WPS Questions and Answers (Part B) 1. At a CLMA meeting last week, 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: A claim must be submitted to Medicare Part B. The modifier "-GZ" could be used to indicate that the provider expects that Medicare will deny an item or service as not reasonable and necessary and there had not been an Advanced Beneficiary Notice signed by the beneficiary. The October 2002 edition of the Communiqué, page 6, gives practical uses of the GY, GA and GZ modifier. 2. UGS (WPS is already working on this one) - The sensitivities are rejecting and the NCD correction is coming out 4/1/03. Will UGS be doing a bulk reprocessing of denied claims or is there another way that providers should get their claims reprocessed for payment? ANSWER: WPS is planning on performing a mass adjustment to process claims previously denied for procedure codes 87184 and 87186. This mass adjustment is scheduled for the week of 4/21/03. 3. Are there CCI edits regarding the following 2 CPT codes being mutually exclusive? 85025 CBC w/automated diff and 85007 manual diff ANSWER: Per CCI, CPT 85007 will not be reimbursed separately when the same rendering physician bills procedure code 85025 on the same date of service. As there are no circumstances in which a modifier would be appropriate, CPT 85007 will be denied even if a valid modifier (i.e., 59) is billed. 4. Just sat in on the CMS Open Forum for ESRD/Labs and heard the following information on ABNs. A CMS representative stated that there are exceptions that allow the administration of ABNs on routine basis for every patient receiving particular services. These exceptions include: a. If a test has an NCD b. If a test has frequency limitations c. If a test is for research d. If a test has an LMRP They said that an ABN could be given to every patient that had a test that met one of the above requirements. They did not 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: WPS’s interpretation of the only reasons an ABN can be given on a routine basis is based on the information on CMS’s website and PM AB-02-168 I.1.A.2.d. This portion is a response taken from CMS’s website. Under what circumstances may physicians, suppliers, and providers routinely issue ABNs (i.e., give an ABN to every beneficiary for a particular item or service)? Physicians, suppliers, and providers may routinely issue ABNs in four situations: 5. (WPS) We would like to utilize the average round trip basis for reimbursement of travel charges to skilled nursing facilities and homebound patients. Is the 2003 per flat rate trip basis $8.10? ANSWER: Yes, $8.10 is the correct flat rate, one way. 6. Regarding the FAQ from UGS for 2nd quarter where they stated that anticoagulation therapy service is not a billable service: Is that under any circumstance? If the patient's vitals are monitored, medication compliance evaluated, and diet is discussed during the visit, it would appear that it fits the description of 99211 " 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". 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. Part B Response: Anticoagulation therapy services are billable to Medicare Part B. These services must be furnished in the physician's office or a clinic setting. If the physician is not performing the service, the criteria as established in MCM 2050.1, "Incident to Physician's Professional Services" must be met. When a patient receives 'anticoagulation therapy' but the physician has no face-to-face contact with the patient, the physician may report and be paid for "incident to" services furnished by one of the physician's employees. The medical records must reflect the physician's active participation in the management of the course of treatment. The correct code for this service is 99211. Additional Topics and handouts -Practical Uses of the GY, GA and GZ Modifiers (Communique Oct, 02) -Beneficiary Signature on File—A Clarification (Communique March, 03) -Changes to the Laboratory National Coverage Determination (NCD) Edit Software for April 1, 2003 (Communigue April, 03) -Additional Documentation Requests (ADR) Requirements for Ordering Providers of Lab Services (Communique April, 03)