After decades of monitoring the annual Medicare therapy caps and temporary exceptions fiascos, I got an early morning call from a Washington DC friend contact that Congress had finally “repealed” the cap on therapy services.

It was well into the early morning hours when the Senate finally voted 71-28 to pass a budget bill known as the Bipartisan Budget Act of 2018 .

I knew word would spread fast and my phone would soon start ringing so I quickly reviewed the bill’s language and found we still had a cap at $2010 but it had been changed back to a “soft” cap and the exception process missing from the previous legislation in January, had now been provided.

Section 50202 – Repeal of Medicare Payment Cap for Therapy Services; Limitation to Ensure Appropriate Therapy – The new law requires for services after December 31, 2017:
* Medicare claims are no longer subject to the therapy caps (one for occupational therapy services and another for physical therapy and speech-language pathology combined);
* Claims for therapy services above $2010, the same amount as the previous therapy caps, must include the KX modifier indicating that such services are medically necessary as justified by appropriate medical record documentation; and
* Claims for therapy services above $3,000 of incurred expenses may be subject to targeted medical review.

So, the threat of a hard cap is gone and Medicare beneficiaries can still obtain necessary therapy services beyond the $2,010 limit as long as you affix the KX modifier to the claim.

Discipline Modifiers:
CMS also implemented a requirement for billing therapy services by ANY PROVIDER. (MM101076) effective 1/1/2018 set an additional billing requirement for any “always therapy” service provided by any provider specialty type. The instruction informed all providers that each code designated as “always therapy” must always be submitted with one of the therapy discipline modifiers GN, GO or GP in addition to any other relevant payment modifier like the KX modifier.

Based on this policy change, even a chiropractor providing an always therapy service must append the appropriate therapy modifier (normally GP) for the service being billed IN ADDITION TO modifier GY to indicate the service is non-covered by Medicare for their provider type.

Many Chiropractic offices are having claims “rejected” by CMS rather than being “denied and forwarded” to the secondary insurance just because they did not append the default GP discipline modifier to the therapy line items.

A rejected claim does NOT PROCESS through the system at all and therefore does not generate a valid denial for purposes of collection from the patient or their secondary coverage carrier. Offices that are not following the new reporting requirements have found themselves in a revolving door of re-submissions.

If, on any claim from any provider, one of the therapy modifiers, GN, GO or GP, is not appended then the claim will reject and not process through the Medicare processing system for denial.

You will need to refile the claim with the appropriate modifiers for it to process for denial.

The last battle: To offset future costs associated with eliminating the hard cap, Congress also enacted a payment differential for PTAs and COTAs like that used for Physician Assistants and Nurse Practitioners, which means therapist assistants will be reimbursed 85% of the amount PTs and OTs receive for the same services.

This reduction is set to go into effect on January 1, 2022 and will have more impact on “facilities and rehab agencies” than the Part “B” office setting where direct supervision of an enrolled PT or OT is required.

Baring any legislative actions to the contrary, we should be firmly set on the issues of caps and exceptions until the end of 2027.

References: CR10001 – Medicare Claims Processing Manual – Pub 100-04 Chapter 12, Sections 50 and 140.   https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

Effective May 15, 2017 CMS revises their manual to bring it in line with current payment policy for moderate sedation and other anesthesia services in light of the CPT changes for January 1, 2017.

Anesthesia services range in complexity from least to the most complex as follows:

  • local or topical anesthesia,
  • moderate (conscious) sedation,
  • regional anesthesia and
  • general anesthesia.

General Payment Rule:

The fee schedule amount for physician anesthesia services furnished is typically based on the allowable base and time units multiplied by an anesthesia conversion factor specific to the geographic locality and communicated to the MACs by means of the annual updates to the Healthcare Common Procedure Coding System (HCPCS) file. The base units and conversion factor are available at https://www.cms.gov/Center/Provider-Type/Anesthesiologists-Center.html

Moderate sedation is a drug induced depression of consciousness during which the patient responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation but does not include minimal sedation, deep sedation or monitored anesthesia care.  Practitioners are instructed to report the appropriate CPT and/or HCPCS code that accurately describes the moderate sedation services performed during a patient encounter, which are performed in conjunction with and in support of a procedural service, consistent with CPT™[1] guidance.

CPT codes 99143-99150 previously used for reporting moderate sedation were deleted from CPT 2017™ and replaced with;

NEW

99151

 

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age

99152     initial 15 minutes of intraservice time, patient age 5 years or older
 

 

99153

 

each additional 15 minutes intraservice time (List separately in addition to    code for primary service)   [Regardless of age of patient.]

99155 Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age
99156     initial 15 minutes of intraservice time, patient age 5 years or older
99157     each additional 15 minutes intraservice time (List separately in addition to code for primary service)

 

According to the AMA guidelines,

Preservice activities required for moderate sedation are included in the work described by each code 99151-99157 and are not reported separately.

Intraservice time:

  • is used to determine the appropriate CPT code to report moderate sedation services:
  • Begins at the administration of the sedating agent(s);
  • Ends when the procedure is completed, the patient is stable for recovery status, and the physician or other qualified healthcare professional providing the sedation and personal continuous face-to-face time with the patient;
  • Includes ordering and/or administering the initial and subsequent doses of sedating agents;
  • Requires continuous face-to-face attendance of the physician or other qualified healthcare professional;
  • Requires monitoring patient response to the sedating agents, including:
    • Periodic assessment of the patient;
    • Further administration of agent(s) as needed to maintain sedation; and
    • Monitoring of oxygen saturation, heart rate, and blood pressure

Intraservice time of less than 10 minutes should NOT be reported.

If the physician or other qualified healthcare professional who provides the sedation services also performs the procedure supported by sedation (99151, 99152, 99153), the physician or other qualified healthcare professional will supervise and direct an independent trained observer who will assist in monitoring the patient’s level of consciousness and physiological status throughout the procedure.

An independent trained observer is defined as an individual who is qualified to monitor the patient during the procedure and who has no other duties during the procedure.

Postservice Work

The postservice activities required for moderate sedation are included in the work described by each code 99151-99157 and are not reported separately.

If the physician performing the medical or surgical procedure also provides a level of anesthesia lower in intensity than moderate or conscious sedation, such as a local or topical anesthesia, then the conscious sedation code should not be reported and no payment should be allowed by the A/B MAC (B). There is no CPT code for the performance of local anesthesia and as payment for this service is considered in the payment for the underlying medical or surgical service.

[1] CPT is a registered trademark of the American Medical Association, used with permission.

Touchscreen TechnologyFor CY 2017, the CPT Editorial Panel will deleted four CPT codes (97001, 97002, 97003, and 97004) and create eight new CPT codes (97X61-97X68) to describe the evaluation procedures furnished by physical therapists and occupational therapists. There are three new codes, stratified by complexity, to replace a single code, 97001, for physical therapy (PT) evaluation, three new codes, also stratified by complexity, to replace a single code, 97003, for occupational therapy (OT) evaluation, and one new code each to replace the reevaluation codes for physical and occupational therapy – 97002 and 97004.

Here is an advanced look at the requirements……

New CPT Code/  CPT Long Descriptors for Physical Medicine and Rehabilitation
97X61 Physical therapy evaluation: low complexity, requiring these components:
● A history with no personal factors and/or comorbidities that impact the plan of care;
● An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
● A clinical presentation with stable and/or uncomplicated characteristics; and
● Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 20 minutes are spent face-to-face with the patient and/or family.

97X62 Physical therapy evaluation: moderate complexity, requiring these components:
● A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care;
● An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following body structures and functions, activity limitations, and/or participation restrictions;
● An evolving clinical presentation with changing characteristics; and
● Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 30 minutes are spent face-to-face with the patient and/or family

97X63 Physical therapy evaluation: high complexity, requiring these components:
● A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
● A clinical presentation with unstable and unpredictable characteristics; and
Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 45 minutes are spent face-to-face with the patient and/or family.

97X64 Reevaluation of physical therapy established plan of care, requiring these components:
● An examination including a review of history and use of standardized tests and measures is required;
and
● Revised plan of care using a standardized patient assessment instrument and/or measurable assessment
of functional outcome
Typically, 20 minutes are spent face-to-face with the patient and/or family.

97X65 Occupational therapy evaluation, low complexity, requiring these components:
● An occupational profile and medical and therapy history, which includes a brief history including
review of medical and/or therapy records relating to the presenting problem;
● An assessment(s) that identifies 1-3 performance deficits (ie, relating to physical, cognitive, or
psychosocial skills) that result in activity limitations and/or participation restrictions; and
● Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component.
Typically, 30 minutes are spent face-to-face with the patient and/or family.

97X66 Occupational therapy evaluation, moderate complexity, requiring these components:
● An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance;
● An assessment(s) that identifies 3-5 performance deficits (ie, relating to physical, cognitive, or
psychosocial skills) that result in activity limitations and/or participation restrictions; and
● Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.
Typically, 45 minutes are spent face-to-face with the patient and/or family.

97X67 Occupational therapy evaluation, high complexity, requiring these components:
● An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance;
● An assessment(s) that identify 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
● A clinical decision-making is of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.
Typically, 60 minutes are spent face-to-face with the patient and/or family.

97X68 Reevaluation of occupational therapy established plan of care, requiring these components:
● An assessment of changes in patient functional or medical status with revised plan of care;
● An update to the initial occupational profile to reflect changes in condition or environment that affect
future interventions and/or goals; and
● A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required.
Typically, 30 minutes are spent face-to-face with the patient and/or family

The changes are shown in CMS proposed plan for 2017.

Combo-Logo-21-150x150

By R.L. Ramsdell, PhD, FACFEI, DABFE, CFC, LFMAAMA.  Executive Director. 

Physical medicine and rehabilitative services are designed to improve, restore, or compensate for loss of physical functioning following disease, injury or loss of a body part which makes them an ideal ancillary inclusion for pain management and rehabilitation practices.  Clinicians use the clinical history, systems review, physical examination, and a variety of evaluations to determine the impairments, functional limitations, and disabilities of the individual patient and then address them through design and implementation of a plan of care tailored to the specific needs of the individual patient.  The services are not only beneficial for the patient but are a good source of revenue for the practice.  Therapy service income often out performs other clinical services on a consistent basis.

Unfortunately many multidisciplinary consultants are apparently uninformed on Medicare “requirements” on who can actually “perform” the therapy services and often misrepresent permissible delegation and the actual supervision requirements over unlicensed individuals in the non-facility (Doctor’s office) setting.

Practitioners are learning the rules the hard way as whistle blower, disgruntled employees and competitor reports prompt on site audits and recoveries in the hundreds of thousands of dollars.

The premise for therapy is based on patients who must have a potential for restoration or improvement of lost functions and require the services of a skilled therapist.  Rehabilitation services are typically short term, intensive and have clear goals for services employed to restore and maintain a level of function. Naturally Medicare patients are often subjected to illnesses and conditions effectively treated with physical therapy rehabilitation efforts.

Under Medicare policies, intervention with PM&R modalities and procedures is indicated when:

  • an assessment by a physician, NPP or therapist supports utilization of the intervention,
    there is documentation of objective physical and functional limitations (signs and symptoms), and
  • the written plan of care incorporates those treatment elements that require services of a skilled therapist for a reasonable and generally predictable period of time.

Skilled therapist, for Medicare reimbursement privileges means that the covered therapy services are “personally performed ONLY by one of the following;

  • Licensed therapy professionals: licensed physical therapists and occupational therapists
  • Licensed PTA with appropriate supervision by a licensed physical therapist.
  • Licensed occupational therapy assistants (OTA) with appropriate supervision by a licensed occupational therapist.
  • Medical Doctors (MDs) and Doctors of Osteopathy (DOs).
  • Doctors of Optometry (ODs) and Podiatric Medicine (DPMs) when performing services within their licenses’ scope of practice and their training and competency.
  • Qualified NPPs, including Advanced Nurse Practitioners (ANPs), Physician Assistants (PAs) or Clinical Nurse Specialists (CNS) when performing services within their licenses’ scope of practice and their training and competency (ANP, PA, CNS).
  • “Qualified” personnel when appropriately supervised by a physician (MD, DO, OD, DPM) or qualified NPP, and when all conditions of billing services “incident to” a physician have been met.Qualified personnel providing physical therapy (PT) or occupational therapy (OT) services “incident to” the services of a physician/NPP must have met the educational and degree requirements of a licensed therapy professional (PT, OT) from an accredited PT/OT curriculum, but are not required to be licensed.

There always seems to be some “consultants” who spend more time advising their clients on possible ways to “beat the system” than educating them on how to do things properly and avoid potential conflicts with regulations.

The basic facts are that reimbursement for services performed have a calculated component based on the amount of “professional” time required to render the service to the patient.  You may have noticed this “little requirement” in the description of various “time based” therapy codes where the language clearly states “one-on-one patient contact by provider”.

In my opinion, it is completely illogical for any provider to expect a carrier to pay for professional time when the services were provided by “trained aides” who lack the comprehensive training necessary to exercise professional judgment over the therapy or procedure.  The Federal programs for example, draw fairly clear lines on who is and who is not qualified to receive reimbursement for “professional time” by reviewing Medicare regulations 230.1(C) and 230.2(C) which clearly state;

Services provided by aides, even if under the supervision of a therapist, are not therapy services in the outpatient setting and are not covered by Medicare. Although an aide may help the therapist by providing unskilled services, those services that are unskilled are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services.

Services of athletic trainers, massage therapists, recreation therapists, kinesio-therapists, low vision specialists or any other profession may not be billed as therapy services.      (This includes services performed by Chiropractors since they are statutorily excluded  for payment for any service performed other than spinal manipulation by CMT.- DrR)

In short, Medicare will not pay for the services of a “qualified provider” unless the services are performed by a “qualified provider”.  Learn the difference and apply the principles.

QUALIFIED PROFESSIONAL means a physical therapist, occupational therapist, speech-language pathologist, physician, nurse practitioner, clinical nurse specialist, or physician’s assistant, who is licensed or certified by the state to perform therapy services, and who also may appropriately perform therapy services under Medicare policies.

  • Qualified professionals may also include physical therapist assistants (PTA) and occupational therapy assistants (OTA) when working under the supervision of a qualified therapist, within the scope of practice allowed by state law……..o    Assistants may not supervise others.

QUALIFIED PERSONNEL means staff (auxiliary personnel) who may or may not be licensed as therapists but who meet all of the requirements for therapists with the exception of a license. Qualified personnel must have been educated and trained as therapists to qualify for furnishing therapy services under direct supervision and incident to a physician or NPP.

PTAs, even if licensed, may NOT perform “incident to” a physician or NPP, since they do not meet the definition of a therapist.

Aides are “everyone other” than those described above.  Med Techs, Chiropractic Assistants, Exercise Physiologists, Athletic trainers, massage therapists, LVNs, LPNs or any individual with a certificate of anything are NOT eligible to perform PT/OT for Medicare reimbursement.

So next time, your so called consultant wants you to bill the services of a med tech under your provider number, remember;

Fraud, as defined by Federal Regulation (42CFR455.2) , is an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in the payment of unauthorized benefits. A scheme does not have to be successful to be considered fraudulent.
Abuse involves actions that are inconsistent with sound medical, business, or fiscal practices. Abuse, directly or indirectly, results in higher costs to the healthcare program through improper payments that are not medically necessary. (under the carrier’s published policy).

The only difference between fraud and abuse is a person’s intent. That is, did they know they were committing a crime?

In either case, the key component is that the perpetrator knew or should have known that the act was improper.  

There are many “restrictions” providing PT / OT –  Don’t hesitate to contact us with questions.

MAAMA SmallMerit-based Payment System (MIPS) 

Writing for the Academy is Dr R.L. Ramsdell, PhD – Executive Director. 

The Centers for Medicare & Medicaid Services (CMS) has added another 900+ page volume to our regulation reading pleasure outlining the proposed details on how physicians will be paid under Medicare in 2019. As I stated, this is a proposal open for public comments, submitted electronically or on paper, until 5 p.m. on June 27, 2016.

There are actually two programs here, the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM) incentive regulation. According to CMS, the MIPS will consolidate components of three existing programs: the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for eligible professionals (EPs). The proposed rule also would establish incentives for participation in certain alternative payment models (APMs) to help advance the Obama Administration’s 2015 goals to move 30% of traditional Medicare fee-for-service payments into alternative payment models that pay providers based on the quality rather than the quantity of care they provide by 2016 and 50% by 2018.

The current proposal is a result of the 2015 law called the Medicare Access and CHIP Reauthorization Act (MACRA), which, after decades of “temporary fixes”, finally abolished the idiotic and unsustainable -sustainable growth rate (SGR) formula for physician compensation. MACRA, as it is now known, gradually shifts reimbursement from fee-for-service to pay-for-performance or value based payment.

Under MACRA, physicians choose between two payment models with MIPS being the default model which will encompass the majority of physicians. MIPS reportedly will incorporate and align three existing Medicare incentive programs:

• meaningful use of electronic health records,
• the Physician Quality Reporting System, and
• the Value-Based Payment Modifier.

Medicare will increase or decrease a physician’s fee-for-service reimbursement in MIPS according to his or her quality of care, cost (resource use), clinical practice improvement, and meaningful use of electronic health records (advancing care information).

Our understanding in reading the proposed regulation is MIPS will be based on a “point score” system for the first year where the quality-of-care component constitutes 50% of the MIPS score; cost 10%; clinical practice improvement 15%; and advancing care information (meaningful use of electronic health records) 25%.

MIPS bonuses and penalties up to 4% each debut in 2019 and increase to

  • 5% in 2020,
  • 7% in 2021, and
  • 9% in 2022 and beyond.

The bonuses and penalties are based on performance 2 years earlier, meaning pay hikes and pay cuts in 2019 will reflect what a clinician did in 2017.

Let’s look briefly at the “scoring” components.

Quality (50 percent of total score in year 1): For this category, clinicians would choose to report six measures from among a range of options that accommodate differences among specialties and practices.

Advancing Care Information (25 percent of total score in year 1): Medicare incorporated EHR and meaningful use into this new catchy term late last year) For this category, clinicians would choose to report customizable measures that reflect how they use technology in their day-to-day practice, with a particular emphasis on interoperability and information exchange. Unlike the existing reporting program, this category would not require all-or-nothing EHR measurement or redundant quality reporting.

Clinical Practice Improvement Activities (15 percent of total score in year 1): This category would reward clinical practice improvements, such as activities focused on care coordination, beneficiary engagement, and patient safety. Clinicians may select activities that match their practices’ goals from a list of more than 90 options.

Cost (10 percent of total score in year 1): For this category, the score would be based on Medicare claims, meaning no reporting requirements for clinicians. This category would use 40 episode-specific measures to account for differences among specialties.

Advanced Alternative Payment Models

Under provisions originally created by the Affordable Care Act, many clinicians are currently participating in alternative payment models but may not meet requirements for sufficient participation in the most advanced models under the new regulations. The proposed rule appears to be designed to provide these clinicians with financial rewards within MIPS. Further it appears that those clinicians who can participate to a sufficient extent in Advanced Alternative Payment Models – would be exempt from MIPS reporting requirements and qualify for financial bonuses under the new models.

These models include the new Comprehensive Primary Care Plus (CPC+) model, the Next Generation ACO model, and other Alternative Payment Models under which clinicians accept both risk and reward for providing coordinated, high-quality care.

Let’s look at these as they are presented by CMS in the proposal.

The Comprehensive Primary Care Plus (CPC+) model
On April 11, CMS announced its largest-ever initiative to transform how primary care is delivered and paid for in America. The initiative, called The Comprehensive Primary Care Plus (CPC+) model, is a national advanced primary care medical home model which will be implemented in up to 20 regions to accommodate up to 5,000 practices.
According to CMS, the initiative is designed to provide doctors the freedom to care for their patients the way they think will deliver the best outcomes and to be paid for achieving results and improving care.

• The CPC+ model incorporates lessons learned from the 5 year CPC initiative model tested through the Center for Medicare & Medicaid Innovation that began October 2012 and runs through December 31, 2016. Under this initiative model, CMS collaborated with 38 commercial and state health insurance plans across seven U.S. regions to support 500 primary care practices in testing aligned payment for the delivery of a single model of comprehensive primary care.

o In addition to regular fee-for-service payments, Medicare and other CPC payers provide a non-visit-based care management fee paid per member per month and an opportunity to share in savings generated in each of the CPC regions. This care management fee has provided CPC practices with the necessary financial resources to create new workflows, hire care management staff, and develop new relationships necessary to coordinate care.

• Center for Medicare and Medicaid Innovation (Innovation Center), was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). Congress created the Innovation Center to test innovative payment and service delivery models, including primary care payment and care delivery reform, to reduce CMS program expenditures and improve quality for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries.

Primary care practices will participate in one of two tracks. While both tracks will be required to meet the criteria of the model, those in Track 2, will actually provide more comprehensive services for patients with complex medical and behavioral health needs.

CPC+ is reportedly designed to help practices move away from one-size-fits-all, Fee-For-Service (FFS) health care to a new system that will give doctors the freedom to deliver the care that best meets the needs of their patients.

In Track 1, CMS will pay practices a monthly care management fee in addition to the FFS payments under the Medicare Physician Fee Schedule for activities

In Track 2, practices will also receive a monthly care management fee and, instead of full Medicare FFS payments for Evaluation and Management services, will receive a hybrid of reduced Medicare FFS payments and up-front comprehensive primary care payments for those services

o CMS has a fact sheet on fees and payments available at:  https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-04-11.html

CMS states “to promote high-quality and high-value care, practices in both tracks will receive up-front incentive payments that they will either keep or repay based on their performance on quality and utilization metrics. Practices in both tracks also will receive data on cost and utilization.”

CPC+ will bring together CMS, commercial insurance plans, and State Medicaid agencies to provide the financial support necessary for practices to make fundamental changes in their care delivery and select regions for CPC+ where there is sufficient interest from multiple payers to support practices’ participation in the initiative. CMS will enter into a Memorandum of Understanding with selected payer partners to document a shared commitment to align on payment, data sharing, and quality metrics in CPC+. CMS will accept payer proposals to partner in CPC+ from April 15 through June 1, 2016. CMS will accept practice applications in the determined regions from July 15 through September 1, 2016.

For additional information on the “specifics” of the CPC+ program, we refer the reader to;
https://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Plus

The Next Generation ACO Model is a new CMS Innovation Center initiative that builds upon experience from the Pioneer ACO Model and the Shared Savings Program. With 21 participating ACOs, the new model offers a new opportunity in accountable care—one that enables providers and beneficiaries greater opportunities to coordinate care and aims to attain the highest quality standards of care. Unlike other models, this model includes a prospectively (rather than retrospectively) set benchmark, allows beneficiaries to choose to be aligned to the ACO, and tests beneficiary incentives for seeking care at Next Generation providers, including increased availability of telehealth and care coordination services.

The Next Generation Model participants will have the opportunity to take on higher levels of financial risk – up to 100 percent risk – than ACOs in current initiatives. While they are at greater financial risk they also have a greater opportunity to share in more of the Model’s savings through better care coordination and care management. In addition, the ACOs will receive their budgets prospectively, in advance of the performance year, to plan and manage care around these financial targets from the outset. The ACOs will also be able to select from flexible payment options, such as infrastructure payments that support ACO investments in care.

There are 18 ACOs currently participating in the Next Generation ACO Model in 14 States.

For more information on the Next Generation ACO Model, including the list of provider participants, and how to apply for 2017, we refer the reader to:
https://innovation.cms.gov/initiatives/Next-Generation-ACO-Model/

Deadline for submission of your letter of intent (LOI) has been extended to May 20, 2016. The actual application must be received by May 25th.

The Next Generation ACO Model is an initiative designed for ACOs that are very experienced in coordinating care for large populations of patients.

The Academy does NOT recommend this for our member practices.

Under the current proposal, as we understand it, we would suggest our members choose the MIPS program and strive to fully participate in that to receive their financial incentive bonuses.

CMS MAC NOVITAS Published LCD L34816 for Arkansas, Louisiana, Mississippi, Colorado, Texas, Oklahoma, New Mexico and revised for the states of Pennsylvania, New Jersey, Maryland, Delaware and District of Columbia to update the reference to L27480 to L34816 to reflect a maximum of  twelve (12) chiropractic manipulation treatments per calendar month  and thirty (30) chiropractic manipulation treatments per calendar year.

This LCD imposes both diagnostic limitations and total service limitations to chiropractic care.  This is the “first” such restrictions placed on Chiropractic care and to our knowledge, J10 MAC B (Alabama, Georgia, Tennessee) is the only other policy with annual service restriction

L32342 limits utilization to 25 visits per year without assignment to the groups.   (This policy, as are many other carrier policies on Chiropractic are will be reviewed in 2014

CMS look 

LCD TitleChiropractic Services Original Effective DateFor services performed on or after 07/24/2014
 Utilization Guidelines
The following number of chiropractic manipulation services per beneficiary is considered reasonable and necessary if the medical record supports the service regardless of the nature of the visit (i.e., acute injury, acute exacerbation).

Twelve (12) chiropractic manipulation treatments per calendar month. And, Thirty (30) chiropractic manipulation treatments per calendar year.

This LCD imposes diagnosis limitations that support diagnosis to procedure code automatic denials. Coverage diagnoses are displayed in four groups in this policy as described in the indications and limitations section of this policy. If 30 visits are performed for group D, then this will also serve as the maximum number of visits for the year.

Local Coverage Article: Chiropractic Services (A47798)

Chiropractic services are subject to national regulation, which provides definitions, indications and limitations for Medicare payment of chiropractic service. Please see Medicare Benefit Manual sections referenced above for national definitions, indications and limitations.

Medicare expects that acute symptoms/signs due to subluxation or acute exacerbation/recurrence of symptoms/signs due to subluxation might be treated vigorously. Improvement in the patient’s symptoms is expected and in order for payment for chiropractic services to continue, should be demonstrated within a time frame consistent with the patient’s clinical presentation. Failure of the patient’s symptoms to improve accordingly or sustained worsening of symptoms should prompt referral of the patient for evaluation and/or treatment by an appropriate practitioner.

This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. Medicare will allow up to 12 chiropractic manipulations per calendar month and 30 chiropractic manipulation services per beneficiary per calendar year. Despite allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment, and Medicare does not expect that patients will routinely require the maximum allowable number of services. Additionally, Medicare requires the medical necessity for each service to be clearly demonstrated in the patient’s medical record.

Covered diagnoses are displayed in four groups in this policy, with the groups being displayed in ascending specificity. Medicare does not expect that substantially more than the following numbers of treatments will usually be required:

  • Twelve (12) chiropractic manipulation treatments for Group A diagnoses. 
  • Eighteen (18) chiropractic manipulation treatments for Group B diagnoses. 
  • Twenty-four (24) chiropractic manipulation treatments for Group C diagnoses. 
  • Thirty (30) chiropractic manipulation treatments for Group D diagnoses.

 As per the definitions supplied in LCD L34816, all treatments must be categorized as either acute subluxation, chronic subluxation or maintenance therapy. An exacerbation of a previous injury should be categorized into either “acute” or “chronic” (e.g., an identifiable re-injury would fall under acute).

 Group 1 Codes

  • 98940    Chiropract manj 1-2 regions
  • 98941    Chiropract manj 3-4 regions
  • 98942    Chiropractic manj 5 regions

 

Group 1 : The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 98940, 98941 and 98942:

Primary Diagnosis Codes   (DrR=These are always your primary diagnoses)

Covered for: Group 1 Codes

  • 739.0     NONALLOPATHIC LESIONS OF HEAD REGION NOT ELSEWHERE CLASSIFIED
  • 739.1     NONALLOPATHIC LESIONS OF CERVICAL REGION NOT ELSEWHERE CLASSIFIED
  • 739.2     NONALLOPATHIC LESIONS OF THORACIC REGION NOT ELSEWHERE CLASSIFIED
  • 739.3     NONALLOPATHIC LESIONS OF LUMBAR REGION NOT ELSEWHERE CLASSIFIED
  • 739.4     NONALLOPATHIC LESIONS OF SACRAL REGION NOT ELSEWHERE CLASSIFIED
  • 739.5     NONALLOPATHIC LESIONS OF PELVIC REGION NOT ELSEWHERE CLASSIFIED

Group 2 Secondary Diagnosis Codes 

Group A Diagnoses Covered for: (Twelve (12) chiropractic manipulation treatments)

Group 2 Codes

  • 307.81   TENSION HEADACHE
  • 719.48*PAIN IN JOINT INVOLVING OTHER SPECIFIED SITES
  • 723.1     CERVICALGIA
  • 724.1     PAIN IN THORACIC SPINE
  • 724.2     LUMBAGO
  • 724.5     BACKACHE UNSPECIFIED
  • 724.8     OTHER SYMPTOMS REFERABLE TO BACK
  • 728.85   SPASM OF MUSCLE
  • 784.0     HEADACHE
  • When using 719.48, you must specify spine as the site.

Group 3 : Group B Diagnoses Covered for:  Eighteen (18) chiropractic manipulation treatments
Group 3 Codes

  • 720.1     SPINAL ENTHESOPATHY
  • 721.0     CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY
  • 721.1     CERVICAL SPONDYLOSIS WITH MYELOPATHY
  • 721.2     THORACIC SPONDYLOSIS WITHOUT MYELOPATHY
  • 721.6     ANKYLOSING VERTEBRAL HYPEROSTOSIS
  • 721.90   SPONDYLOSIS OF UNSPECIFIED SITE WITHOUT MYELOPATHY
  • 721.91   SPONDYLOSIS OF UNSPECIFIED SITE WITH MYELOPATHY
  • 724.79   OTHER DISORDERS OF COCCYX
  • 729.1     MYALGIA AND MYOSITIS UNSPECIFIED
  • 729.4     FASCIITIS UNSPECIFIED
  • 846.0     LUMBOSACRAL (JOINT) (LIGAMENT) SPRAIN
  • 846.1     SACROILIAC (LIGAMENT) SPRAIN
  • 846.2     SACROSPINATUS (LIGAMENT) SPRAIN
  • 846.3     SACROTUBEROUS (LIGAMENT) SPRAIN
  • 846.8     OTHER SPECIFIED SITES OF SACROILIAC REGION SPRAIN
  • 847.0     NECK SPRAIN
  • 847.1     THORACIC SPRAIN
  • 847.2     LUMBAR SPRAIN
  • 847.3     SPRAIN OF SACRUM
  • 847.4     SPRAIN OF COCCYX

Group 4: Group C Diagnoses Covered for: Twenty-four (24) chiropractic manipulation treatments
Group 4 Codes

  • 353.0     BRACHIAL PLEXUS LESIONS
  • 353.1     LUMBOSACRAL PLEXUS LESIONS
  • 353.2     CERVICAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED
  • 353.3     THORACIC ROOT LESIONS NOT ELSEWHERE CLASSIFIED
  • 353.4     LUMBOSACRAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED
  • 353.8     OTHER NERVE ROOT AND PLEXUS DISORDERS
  • 722.91   OTHER AND UNSPECIFIED DISC DISORDER OF CERVICAL REGION
  • 722.92   OTHER AND UNSPECIFIED DISC DISORDER OF THORACIC REGION
  • 722.93   OTHER AND UNSPECIFIED DISC DISORDER OF LUMBAR REGION
  • 723.0     SPINAL STENOSIS IN CERVICAL REGION
  • 723.2     CERVICOCRANIAL SYNDROME
  • 723.3     CERVICOBRACHIAL SYNDROME (DIFFUSE)
  • 723.4     BRACHIAL NEURITIS OR RADICULITIS NOS
  • 723.5     TORTICOLLIS UNSPECIFIED

 Group 5 : Group D Diagnoses Covered for: Thirty (30) chiropractic manipulation treatments

Group 5 Codes

  • 721.3     LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY
  • 721.41   SPONDYLOSIS WITH MYELOPATHY THORACIC REGION
  • 721.42   SPONDYLOSIS WITH MYELOPATHY LUMBAR REGION
  • 721.7     TRAUMATIC SPONDYLOPATHY
  • 722.0     DISPLACEMENT OF CERVICAL INTERVERTEBRAL DISC WITHOUT MYELOPATHY
  • 722.10   DISPLACEMENT OF LUMBAR INTERVERTEBRAL DISC WITHOUT MYELOPATHY
  • 722.11   DISPLACEMENT OF THORACIC INTERVERTEBRAL DISC WITHOUT MYELOPATHY
  • 722.4     DEGENERATION OF CERVICAL INTERVERTEBRAL DISC
  • 722.51   DEGENERATION OF THORACIC OR THORACOLUMBAR INTERVERTEBRAL DISC
  • 722.52   DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC
  • 722.6     DEGENERATION OF INTERVERTEBRAL DISC SITE UNSPECIFIED
  • 722.81   POSTLAMINECTOMY SYNDROME OF CERVICAL REGION
  • 722.82   POSTLAMINECTOMY SYNDROME OF THORACIC REGION
  • 722.83   POSTLAMINECTOMY SYNDROME OF LUMBAR REGION
  • 724.01   SPINAL STENOSIS OF THORACIC REGION
  • 724.02   SPINAL STENOSIS, LUMBAR REGION, WITHOUT NEUROGENIC CLAUDICATION
  • 724.03   SPINAL STENOSIS, LUMBAR REGION, WITH NEUROGENIC CLAUDICATION
  • 724.3     SCIATICA
  • 724.4     THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED
  • 724.6     DISORDERS OF SACRUM
  • 738.4     ACQUIRED SPONDYLOLISTHESIS
  • 756.11   CONGENITAL SPONDYLOLYSIS LUMBOSACRAL REGION
  • 756.12   SPONDYLOLISTHESIS CONGENITAL
  • 839.01   CLOSED DISLOCATION FIRST CERVICAL VERTEBRA
  • 839.02   CLOSED DISLOCATION SECOND CERVICAL VERTEBRA
  • 839.03   CLOSED DISLOCATION THIRD CERVICAL VERTEBRA
  • 839.04   CLOSED DISLOCATION FOURTH CERVICAL VERTEBRA
  • 839.05   CLOSED DISLOCATION FIFTH CERVICAL VERTEBRA
  • 839.06   CLOSED DISLOCATION SIXTH CERVICAL VERTEBRA
  • 839.07   CLOSED DISLOCATION SEVENTH CERVICAL VERTEBRA
  • 839.08   CLOSED DISLOCATION MULTIPLE CERVICAL VERTEBRAE
  • 839.20   CLOSED DISLOCATION LUMBAR VERTEBRA
  • 839.21   CLOSED DISLOCATION THORACIC VERTEBRA
  • 839.41   CLOSED DISLOCATION COCCYX
  • 839.42   CLOSED DISLOCATION SACRUM
  • 953.0     INJURY TO CERVICAL NERVE ROOT
  • 953.1     INJURY TO DORSAL NERVE ROOT
  • 953.2     INJURY TO LUMBAR NERVE ROOT
  • 953.3     INJURY TO SACRAL NERVE ROOT
  • 953.4     INJURY TO BRACHIAL PLEXUS
  • 953.5     INJURY TO LUMBOSACRAL PLEXUS
  • 953.8     INJURY TO MULTIPLE SITES OF NERVE ROOTS AND SPINAL PLEXUS

 Notify your billing people and managers that they will see the following denials on your RA/EOBs.

These are the Edits and suggested MSN and RA messages.

Do not pay for manual manipulation of the spine in treating conditions other than those indicated in Pub. 100-02, Benefits Policy Manual, Chapter 15, Section 240.1.3 and deny claims for treatment of any condition not reasonably related to a subluxation involving vertebrae at the spinal level specified. Use the MSN 15.4, “The information provided does not support the need for this service or item.” For the RA, use the Claim Adjustment Reason Code 50, “These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.”

Edit to verify that the claim has the primary diagnosis of subluxation. Use the MSN 15.4, “The information provided does not support the need for this service or item.” For the RA, use the Claims Adjustment Reason Code B22, “This payment is adjusted based on the diagnosis.”

One other little thing …..  Initial Treatment Date on Chiropractic Claims

Novitas also reminds providers that according to the Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 220 all chiropractic claims must contain the date of initial treatment or date of exacerbation of the existing condition so consistent with Medicare guidelines, Novitas will require that all chiropractic claims contain the initial treatment date or the date of exacerbation of the existing condition effective for dates of service July 24, 2014 and after.

They will edit to verify that the date of the initial visit or the date of exacerbation of the existing condition is entered in Item 14 of Form CMS-1500. Use the MSN 9.2, “This item or service was denied because information required to make payment was missing.” For the RA, use the Claims Adjustment Reason Code 16, “Claim/service lacks information which is needed for adjudication.

blind injectionWhat’s Up With Guidance?

We have been monitoring carrier changes with respect to the use of “guidance” with various injection procedures.  As we look at the 2014 PFS look-up tools we see  that code 76942 (ultrasound guidance for needle placement) has taken a dramatic cut in reimbursement with the Medicare reimbursement for 2014 set around $70.00, down from around $200.00 in 2013.

This code has been a target of Medicare for quite a while having been deemed both over valued and over used by practitioners.  The first step against the code was to assign it to those codes subject to the multiple procedure payment reduction list.  This reduced the payment to practitioners to 100% of the first procedure and only 50% on subsequent procedures.

Next, Medicare and others declared “injection guidance” procedures were limited to one (1) per day regardless of the number of injection type procedures performed.  Now, they have retained that position for now but reduced the value of the code.

There is no AMA CPT coding restriction to reporting CPT code 76942 (Ultrasonic guidance for needle placement [eg, biopsy, aspiration, injection, localization device], imaging supervision and interpretation) when ultrasound guidance is medically necessary to accurately place the needle for the injection. Carriers however, feel in most cases, imaging guidance to penetrate an easily palpable joint seems neither reasonable nor necessary.

CPT code 76942 has both professional and technical components, meaning that a separate radiology report (not part of the procedure note) is required to meet the code’s radiology requirements. The specific documentation requirements for ultrasound guidance include the following:

  • A final, written report should be issued for inclusion in the patient’s medical record.
  • Ultrasound guidance procedures also require permanently recorded images of the site to be localized, as well as a documented description of the localization process, either separately or within the report of the procedure for which the guidance is utilized.
  • Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, is not separately reportable.

 

Other carriers are mounting challenges based on the “performing provider” charging that “interpretation” of the imaging is outside the scope of NPPs.

Although reporting code 76942 with the joint injection code 20610 is permissible, many payers are denying this service as not medically necessary. For example, under the Florida First Coast Medicare local coverage determination (LCD) 29307, “Imaging procedures performed routinely for the purpose of visualization of the knee to provide guidance for needle placement will not be covered. Fluoroscopy may be medically necessary and allowed if documentation supports that the presentation of the patient’s affected knee on the day of the procedure makes needle insertion problematic. No other imaging modality for the purpose of needle guidance and placement will be covered.”

Other Medicare carriers, such as National Government Services, have initiated payment recovery for CPT code 76942 on the basis of lack of medical necessity as well as recouping amounts paid for multiple procedures when only one unit was payable.  We have seen similar actions by other carriers.

On the flip side, code 77002 for fluoroscopic guidance has been increased from around $74 to $96 for this fee schedule BUT we now seeing various restricting tactics on these procedures by NPP’s as well.

Carriers such as NGS also challenged fluoroscopic guidance when performed by nonphysician practitioners.  In specific NGS invoked “in compliance with State laws” as part of their recovery tactics. We joined others in challenging this since it is NOT true in all States within their jurisdiction.

When questioned they did post the “specifics” for J6 Part B for the States of Illinois, Minnesota and Wisconsin…….and we published their answers in our MedCorp Alert.

“We have finally received specific answers from NGS on covered nonphysician practitioner radiology services within the J6 Part B for the states of Illinois, Minnesota, and Wisconsin.

Which nonphysician practitioners may use fluoroscopy or ionizing radiation?

  • Certified Registered Nurse Anesthetist (Specialty 43) –  NO in all three states.
  • Certified Nurse Midwife (Specialty 42 NO in all three states
  • Clinical Nurse Specialist (Specialty 89)-   NO in all three states.
  • Nurse Practitioner (Specialty 50)-    Illinois and Minnesota:  NO
    • Wisconsin:  YES, according to Wisconsin Administrative Code § DHS 157.03 and 157.76
  • Physician Assistant (Specialty 97)-    Illinois:  NO
    • Minnesota:  YES, according to Minnesota Rules 2007, Chapter 4732
    • Wisconsin:  YES, according to Wisconsin Administrative Code § DHS 157.03 and 157.76

Which nonphysician practitioners may provide supervision of radiology procedures?

Supervision of others by NPPs is NOT permitted in Illinois, Minnesota, or Wisconsin or under Medicare.

 Which nonphysician practitioners may bill for the technical component?

  • Certified Registered Nurse Anesthetist (Specialty 43) NO in all three states.
  • Certified Nurse Midwife (Specialty 42) NO in all three states.
  • Clinical Nurse Specialist (Specialty 89) NO in all three states.
  • Nurse Practitioner (Specialty 50)NO in Illinois and Minnesota.
  • o          Wisconsin:  YES, only if personally performed
  • Physician Assistant (Specialty 97)  NO in Illinois
  • o          Minnesota and Wisconsin:  YES, only if personally performed.

Which nonphysician practitioners may bill for the professional component?

 

  • All three States permit the professional component by Certified Registered Nurse Anesthetist (Specialty 43); Certified Nurse Midwife (Specialty 42);Clinical Nurse Specialist (Specialty 89); Nurse Practitioner (Specialty 50) and PA (Specialty 97)

Which NPPs may bill for global if the technical component is personally performed?

  • Certified Registered Nurse Anesthetist (CRNA) (Specialty 43) NO in all three states.
  • Certified Nurse Midwife (Specialty 42) NO in all three states
  • Clinical Nurse Specialist (Specialty 89) NO in Illinois and Minnesota.
    • Wisconsin:  YES
  • Nurse Practitioner (Specialty 50);  NO in Illinois and Minnesota:
    • Wisconsin:  YES
  • Physician Assistant (Specialty 97)  NO in  Illinois
    • Minnesota and Wisconsin:  YES

 

While we have some “permissions” in some instances, CMS still essentially prohibits NPP performance under their required physician supervision level for the technical component of Fluoroscopic guidance codes as being level “03” which requires procedure must be performed under the personal supervision of a physician.”   This applies to

  • 77001-TC Fluoroguide for vein device;
  • 77002-TC Needle localization by xray –
  • 77003-TC Fluoroguide for spine inject

and would naturally extend to the procedures such as the 6449x facet joint injections that “require” either Fluroscopic or CT guidance.

 To “double check” the “actual enforcement” of these levels, I contacted the specific contacts in CMS for these issues.   Our exchange is below….

Dear Mr. Chan:

I am writing in regards to the reclassification of CPT codes 77001-77003  technical component of fluoroscopic guidance to “3” requiring personal supervision of the physician.  This would appear to again preclude the use of NP/PA “personal performance” and/or the use of certified radiology technicians who have previously been permitted to operate the C-Arms under the general supervision of the physician.

Can you please provide us with the “specifics” on the fluoroscopic guidance procedures (who can and who can’t perform) so we can provide the proper guidance to our members as they call us with these questions.  We are already getting quite a few calls based on the various June 2014 Medicare Advisory publication which is considerably lacking in details on this matter.

 

Dear Dr. Ramsdell,

 Thank you for your email and your voice message concerning the technical component for CPT codes 77001 – 77003.  In our April 2014 update to the Physician Fee Schedule, we corrected an inadvertent technical error to the files as displayed for January 1, 2014.  In the January files, a “09” code (“Concept does not apply”) was inadvertently entered into the Physician Supervision of Diagnostic Procedures indicator for CPT codes 77001 – 77003.  Previously the indicator for these codes was “03” (“Procedure must be performed under the personal supervision of a Physician”).  The April update corrected the data file to reflect the established policies.  Please see section 100.1.5, from Chapter 12 of the internet only claims manual (available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/internet_only_manuals.pdf), and 42 CFR 410.32(b)(1) for specific guidance regarding physician supervision.

 I hope this clarifies any confusion.

Larry Chan

 [RLR]Thank you for your reply.  So if I am interpreting this correctly, the “physician” must be in the room when either a mid-level or a rad-tech operates the fluoroscope for guidance of the injection?   This is the question we keep getting hit with and keep trying to get the specific yes or no on.   We understand that the mid-level can not supervise the rad-tech.

{LC} You are correct.  The supervision for the TC of these CPT code is “03” (“Procedure must be performed under the personal supervision of a Physician”).  The Physician is to be present in the room with the tech.

These positions make it virtually impossible for a mid-level to perform injections that require guidance including those procedures where “fluoroscopic / CT guidance” is required and if the physician is required to be in the room, the economics would appear to be logically for him/her to perform the injection procedure in its entirety.

We would like your comments on this AND your assistance by writing or contacting HHS/CMS and your local Medical Association.

CMS lookNational CERT data showed projected rises in improper payments for outpatient E&M services for 2013 with CPT codes 99205 and 99215 being in the top 15 codes identified for improper payment. Previous review of high level outpatient E&M services resulted in high error rates because services were frequently billed at a higher level than could be supported for medical necessity by the medical record.

Audit Results: The overall percentage of services recoded or denied for CPT 99205 was 78.66%. The overall percentage of services recoded or denied for CPT 99215 was 78.50%. The key reasons services were denied are as follows:

  • Failure to respond to the request for documentation
  • Documentation was missing a provider signature
  • Insufficient or missing documentation
  • The medical record did not support the coverage requirements forservices of nonphysician personnel furnished incident to physician’s services billing
  • Documentation did not support a separately identifiable E&M service performed in addition to procedure billed for the same date of service (inappropriate use of modifier 25)

The key reasons services were recoded to a lower level E&M service are as follows:

  • The medical record failed to support the medical necessity of the highest level of outpatient E&M service
  • For new patient E&M service CPT 99205, all 3 key components (comprehensive history, comprehensive examination, and high complexity medical decision making) were not supported at the level billed
  • The provider selected the level of E&M using time as the controlling factor, but the medical record failed to differentiate physician time devoted to face-to-face counseling with the beneficiary from the time dedicated to history and physical examination; or the record failed to provide sufficient detail about the coordination of care or counseling provided to justify the level of E&M billed

The majority of the services billed as CPT 99205 were recoded one or two levels, and the majority of the services for CPT 99215 were recoded one level. Based on the results of this widespread audit, prepayment review of CPT 99205 and CPT 99215 will resume for Part B claims in Illinois, Minnesota and Wisconsin beginning June 2014.

You should always insure that  your written policies identify the level of supervision required in the Medicare fee schedule for specific tests AND your State regulations on performance so you are consistently in compliance. While Medicare may permit a service under “general supervision” of a physician, your State regulations may require specific certifications to operate the testing equipment. We see this frequently with the technical components for radiation regulations and neuro testing procedures.
That being said, general Medicare regulations require all diagnostic x-ray and other diagnostic tests to be furnished under at least a general level of physician supervision with some tests more restricted and require either direct or personal supervision.

General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually perform the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician. (Supervision Indicator 1)

Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. (Supervision Indicator 2)

Personal supervision means a physician must be in attendance in the room during the performance of the procedure. (Supervision Indicator 3)
Indicators 

  • 1    Procedure must be performed under the general supervision of a physician.
  • 2    Procedure must be performed under the direct supervision of a physician.
  • 3    Procedure must be performed under the personal supervision of a physician.
  • 6    Procedure must be performed by a physician or by a physical therapist (PT) who is certified by the American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysiologic clinical specialist and is permitted to provide the procedure under State law.
  • 6a    Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may supervise another PT but only the PT with ABPTS certification may bill.
  • 7a    Supervision standards for level 77 apply; in addition, the PT with ABPTS certification may supervise another PT but only the PT with ABPTS certification may bill.
  • 9    Concept does not apply.
  • 21    Procedure must be performed by a technician with certification under general supervision of a physician; otherwise must be performed under direct supervision of a physician.
  • 22    Procedure may be performed by a technician with on-line real-time contact with physician.
  • 66    Procedure must be performed by a physician or by a PT with ABPTS certification and certification in this specific procedure.
  • 77    Procedure must be performed by a PT with ABPTS certification or by a PT without certification under direct supervision of a physician, or by a technician with certification under general supervision of a physician.