Therapy Claims for 2018 and beyond for Medicare.

Posted on April 20, 2018 by kellyausiello

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exceptions fiascos, I got an early morning call from a Washington DC friend contact that Congress had finally “repealed” the cap on therapy services.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.

Moderate Sedation – 2017

Posted on April 27, 2017April 27, 2017 by kellyausiello

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.

2017 CPT will expand Therapy Evaluation Codes.

Posted on July 8, 2016 by kellyausiello

For 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.

Medicare Audits Result In Large Paybacks on Therapy Services.

Posted on June 19, 2016 by kellyausiello

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.

Modifier 59 Subsets, “CMS separates the separate and distinct modifier”

Posted on May 18, 2015 by kellyausiello

Modifier “59” “Distinct Procedural Service” is probably one of our most widely used and most frequently abused coding modifiers.

The modifier was created to identify a wide variety of circumstances and exceptions that qualify additional services for separate payment such as different encounters; different anatomic sites; or distinct additional services by bypassing the established NCCI edits so the additional work of both the primary and the additional procedures will be paid.

NCCI edits are in place to prevent unbundling of services where one code is considered to be a subset of the work of another code billed on the same claim. This sets the column 1/ column 2 scenario of the NCCI where edits define when two codes should not be reported together and also assigns a “Correct Coding Modifier Indicator” (CCMI) for exceptions.

A CCMI of “0” indicates that the codes never be reported together by the same provider for the same beneficiary on the same date of service. They are considered mutually exclusive and therefore the column 1 code would be eligible for payment but the column 2 code is not.

A CCMI of “1” however indicates that the codes “may be reported together” only when the defined circumstances are such that what would be normally considered an overlapping service was actually separate and distinct and independent of the other services performed.

Most carriers increase scrutiny of the modifier in “manual reviews” since the use of the modifier will typically bypass the automated “front end” edits by the claims processing software. The modifier has long been identified as one of considerable abuse and since it is “very broad” in its application, manual reviews of its use frequently result in denials and even allegations against the provider of fraud and abuse.

CMS has established four new HCPCS modifiers (referred to collectively as -X{EPSU} modifiers) to identify specific circumstances as subset replacements of the -59 modifier.

XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter

Patients returning for a separate encounter on the same DOS are rare in the office setting. This would be used for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are performed during different patient encounters on the same day and that cannot be described by one of the more specific NCCI-associated modifiers – i.e., 24, 25, 27, 57, 58, 78, 79, or 91.

XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ or Structure,

One of the common uses of modifier 59 is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are performed at different anatomic sites, are not ordinarily performed or encountered on the same day, and that cannot be described by one of the more specific anatomic NCCI-associated modifiers – i.e., RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, or RI.

XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner

XU Unusual Non-Overlapping Service, A Service That Is Distinct Because It Does Not Overlap Usual Components of The Main Service.

CMS originally set an “effective date” of January 1, 2015 however they have also declared that the modifiers are valid even before national edits are in place.

MACs are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier, when necessitated by local program integrity and compliance needs. In short, that means that while CMS will continue to recognize the -59 modifier in many instances, the MAC may selectively require a more specific – X{EPSU} modifier for billing certain codes at high risk for incorrect billing. Check your MAC’s policies frequently.

You should also check your major medical carriers for changes to the more descriptive modifiers. United Health care published in their network bulletin in January, 2015 that they were following the CMS lead and would accept either but NOT BOTH on the same line item.

In the CMS release they stated: “The combination of alternative specific modifiers with a general less specific modifier creates additional discrimination in both reporting and editing. As a default, at this time CMS will initially accept either a -59 modifier or a more selective – X{EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged.”

If the carrier accepts the new subsets, you may find them beneficial on your multiple injections or to establish that a therapy such as 97140 was administered to a separate anatomical region.

You should use one or the other. You should NOT report both the 59 and one of the X* modifiers on the same line item.

The CR (CR8863) to the Carriers is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1422OTN.pdf

Fingerprint-based Background Check for CMS Enrollment

Posted on August 20, 2014August 20, 2014 by kellyausiello

Fingerprint-based Background Check for CMS Enrollment Effective August 6, 2014.

The implementation of fingerprint-based background checks as part of enhanced enrollment screening provisions contained in Section 640 of the Affordable Care Act has begun.

Fingerprint-based background checks will now be required for all individuals with a 5 percent or greater ownership interest in a provider or supplier that falls into the high risk category and is currently enrolled in Medicare or has submitted an initial enrollment application. The fingerprint-based background check requirement will be conducted in phases. In the first phase, providers or suppliers will receive notification of the fingerprint requirements from their MAC and will have 30 days from the date of the letter to be fingerprinted.

If an initial enrollment application is received by the MAC and the provider or supplier is required to obtain a fingerprint-based background check, the MAC will not begin processing the application until the fingerprint-based background check has been completed and the results are received. The effective date of enrollment will be determined by the date the fingerprint results are received.

Chapter 15, Section 19.2.1 of the “Program Integrity Manual” (PIM) provides the list of the three screening categories, the provider types assigned to each category, a description of the applicable screening processes and the procedures to be used for each category.

CMS awarded the Fingerprint-based Background Check contract to Accurate Biometrics located in Chicago, Illinois on July 8, 2014. Individuals with questions should contact Accurate Biometrics prior to being fingerprinted to ensure the fingerprint results are accurately submitted to the Federal Bureau of Investigation (FBI) and properly returned to CMS.

Accurate Biometrics may be contacted by phone (866-361-9944) or by accessing their website

at www.cmsfingerprinting.com.

Potential High Risk Applicants(DMEPOS, HHA and those with adjusted assignment by CMS to High Risk due to previous problems) can now expect the following agency screening actions;

(1) Verifies that a provider or supplier meets all applicable Federal regulations and State requirements for the provider or supplier type prior to making an enrollment determination.

(2) Conducts license verifications, including licensure verifications across State lines for physicians or nonphysician practitioners and providers and suppliers that obtain or maintain Medicare billing privileges as a result of State licensure, including State licensure in States other than where the provider or supplier is enrolling.

(3) Conducts database checks on a pre- and post-enrollment basis to ensure that providers and suppliers continue to meet the enrollment criteria for their provider/supplier type.

(4) Conducts an on-site visit.

(5) Conducts a fingerprint-based criminal history record check of the Federal Bureau of Investigation’s Integrated Automated Fingerprint Identification System on all individuals who maintain a 5 percent or greater direct or indirect ownership interest in the provider or supplier.

Application Fees = Don’t forget to submit your “fees”.

All providers and suppliers must submit the current application fees when they are;

initially enrolling in Medicare,
adding a practice location, or
revalidating their enrollment information,

Physicians, non-physician practitioners, physician group practices and non-physician group practices are exempt from the application fees UNLESS they are enrolling as a DMEPOS supplier via the CMS-855S.

The fee for January 1, 2014, through December 31, 2014 is $542.00.

42CFR424.518 As of 8/20/2014

Title 42: Public Health
PART 424—CONDITIONS FOR MEDICARE PAYMENT
Subpart P—Requirements for Establishing and Maintaining Medicare Billing Privileges

§424.518 Screening levels for Medicare providers and suppliers.

A Medicare contractor is required to screen all initial applications, including applications for a new practice location, and any applications received in response to a revalidation request based on a CMS assessment of risk and assignment to a level of “limited,” “moderate,” or “high.”

(a) Limited categorical risk—

(1) Limited categorical risk: Provider and supplier categories. CMS has designated the following providers and suppliers as “limited” categorical risk:

(i) Physician or nonphysician practitioners (including nurse practitioners, CRNAs, occupational therapists, speech/language pathologists, and audiologists) and medical groups or clinics.

(ii) Ambulatory surgical centers.

(iii) Competitive Acquisition Program/Part B Vendors.

(iv) End-stage renal disease facilities.

(v) Federally qualified health centers.

(vi) Histocompatibility laboratories.

(vii) Hospitals, including critical access hospitals, Department of Veterans Affairs hospitals, and other federally owned hospital facilities.

(viii) Health programs operated by an Indian Health Program (as defined in section 4(12) of the Indian Health Care Improvement Act) or an urban Indian organization (as defined in section 4(29) of the Indian Health Care Improvement Act) that receives funding from the Indian Health Service pursuant to Title V of the Indian Health Care Improvement Act.

(ix) Mammography screening centers.

(x) Mass immunization roster billers

(xi) Organ procurement organizations.

(xii) Pharmacies newly enrolling or revalidating via the CMS-855B application.

(xiii) Radiation therapy centers.

(xiv) Religious non-medical health care institutions.

(xv) Rural health clinics.

(xvi) Skilled nursing facilities.

(2) Limited screening level: Screening requirements. When CMS designates a provider or supplier as a “limited” categorical level of risk, the Medicare contractor does all of the following:

(i) Verifies that a provider or supplier meets all applicable Federal regulations and State requirements for the provider or supplier type prior to making an enrollment determination.

(ii) Conducts license verifications, including licensure verifications across State lines for physicians or nonphysician practitioners and providers and suppliers that obtain or maintain Medicare billing privileges as a result of State licensure, including State licensure in States other than where the provider or supplier is enrolling.

(iii) Conducts database checks on a pre- and post-enrollment basis to ensure that providers and suppliers continue to meet the enrollment criteria for their provider/supplier type.

(b) Moderate categorical risk—

(1) Moderate categorical risk: Provider and supplier categories. CMS has designated the following providers and suppliers as “moderate” categorical risk:

(i) Ambulance service suppliers.

(ii) Community mental health centers.

(iii) Comprehensive outpatient rehabilitation facilities.

(iv) Hospice organizations.

(v) Independent clinical laboratories.

(vi) Independent diagnostic testing facilities.

(vii) Physical therapists enrolling as individuals or as group practices.

(viii) Portable x-ray suppliers.

(ix) Revalidating home health agencies.

(x) Revalidating DMEPOS suppliers.

(2) Moderate screening level: Screening requirements. When CMS designates a provider or supplier as a “moderate” categorical level of risk, the Medicare contractor does all of the following:

(i) Performs the “limited” screening requirements described in paragraph (a)(2) of this section.

(ii) Conducts an on-site visit.

(c) High categorical risk—

(1) High categorical risk: Provider and supplier categories. CMS has designated the following home health agencies and suppliers of DMEPOS as “high” categorical risk:

(i) Prospective (newly enrolling) home health agencies.

(ii) Prospective (newly enrolling) DMEPOS suppliers.

(2) High screening level: Screening requirements. When CMS designates a provider or supplier as a “high” categorical level of risk, the Medicare contractor does all of the following:

(i) Performs the “limited” and “moderate” screening requirements described in paragraphs (a)(2) and (b)(2) of this section.

(ii)(A) Requires the submission of a set of fingerprints for a national background check from all individuals who maintain a 5 percent or greater direct or indirect ownership interest in the provider or supplier; and

(B) Conducts a fingerprint-based criminal history record check of the Federal Bureau of Investigation’s Integrated Automated Fingerprint Identification System on all individuals who maintain a 5 percent or greater direct or indirect ownership interest in the provider or supplier.

(3) Adjustment in the categorical risk. CMS adjusts the screening level from “limited” or “moderate” to “high” if any of the following occur:

(i) CMS imposes a payment suspension on a provider or supplier at any time in the last 10 years.

(ii) The provider or supplier—

(A) Has been excluded from Medicare by the OIG; or

(B) Had billing privileges revoked by a Medicare contractor within the previous 10 years and is attempting to establish additional Medicare billing privileges by—

(1) Enrolling as a new provider or supplier; or

(2) Billing privileges for a new practice location;

(D) Has been excluded from any Federal health care program; or

(E) Has been subject to any final adverse action, as defined at §424.502, within the previous 10 years.

(iii) CMS lifts a temporary moratorium for a particular provider or supplier type and a provider or supplier that was prevented from enrolling based on the moratorium, applies for enrollment as a Medicare provider or supplier at any time within 6 months from the date the moratorium was lifted.

(d) Fingerprinting requirements.

An individual subject to the fingerprint-based criminal history record check requirement specified in paragraph (c)(2)(ii)(B) of this section—

(1) Must submit a set of fingerprints for a national background check.

(i) Upon submission of a Medicare enrollment application; or

(ii) Within 30 days of a Medicare contractor request.

(2) In the event the individual(s) required to submit fingerprints under paragraph (c)(2) of this section fail to submit such fingerprints in accordance with paragraph (d)(1) of this section, the provider or supplier will have its billing privileges—

(i) Denied under §424.530(a)(1); or

(ii) Revoked under §424.535(a)(1).

Chiropractic Maximum Visits under NOVITAS Part B MAC Mandate.

Posted on July 26, 2014 by kellyausiello

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

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.

Injections under Guidance ?

Posted on June 7, 2014July 12, 2014 by kellyausiello

What’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.