UGS/WPS CLMA Quarterly Minutes October 17,2003 UGS Questions and Answers (Part A) 1.Do you have any information on the 20% lab co-pay that is included in the prescription bills at the federal level? If passed what kind of timeline for implementation would occur? Answer: We do not have any information to pass on. 2.Many subscribers were surprised to see denied claims for direct measure LDL cholesterol tests when the procedures were submitted for payment with a lipid panel. The reason for the denials is that Medicare recently adopted a CCI edit concerning a lipid panel (CPT code 80061) and direct measurement LDL (CPT code 83721). If a provider submits a claim for these two procedures for the same beneficiary, payment for the cholesterol will be denied. However, if the LDL cholesterol is reported with a modifier 59 (distinct procedure) the claim should be paid. Answer: The edit permits providers to report directly measured LDL when the triglycerides are too high to permit an accurate calculation of LDL. The purpose of the edit is to emphasize to providers that 83721 is not the calculated value one normally reports with 80061. If it is reasonable and necessary (and ordered), providers can report 83721 if they do the direct measurement of LDL using modifier 59. 3.Is Medicare covering Natriuretic peptide (BNP) now? Answer:No. 4.Which modifier should be used in the following case? A comprehensive metabolic panel is performed. Later the same day a potassium is performed (it was abnormal on the CMP). The CPT codes are not the same, but the potassium is denied as a duplicate. Answer: We have tested the scenario above and the correct modifier is 91. 5.Specimen collection (G0001) Can this be billed more than once on an OP (outpatient claim) if they have 2 separate visits on the same day with lab tests with each visit? This question may also apply with an observation patient. I know that with a series of test (glucose tolerance), we an only bill for one specimen collection for the whole tolerance. Answer: If the visits are independent and distinct, the OPPS manual and program memos have instructed providers to use condition code G0 (zero) on the claim so that duplicate edits will not fired. There is a maximum limit on G0001 of 3(date of service) in the OCE. 6.Please explain how to correctly bill for the following scenario: Physician orders chemotherapy: Cisplatin 100mg in Dextrose 5% and ? Normal Saline 1000ml, Pre meds- 50 gm, Mannitol in D 5 ? NS 1000ml. Followed by 125 methylprednisolone IV push, IV Zofran 16mg. Post chemotherapy- IV D5W ? NS with 1gm Magnesium. 1. An IV site is started. The patient is hydrated and diuresis encouraged with an IV bag of D5 ? NS 1000ml containing 50gm of mannitol. 2. The IV is stopped, the line flushed at the lowest port with normal saline 125 mg of methylprednisolone is given IV push, and line is flushed again with normal saline. 3. Zofran 16 mg in 50 cc Normal Saline is then given into the lowest port by IV piggyback. The line is flushed with saline. 4. Cisplatin 100mg in 1000 ml D5 ? NS is infused. 5. Finally, an IV of D5W ? NS with 1 gm of magnesium is infused after the chemotherapy. When we use this method of billing, the 90784 and Q0081 are identified as non-compatible codes on the same bill (with or without a 59 modifier) Answer: Since there is a CCI edit in place that will not allow you to bill even with a modifier, if you want the claim to process you cannot add the combination to it. UGS suggest that you bill the Q codes and any drugs (J codes) that are billable to Medicare for consideration of payment. Notes from meeting: The meeting was not very long. One suggestion for providers to look at as resources for CCI questions is the web-site at www.cms.hhs.gov/physicians/cciedits. On the web-site is an address that will allow providers to address the coding questions to CMS. We also encourage providers to get on CMS listserv for updates and meeting at www.cms.hhs.gov/opendoor. In addition, program memorandum AB-03-104 was issued regarding changes to the laboratory national coverage determination (NCD) edit software for October 1, 2003. Disclaimer: The guidance provided during this teleconference/meeting is deemed to be reliable. However, at any time, such guidance is subject to change or clarification. For that reason, please be sure to check the UGS web-site for the most current information before taking action on any issue. WPS CLMA Quarterly Minutes October 17,2003 WPS Questions and Answers (Part B) 1.If I remember correctly I think everyone in this group was having out-of-state reference labs do their own billing but I would like to pass this question along to WPS as we would like to some day complete the necessary paperwork to be able to bill for tests that are performed within the Advocate Hospital system (Illinois) without actually sending claims to Illinois. ACL received paper work from Empire Medicare Services, the New Jersey carrier, that Spectra East Laboratories has requested to submit claims to them for tests performed by ACL. Empire assigned ACL a Medicare reference number that Spectra East will use to identify ACL as the testing lab and will be able to submit these claims to Empire for reimbursement. Has or will the WPS referred laboratory policy referenced in the March 2002 CommuniquÈ be undergoing any changes (i.e., Can a referring laboratory request a Medicare identification number for an out-of-state reference laboratory and submit claims to WPS for reimbursement)? Answer:At this point in time, the information in the March 2002 CommuniquÈ is accurate. If ACL wants to bill for tests performed in Illinois, they may contact the Provider Enrollment Unit to apply for an Illinois Medicare Part B number. The claims must be submitted to the state that has jurisdiction as the carrier does not have the out-of-state reference laboratory's certification information or the appropriate fee schedule allowance. Please contact the Provider Enrollment department at 877-908-8476 for additional information. 2. Requesting information on the 20 percent lab co pay that is included in the prescription bills at the federal level. If passed, what kind of time line for implementation would occur? Answer:If this is being proposed at this time, there is no telling when it will pass and when it will be implemented. Normally, anything in the proposed rule that makes it to the final rule is implemented January 1st of each year. However, I have seen other things go into effect on other dates. If it passes, it will also state when it goes into effect in the final rule. 3. Specimen collection - can this be billed more than once on an OP (Outpatient?) if they have two separate visits on the same day with lab tests each visit? This question may also apply with an observation visit. I know that with a series of tests (glucose tolerance), we can only bill for one collection for the whole tolerance. Answer: Specimen Collection Fee - HCPCS - G0001 Routine venipuncture for collection of specimen(s) - Only one collection fee is allowed for each patient encounter, regardless of the number of specimens drawn (e.g., glucose tolerance test). Billing for more than one venipuncture per day must be documented with claim information giving times of the separate encounters or with modifier 91 (repeat clinical diagnostic laboratory test). MCM 2255 prohibits Part B payment for hospital services reimbursable by Part A (e.g., G0001 in places of service inpatient, outpatient, emergency room). Venipuncture billed in Place of Service 81 by an Independent Lab is reimbursable by Medicare Part B. 4. We are a reference laboratory that performed a Protein -24H Urine (84155) and a Urine Volume Measure (81050). The claim was denied by WPS stating that the service was partially or fully furnished by another provider. When we contacted the referring clinic they did perform a Serum Protein on the same date of service (ICN: 2203169145450). How do we get paid for this service? Answer: The Independent Laboratory's claim was denied because the referring physician billed and was reimbursed for this lab test. The Independent Laboratory may request an appeal but unless they performed their own venipuncture and drew the blood (and didn't use blood from the referring physician) the first determination would stand. It might be necessary for the Independent Laboratory to educate the referring physician in this type of situation. 5. CCI Edits Many subscribers were surprised to see claims denied for direct measure LDL cholesterol tests when these procedures were submitted for payment with a lipid panel. The reason for the denials is that Medicare recently adopted a CCI edit concerning a lipid panel (CPT code 80061) and direct measurement LDL (CPT code 83721). If a provider submits a claim for these two procedures for the same beneficiary, payment for the LDL cholesterol will be denied. However, if the LDL cholesterol is reported with a "-59" modifier (distinct procedure), the claim will be paid. Answer: Procedure code 83718 will be denied when 80061 is billed on the same day unless 83718 is billed with modifier 59. In a post payment review modifier 59 would need to verify that the signs and symptoms were such to need a distinct and separate service in addition to a separate ICD-9 billed for each code. Procedure codes 80061 and 83718 are a CCI edit and CCI edits are updated quarterly by AdministarFederal. Any review of the CCI edits would need to be addressed with them. 6. We are getting denials on immunoperoxidase stains that are performed with consultations. I am including examples of documentation. Our pathologists/doctors feel that it is necessary to perform these stains in order to perform the consultation. How do we obtain payment? Answer: This is a CCI denial effective with the last installation by AdministarFederal. CPT 88342-26/88342-26-76 will be denied when CPT 88321 or 88323 is billed on the same day unless 88342-26 is billed with modifier 59. 7. We are receiving denials on our G0123 and P3000 pap smears. They were originally filed under provider 72025, but were resubmitted under provider number 72180. They are being denied as either "PR119" or "CO119". Can you help us please? Are they running up against the other provider number? How can we obtain payment? Answer: Based on the examples you sent, it appears to the system that you are billing for one G0124, which tells us the physician is billing for the pap smear and the interpretation. Along with this code you are then billing G0123, which tells us the lab is billing for the technical portion of a pap smear. The system sees this as two pap smears where taken and one was read. When G0123 is billed by anyone other than an independent lab, it is denied for ìpayment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of serviceî. Based on policy GU-003, G0123 and P3000 are paid off of the clinical lab fee schedule. You then rebilled G0123 under an independent lab provider number, but the claim was denied correctly because enough time had not gone by since the last pap smear was done, (which was the payment of G0124 to the physician). Please refer to policy GU-003. It states in this policy that G0124 and P3001 are payable off of the physician fee schedule and G0123 and P3000 are payable off of the clinical lab fee schedule.