UGS/WPS CLMA Quarterly Minutes April 11, 2003 UGS Questions and Answers (Part A) 1.When will the sensitivities process be corrected so that sensitivities on non-urine specimens are paid? Will UGS do mass adjustments of denied claims or is there another way that providers should get their claims reprocessed for payment? Answer: The correction for the non-urine specimens have been corrected with the April 2003 updates. The process for the claims effected is an adjustment. UGS, LLC has decided to do mass adjustments on the claims. 2. When will the edits for Prothrombim time go into effect? Answer: The NCD edits went into effect January 1, 2003. There are additional changes for PT effective April 1, 2003. Please refer to PM AB-03-030 issued February 28, 2003. 3.We have a concern that UGS and WPS are not trying to be consistent in their LMRP policies. For example, UGS retained their LMRP for magnesium, but retired policies for calcium, alpha-1 antitrypsin and helicobacter testing. WPS retained those policies, so depending on whether a beneficiaryís claim is filed with the carrier or fiscal intermediary, there are different coverage policies and necessity for presenting an ABN to the beneficiary is not consistent. What actions will UGS and WPS be taking to become more consistent? Does the FI edit Part B claims for hospital non-patients based on the carrierís policies or their own? Side note on the issue: In the past, the UGS Medical Director has indicated at CAC meetings that the Part A and Part B policies are to be similar as they stem from the same national directives. I believe at other CLMA UGS-WPS meetings, the intermediary has indicated that the Part B policies implemented by WPS apply to Part A even though there werenít obvious edits. Answer: There isnít a rule or requirement that says UGS and WPS have to match in policy. But we work with WPS whenever possible to make policy compatible. 4.Is a hospital required to use the GA modifier (on UB-92) for non-covered tests where an ABN obtained? The transmittals have not been clear. Currently we use bill type 131 or 141, leave the charge as ìcoveredî and use occurrence code 32 with the date the ABN was signed. Answer: If a service not pertaining to the ABN was rendered in the same time period as service(s) requiring an ABN, such services must be submitted on separate claims, and the statement dates of these claims cannot overlap. If the time periods cannot be separated (i.e., a service requiring an ABN is given on the same day a service not requiring an ABN), a single claim must be submitted, just for the overlapping period, using occurrence code 32, showing all services as covered, and placing modifier GA on the HCPCS code to identify the service (revenue code) line for which the ABN was given. 5.Are there CCI edits regarding the following 2 CPT codes being mutually exclusive 85025 and 85007? Last time the question was asked UGS we were told that we could bill both codes. Answer: The CCI edit for the codes above is a component of comprehensive procedure edit. The narrative says there is misuse of column 2 code with column 1 and even with a modifier on the claim the system will not accept the combination for payment. As a provider you might consider 85007 and 85027 as HCPCS codes for the test you are performing. 6.Does CPT code 86255 require the use of a modifier if billed frequently than once per day? Does CPT code 88180 require the use of a modifier if billed more frequently than once per day? Do the tissue CPT codes in the range 88300-88313 require modifiers if billed more frequently than once per day? Note: if the above CPT codes require a modifier, we feel ñ59 is the most appropriate modifier to use indicating different sources, antibodies, etc. Would UGS agree? Answer: No modifier is required for any of the codes listed above. For each code listed above you can bill multiple units. As a reminder, OCE edit W7015 (units edit) has been turn back on as of April 2003 and is editing against a limited number of HCPCS codes. 7.Does the software require the edit module fix scheduled for April to correctly pay for 87184 and 87186 CPT codes? To receive payment, should we resubmit claims after the edit module is updated? Answer: Yes, the Outpatient update for April 2003 will include the correction of the 87184 and 87186. Please see answer to question #1. 8.Regarding the FAQ from UGS from 2nd quarter where it is stated that anticoagulation therapy service is not a billable service: Is that under any circumstance? ñ If the patientís vitals are monitored, medication compliance evaluated, and diet is discussed during the visit, it would appear that it fits the description of 99211 ì office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually the presenting problem(s) are minimal. Typically 5 minutes are spent performing or supervising these services.î Also, do UGS and WPS have the same understanding of whether this is billable? The literature shows that patients managed in this type of a setting have better outcomes with respect to bleeding episodes and clotting which is more cost effective in the long run. Answer: A provider cannot bill 99211. 9.Per the Roots at our meeting (billing consultants who presented at a recent CLMA meeting), and other consultants, we should be able to bill 85025 and 85007 when reflexed due to predetermined clinical criteria. We are seeing this combination denied ñ the 85025 was not paid. What is their policy on this? Answer: Please see the answer to #5. 10.It is my belief that Medicare does not pay for pre-operative screening, however in the NCDís, pre-operative codes are listed as covered for several tests. Example, V72.4 pre-operative examination, unspecified is listed as covered for PTT; V72.81 and V72.83 are also listed as covered. We find this confusing, especially since we have automated software that passes these V codes when entered for tests on pre-op patients. Should we pull these codes from our software? Answer: The decision to pull codes is left up to the provider not UGS, LLC. CMS negotiated policy with the lab industry on the NCDs and therefore, If you have a concern you may go through the NCD process to bring it to the attention of CMS. Please log on to www.cms.hhs.gov/ncd/. 11. We have a reflex test where physicians can order a urinalysis; culture if indicated. Specific criteria are set up for the urinalysis to reflex to the culture, such as blood in the urine, etc. Can we use the results of the urinalysis in this example as DX for the urine culture? To go back to the MD to get an additional order for the culture with the DX listed defeats the purpose of the reflex ordering process. Answer: In general yes, please look at the NCD for urine culture. There are relevant ICD-9 codes listed in the policy. You must go back to the MD to get a culture order (4/15/2003). 12.At a CLMA meeting, a consultant was asked the following question: When no ABN has been collected, and the diagnosis given does not indicate that the test will be processed as medically necessary by Medicare due to a NCD or LMRP, must a claim be submitted or not? We understand that a claim should be submitted if the patient requests it or in order to bill a secondary insurance, but what if Medicare is the only possible pay source? We also understand that the patient cannot be billed since the ABN was not collected. Answer: Currently, CMS has no mandatory claims submission requirements for institutional claims (Part A or B of A) like those that exist for professional claims. If there is not a covered diagnosis and they did not obtain an ABN, they can elect not to bill Medicare and write off the charge. 13.On a CMS open door call for ESRD I heard the following information on ABNs. A CMS representative stated that there are exceptions that allow the administration of ABNs on a routine basis for every patient receiving a particular service. These exceptions are: a)If a test has an NCD b)If a test has a frequency limits c)If a test is for experimental use d)If a test has an LMRP It was also stated that an ABN could be given to every patient that had a test that met one of the above requirements. They did indicate that the ABN administrator had to take any steps to verify the likelihood of a denial based on the diagnosis information given or frequency of testing prior to giving the ABN. The indication in the call was that many carriers/intermediaries were interpreting this differently, but that a FAQ was published in February to clarify this issue. Is it also your interpretation then that an ABN can be collected from the Medicare patient every time, for example, a Pap test is performed? No matter what supporting diagnosis or frequency information is supplied? Answer: Yes, an ABN could be given each time for the items listed above. Note the answer on CMSí web-site as an example: ìIf you receive an ABN for services that give a frequency limit as its reason, it means that Medicare will not pay if the test exceed the limit for the service. Otherwise, Medicare may pay.î Please remember in most other situations a routine ABN is not allowed. 14.We now do End Tidal CO at monitoring at our facility, the system is incorporated with our new telemetry monitors, the CPT code is 94770, is this an item we can charge for? If yes, is it a once a day charge or can it be by units? Answer: HCPCS code 94770 is paid under Outpatient PPS, the APC is 367. HCPCS code 94770 is not a timed code thus it should be billed per episode. If you are doing a procedure and use the analyzer you should bill it once. If it is medically necessary that you use it again in the same day for a different procedure you may bill it again. Click here WPS Notes to see the WPS Notes