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LATEST WPS QUESTIONS AND ANSWERS
CLMA/WPS MEETING
APRIL 19, 2002
10AM TO 12PM
1. When will WPS-MC be providing us with information regarding implementation of the policies?
ANSWER: Per the Policy department, we will publish this information once we have received the instruction from CMS to do so. PM AB-02-030 informed carriers and intermediaries that CMS will issue subsequent instructions implementing the administrative policies requiring system changes. At this time, we have received this instruction. Therefore, providers should continue to bill according to our LMRP’s as the national rule making documents have not gone into effect yet.
2. Upon reviewing the Negotiated Rulemaking policies, there have been ICD-9 codes that our Health Information Management coders have questioned. Who should we notify when there are questions related to ICD-9 codes? Examples are enclosed in the Glucose policy:
- Unspecified retinal disorders should be 362.9 instead of 362.0 as cited in the policy.
- Autonomic nervous system neuropathy is listed in the policy under both 377.9 and 337.9. The correct code for autonomic nervous system neuropath is 337.9.
- Was the intent to pay for code 377.9 (unspecified disorder of optic nerve and visual pathways) also?
- Abnormal loss of weight, should be 783.21 instead 783.2 as listed in the policy.
ANSWER: For incorrect ICD-9 codes and related issues, you can work through your association or societies to notify the lab representative (the person who represented you in the lab negotiated rule-making process) who, in turn, may notify their CMS contact.
3. Who should be notified when providers want to submit other codes to be added to the payable list?
ANSWER: Upon speaking with our policy department, the understanding is that the purpose of implementing a national document is to seek uniformity, and, therefore, the allowance for codes to be added would be determined by CMS. The recommendation, again, would be to send requests through your associations or societies. For changes that can be made by the carrier, providers may write to the policy department or the CMD with an explanation of why the code should be added.
4. We would like an update or review on the modifier issue and what steps are being taken to standardize the variance between Part A & B interpretation and the various interpretations of how the modifiers are to be used.
ANSWER: For WPS Medicare Part B, modifiers 76 or 91 continue to be the acceptable modifiers to use for repeat clinical diagnostic lab services. No change has been made in the MCS system to accept modifier 59 for such services; currently the system only accepts modifier 59 in CCI situations. Most recently, we have sought input from CMS and are awaiting a decision.
5. WPS’ preliminary information provided was to use modifier 76. When is the effective date for accepting modifier 59? Is modifier 59 appropriate for the following test requests:
- Immunoglobulins IgG, IgA, and IgM (CPT code 82784 description Gammaglobulin IgA, IgD, IgG, IgM, each)
- Complement C3 and C4 (CPT code 86160 description Complement, antigen, each component)
- Leukemia markers by flow cytometry (CPT code 88180 description Flow cytometry, each cell or marker)
ANSWER: Again, right now only modifiers 76 and 91 are acceptable and modifier 59 is for CCI situations. We will be able to answer this question more effectively once we have received clarification.
6. Our reference laboratory currently uses a V76.2 code for screening paps as it reads that this is for "Special screening for malignant neoplasms of the cervix—routine cervical Pap smear excluded as part of a general gyn exam." Our doctors feel that a more appropriate code would be V72.3 which reads "Special investigations and examinations, Gynecological examinations with pap smear as part of the general gyn exam. Excludes cervical pap smear without general gyn exam (V76.2)." Since the client performs the gynecological exam and the pap smear collection as part of that exam, they are wondering why the V72.3 shouldn’t be used? Can WPS address their position on this?
ANSWER: The position WPS has taken on this is based on the direction given by CMS. MCM 4603.1-4603.3 instruct carriers to accept diagnosis code V76.2 for screening paps. This is something that WPS has no control over. If a provider has a concern regarding the usage of this code, or would like to see a different code added, they would need to work through CMS.
7. We have recently adopted the NCEP Cholesterol guidelines recommending patients have a screening FASTING lipid profile at least every 5 years. At this point Medicare would not reimburse the lipid profile as it is being done as a screen. However, another recommendation from the study is to perform a measured LDL cholesterol whenever the triglycerides are greater than 400 mg/dl. In this case, can the measured LDL be coded and submitted to Medicare as hyperlipidemia?
ANSWER: Per policy PATH-017, Lipoprotein by direct (not calculated) measurement LDL-Cholesterol (83721) is allowed by Medicare. This is not covered as a screening test but is covered only as a monitoring tool for patients under treatment for high cholesterol levels (ICD-9 272.0), or when triglycerides exceed 400 mg/dl (ICD-9 272.1; documentation must indicate the level is >400 mg/dl).
7. In the case of a patient with previously diagnosed hyperlipidemia, can both the follow-up lipid profile and measured LDL cholesterol be submitted for Medicare payment, or does PATH-017 policy allow reimbursement for only one or the other?
ANSWER: Currently, when a lipid panel (80061) and direct measurement LSL (83721) are billed on the same day, both are not being paid. One or the other will pay depending on which service is processed first. One thing to keep in mind is that these lipid CPT codes are part of the Final Rule for laboratory services and will become part of a National Coverage Decision (NCD). As it stands now, this will go into effect late this year. The NCD for lipids will contain frequency guidelines to assist in the processing of these services. How these services will be processed once the NCD is implemented is unknown at this time.
July 19, 2002 UGS/WPS Meeting Notes
UGS/WPS CLMA Quarterly Minutes
July 19, 2002
Attendees:
Paul Hable
Mike Lawton
Monique Fourrier
Kathy Lundeen
Debbie Christian
Jo Ann Lang
Sue Jahane
Beth Stenklyft
Teena Wigley
Discussion:
Scenarios regarding billing of labs to Part A and B. A request was made by Monique to have them e-mailed to her. Then Monique and Teena will collaborate on the answers as needed.
Why would Magnesium be paid under Part B for DX 585, but not payable under Part A? It makes a difference what lab we send our O labs to.
Answer: Yes, the policy are different if you have a code that you want the medical director of UGS, LLC to consider please submit the code and documentation on why you think the code should be added to:
Carol Covelli
United Government Services, LLC.
401 W. Michigan Street C-3
Milwaukee, WI 53203-2804
Open Action Item:
1. Would the hospital ever have to put a TC modifier on a CPT code billed to Medicare? If, for instance, during a cardiac cat the physician using the 26 modifier bills the injection and supervision and interpretation codes would the hospital have to append the TC modifier to those codes? Is there a resource available on how to clearly use the TC modifier (AB-01-047 is not clear)?
Answer: Per CMS Region V Policy Department, the technical component of a service is the actual performance of the test. It does not require the expertise of a physician. Normally, the office staff or hospital performs the technical portion of the test. If a code showing “tracing only, without interpretation and report“ is not available, use the global procedure code with modifier TC, technical component.
When a technical service is rendered in a hospital inpatient or outpatient setting, nursing facility or comprehensive outpatient rehabilitation facility (CORF), Medicare Part B does not pay for it. The cost is submitted to Medicare Part A by the facility.
Technical services rendered in an ambulatory surgery center (ASC) are not covered as a charge separate from the facility fee. They are included in the reimbursement of the facility fee charge.
Questions and Answers for July 19, 2002 meeting:
1. When laceration repair is done, is it appropriate to bill splint/strapping charges as well if (repair is) performed?
Answer: UGS would like an example if possible please supply a HIC number and date of service.
2. Will UGS and WPS have their LMRPs in line with National Coverage Decisions arrived at through the negotiated rulemaking by the November 25, 2002 start date and will your computers be set to audit claims accordingly?
Answer: Yes, the LMRPs that UGS has will retire when the national policy becomes effective. As for editing, it will be consistent nationally. Please refer to PM AB-02-87.
3. Please review again when the modifiers for multiple procedures should be used for services provided on the same day. Outline the difference in how it should be handled for UGS claims.
Answer:
Modifier 91 is used for test that are performed more than once on the same day for the same patient, only when it is necessary to obtain multiple results in the course of treatment. This modifier may not be used when tests are re-run to confirm initial results, due to testing problems with specimens or equipment, or any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when there are standard HCPCS codes available that describes the series of results (e.g., glucose tolerance tests, evocative/suppression testing, etc). This modifier may only be used for laboratory tests paid under the clinical diagnostic laboratory fee schedule.
Modifier 76 is used to indicate that a procedure:
Use when a procedure is repeated –
In a separate session
On the same day
By the same physician
The procedure repeated must be the same procedure (same HCPCS code)
May be used in surgery, radiology, and other diagnostic test
Modifier 59 is used for distinct procedural services:
Use for services not normally reported together
Use to indicate a service distinct or independent from other services performed on the same day
Use to represent (not ordinarily performed on the same day):
Different procedure
Different site or organ system
Separate incision
Separate injury (or area or injury in extensive injuries)
Do not use if a level II modifier can be used.
May be used with surgery, radiology and other diagnostic test
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