Why Is Medicare Denying My Claims for Mammography and Breast Biopsies?

By:Jacqueline Thelian, CPC, CPC-I, CHCA

When Medicare updated their systems with the updates to mammography and breast biopsy policies some ICD-10-CM codes were inadvertently left out. 

The omitted new codes are N63.11-N63.14, N63.21-N63.24, N63.31, N63.32, N63.41, and N63.42, which will replace the truncated ICD-10 diagnosis N63.

The Centers for Medicare & Medicaid Services (CMS) will correct the policies with its next update, which is scheduled for April 1. But CMS did not require its Medicare contractors to reprocess the denied claims. 

CMS has instructed MACs to adjust any claims brought to their attention that were processed in error for any of the NCDs included in CR 10318. These adjustments will not take place until after April 2, 2018 unless otherwise noted.

National Government Services (NGS) has already updated their system and will reprocess claims upon the providers request.

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 Source:

• CMS Transmittal 2005 ICD-10-CM and other Coding Revisions to National Coverage Determinations (NCDs)

KX Modifier Temporary Fix

By:Jacqueline Thelian, CPC, CPC-I, CHCA

Did CMS reinstate the use of the KX Modifier for therapy claims? Yes and No. CMS implemented a temporary fix.

Despite Congressional failure to remove the cap exception, on January 28, 2018 CMS announced they will start to pay claims submitted with the KX modifier (Requirements specified in the medical policy have been met).

Starting January 25, 2018, CMS will immediately release for processing held therapy claims with the KX modifier with dates of receipt beginning from January 1-10, 2018.  Then, starting January 31, 2018, CMS will release for processing the held claims one day at a time based on the date the claim was received, i.e., on a first-in, first-out basis.

At the same time, CMS will hold all newly received therapy claims with the KX modifier and implement a “rolling hold” of 20 days of claims to help minimize the number of claims requiring reprocessing and minimize the impact on beneficiaries if legislation regarding therapy caps is enacted.

CMS did not indicate if this temporary fix will continue until Congress can get the cap extension reinstated. 

For further updates please go to CMS All Fee For Services Providers Page https://www.cms.gov/Center/Provider-Type/all-fee-for-service-providers-center.html

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 Source:

• CMS All Fee For Services Providers Page https://www.cms.gov/Center/Provider-Type/all-fee-for-service-providers-center.html

No Therapy Cap Exceptions for 2018

By:Jacqueline Thelian, CPC, CPC-I, CHCA

Beginning January 1, 2018, the cap on physical therapy services has a slight increase to $2,010.00.  That’s the good news.

The bad news, the “exception process” which would allow the continuation of PT services up to $3,700.00 with the use of the “KX” modifier (Requirements specified in the medical policy have been met) is no longer applicable. 

Additionally, the manual review process for claims that would exceed the $3,700.00 is also no longer a valid option.

The Final Rule which put the end to the exception process states, “Without a therapy cap exceptions process, the statutory limitation requires that beneficiaries become financially liable for 100% of expenses they incur for services that exceed the therapy caps” The rules goes on to state, “the therapy caps will be applicable without any further medical review, and any use of the “KX” modifier on claims for these services by providers of outpatient therapy will have no effect.” In short, without the renewal of the exception process:

• CMS will deny reimbursement of any claims that exceed the current therapy cap of $2,010.00
• Medicare beneficiaries will be responsible for claims over the cap amount of $2,010.00
• The KX modifier for Physical Therapy claims will have no impact on the claims

So, what can you? Providers can issue Advanced Beneficiary Notices (ABNs). The ABN is a notice of non-coverage which advises the Medicare beneficiaries of non-coverage and their financial responsibility for therapy over the cap. Click on the link below to brush up on how to complete the ABN.  

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 Source:

• CMS Final Rule 2018
  https://www.gpo.gov/fdsys/pkg/FR-2017-11-15/pdf/2017-23953.pdf

• ABN
  https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html

New CPT Codes for INR Testing Reimbursed by Medicare

By:Jacqueline Thelian, CPC, CPC-I, CHCA

CPT 2018 introduces new codes for home and outpatient International Normalized Ratio (INR) services. The new codes are more user friendly than the former INR CPT codes 99363 and 99364 which were deleted for 2018. 

The new codes include the ordering, review, and interpretation of new INR test result(s), patient instructions, and dosage adjustments as needed. 

An Evaluation & Management (E/M) code may be reported in addition to the new codes as long as the E/M is significant and separately identifiable. Additionally, the codes do not include the provision of the test materials and equipment which is reported separately.
Unlike the former INR codes which required physician review the new codes may be performed by the clinical staff under the direction of a physician or qualified healthcare professional.

The new codes are:
93792 Patient/caregiver training for initiation of home international normalized ratio (INR) monitoring under the direction of a physician or other qualified health care professional, face-to-face, including use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient's/caregiver’s ability to perform testing and report results

93793 Anticoagulant management for a patient taking warfarin, must include review and interpretation of a new home, office, or lab international normalized ratio (INR) test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed

The best news is saved for last as CMS recognizes and reimburses for the new codes. The national reimbursement rate for CPT code 93792 is $55.06 and CPT code 93793 reimburses nationally at $12.24. You can search for reimbursement rates for your locality on the CMS Physician Fee Schedule Look Up Tool by going to: 

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSlookup/index.html

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 Source:

• Current Procedural Terminology (CPT) 2018

• CMS Physician Fee Schedule Look Up Tool

New Year, New Codes, New Rules and Regulations- Free Sources for Coding Compliantly

By: Lorna Simons, CPC
Medco Consultants, Inc

New Year, New codes, New rules and regulations. But not to worry there are resources available that can help you code and bill compliantly for free. 

We all like free. But how do you find free credible resources online? There are a lot of places that offer coding information and forums that offer coding advice but how do you know if this will apply to you and your state? How do you know if the source is accurate and compliant? The best places to look for coding advice are from the code sets themselves or through governmental agencies.    

The government through CMS.gov and the websites of Local Medicare Administrative Contractors or MACs offer a lot of free information that can be used along side of the medical coding manuals to help healthcare professionals stay up to date with rules, regulations and compliance.

If you don’t know your local MAC, don’t worry, CMS has a jurisdiction map on their “Who are the MACs” page that will let you know which contractor is servicing your region. Your MAC will have tips, alerts and updates, news, local coverage determinations, local coverage articles and even a fee schedule look tool that you can use.  The MACs are National Government Services, Novitas, Palmetto GBA, Cahaba, FCSO, WPS, CGS and Noridian. 

For resources at the national level go to CMS.gov .

The Medicare tab has the contractor information and under “Coding” you can find information about the code sets, ICD-10, and National Correct Coding Initiative Edits. 

The Innovation Center is currently playing and integral role in implementing the Quality Payment Program. You can find different innovations happening in your state or if you are working remotely you will have access to the innovations that you or your client needs in the area they are located. The Innovation Center is also where you will find Webinars and Forum and Data and reports. These will keep you up to date and educated on the newest trends in healthcare.
 
“Regulation and Guidance” on CMS.gov has the Internet Only Manuals (IOMs), transmittals for coding correctly and documentation requirements, administrative simplification, regulations and policies and more. These will keep you up to date with compliance concerns.

Finally, the “Outreach and Education” tab offers many different tools that can be used as well as education.  CMS offers podcast, webinars and calls. You can also view the Medicare Learning Network® (MLN) where you can access training materials and even get continuing education credits.  These credits include both Continuing Education Units (CEUS) for individuals credentialed in Health Information Management like coders and Continuing Medical Education healthcare providers. 
 

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Source:

• Centers for Medicare and Medicaid Services www.cms.gov

Laboratory Fee Schedule Takes A Big Hit In 2018

By:Jacqueline Thelian, CPC, CPC-I, CHCA & Lorna Simons, CPC
Medco Consultants, Inc

Your practice may see a marked decrease in Medicare reimbursements for certain laboratory services in 2018. As a part of the Protecting Access to Medicare Act (PAMA) of 2014, CMS has revised the laboratory fee schedule to make the rates more equivalent to private insurance plans which have lower rates. 

Many of the common laboratory tests performed in physicians’ practices such as CBC (85025) Comprehensive Metabolic Panel (80053) Prothrombin (85610) and hundreds of others are set to for a 10% payment reduction and an additional 115 codes will see a 9% reduction in reimbursement.

The lab fee schedule will affect all practices submitting claims for Medicare laboratory services. Many physicians running labs are doing so on a very slim profit margin and the reduction will bring the sustainability of in office laboratory testing in question. It is important to note, not all laboratory reimbursements will be decreased. In some cases, the fee schedule has gone up. 

For a sampling of affected services please see the below table:
 

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 Source:

• Clinical Laboratory Fee Schedule Files https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files.html?DLSort=2&DLEntries=10&DLPage=1&DLSortDir=descending

• PAMA Regulations
  https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files.html?DLSort=2&DLEntries=10&DLPage=1&DLSortDir=descending
   

• Current Procedural Terminology (CPT) Manual 2017

Therapy Caps Are Going Up For 2018

By: Lorna Simons, CPC
Medco Consultants, Inc

Great news! The therapy cap will be going up for 2018. Announced on November 9, 2017, the therapy cap will be going from $1,980 to $2,010. 

Therapy caps were created under Section 4541 of the Balanced Budget Act to financially limit the Outpatient Therapy services provided to Medicare beneficiaries. Speech Language Pathology (SLP) and Physical Therapy share a cap while Occupational Therapy has separate cap. 

It is important to remember, when coding therapy services, to append the appropriate modifier to the services so that it is applied to the right cap. Certain CPT codes considered “always therapy” codes, as well as any service performed in a Therapist in Private Practice (TPP) setting, should be appended with the appropriate modifier. 

• Modifier GN- Services delivered under an outpatient speech language pathology plan of care
• Modifier GO- Services delivered under an outpatient occupational therapy plan of care
• Modifier GP- Services delivered under an outpatient physical therapy plan of care

Exceptions can be made to the therapy caps based on the patient and medical necessity, however, it is important to note that providers who routinely go beyond the therapy caps can be subject to post-payment reviews. While MACRA has eliminated the manual medical review requirements for services over therapy threshold ($3,700), providers with a high patient population receiving therapy beyond the cap threshold may be selected for review.

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 Source:

• American Medical Association Current Procedural Terminology Manual (CPT) 2018

• Healthcare Common Procedure Coding System (HCPCS) 2018

• Manual Medical Review of Therapy Claims above the $3,700 Threshold, https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/TherapyCap.html 

• Pub 100-04 Medicare Claims Processing, Transmittal 3918, https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3918CP.pdf

• MLN Matters number MM10176, Updated Editing of Always Therapy Services https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10176.pdf 

• Pub 100-04 Medicare Claims Processing, Transmittal 3863, https://www.cms.gov/regulations-and-guidance/guidance/transmittals/2017downloads/r3863cp.pdf 
   

Opioid Use, Abuse and Dependence in ICD-10-CM

By: Lorna Simons, CPC
Medco Consultants, Inc

It is seldom that we go a week without seeing a new opioid linked headline in the news. As medical coders and healthcare professionals it is important to understand the nuances of coding for opioid use (prescribed or recreational), abuse and dependence. Though three separate sections of the ICD-10-CM book can be used to code patients using opioids (Chapter 21 Factors influencing health status and contact with health services (Z00-Z99); Chapter 5 Mental, Behavioral and Neurodevelopmental disorders (F01 – F99) and; Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88)), we will be focusing on the difference between prescribed and recreational use abuse and dependence (chapters 21 and 5).

Prescription use of opioids is identified in Chapter 21 of the ICD-10-CM manual. When a patient is receiving prophylactic prescription maintenance for a condition using an opioid it should be documented and coded with Z79.891 Long term (current) use of opiate analgesic. Do not use this code for patients who have addiction or are seeking treatment for addiction. The Chapter 21 Guidelines state: “This subcategory is not for use of medications for detoxification or maintenance programs to prevent withdrawal symptoms in patients with drug dependence (e.g., methadone maintenance for opiate dependence). Assign the appropriate code for the drug dependence instead.”

The codes for opioid related disorders are found in Chapter 5 under category F11. The term “use” in Chapter 5 can mean non-prescription (recreational) use or any use not documented as abuse or dependence. The distinction between use, abuse and dependence is based on clinical evaluation and documentation. As per the ICD-10-CM guidelines for coding substances use, abuse and dependence, “only one code should be assigned to identify the pattern of use based on the following hierarchy:

• If both use and abuse are documented, assign only the code for abuse 
• If both abuse and dependence are documented, assign only the code for dependence 
• If use, abuse and dependence are all documented, assign only the code for dependence 
• If both use and dependence are documented, assign only the code for dependence.”

A patient with a history of opioid abuse or dependence should be coded with the appropriate remission code (F11.11 Opioid abuse, in remission or F11.21 Opioid dependence, in remission). ICD-10-CM does not include a code for history of opioid use. 

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 Source:

• ICD-10-CM Coding Guidelines Section C.5. Psychoactive Substance Use, Abuse and Dependence

• ICD-10-CM Coding Guidelines Section C.21. Factors influencing health status and contact with health services (Z00-Z99)

• ICD-10-CM Coding Guidelines Section C.19.  Injury, poisoning, and certain other consequences of external causes (S00-T88)