The purpose of this page is to provide answers to questions about the Medicare program. The official program provisions can be found The Centers for Medicare and Medicaid website at:
www.hcfa.gov/pubforms/transmit/memos

LCD/Coverage Frequently Asked Questions

LCD/LPET Frequently Askde Questions 3rd Quarter Fiscal Year 2005

Q. Within the ADR Letter the information requested includes: "Medical record showing chief complaint, history of past and present illness, physical examination and medial necessity of service". However, the hospital's only medical record is the interpreted report and the prescription. The patient's complete H&P would be maintained in the referring physician's office, NOT the hospital. Do we need to request the complete medical record from the physician's office?
A. Each ADR letter is formulated to request the specific information required to review the type of claim suspended. It is necessary to submit ALL requested documentation to establish that services were rendered and to support medical necessity of these services.

If the requested information is located at another site such as a physician's office, off-site clinic or an emergency room at another facility, it is the provider's responsibility to contact the other facility, obtain the necessary information and forward it with the requested records. Medicare will not contact sources other than the provider who is billing the claim. Each provider must work with physicians and other facilities to gain their cooperatoin in providing the required information.

Q. May the Radiologist order a further study as a result of a questionable or positive finding (e.g., an ultrasound as a result of a questionable mammogram)? Or does the PCP have to be contacted for the order to meet Medicare guidelines?
A. Effective November 25, 2002, 42 CFR 410.32(a) requires that when billed to any contractor, all diagnostic x-ray services, diagnostic laboratory services, and other diagnositic services must be ordered by the physician who is treating the beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. (Program Intergrity Manual, Chapter 3, Section 4.1.1 D)

Q. If a facility does not respond to an Additional Development Request (ADR), can they appeal the denial?
A. Yes, they can appeal. The facility needs to understand, though, that the Appeals Deparment must review every line denied on the claim pertaining to the appeal before the denial can be overturned. Since the entire claim was denied for non-receipt of medical records, every line on the claim is subject to review, not just the line item(s) pertaining to the Medical Review edit. Therefore, if ALL documentation pertaining to the entire claim is not submitted for the appeals review, lines will still be denied for lack of documentation, and the entire claim will not be paid. Returning only the documentation requested on the initial ADR is not sufficient.

Q. What do providers risk in not responding to the CERT request made by AdvanceMed?
A. Providers that do not respond to the CERT request will receive an "error" and will be assessed an overpayment. Providres who repeatedly do not respond to a CERT request for documentation are considered "recalcitrant". Recalcitrant providers with a claim line total or claim total of $40.00 or more in question may be referred to the OIG for action.

Q. Why has our facility received denials for insufficient documentation when we never received an initial request for medical records from CareFirst of MD, Inc. Medicare Part A? The FISS system shows that these claims were previously paid. Can these claims be appealed?
The claim denails were Comprehensive Error Rate Testing (CERT) denials reviewed by the CERT contractor who contracts with CMS to complete these reviews. The CERT contractor sends a letter requesting records for their review; however, the CareFirst logo would not appear on the letter. When complete records are not received, CareFirst is notified by the CERT contractor to recoup the money previously paid. The claims can be appealed like any other claim that has been denied by submitting the request to CareFirst Medicare A Appeals Department.

Q. When submitting a claim for payment for labs, x-rays or routine tests, what documentation is required in order to avoid having the claim denied by super-op edits for a noncovered diagnosis?
A. A covered diagnosis should be initially submitted on the claim. If a covered diagnosis is not submitted and the claim is sent for an appeal, an additional covered diagnosis can be added to the claim. Documentation submitted should support the added diagnosis. This could include the initial referral with the covered diagnosis on it, a progress note from the physician supporting the covered diagnosis or why the test was being ordered. A letter from the physician after the fact or a face sheet from the hospital with a diagnosis on it is not sufficient and will not support the reason for the test being ordered. Providers should closely review applicable Local Coverage Determinations (LCDs) and/or National Coverage Decisions (NCDs) for covered diagnosis codes before submitting claims for payment to avoid these denials.

Q. If an average program day in an outpatient Partial Hospitalization Program (PHP) is between 4 and 6 hours, one hour of those being individual and/or group psychotherapy, what other services make up the reaminder of the day?
A. The remaining services can be activity therapy, psycho-educational therapy, occupational therapy, medication management, family counseling, and diagnostic services. However, it is important to note that the treatment provided must be medically reasonable and necessary for the individual needs of the patient. The documentation must reflect the medical necessity of the treatment, must show that qualified staff are providing the treatment and that the patient is actively participating and progressing toward the goals established in their plan of care.

Q. What time should be used to determine the "in time for outpatient observation"?
A. Observation time begins at the clock time appearing on the nurse's observation admission note. (This should concide with the initiation of observation care or with the time of the patient's arrival in the observation unit.)

Q. What constitutes the "out or ending time for outpatient observation services"?
A. Observation time ends at the clock time documented in the physician's discharge orders, or, in the absence of such a documented time, the clock time when the nurse or other appropriate person signs off on the physician's discharge order.

Q. What are the current CMS guidelines addressing what to do when a patient refuses to sign the ABN but demands a laboratory test be done?
A.Refer to CMS Pub 100-04 CH 30 40.3.4.6 which states "If the beneficiary demands the service and refuses to pay, the notifier should have a second person witness the provision of the ABN and the beneficiary's refusal to sign. They should both sign an annotation on the ABN attesting to having witnessed said provision and refusal. Where there is only person on site (e.g., in a draw station), the second witness may be contacted by telephone to witness the beneficiary's refusal to sign the ABN by telephone and may sign the ABN annotation at a later time. An unused patient signature line on the ABN form may be used for such an annotation; writing in the margins of the form is also permissible. The notifier should file its claim as having given the ABN. The beneficiary will be held liable per 1879(c) of the Act in case of a denial." You may also refer to cms.hhs.gov/medlearn/refabn.asp regarding CMS guidelines for ABN standards.

Q. If the respiratory therapist performs a Doctor ordered 6-minute walk test for pre-op for surgery; does he bill the 97750 code?
A. No, only the disciplines (PT/OT) can bill using the rehabilitation codes.

Q. In addition to using the "G" codes, for billing by a respiratory therapist (RT) for Outpatient Pulmonary Rehabilitation Services can they also bill 97535 for education?
A. No, refer to the Outpatient Pulmonary Rehabilitation Services policy for Coding Guidelines under each discipline.

Q. What do I do if my biller has used a condition code 20 on a claim when she really should have used a condition code 21?
A. You should call your Provider Representative and ask them to delete the claim with the condition code 20 and re-bill with condition code 21. The system will automatically work the claim without asking for records/medical review of the claim.

Q. Can I use a V-code as a primary diagnosis when coding a claim?
A. No. Refer to the "V" codes section of the ICD-9-CM book, which states that this is a supplementary classification of factors influencing health status. As this is a supplementary code, it should not be the one selected for use as the primary or admitting diagnosis.

Q. The claims/service area receives a request for hard-copy adjustment to a previously medically denied claim. Included in the request is a statement regarding "changing diagnosis" on the original claim. How should this be handled?
A. The Fiscal Intermediary cannot accept hard-copy records for adjustments to MR denials. If the provider wishes to appeal, the request must be in writing to the MR department. A letter requesting the appeal and the supporting medical records should be mailed to the Appeals Coordinator. The request must be timely (At the present time, the request for outpatient The request must be timely (At the present time, the request for outpatient original denial.). Requests for hard-copy adjustments on previously medically reviewed claims should be returned to the provider. In addition, changing the original diagnosis could be perceived as fraudulent activity. Adding to the original diagnosis (es) on a claim would be acceptable, along with documentation to support the medical necessity of the additional diagnosis (es).

Q. Can education be provided and billed for on the same day as the initial evaluation?
A. They can bill per policy, however medical necessity will have to be determined, supported and justified in the clinical record.

Q. Can we bill for the code 99361?
A. No, team conferences are considered in the calculation of the interim rate (administrative services). See the Medicare Intermediary Manual CMS Pub 13-3), § 3650 (A).

Q. Q. Is the recertification that must be performed every 30 days while the patient receives outpatient pulmonary rehabilitation billable?
A. No, this is considered an administrative service, follow the instructions in the CORF manual (CMS Pub 9, §406 (A) and the pulmonary rehabilitation policy.

Q. We had previously billed the wrong code for the initial RT evaluation and payment was denied. Should we re-bill the correct code or should we submit the corrected code through the appeal process?
A. The original bill should not change on appeal. Future bills should only include skilled services as defined by the CORF manual and the pulmonary rehabilitation policy. The documentation for the evaluation should support the need for the skilled service and be medical necessary.

Q. Can HCPCS code 78195, lymphatics and lymph node imaging, only be billed with HCPCS codes 38500, 38525, 38530, and 38792 which are specific to biopsy of the breast and injection procedure for identification of sentinel nodes?
A. No. The policy on Sentinel Lymph Node Biopsy in Breast Carcinoma is written specifically to address issues of breast carcinoma. The use of HCPCS code 78195 is not limited only to this policy, but is incorporated as a secondary part of the sentinel node identification procedure. Documentation of the ICD-9 codes and any other documentation in the medical records to support the medical necessity of the procedures should support billing of 78195 in conjunction with any of the other 4 codes. (3/26/2003)

FREQUENTLY ASKED QUESTIONS FOR FY 2003, 4TH QUARTER

Q. Could you clarify the use of codes used for injections and infusion therapy services?
A.

• Q0081 is for infusion therapy, other than chemotherapeutic drugs, per visit. This code should be billed when infusing intravenous therapy for hydration, or the administration of antibiotics, anti-emetics, or analgesics. Administration of Q0081 is a per visit charge under revenue codes 260 and 269. This code should not be billed more than once per visit.
• Q0083 is for administration of chemotherapy by other than infusion, such as subcutaneous injection, intramuscular injection or IV push. This is a per visit charge and should not be billed more than once per visit.
• Q0084 is for administration of chemotherapy by infusion only and should be billed under revenue code 335. This code is a per visit charge and should not be billed more than once per visit.
• Q0085 is billed for the administration of chemotherapy by both infusion and other techniques, such as subcutaneous injection, intramuscular injection, or IV push. This code is a per-visit charge and should not be billed more than once per visit.

NOTE: The above codes were inadvertantly deleted for 2002 but they are valid code and should be billed for the appopriate services.

It is important to restate that HCPCS codes Q0081, Q0083, Q0084, and Q0085 may only be billed once per visit.

• The injection codes 90782, 90783, 90784, 90788 are considered separate services from infusion therapy and are separately billable to Medicare. It is important to read the descriptor for each code in order to insure that the proper code has been billed. It is appropriate to bill IV infusion therapy, injection, drugs, and supplies separately. Drugs with a CPT/HCPCS code should be billed under revenue code 636.

Q. Why did we receive a comparative billing report?

A. As a part of Local Provider Education and Training, the Centers for Medicare and Medicaid Services (CMS) has instructed the Intermediaries that they may develop and issue comparative billing reports in 3 situations:

• Provider-specific reports for high utilization individuals,
• Provider-specific or specialty-specific, or;
• Service-specific.

The majority of comparative billing reports developed thus far have identified high utilization providers.

Q. What do we should we do with this report?

A. The Comparative Billing Reports are informational to the provider. The report provides a facility with information on a code(s) that demonstrate high utilization of a particular service(s). The report includes a graphic presentation and specific written information concerning the billing report.

LCD/Coverage Frequently Asked Questions

LCD/LPET Frequently Askde Questions 2nd Quarter Fiscal Year 2005

Q. Does Medicare cover the VAX-D procedure?
A. No. According to CMS Pub 100-03 Section 160.16 of the National Coverage Determinations Manual, Vertebral Axial Decompression (VAX-D) is considered non-covered. Listed below is the national policy statement: Vertebral axial decompression is performed for symptomatic relief of pain associated with lumbar disk problems. The treatment combines pelvic and/or cervical traction connected to a special table that permits the traction application. There is insufficient scientific data to support the benefits of this technique. Therefore, VAX-D is not covered by Medicare.

Q. Is Gastric freezing covered by Medicare?
A. Since the procedure is now considered obsolete, it is not covered. According to the National Coverage Determinations Manual (CMS Pub 100-03 Section 100.6), Gastric freezing for chronic peptic ulcer disease is a non-surgical treatment which was popular about 20 years ago but now is seldom done. It has been abandoned due to a high complication rate, only temporary improvement experienced by patients, and lack of effectiveness when tested by double-blind, controlled clinical trials.

Q. Is electrical stimulation covered for Stage II decubiti?
A. According to the National Coverage Determinations Manual (CMS Pub 100-03 Section 270.1.1), CMS issued a coverage decision on the use of electrical stimulation only for CHRONIC Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers. Electrical stimulation will not be covered as an initial treatment modality. The use of electrical stimulation will be covered only after standard wound therapy has been tried for at least 30 days, and there are no measurable signs of healing.

Q. When the re-certification to a plan of care is signed on the 25th day from the initial evaluation, does the 30 days begin from that day?
A. No, a re-certification period begins on the day the last certification period ends. When outpatient therapy services are continued under the same plan of treatment for a period of time, the physician must recertify at intervals of at least once every 30 days from the date last seen by the referring physician that there is a continuing need for such services and estimate how long services are needed. Obtain the recertification at the time the plan of treatment is reviewed since the same interval (at least once every thirty days) is required for the review of the plan. (CMS Pub 100-02 CH 15 §220.3.1) According to the National Coverage Determinations Manual (CMS Pub 100-03 Section 270.1.1), CMS issued a coverage decision on the use of electrical stimulation only for CHRONIC Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers.

Q. If there is an order to perform a physical therapy evaluation, is a certification needed for an evaluation only?
A. No, a certification is not needed for an evaluation only. However, there must be a physician's order for the evaluation. The purpose of the certification is to establish the medical necessity of skilled therapy under a plan of treatment. Medicare will cover claims for the FDA approved drug starting on 9/25/98. The LCD coverage guidelines for the drug become effective on 8/2/04.

Q. When a drug (Herceptin) has been FDA approved on 9/25/98 and the new LCD for that drug has an effective date of 8/2/04, what date is the drug covered by Medicare?
A. Medicare will cover claims for the FDA approved drug starting on 9/25/98. The LCD coverage guidelines for the drug become effective on 8/2/04.

Q. Is breast reconstruction a covered Medicare procedure?
A. Yes. CMS Pub 100-03 Section 140.2 of the National Coverage Determinations Manual states that breast reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is a covered procedure. Medicare will not cover breast reconstruction for cosmetic reasons.

Q. In the Outpatient Pulmonary Rehabilitation Services policy, HCPCS 97750, used for the 6-minute walk is under revenue codes 42X and 43X only. In most programs, PT and OT are not involved in pulmonary rehabilitation, so how can the nurses or RT bill for the 6-minute walk?
A. The 6-minute walk should be coded with 97XXX codes, which require that a PT or OT perform them. If a facility chooses not to employ PTs and OTs in their Pulmonary Rehabilitation program, they may not bill these services. Other disciplines maybe capable of performing the functions described by these codes, but may not use these codes in billing.

Q. For the physical therapist to perform an unnecessary evaluation in order to do the 6-minute walk test for Outpatient Pulmonary Rehabilitation Services seems to me to be inefficient, use of scarce resources unnecessarily and adds additional cost to the Medicare Program. Could you clarify this?
A. If a physician orders a physical therapist to do a 6-minute walk test, hopefully the physical therapist could perform the test without a full physical therapy evaluation. While there are restrictions referring to a PT not being able to "treat" a patient without an evaluation, this is a test and is not to be considered "treatment." It is purely for evaluation.

Q. Can a RT bill a "G" code for the 6-minute walk test?
A. No, G0238 and G0239 could include educational activities as therapeutic procedures to improve respiratory function. The 6-minute walk test is not therapeutic and should not be billed with these codes.

Q. If the respiratory therapist performs a Doctor ordered 6-minute walk test for pre-op for surgery; does he bill the 97750 code?
A. No, only the disciplines (PT/OT) can bill using the rehabilitation codes.

Q. In addition to using the "G" codes, for billing by a respiratory therapist (RT) for Outpatient Pulmonary Rehabilitation Services can they also bill 97535 for education?
A. No, refer to the Outpatient Pulmonary Rehabilitation Services policy for Coding Guidelines under each discipline.

Q. What do I do if my biller has used a condition code 20 on a claim when she really should have used a condition code 21?
A. You should call your Provider Representative and ask them to delete the claim with the condition code 20 and re-bill with condition code 21. The system will automatically work the claim without asking for records/medical review of the claim.

Q. Can I use a V-code as a primary diagnosis when coding a claim?
A. No. Refer to the "V" codes section of the ICD-9-CM book, which states that this is a supplementary classification of factors influencing health status. As this is a supplementary code, it should not be the one selected for use as the primary or admitting diagnosis.

Q. The claims/service area receives a request for hard-copy adjustment to a previously medically denied claim. Included in the request is a statement regarding "changing diagnosis" on the original claim. How should this be handled?
A. The Fiscal Intermediary cannot accept hard-copy records for adjustments to MR denials. If the provider wishes to appeal, the request must be in writing to the MR department. A letter requesting the appeal and the supporting medical records should be mailed to the Appeals Coordinator. The request must be timely (At the present time, the request for outpatient The request must be timely (At the present time, the request for outpatient original denial.). Requests for hard-copy adjustments on previously medically reviewed claims should be returned to the provider. In addition, changing the original diagnosis could be perceived as fraudulent activity. Adding to the original diagnosis (es) on a claim would be acceptable, along with documentation to support the medical necessity of the additional diagnosis (es).

Q. Can education be provided and billed for on the same day as the initial evaluation?
A. They can bill per policy, however medical necessity will have to be determined, supported and justified in the clinical record.

Q. Can we bill for the code 99361?
A. No, team conferences are considered in the calculation of the interim rate (administrative services). See the Medicare Intermediary Manual CMS Pub 13-3), § 3650 (A).

Q. Q. Is the recertification that must be performed every 30 days while the patient receives outpatient pulmonary rehabilitation billable?
A. No, this is considered an administrative service, follow the instructions in the CORF manual (CMS Pub 9, §406 (A) and the pulmonary rehabilitation policy.

Q. We had previously billed the wrong code for the initial RT evaluation and payment was denied. Should we re-bill the correct code or should we submit the corrected code through the appeal process?
A. The original bill should not change on appeal. Future bills should only include skilled services as defined by the CORF manual and the pulmonary rehabilitation policy. The documentation for the evaluation should support the need for the skilled service and be medical necessary.

Q. Can HCPCS code 78195, lymphatics and lymph node imaging, only be billed with HCPCS codes 38500, 38525, 38530, and 38792 which are specific to biopsy of the breast and injection procedure for identification of sentinel nodes?
A. No. The policy on Sentinel Lymph Node Biopsy in Breast Carcinoma is written specifically to address issues of breast carcinoma. The use of HCPCS code 78195 is not limited only to this policy, but is incorporated as a secondary part of the sentinel node identification procedure. Documentation of the ICD-9 codes and any other documentation in the medical records to support the medical necessity of the procedures should support billing of 78195 in conjunction with any of the other 4 codes. (3/26/2003)

FREQUENTLY ASKED QUESTIONS FOR FY 2003, 4TH QUARTER

Q. Could you clarify the use of codes used for injections and infusion therapy services?
A.

• Q0081 is for infusion therapy, other than chemotherapeutic drugs, per visit. This code should be billed when infusing intravenous therapy for hydration, or the administration of antibiotics, anti-emetics, or analgesics. Administration of Q0081 is a per visit charge under revenue codes 260 and 269. This code should not be billed more than once per visit.
• Q0083 is for administration of chemotherapy by other than infusion, such as subcutaneous injection, intramuscular injection or IV push. This is a per visit charge and should not be billed more than once per visit.
• Q0084 is for administration of chemotherapy by infusion only and should be billed under revenue code 335. This code is a per visit charge and should not be billed more than once per visit.
• Q0085 is billed for the administration of chemotherapy by both infusion and other techniques, such as subcutaneous injection, intramuscular injection, or IV push. This code is a per-visit charge and should not be billed more than once per visit.

NOTE: The above codes were inadvertantly deleted for 2002 but they are valid code and should be billed for the appopriate services.

It is important to restate that HCPCS codes Q0081, Q0083, Q0084, and Q0085 may only be billed once per visit.

• The injection codes 90782, 90783, 90784, 90788 are considered separate services from infusion therapy and are separately billable to Medicare. It is important to read the descriptor for each code in order to insure that the proper code has been billed. It is appropriate to bill IV infusion therapy, injection, drugs, and supplies separately. Drugs with a CPT/HCPCS code should be billed under revenue code 636.

Q. Why did we receive a comparative billing report?

A. As a part of Local Provider Education and Training, the Centers for Medicare and Medicaid Services (CMS) has instructed the Intermediaries that they may develop and issue comparative billing reports in 3 situations:

• Provider-specific reports for high utilization individuals,
• Provider-specific or specialty-specific, or;
• Service-specific.

The majority of comparative billing reports developed thus far have identified high utilization providers.

Q. What do we should we do with this report?

A. The Comparative Billing Reports are informational to the provider. The report provides a facility with information on a code(s) that demonstrate high utilization of a particular service(s). The report includes a graphic presentation and specific written information concerning the billing report.

FREQUENTLY ASKED QUESTIONS FOR FY 2004, 4TH QUARTER

Q. What should the provider place in the blank space on the Advance Beneficiary Notice (ABN) for a possible denial by Medicare?
A. The clinical reason the provider thinks the service will be denied (i.e. "Medicare does not pay for services which it considers to be experimental or for research use"). Do NOT put "because Medicare will possibly not pay". This is not the correct answer.

Q. How long does it take for Medicare to adjudicate a claim once it is placed in the medical review (MR) location?

A. Medical review must review the claim within 60 days after MR receives the documentation and places in their system location. After the claim is adjudicated by MR, the adjudication process will continue through the FISS system for approximately one additional week.

Q. When a claim is being appealed, does the provider need to submit the documentation again?

Yes, the MR area will look at all documentation the provider has submitted to compare and update the information. Medical records are the only way to verify services billed were completed properly.

Q. Why do a lot of my claims get hung up in the FISS system?
A. There are various reasons why and the following are a few examples:

• Billing incorrectly
• Leaving off the occurrence code when you bill a condition code 20
• Billing drugs with the incorrect type of revenue code
• Using unlisted codes when there are new CPT/HCPCS codes available
• Adding the bill incorrectly
• Billing the old CPT/HCPCS codes that have been deleted and no longer recognized by the system
• Using the wrong HIC #
• Using overlapping claim dates

Q. Why do some claims automatically receive ADRs and others do not?

A. MR is updating and changing their system edits continuously. These changes may vary with the updates of HCPCS/CPT codes, changes in CMS instructions, new or altered National Coverage Determinations (NCDs), or new Local Coverage Determinations (LCDs).

Q. As a provider we are having a problem with denial of claims and the reason is usually because the documentation was incorrect. Is there anyway that a provider could set up a meeting with the Medical Review team?

A. Yes and we suggest that you do ask for assitance. If you think the problem is a medical review issue please contact Janice Austin, RN at (410) 561-4158.

Q. What type of documentation is required for J3490 when information is requested?

A. The following documentation is required: Full name/description of the drug, dosage, route of adminstration, time, date, physician order, and professional signature. The itemized statement must identify the exact amount billed.

Q. When a claim is appealed because the ICD-9 CM diagnosis was orginally denied - do we need to send in supporting documentation to verify the new ICD-9-CM diagnosis?

A. Yes. Because the original diagnosis did not support the medical necessity of the service, supporting documentation verifying the new ICD-9 CM code / condition must be submitted (i.e., H&P or signs and symptoms)

Q. Therapy progress notes - What do they need to state?

A. These notes should include the service provided, indication of progress or decline, measurable data (exp. pain scale, ROM, muscle strength, gait deviation, specific gait training, etc.), time spent per modality, and professional signatures all in legible handwriting.

Q. When can follow-up diabetes self-management training be provided?

A. Providers cannot bill follow-up diabetes self-management training until the year after the completion of the initial 10 hour training. (The 10 hours of training can be done in a combination of 1/2-hour increments; spread over the 12-month period or less.)

Q. When ancillary services are furnished in both the emergency room and the observation room setting, is it appropriate to bill for both settings? For example, IV injections administered in the Emergency Room, followed by IV injections adminstered in the observation room setting?

A. Yes. Most ancillary services, such as injections, if rendered in both settings would be billable. The provider should bill the appropriate HCPCS code in the revenue center where the service took place. For example, revenue code 450 with HCPCS 90784 with the number of units indicating the number of IV injections given in that setting. Subsequently, if IV injections are rendered in the observation room setting, bill revenue center 760 with HCPCS 90784 with the number of units reflecting the number of IV injections administered.

Q. Can an anesthesiologist meet the Medicare requirement for direct physician supervision for Phase II cardiac rehabiliation services?

A. Yes. The coverage criteria for cardiac rehabilitation services located in the Coverage Issues Manual under Publication 100-3, Chapter 1, Section 20-10) states that "services of non-physician personnel must be under the direct supervision of a physician". The guidelines do not specify a particular physician specialty such as a cardiologist; however, the designated physician must be ACLS certified. It is imperative that providers ensure that the physician designated to cover the rehabiliation unit during the Phase II cardiac rehabilition sessions is aware that she/he is the supervising physician. Direct supervision means that a physician must be in the exercise program area and immediately available and accessible for an emergency at all times the exercise program is conducted.

Q. Does Medicare pay for therapy treatment performed by technical staff members?

A. Medicare does not pay for therapy treatment performed by technical staff members. Medicare covers skilled therapy services only when performed by a: qualified physical therapist, qualified physical therapy assistant under the supervision of a qualified physical therapist, or qualified occupational therapy assistant under the supervision of a qualifed occupational therapist. The regulations can be found in the Code of Federal Regulations, 42 CFR 409.44 and 42 CFR 484.

FREQUENTLY ASKED QUESTIONS 1st Quarter FY 2005

Q. What is the proper use of modifier GZ, GY and GA?

A. Modifier GA is used when an item or service is expected to be denied as not reasonable and necessary and an advanced beneficiary notice (ABN) was given to the beneficiary. You are required to use an occurrence code 32 along with your modifier GA. The services should be billed as covered. If you do not use modifier GA and occurrence code 32 on the claim, it will be reviewed as any other claim and may or may not be denied. If the claim is denied, the provider will be liable. Modifier GZ is used when an item or service is expected to be denied as not reasonable and necessary and an ABN was not signed by the beneficiary and you furnish the services anyway. Medicare will review the claim like any other claim without regard to the “GZ” modifier. If Medicare pays the claim, the GZ modifier is irrelevant. However, if Medicare denies the claim, the provider will be liable. This modifier does not need to be used when payment is expected by Medicare. The provider has the option to choose to use or not to use modifier GZ. Modifier GY is used when you are filing for statutorily excluded services. ABNs are not an issue in this case. Modifier GY is used (a) when you think a claim will be denied because it is not a Medicare benefit or because Medicare law specifically excludes it, (b) when you think a claim will be denied because it is not a benefit under the law, or (c) when you submit a claim to obtain a denial from Medicare to bill a secondary payer (use condition code 21) in this case. Medicare will deny the claim.

Q. Can I bill more than one unit of 97601 (selective debridement) per patient on a given treatment day?

A. We would not expect to see 97601 billed in multiple units per treatment session. The CPT Manual defines this as the removal of devitalized tissue from wound(s) indicating multiple wounds per session.

Q. What are the CORF physicians requirements regarding the plan of treatment?

A. Per CMS Pub. 100-2, CH 12, §30 E, CORF services must be furnished under a written plan of treatment established by a physician. The physician may be either a physician associated with the CORF, or the referring physician if the physician provides a detailed plan of treatment that must contain the diagnosis, the type, amount frequency, and duration of services to be performed, and the anticipated rehabilitation goals.
The CORF physician must review the plan of treatment at least once every 60 days. Following the review, the physician should certify that the plan of treatment is being followed and that the patient is making progress in attaining the established rehab goals.

Q. What is Adenosine Injection (HCPCS J0152) used for and is it the same as Adenocard (J0150)? How do I know the difference? How do I code appropriately?

A. Medicare allows coverage for Adenosine as a pharmacologic stress agent for Myocardial Perfusion Imaging. Pharmacologically, Adenosine and Adenocard are both adenosine injection. The concentrations and indications for usage, however, are much different. Adenosine (trade name Adenoscan) is used for the myocardial perfusion studies diagnostic and is coded per 30 mg vial. Adenocard is the trade name used for treatment of supraventricular tachycardia and is coded per 6 mg vial. They are not interchangeable.

Q. When should a provider have a beneficiary sign an Advanced Beneficiary Notice (ABN)?

A. Providers should have the beneficiary sign an ABN in advance of furnishing services that Medicare is likely to deny payment for them. The ABN is to inform a Medicare beneficiary before they receive a specified item or service that it may not be paid for. It allows the beneficiary to make an informed decision whether or not to receive the item or service for which they may have to pay out of pocket or through other insurance.

Q. Can I bill the beneficiary for non-covered charges without having the patient sign an Advanced Beneficiary Notification (ABN)?

A. The only time a beneficiary can be held liable for non-covered charges without signing an ABN is in the event they are being billed for statutorily excluded services or items.

Q. Does Medicare cover drug and alcohol rehabilitation?

A. Coverage is available for both diagnostic and therapeutic services furnished for the treatment of drug abuse and alcoholism. Hospitals may provide structured inpatient alcohol rehabilitation programs to the chronic alcoholic. These programs are composed primarily of coordinated educational and psychotherapeutic services provided on a group basis. Depending on the subject matter, a series of lectures, discussions, films, and group therapy sessions are led by either physicians, psychologists, or alcoholism counselors from the hospital or various outside organizations.
In addition, individual psychotherapy and family counseling (CMS Pub. 100-3, §130.2) may be provided in selected cases. These programs are conducted under the supervision and direction of a physician.

Q. Will Medicare cover dental surgery in a hospital?

A. Items and services in connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth are not covered. However, the extraction of teeth to prepare the jaw for radiation treatments of neoplastic disease is covered. The guidelines can be found in CMS Pub. 100-2, CH 16, §140.

Q. Does Medicare cover pulmonary rehabilitation?

A. Pulmonary rehab, as a complete program like cardiac rehab is not a covered service. Medicare will cover for pulmonary rehab and endurance exercises. The services must be ordered by a physician, reasonable and necessary for the individualized treatment of the patient’s condition, and must be re-certified by the physician every 30 days. Refer to the Outpatient Pulmonary Rehabilitation Services Local Coverage Determination (LCD) on www.marylandmedicare.com.

Q. What are the Medicare guidelines for Gastric Bypass Surgery?

A. Gastric bypass surgery, which is a variation of the gastrojejunostomy, is performed for patients with extreme obesity. Gastric bypass surgery for extreme obesity is covered under the program if: (1) it is medically necessary for the individual to have such surgery, AND (2) the surgery is to correct an illness which caused the obesity or was aggravated by the obesity. Refer to CMS Pub. 100-3, §100.1.

Q. Will Medicare cover a combined left and right heart catheterization?

A. In order for Medicare to cover combined left and right heart catheterization, providers must report a diagnosis from the list of codes supporting medical necessity for the left and the right heart catheterization. For conditions that appear on both lists, reporting the diagnosis code once on the claim is sufficient, as long as the documentation in the medical record supports medical necessity for doing both. A diagnosis code may not support medical necessity by itself. Refer to the Cardiac Catheterization Local Coverage Determination (LCD) on www.marylandmedicare.com.

Q. Do we need a written order for therapy?

A. Yes, therapy services must be furnished to an individual who is under the care of a physician and certifies that the patient’s therapy services are reasonable and necessary to the treatment of the individual’s illness or injury. A written plan of treatment is required and if established by the therapist must be reviewed and signed by the physician. Refer to the Physical Medicine and Rehabilitation Local Coverage Determination (LCD) on www.marylandmedicare.com. Additional information can be found in 42CFR 482.12 and CMS Pub. 100-2, CH 15, §220.3.2.

Q. Can I bill more than one unit on a therapy evaluation (CPT 97001, 97003, 92506, 92610) or re-evaluation (CPT 97002, 97004)?

A. No. Only one unit can be billed for a therapy evaluation or reevaluation. These codes are not defined by a specific time frame; therefore, only one unit may be billed regardless of the amount of time spent delivering the service. Refer to CMS Pub. 100-4 CH 5, §20.2. Also, see the Physical Medicine and Rehabilitation LCD on www.marylandmedicare.com.

Q. What are the basic elements for documentation for therapy services?

A. The necessary documentation for therapy services should include the following:

• Physician Orders
• Modality or type of care to be furnished
• Duration and frequency of service
• Date and signed by physician
• Plan of Treatment (Initial and current plan of care signed and dated by the physician)
• Type and nature of care to be furnished
• Functional goals and estimated rehabilitation potential
• Treatment objectives
• requency of visit
• Estimated duration of treatment
• Signed and dated by physician
• Physician Certification and/or Re-certifications (Certification is obtained at the time the plan of treatment is established)
• The services are or were furnished while the patient was under care of a physician.
• A plan for furnishing such services is or was established by the physician, physical therapist, occupational therapist, or speech pathologist and periodically reviewed by the physician.
• Services are or were required by the patient.
• Evaluations and/or Re-evaluations
• Evidence of the assessment
• Functional goals and or disabilities
• Patient baseline and goals
• Discharge planning
• Frequency, duration, type of treatment
• Short term and long term goals
• Progress Notes (Treatment Summary for Billing Period)
• Initial functional communication status of the patient at your provider setting
• Present functional status of the patient for this billing period
• Changes in the plan of treatment if appropriate
• Documented patient progress

Cardiac Rehabilitation Services

Q. What is the physician’s involvement for cardiac rehab?

A. The physician fulfills two roles in cardiac rehab. The first is direct supervision and the second is “incident-to”.

Q. What is involved in ‘direct physician supervision’?

A. The physician must be a) in the exercise program area and b) immediately available and accessible for an emergency at all times the exercise program is conducted. It does not require the physician be physically present in the exercise room itself. The supervision requirement would not be met by a physician who is involved in an activity (e.g. cardiac catheterization, another emergency) or is too remote from the exercise program area that would prevent him/her from being immediately available and accessible. Each provider should insure that protocols are established, posted, and verified to insure that a designated physician(s) fulfills this requirement.

Q. What is meant by ‘in the exercise program area’?

A. The supervision requirement is met when the physician is in such proximity to the CR exercise area that he/she can respond as noted in ‘b’ in question 2. The supervision requirement would not be met by a physician who is so physically displaced from the exercise program area preventing him/her from being immediately available and accessible.

Q. How is the ‘incident-to’ requirement met?

A. In order to be covered under the ‘incident-to’ benefit in an outpatient hospital department, services must be furnished as an integral, although incidental part of a physician’s professional service in the course of diagnosis or treatment of an illness or injury. The benefit does not require that a physician perform a personal professional service on each occasion of service by a non-physician. However, during any course of treatment rendered by auxiliary personnel, the physician must personally see the patient periodically and sufficiently often to assess the course of treatment and the patient’s progress and, where necessary, to change the treatment program.

Q. A patient had a coronary bypass surgery in 1998, can they participate in Cardiac Rehab?

A. Medicare coverage of cardiac rehabilitation is considered reasonable and necessary for patients with a clear medical need, who are referred by their attending physician and have had coronary bypass surgery. There is no time limit for the surgery. The guidelines for cardiac rehab services can be found in CMS Pub. 100-3 §20.10.

Skilled Nursing Facility (SNF)

Q. Would you explain what information is required when I send in an ADR?
A. The following medical record documentation should be submitted when responding to an additional development request (ADR).

• Hospital discharge summary or hospital or SNF transfer sheet
• History and physical
• Physician signed orders and physician progress notes
• Signed and dated certification or recertification for skilled care
• All nurses notes, therapy plan(s) of treatment, therapy evaulations, therapy minutes, therapy notes and progress notes from 30 days prior to the assessment reference date or since admission for each Rug III code billed and through the dates of service
• Medication, treatment, and wound care records, dietician notes
• Signed Medicare MDS for each of the RUG III codes billed
• If this is an adjusted claim and the HIPPS was changed due to an error on a prior claim, submit documentation for the reason for the correction

It is important to note that each RUG III code billed must be supported by the information within the medical record. Therefore, you will need to submit medical record documentation to support the MDS "look back" period for each code billed. For example, the dates of service on a claim are May 1 through May 9, admission date was April 26, and the 5 day MDS has the assessment reference date of April 30. The RUG III code billed is RHA01 for 9 days. The information to support this code would include the information from the admission date of April 30 through the dates of service on the claim, which is May 1 through May 9.

Q. When should an Other Medicare Required Assessment (OMRA) be completed?

A. This type of assessment is used only for those beneficiaries who remain in a Part A SNF stay after all rehabilitation therapy has been discontinued, but continue to have another skilled nursing service. The OMRA must be performed with an assessment reference date that is the 8th, 9th or 10th day after therapy ends. This would cause the claim to be downcoded to a lower level of nursing care. (CMS Pub. 100-4, CH 6, §30.2-30.3; Federal Register, Volume 64, July 30, 1999 page 41656)

Q. When should a MDS assessment schedule be started again?

A. A new MDS assessment schedule should be started if the patient is out of the facility greater then 24 hours or if the patient has been discharged from skilled care and readmitted. (CMS Pub. 100-6. CH 6, §30.2- 30.3; Federal Register, Volume 64, July 30, 1999 page 41658)

Q. Why does an Intermediary need to review a Skilled Nursing Facility demand bill?

A. Your facility may determine upon admission that the level of care will be non-covered or excluded and therefore Medicare will not pay. You must advise the beneficiary that, in your opinion, Medicare will not pay for these services. If the beneficiary disagrees and requests you to submit a bill to the Intermediary, you must submit a "demand bill". The Intermediary will determine whether the provider is incorrectly determining and advising beneficiaries and/or beneficiaries' representatives that services are not covered by Medicare where, in fact, some or all of the services may be covered. The Intermediary also determines by review of the "demand bill" if adequate notice of non-coverage of skilled care was provided to the beneficiary and/or the beneficiaries representatives.

Q. What documents should be submitted by a Skilled Nursing Facility (SNF) in response to a Medical Review Additional Development Request (ADR)?

A. SNF providers should submit all documents listed in the ADR as well as any other supporting documentation, including, but not limited to physician’s orders, history and physical, MDS, progress notes, nurses’ notes, therapy orders, plan of care, certifications, and treatment notes.