Wisconsin Medical Journal
107 #7
107 #7
Questions and Answers—Medicare Spring Update 2007
Question:
Do Ambulatory Surgery Centers have a way of reporting under PQRI?
Answer: At this time, there are no specific measures for ASC facilities under the PQRI.
Question:
When reporting 8 DX on a claim, does the system read all 8 DX or does the system only read the ones linked?
Answer:
Always link (point) to the primary diagnosis, the system has edits and audits to indicate when it should review all 8 of the DX codes.
Question:
If you start reporting quality measures for PQRI after July are you still eligible for the 1.5% or does bonus payment percent get reduced?
Answer:
Data from the entire period still must meet 80%. If you don’t begin reporting until October, the 80% of eligible reporting opportunities will still be measured from July 1, 2007.
Question:
CERT - Is it possible to set a single person for CERT letters versus the physician?
Answer:
Yes. CMS has allowed the function to the CERT contractor’s website. The CERT Website that providers can use to update contact information for CERT medical records requests is http://www.certcdc.com/certproviderportal/
If there are any other issues, providers can contact the CERT Documentation Contractor customer service line at 301-957-2380.
Question:
Which WPS processes use calendar days versus working days?
Answer:
Reconsideration – 60 calendar days
Contact Us Response – 45 business days
Claims Processing (electronic submission) – 14 calendar days
Claims Processing (paper submission) – 29 calendar days
Written Letter – 45 business days
Question:
Where is the current list of Medicare HMOs?
Answer:
http://www.cms.hhs.gov/HealthPlansGenInfo/Downloads/claims_processing_20060120.pdf
Question:
Is there an edit to allow lab payment TC component to an outsourced hospital lab?
Answer:
We will need the individual procedure code to look up. Edits and Audits are based on procedure codes and there is no way to generalize this across the board.
Question:
When will the mass adjustment for the unilateral mammogram fee correction be made?
Answer:
From the information that I have the mass adjustment has been completed.
Question:
Anticoagulation Management follow-up
Answer:
The following was printed in the June, 2006 Communique on page 14. An Evaluation and Management (E/M) visit is not routinely necessary in order to draw blood for prothrombin time (CPT code 85610). Therefore, an E/M code should not be billed along with CPT code 85610 when the sole purpose of the visit is to obtain a blood draw for analysis. CPT 99211 is used to report a low level E/M service. If this E/M code is billed along with CPT code (85610), the medical record must demonstrate that the E/M service was performed and was medically necessary. For these exceptional occurrences that do require an E/M service along with a prothrombin time laboratory draw, the medical report should identify significant new symptoms for which the patient needed to be seen. If the patient has no new symptoms, then the relevance of why the E/M service was required must be documented.
Resource: E & M Provider Education; WPS Medicare Part B Publication. March 2005; pp. 118-119.
Question:
For therapy - is there a different time frame for ending therapy w/o improvement?
Answer:
We do not have an established guideline for this. The therapist and referring provider should work together to see if there is a reasonable expectation of improvement. In the 30-day review, this is something for the providers to discuss and decide on.
Question:
List of April updates to ICD-9 codes?
Answer:
I can not locate these other than the publication for the “updateable” ICD-9 books. Unfortunately, I do not have an “updateable” book and do not have a list of these.
Question:
ABN - How specific does the wording need to be?
Answer:
Medicare Claims Processing Manual 100-4, Chapter 30, Section 40.3.1.2 states, “An ABN must:
Be written in lay language;
Cite the particular items or services for which payment will be or is likely to be denied;
Cite the notifier’s reasons for believing Medicare payment will be or is likely to be denied. (See §40.3.8);
Be delivered by a qualified notifier to the beneficiary (or to the beneficiary’s authorized representative), before those items or services were furnished; and
Be received by, and its contents must be comprehended by, the beneficiary (or authorized representative)."
This chapter covers in depth the ABN requirements.
Question:
24J - Does this field need to be completed for a facility or for a provider?
Answer:
No need to complete for a facility claim.
Question:
If a patient has had a mastectomy and comes in with the intent of a screening mammorgram, should we be using the screening CPT and Dx or the diagnostic? Would it be appropriate to use a 52 modifier if using the screening?
Answer:
What is the intent of the visit? If the intent is for a screening bill, then bill for a screening CPT and DX. It is appropriate and WPS Medicare system will accept the Modifier 52.
Question:
The first one is regarding a consult in the hospital in the global period following surgery (perhaps an infection, etc). Can we bill with a modifier and which one or is all the care global?
Answer:
If this is the same physician, modifier 24 would be used to indicate this is an unrelated service. Although I would be hesitant to report these as consultations. If another physician in a separate specialty performs the consultation, there would be no need for a modifier. You would want to be sure there is an unrelated diagnosis associated with this claim.
Question:
We are getting denied now for Medicare as a secondary insurance if we send by paper. How can we send electronic and don't they need the EOB's from the primary insurance?
Answer
The following Website article will help you submit electronic secondary claims: http://www.wpsmedicare.com/provider/x12n837_for_msp.shtml.
If you have further questions contact WPS Medicare Electronic Date Interchange Department at (877) 567-7261.
Question:
Lastly, we have two offices. The main is our practicing and billing. Then we have a satellite office that we put in box 32, but billing is still done in primary office. We also have a therapy office at another location, but again the billing is at our main office. All are billed under one tax ID. Do we need separate NPI's or is the one we have sufficient?
Answer:
If the main office does all of the HIPAA standard transactions, and the other offices are not legal entities, and the other offices do not supply Durable Medical Equipment; you are able to have NPI. If you make a business decision to get more then one you are eligible to do so.
From the situation described above it appears you will only need one NPI.
Do Ambulatory Surgery Centers have a way of reporting under PQRI?
Answer: At this time, there are no specific measures for ASC facilities under the PQRI.
Question:
When reporting 8 DX on a claim, does the system read all 8 DX or does the system only read the ones linked?
Answer:
Always link (point) to the primary diagnosis, the system has edits and audits to indicate when it should review all 8 of the DX codes.
Question:
If you start reporting quality measures for PQRI after July are you still eligible for the 1.5% or does bonus payment percent get reduced?
Answer:
Data from the entire period still must meet 80%. If you don’t begin reporting until October, the 80% of eligible reporting opportunities will still be measured from July 1, 2007.
Question:
CERT - Is it possible to set a single person for CERT letters versus the physician?
Answer:
Yes. CMS has allowed the function to the CERT contractor’s website. The CERT Website that providers can use to update contact information for CERT medical records requests is http://www.certcdc.com/certproviderportal/
If there are any other issues, providers can contact the CERT Documentation Contractor customer service line at 301-957-2380.
Question:
Which WPS processes use calendar days versus working days?
Answer:
Reconsideration – 60 calendar days
Contact Us Response – 45 business days
Claims Processing (electronic submission) – 14 calendar days
Claims Processing (paper submission) – 29 calendar days
Written Letter – 45 business days
Question:
Where is the current list of Medicare HMOs?
Answer:
http://www.cms.hhs.gov/HealthPlansGenInfo/Downloads/claims_processing_20060120.pdf
Question:
Is there an edit to allow lab payment TC component to an outsourced hospital lab?
Answer:
We will need the individual procedure code to look up. Edits and Audits are based on procedure codes and there is no way to generalize this across the board.
Question:
When will the mass adjustment for the unilateral mammogram fee correction be made?
Answer:
From the information that I have the mass adjustment has been completed.
Question:
Anticoagulation Management follow-up
Answer:
The following was printed in the June, 2006 Communique on page 14. An Evaluation and Management (E/M) visit is not routinely necessary in order to draw blood for prothrombin time (CPT code 85610). Therefore, an E/M code should not be billed along with CPT code 85610 when the sole purpose of the visit is to obtain a blood draw for analysis. CPT 99211 is used to report a low level E/M service. If this E/M code is billed along with CPT code (85610), the medical record must demonstrate that the E/M service was performed and was medically necessary. For these exceptional occurrences that do require an E/M service along with a prothrombin time laboratory draw, the medical report should identify significant new symptoms for which the patient needed to be seen. If the patient has no new symptoms, then the relevance of why the E/M service was required must be documented.
Resource: E & M Provider Education; WPS Medicare Part B Publication. March 2005; pp. 118-119.
Question:
For therapy - is there a different time frame for ending therapy w/o improvement?
Answer:
We do not have an established guideline for this. The therapist and referring provider should work together to see if there is a reasonable expectation of improvement. In the 30-day review, this is something for the providers to discuss and decide on.
Question:
List of April updates to ICD-9 codes?
Answer:
I can not locate these other than the publication for the “updateable” ICD-9 books. Unfortunately, I do not have an “updateable” book and do not have a list of these.
Question:
ABN - How specific does the wording need to be?
Answer:
Medicare Claims Processing Manual 100-4, Chapter 30, Section 40.3.1.2 states, “An ABN must:
Be written in lay language;
Cite the particular items or services for which payment will be or is likely to be denied;
Cite the notifier’s reasons for believing Medicare payment will be or is likely to be denied. (See §40.3.8);
Be delivered by a qualified notifier to the beneficiary (or to the beneficiary’s authorized representative), before those items or services were furnished; and
Be received by, and its contents must be comprehended by, the beneficiary (or authorized representative)."
This chapter covers in depth the ABN requirements.
Question:
24J - Does this field need to be completed for a facility or for a provider?
Answer:
No need to complete for a facility claim.
Question:
If a patient has had a mastectomy and comes in with the intent of a screening mammorgram, should we be using the screening CPT and Dx or the diagnostic? Would it be appropriate to use a 52 modifier if using the screening?
Answer:
What is the intent of the visit? If the intent is for a screening bill, then bill for a screening CPT and DX. It is appropriate and WPS Medicare system will accept the Modifier 52.
Question:
The first one is regarding a consult in the hospital in the global period following surgery (perhaps an infection, etc). Can we bill with a modifier and which one or is all the care global?
Answer:
If this is the same physician, modifier 24 would be used to indicate this is an unrelated service. Although I would be hesitant to report these as consultations. If another physician in a separate specialty performs the consultation, there would be no need for a modifier. You would want to be sure there is an unrelated diagnosis associated with this claim.
Question:
We are getting denied now for Medicare as a secondary insurance if we send by paper. How can we send electronic and don't they need the EOB's from the primary insurance?
Answer
The following Website article will help you submit electronic secondary claims: http://www.wpsmedicare.com/provider/x12n837_for_msp.shtml.
If you have further questions contact WPS Medicare Electronic Date Interchange Department at (877) 567-7261.
Question:
Lastly, we have two offices. The main is our practicing and billing. Then we have a satellite office that we put in box 32, but billing is still done in primary office. We also have a therapy office at another location, but again the billing is at our main office. All are billed under one tax ID. Do we need separate NPI's or is the one we have sufficient?
Answer:
If the main office does all of the HIPAA standard transactions, and the other offices are not legal entities, and the other offices do not supply Durable Medical Equipment; you are able to have NPI. If you make a business decision to get more then one you are eligible to do so.
From the situation described above it appears you will only need one NPI.
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