Empire Blue Cross and Blue Shield Medicare Private Fee For Service Product Significant Edits Implementation Date: May 31, 2008

Transcription

1 Empire Blue Cross and Blue Shield Medicare Private Fee For Product Significant Edits Implementation Date: May 31, 2008 The table below represents those edits which Empire Blue Cross Blue Shield considers to be a significant edit. We define a significant edit as: An edit that, based on experience with submitted claims, will cause, on initial review of submitted claims, the denial or reduction in payment for a particular CPT code or HCPCS Level II code more than two-hundred and fifty (250) times per year in any state in which Empire s Medicare Private Fee for operates. Empire Blue Cross Blue Shield s Private Fee for product is paid in a manner consistent with that prescribed by CMS for the Fee for Medicare products. Therefore, if you wish to view more detailed information, such as, but not limited to, individual CCI edits, permissible modifiers, and Medicare Coverage Determinations they can be viewed by visiting CMS s website at: and selecting the Medicare homepage. The Significant Edits table will be updated annually and when significant edit changes occur throughout the year. The Significant Edit listing is based on a review of historical claims data for claims processed in 2008 and is based on CPT/HCPCS codes in effect during that time. (Yellow highlighted rows are new to the listing, based on updated analysis) Add-on Code Anesthesia Assistant Surgeon Assistant Surgeon Bundled Add-on Codes Anesthesia Crosswalk Non-Physicians Billing With Modifiers 80, 81 or 82 Primary Surgeon and Assistant Surgeon Cannot be the Same Provider Bundled Billed on the Same Day as Other Payable According to the AMA CPT Manual, an add-on code describes additional intra-service work associated with the primary procedure and must never be reported as a stand-alone code. According to the American Society of Anesthesiologists, anesthesia services should be billed with the appropriate anesthesia CPT codes for appropriate reimbursement. According to CMS guidelines, modifier AS is the proper modifier to indicate an assistant at surgery service for a nurse, physician's assistant, or midwife. The primary surgeon and surgical assistant cannot be the same provider. Bundled are identified with status indicator "P" or "T" on the CMS Physician Fee Schedule list. These services are considered incidental to other payable services performed by the same provider on the same day.

2 Bundled Bundled CMS Coverage Policies CMS Coverage Policies CMS Coverage Determinations (NCD) Deleted HCPCS Codes Device and Supply Diagnosis Validity Diagnosis Validity Diagnosis- Gender Bundled Not Payable Under Any Circumstances Lidocaine Non-covered on the Medicare Physician Fee Schedule Not Valid for Medicare on the Medicare Physician Fee Schedule CMS Coverage Determinations (NCD) Policy Non-Payment for Deleted Codes Diagnostic/Therapeutic Imaging Radiopharmaceutical and Contrast Agent Link Diagnosis Specificity Invalid/Deleted Diagnosis Codes Diagnosis-Gender Consistency The codes identified with status indicator "B" from the CMS Physician Fee Schedule list, without Relative Value Units, are routinely "bundled" into other payable services unless there are no other physician fee schedule services being paid. According to CMS policy, Lidocaine, when used as a local anesthetic is bundled into the service rendered at the same time. According to CMS guidelines, certain HCPCS codes are considered noncovered services and have a status 'N' on the Physicians Fee Schedule. According to CMS guidelines, certain HCPCS codes have been designated as not valid for Medicare purposes and have a status 'I' indicator on the Physicians Fee Schedule. Medicare uses another code for reporting of, and payment for, these services. The CMS Coverage Determinations Manual describes whether specific medical items, services, treatment procedures, or technologies are covered by Medicare. Items, services, etc, may be (1) excluded as "not reasonable and necessary;" or, (2) covered but explicitly limited to specified indications or specified circumstances. codes, such as Level II HCPCS and AMA CPT-4 Codes, undergo revision by their governing entities on a regular basis. Revisions typically include adding new procedure codes, deleting procedure codes, and redefining the description or nomenclature of existing procedure codes. These revisions are normally made on an annual basis by the governing entities. Providers should only submit procedure codes that are active as of the date the service was provided. According to CMS policy, when a radiopharmaceutical or imaging agent is billed, it is to accompany an appropriate, related imaging procedure. Per CMS guidelines, HCPCS codes should be accompanied by diagnosis codes that are coded to the highest level of specificity according to the ICD-9 coding manual. Diagnosis codes undergo revision on a regular basis. Revisions typically include adding new diagnosis codes, deleting diagnosis codes, and redefining the description or nomenclature of existing diagnosis codes. These revisions are normally made on an annual basis. Providers should only submit diagnosis codes that are active as of the date the service was provided. The ICD-9 Manual has certain services that are specific to one gender. The diagnosis code should be consistent with the patient's gender.

3 Diagnosis- Diagnosis- Duplicate Claims Duplicate Claims Duplicate Claims Chiropractic Manipulation Chiropractic Manipulation Duplicate Claim Logic for Anesthesia by Different Providers Duplicate Claims From Any Provider Under Same Tax ID And Specialty Duplicate Logic for Laboratory Blood Glucose Monitoring DME Purchases DME Rentals DME Rentals Maximum Units Over Time Modifiers for DME Nebulizers Orthotics and prosthetics According to CMS policy, for chiropractic manipulation to be a covered service a primary diagnoses must be for a nonallopathic lesion of the spine. According to CMS policy, chiropractic manipulation claims must include an appropriate secondary diagnosis for disorders of the spine to be a Medicare covered benefit. Two different anesthesia providers should not bill for the same service for the same member and date of service. Two providers with the same Tax ID and specialty should not bill for the same service for the same member and date of service. A single laboratory service should not be billed by both a physician and a laboratory. According to CMS policy, glucose monitors and supplies are considered appropriate only for diabetics, therefore modifiers KS (non-insulin dependent) or KX (insulin dependent) must be included to identify diabetic patients. According to CMS policy, certain items of DME are only approved as a purchase and are not to be rented. Purchase-only DME items must have modifier NU appended to the HCPCS code. According to CMS policy, rental items are paid a flat monthly rate. Therefore it is not appropriate to bill a rental more than once per calendar month. According to CMS policy, capped rental equipment is paid for a total of 13 months. There is a maximum number of units or services allowed for DME, prosthetics, orthotics and supplies over a specified period of time (e.g, three months). Units in excess of the maximum will be denied. The maximum number of units assigned to each code is based on the procedure code definition or nomenclature in the HCPCS Manual or due to their reference to anatomical sites, clinical guidelines and/or payment guidelines established by CMS. According to CMS policy, capped rental modifiers can only be used with capped rental DME items. According to CMS policy, both the inhalation drug and the pharmacy dispensing fee for the inhalation drugs must be billed on the same claim. According to CMS policy, prosthetics and orthotics that can be billed bilaterally are to be billed with the appropriate anatomic modifiers (RT and/or LT).

4 Surgical Dressings Cardiovascular with Multiple on the Same Day Multiple Inpatient Admission or Consultation within 7 Days New Patient Visits Rhythm EKG with Bone Density Chiropratic Manipulaton Colorectal Cancer Screening - Pacemaker Analysis According to CMS policy, claims for surgical dressings require an appropriate wound modifier (A1-A9) According to CMS policy, an service is included in the evaluation of cardiovascular function with a tilt table test or electronic analysis of a pacing cardioverter-defibrillator. According to CMS Policy only one service should be billed for a single date of service by the same provider, regardless of place of service except for add-on E/M codes; physician standby services, preventive medicine visits, critical care codes, initial nursing facility care, annual nursing facility assessment, domiciliary, rest home, or home care plan oversight, care plan oversight, attendance-at-delivery, or newborn resuscitation. A second hospital admission or consultation should not be billed by the same provider unless the patient has been discharged and readmitted. The American Association (AMA) defines a new patient as "one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group within the past 3 years". Given this definition, a new patient office visit should only be billed when the patient has not had any previous services in the last 3 years by that provider, including other providers in the same group with the same specialty. According to the AMA CPT Manual Guidelines, the physician's interpretation of the results of diagnostic tests/studies should only be billed separately upon preparation of a separate, distinctly identifiable, signed written report. The interpretation of a rhythm ECG is included in the evaluation and management services when performed in the hospital, observation area, or emergency room. According to CMS policy, a bone density study should only be performed once within a 23-month period. According to CMS Policy, chiropractic procedures should not be billed more than once per day by the same or different providers. According to CMS policy, fecal occult blood tests should only be billed once within a 12-month period for patients 50 years old or greater. CMS has established guidelines for the frequency of electronic analysis of pacemakers.

5 ICD-9 Guidelines ICD-9 Guidelines Major Surgery 90 Day s Minor Surgery 0 Day s Minor Surgery 10 Day s Modifier Reimbursement for Return to Operating Room Other and Surgical during the 10 day Post Operative Period Other and Surgical performed during the 90 day Post-Operative Period E Diagnosis Cannot be Principal or Primary Diagnosis Manifestation Codes CMS has identified a list of major surgical procedures with a 90 day postoperative period. The major surgery package includes visits (office or hospital) rendered the day prior, same day or within 90 days after a major surgical procedure. E&M services should only be billed if they are related to a decision for surgery. CMS has identified a list of minor surgical procedures with a 0 day postoperative period. The minor surgery package includes visits rendered on the same day as the minor procedure. E&M services should only be billed if they are significant and separately identifiable. CMS has identified a list of minor surgical procedures with a 10 day postoperative period. The minor surgery package includes visits rendered within 10 days of the minor procedure. E&M services should only be billed if they are significant and separately identifiable. According to CMS guidelines, procedures billed with a modifier 78 (Return to OR) will be reimbursed at a reduced percentage of the global amount. CMS has identified a list of minor surgical procedures with a 10 day postoperative period. The services included in the minor surgery global period include additional surgical services which do not require additional trips to the operating room. The Global Surgery package includes all necessary services normally furnished by the surgeon before, during and after a surgical procedure. The global surgery concept applies only to primary surgeons and co-surgeons. CMS has identified a list of major surgical procedures with a 90 day postoperative period. The services included in the major surgery global period include additional surgical services which do not require additional trips to the operating room. The Global Surgery package includes all necessary services normally furnished by the surgeon before, during and after a surgical procedure. The global surgery concept applies only to primary surgeons and co-surgeons. According to CMS policy, External causes of injury and poisoning (E800-E999) can not be listed as the principal diagnosis on a claim. According to the ICD-9 Manual coding guidelines, manifestation codes cannot be used alone on a claim because each describes a manifestation of some other underlying disease, not the etiology of the disease itself.

6 Incident To Maximum Units Modifier Processing Multiple Reduction for Radiology Initiative Initiative Manual Manual Manual Place of Place of Incident To Maximum Units Per Date of Global Modifier Hierarchy Radiology Multiple Reductions CCI Mutually Exclusive Edits Column I and Column II Code Edits with Cardiac Studies Radiology services with CCI Comprehensive Codes involving IV infusion and Chemo administration CMS Physician Fee Schedule Non-Facility N/A Indicator Place of Restrictions According to CMS, incident to services are defined as those services or supplies furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an illness or injury. When these services are billed in an inpatient hospital or outpatient facility setting, separate payment is not allowed. All procedure codes are assigned a maximum number of units that may be billed on a single date of service. Units in excess of the maximum will be denied. code modifiers are reordered to place the modifiers that most affect claims payment before other modifiers. According to CMS guidelines, certain imaging procedures are subject to a reduction in payment for the technical components if they are from the same code family as another procedure billed on the same date of service. The Initiative (CCI) has identified procedures that are considered mutually exclusive of each other. Mutually exclusive procedures are those procedures that cannot be reasonably performed in the same operative session. CCI has identified comprehensive procedure codes and their associated component codes. Component codes are considered part of the more global comprehensive code and are not eligible for reimbursement when billed with the comprehensive code. According to CMS's Initiative, established patient services are included in cardiac stress tests, transthoracic echocardiography, and myocardial perfusion imaging unless a significant, separately identifiable service was performed. According to CMS policy, when physician interaction is necessary to accomplish the radiographic procedure, an evaluation and management code is not separately reported by the radiologist. To be separately reportable, the E/M service must involve taking a history, performing an exam and making decisions that are distinct from the procedure. Venipuncture and/or phlebotomy is included in intravenous infusion and administration of chemotherapy services unless they are significant, separately identifiable services. CMS has identified procedures that are rarely or never performed in a non-facility setting. CMS policy and the AMA CPT Manual define which Evaluation and service codes can be billed for a specific place of service.

7 Place of Place of Place of Code Definition Code Guideline -Age - Modifier - Modifier Professional, Technical, and Global Professional, Technical, and Global Professional, Technical, and Global Professional, Technical, and Global Quality of Care Quality of Care Place of Restrictions Inpatient Only and Equipment Provided in the Facility Setting Code Definitions Code Guidelines -Age Consistency Distinct Modifiers Non-payable Modifiers Diagnostic Tests and Radiology performed outside the office setting Professional Component when Billed in the Office Setting Clinical Laboratory Technical Component when billed in the Facility Setting E&M billed by Physical or Occupational Therapists Pathology billing for Professional The AMA CPT Manual defines those psychotherapy services that must be performed in an inpatient hospital, partial hospital or residential care facility. CMS has identified a list of procedures that are appropriate for the inpatient setting. According to CMS, medical supplies, surgical supplies and durable medical equipment can be billed by the physician in the office setting. However, these services should not be billed by the physician for the outpatient or inpatient setting, because the facility would be responsible for providing and billing the supply in these settings. According to the AMA CPT Manual, a comprehensive code should not be unbundled into its component parts. According to the AMA CPT Manual, it is inappropriate to use a subcutaneous or intramuscular injection code for the administration of vaccines and toxoids. The AMA CPT manual has assigned specific procedure codes for preventive services based on particular age ranges. The AMA CPT Manual and CMS HCPCS Manual have descriptions of modifiers indicating the intended use of the modifier. Modifiers should be appropriate for the service codes to which they are appended. According to CMS policy, procedure codes with modifier GY are "statutory exclusions" or "categorical exclusions" or "technical denials." It is not appropriate for a provider to bill the global or technical only component in an inpatient or outpatient place of service as the technical component should be billed by the facility where the procedure was done. Only the professional component is covered when a diagnostic test or radiologic service is performed in an inpatient or outpatient facility. The interpretation of an x-ray is included in an office evaluation and management service when additional radiology review is performed by a radiologist. According to the CMS Physician Fee Schedule, certain laboratory services do not have a professional component and are therefore not separately payable. It is not appropriate for a provider to bill the technical component of a procedure performed in the inpatient or outpatient place of service. The technical component should be billed by the facility where the procedure was performed. According to CMS policy, codes are not to be paid to physical therapists or occupational therapists in independent practice. Pathologists can only bill for services that have a professional component.

8 Only Quality of Care Split Surgical Care Quality of Care Billing and Modifier Reimbursement for Split Surgical Care According to CMS Policy, chiropractic manipulative treatment services ( ) are allowed for the specialty of Chiropractic medicine where one is trained and skilled in performing these services. According to CMS guidelines, care split between providers should be billed using the procedure code with modifiers 54 (Surgical care only), 55 (Post-operative care only), and 56 (Pre-operative care only) appended to them. It is assumed that a procedure code without one of these modifiers represents the entire service from pre-operative care to post-operative care. s billed with modifier 54 or modifier 55 will be reimbursed at a reduced percentage of the global amount. Empire HealthChoice Assurance Inc. ("Empire") has contracted with the Centers for Medicare and Medicaid (CMS) to offer the Medicare Advantage Private Fee for (PFFS) plans noted above or herein. Empire is the state-licensed, risk-bearing entity offering these plans. Empire has retained the services of its related companies and authorized agents/brokers/producers to provide administrative services and/or to make the PFFS plans available in this region. provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.