the surgical removal of a tumor (for other than dental purposes); and/or
- The extraction of teeth to prepare the jaw for radiation treatments of neoplastic disease.
Date Posted: 06/22/2004, Date Reviewed/Revised: 01/10/2008
What are structures contiguous to the jaw?
In general, the jaw or any structure contiguous of the jaw includes structures of the facial area below the eyes, e.g., mandible, gums, tongue, palate, salivary glands, sinuses, etc.
Date Posted: 06/22/2004, Date Reviewed/Revised: 01/10/2008
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Medicare makes payment for a covered dental procedure no matter where the service is performed. The hospitalization or non-hospitalization of a patient has no direct bearing on the coverage or exclusion of a given dental procedure.
Date Posted: 06/22/2004, Date Reviewed/Revised: 01/10/2008
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Items and services in connection with care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth are not covered.
Date Posted: 06/22/2004, Date Reviewed/Revised: 01/10/2008
Does Medicare offer a covered benefit for diagnostic audiology testing?
Diagnostic testing, including hearing and balance assessment services may be eligible for payment under Section 1861(s)(3) of the Social Security Act if:
- The services are medically necessary,
- A qualified audiologist, as part of a complete diagnostic work-up, performs the audiology services, and
- A physician orders (makes a referral for) such testing to obtain information as part of a diagnostic evaluation, or to determine the appropriate medical surgical treatment of a hearing deficit or related medical problem.
Date Posted: 05/24/2004, Date Reviewed/Revised: 01/10/2008
Are evaluations of chronic hearing loss covered?
Payment is determined by the reason the tests were performed, rather than the diagnosis of the patient’s condition. Services are excluded under Section 1862(a)(7) of the Social Security Act when the diagnostic information required to determine the appropriate medical or surgical treatment is already known to the physician, or the diagnostic services are performed only to determine the need for, or the appropriate type, of a hearing aid.
Date Posted: 05/24/2004, Date Reviewed/Revised: 01/10/2008
What is a qualified audiologist?
As provided in Section 1861 (II) (3) of the Social Security Act, a qualified audiologist is an individual with a master’s or a doctoral degree in audiology and who is licensed as an audiologist by the state in which the individual furnishes such services. Or in the case of an individual who furnishes services in a state which does not license audiologists, has:
- Successfully completed 350 clock hours of supervised clinical practicum (or is in the process of accumulating such supervised clinical experience),
- Performed not less than 9 months of supervised full-time audiology services after obtaining a master’s or doctoral degree in audiology or a related field, and
- Successfully completed a national examination in audiology approved by the Secretary.
Date Posted: 05/24/2004, Date Reviewed/Revised: 01/10/2008
Is a physician referral required for coverage of diagnostic audiology testing?
If a physician refers a beneficiary to an audiologist for evaluation of signs or symptoms associated with recent hearing loss or ear injury, the audiologist’s diagnostic services may be covered, even if the only outcome is the prescription of a hearing aid.
Date Posted: 05/24/2004, Date Reviewed/Revised: 01/10/2008
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If a beneficiary undergoes diagnostic testing without physician involvement or referral, then the tests are not covered, even if the audiologist discovers a pathologic condition.
Date Posted: 05/24/2004, Date Reviewed/Revised: 01/10/2008
What documentation is required to submit an audiology claim?
When providers receive Additional Development Requests (ADRs), they should submit all of the documentation requested on the ADR:
- Physician orders;
- Clinical documentation of diagnosis or symptoms to justify services;
- Reports of audiology / services rendered; and
- An itemized bill.
Date Posted: 05/24/2004, Date Reviewed/Revised: 01/10/2008
What documentation is required to submit vestibular testing claims?
When providers receive Additional Development Requests (ADRs) they should submit all of the documentation requested on the ADR:
- Physician orders;
- Clinical documentation of diagnosis or symptoms to justify services;
- Reports of audiology / services rendered; and
- An itemized bill.
- History of present illness and prior treatment;
- Any other contributing diagnosis or factors; and
- Documentation of vestibular rehab services.
Date Posted: 05/24/2004, Date Reviewed/Revised: 01/10/2008
What is the most common reason for denial of claims for diagnostic audiology testing?
- Our analysis shows the most common denial reason is provider submission of insufficient documentation to support medical necessity. As a reminder, services are excluded under Section 1862(a)(7) of the Social Security Act when:
- The diagnostic information required to determine the appropriate medical or surgical treatment is already known to the physician, or
- The diagnostic services are performed only to determine the need for, or the appropriate type, of a hearing aid.
Date Posted: 05/24/2004, Date Reviewed/Revised: 01/10/2008
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Any of the diagnosis codes from 285.0 through 285.9 may be entered on an ESRD claim to support the medical necessity for EPO (Q4054 and Q4055).
It is important that documentation be available to suport the diagnosis listed on the claim. The additional documentation is submitted for review when requested via an Additional Development Request (ADR).Date Posted: 02/20/2006, Date Reviewed/Revised: 01/20/2008
With regards to electronic billing, what will I use in July 2007?
We have to wait and see, for now we do not have anymore information that what is being reported today.
Date Posted: 03/19/2007, Date Reviewed/Revised: 01/20/2008
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In CY 2005, hospitals were instructed to bill CPT codes 90781, 96412, and 96423 in 8 unit increments for additional hours of infusion on a separate line on the bill. CPT codes 90781 and 96412 included a limit of 8 hours in their code descriptors. Therefore, there were a maximum of 8 units that could be billed on a single line and hospitals were instructed to include additional hours on a separate line (again, maximum of 8 units).
For CY 2006 OPPS, CPT code 90781 has been replaced with HCPCS code C8951 and CPT code 96412 has been replaced with HCPCS code C8955. Neither C8951 nor C8955 include the unit restrictions that were inherent in the CY 2005 CPT code descriptors. Therefore, hospitals may bill the total number of additional hours of infusion with C8951 and C8955 on the same line.
CPT code 96423 continues to be active for CY 2006 OPPS. Therefore, CPT code 96423 should continue to be billed with a maximum of 8 units per line.
Additional guidance for billing and payment for drugs and drug administration is available through the Pub 100-4, Chapter 4, Section 230 and the following CMS Q&A link: http://www.cms.hhs.gov/HospitalOutpatientPPS/Downloads/OPPSGuidance.pdf
Date Posted: 07/31/2007, Date Reviewed/Revised: 01/20/2008
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This was a systems problem until recently. All claims impacted by this issue will be adjusted soon.
Date Posted: 07/31/2007, Date Reviewed/Revised: 01/10/2008
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We are aware that claims are being returned with reason codes 31422 and 31432. However, the Centers for Medicare and Medicaid Services (CMS) gave the contractors permission to turn off the edit until a resolution is found.
Date Reviewed/Revised: 01/20/2008
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No.
Reference: Program Memorandum A-01-110
Date Posted: 01/30/2003, Date Reviewed/Revised: 01/20/2008
Is the moratorium on the financial limitation for outpatient rehabiliation service still in effect?
No, the moratorium on the financial limitation for outpatient rehabiliation services expired December 31, 2002. The financial limitation will be effective for dates of servic on or after July 1, 2003.
Reference: Program Memorandum AB-03-018 and Provider Notice 03-109.
For each subsequent calendar year, the financial limitations will be effective for the entire calendar year.
Date Posted: 02/27/2003, Date Reviewed/Revised: 01/20/2008
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Section 221 of the BBRA of 1999 placed a 2-year moratorium on the application of the financial limitation for claims for therapy services with dates of service January 1, 2000, through December 31, 2001. Section 421 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000, extended the moratorium on application of the financial limitation to claims for outpatient rehabilitation services with dates of service January 1, 2002, through December 31, 2002. Therefore, the moratorium was for a 3-year period and applied to outpatient rehabilitation claims with dates of service January 1, 2000, through December 31, 2002. In 2003, there was not a moratorium on therapy caps. Implementation was delayed until September 1, 2003. Therapy caps were in effect for services rendered on September 1, 2003 through December 7, 2003. Congress re-enacted a moratorium on financial limitations on outpatient therapy services on December 8, 2003 that extended through December 31, 2005. Caps were implemented again on January 1, 2006 and policies were modified to allow exceptions as directed by the Deficit Reduction Act only for calendar year 2006.
The Tax Relief and Health Care Act of 2006 extended the cap exceptions process through calendar year 2007.
Date Posted: 07/11/2006, Date Reviewed/Revised: 02/08/2008
When should I submit documentation for a “manual request” of a therapy cap exception?
In 2006, Exception Processes fell into two categories, Automatic Process Exceptions, and Manual Process Exceptions. 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.) Also, use of the automatic process for exception does not exempt services from manual or other medical review processes as described in 100-08, Chapter 3, Section 3.4.1.1.1.
Date Posted: 07/11/2006, Date Reviewed/Revised: 02/08/2008
What documentation is necessary to submit with an ADR request?
Providers should send the following information for dates of service and the look back period:
1. Certification/recertification.
2. Physician’s orders and progress notes.
3. Nurse’s notes.
4. All MDS assessments to support these service dates.
5. Documentation to fully support each MDS.
6. Medication and treatment records.
7. If applicable, records for physical therapy, occupational therapy, speech therapy, and decubitus ulcer records including:- initial evaluation
- therapy progress notes
- treatment records to verify treatment plan, goals, and therapy minutes.
- therapy minutes to support RUG assessment if outside billed dates of service.
Date Posted: 01/26/2006, Date Reviewed/Revised: 01/29/2008
What determines the rehab RUG levels?
Rehabilitation therapy is any combination of the disciplines of physical, occupational, or speech therapy. Rehabilitation groups represent ten different levels of rehabilitation services according to the number of therapy minutes. (Reference: RAI Users Manual Chapter 6, Section 6.6 which can be accessed by the following web link: http://www.cms.hhs.gov/NursingHomeQualityInits/20_NHQIMDS20.ASP
Date Posted: 01/26/2006, Date Reviewed/Revised: 01/29/2008