: latest news

There was a MLN Article just released this week regarding a new HCPCS code that CMS is implementing for reporting administrations for the H1N1 vaccine for its beneficiaries. This code will need to be added to the CDM soon.



Here is the information you will need to set up the charge in the CDM:



Code: G9141 (for all other payers continue to charge CPT code 90471)

Description: H1N1 immunization admin

Revenue code: 771

Estimated payment: $24.89

Per the instruction in the link provided, it appears that the vaccine will be issued to providers at no cost; therefore there will not be a separate charge for the vaccine. Also, there is no copay or deductible associated with the administration. Please review the article with applicable staff.

http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0920.pdf

Effective October 1, 2008 CMS will publish most of the edits utilized in the Medically Unlikely Edit (MUE) program. The October 1, 2008, version of MUE will contain edits for about 9,700 HCPCS/CPT codes that have been assigned unit values for MUEs. Keep in mind that CMS will not publish all MUEs on October 1, 2008. The listing can be found at the following website:
http://www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage.

By 2010, CMS will have expanded the Recovery Audit Contractor (RAC) audits nationally. The audits will cover a look back period of three years and up to the date of the claim submission.

HMI Corporation is offering the following services to hospitals to help identify and reduce potential risk and to address RAC notification of improper payments. The Revenue Recovery Contractor Preaudit and the Revenue Recovery Contractor Reviews and Appeals services encompass specific approaches to assisting hospitals in managing their internal RAC processes. Our services also identify opportunities to make process improvements and further educate the staff in the health information management, business office, and compliance/audit departments.

RAC Reviews and Appeals

This service provides hospitals assistance in reviewing the results of the RAC’s audit to determine if the hospital should actively pursue a rebuttal in the event the RAC has issued an improper payment letter. The service includes:

 Review of the RAC’s audit report and supporting Medicare coding and billing criteria cited,
 Review of the patient medical record and corresponding billing document, and
 Assist in preparing the rebuttal statement that will be used by the hospital to appeal the overpayment identified.

RAC Preaudit Reviews

This service assists hospitals in reviewing billed inpatient and/or outpatient services to identify potential risk and improve processes to reduce future occurrences. The service includes:

 Review of the patient medical records and corresponding billing documents to assess documentation,
 Validation of coding and billing, and
 Verification of medically necessary services.


With both services, HMI also provides the designated staff with an overview of the findings and recommendations for improvements and provide coding and billing guidance to support the recommended changes.

To learn more about these services or request information, please contact (800) 659-5145 to speak with a corporate development representative.

CMS transmittal 1490 updates Chapter 12, §§30.6.15.1 and 30.6.15.2. Several code changes, code deletions, and typical/average time units have changed in the American Medical Association Current Procedural Terminology (CPT) coding system since the manual section was first written. Physician visits for counseling and/or coordination of care are based on typical/average time units necessitating a section explaining current Medicare policy. The time approximation must meet or exceed the typical/average time of a specific code and shall not be "rounded" to the next higher level. Prolonged services may only be reported with the highest code level in a code family for counseling and/or coordination of care services based on time. The tables for threshold times are corrected and updated.

The Prolonged Services definition and required evaluation and management companion codes are explained. The explanations are in keeping with current Medicare payment policy for physician presence, supporting documentation and in recognition of code changes that have occurred since last revised. The tables for threshold times are corrected and updated to reflect code changes and current typical/average time units associated with the CPT levels of care in code families. A new subsection (30.6.15.1 (H) is added to explain how to report physician visits for counseling and/or coordination of care when the visit is based on time, and when the counseling and/or coordination service is prolonged. The time approximation must meet or exceed the typical/average time of a specific CPT code billed and shall not be “rounded” to the next higher level. Prolonged Services may only be reported with the highest code level in a code family for counseling and/or coordination based on time.

CMS has provided with this transmittal an updated time table as well as examples of code usage. To view the entire transmittal go to http://www.cms.hhs.gov/transmittals/downloads/R1490CP.pdf

Section 911 of the Medicare Prescription Drug Improvement and Modernization Act of 2003 mandated that CMS replace the many fiscal intermediaries (FI) and carriers currently administering the Medicare Part A and Part B fee-for-service programs with Medicare administrative contractors (MAC). CMS expects to have all 15 A/B MACs fully operational by late 2009.

This transition is difficult to analyze and prepare for, to be certain. But it is fairly safe to assume that the process will mean processing headaches and reimbursement issues occurring as a result of changes to edits and local coverage determinations (LCD).

Watch out for LCD changes

Although hospitals and physicians will submit both Part A and Part B claims to the MAC, the claims adjudication process is separate, very similar to the currently FI and carrier claims processing system.

LCD’s could change though, so it will be very important to be aware of these adjustments. As the MACs begin operating in their jurisdictions, each contractor will combine all the LCDs for its jurisdiction by selecting the least restrictive LCD from the existing policies.

According to the patient accounts manager at one hospital undergoing the MAC transition, the facility experienced an issue with new service exclusions that weren’t excluded under old LCD policies. There have also been instances in which the MAC set up edits improperly, so it is very important that medical necessity denials are monitored closely to ensure the denial is appropriate.

If facilities aren’t carefully watching rejected/denied claims, legitimate reimbursement could be forfeited.

Tips for a Smooth Transition

Once your facility knows which MAC it will work with, check out the MACs website and review its specific coding guidance.

One area of particular interest is coding guidance for drug administration services. Historically, FI’s have provided advice for proper documentation, but MAC’s may have their own policies about these services.

Delays in reimbursement are likely during this transitional period, as staff should be expected to devote more time and energy into monitoring claims, and getting them out the door.

If your facility has the resources, it could prove beneficial to increase staffing in the following areas:

CMS is replacing the Physician Voluntary Reporting Program (PVRP) with the Physician Quality Reporting Initiative (PQRI). PQRI will involve all emergency care providers, including physician assistants and nurse practitioners. The program is voluntary for 2007; but in 2008 financial penalties may be imposed on providers who either do not participate or do not meet the reporting thresholds. However, incentives are expected to be increased for those providers who do comply with the new program. CMS strongly encourages providers to begin participating in PQRI while the program is still voluntary in order to gain experience with reporting clinical quality data to CMS.



Currently, PQRI includes 74 quality measures into the program. Ten of these measures directly relate to emergency medicine and were developed in conjunction with ACEP and other professional medical organizations. These 10 measures are:



Aspirin on arrival for AMI
Beta blocker on arrival for AMI
ECG performed for non-traumatic chest pain
ECG performed for syncope
Vital signs for CAP
Assessment of oxygen saturation for CAP
Assessment of mental status for CAP
Empiric antibiotic for CAP
t-PA considered in ischemic stroke
Dysphagia screening in acute stroke


Both PQRI and PVRP are provider-focused programs established by CMS to further the ideal of practicing quality, evidence-based medicine with the goal of improved patient outcomes. The PQRI program will most likely expand over the next several years, adding new measures as they are identified and approved by various quality care organizations. The program may also impose financial penalties on providers who are found to deliver sub-optimal care. The purpose of the PQRI program is to positively affect efforts in achieving high-quality, safe, efficient and cost-effective patient care, which are the goals of all who practice emergency medicine.



For detailed information about the PQRI program and its measures, please visit the CMS website at click here.

In 2004, the final rule establishing the NPI (National Provider Identifier) as the standard unique health provider identifier was published. The rule requires all entities to be in compliance with its provisions by May 23, 2007. Small health plans are granted an extension of this deadline until May 23, 2008. The NPI replaces all "legacy" identifiers that are currently in use, such as Medicaid provider IDs, UPINs, etc., and will be required for use on health care claims and other HIPAA transactions.

CMS' decision to announce this clarification to its enforcement approach was prompted as it became apparent that many covered entities would not be able to completely comply with the NPI regulations by May 23, 2007. CMS has clarified that covered entities will be protected from enforcement action if they continue to act in good faith to come into compliance. Entities must also show evidence of development and implementation of contingency plans to enable them and their trading partners to continue to move toward compliance with the NPI regulations. Contingency plans may not extend beyond May 23, 2008, but entities may elect to end their own contingency plans earlier.

Less than a month after CMS released Transmittal 187, the agency retracted it with little explanation. The Transmittal outlined the newest changes to compliance standards for Independent Diagnostic Testing Facilities which were to go into effect January 26, 2007. An agency spokesperson offered the following explanation: "We received a number of comments on the policy that we felt needed further consideration." It is unknown when new enrollment and licensing requirements will be put in place.

Emergency Department Visits

• Postponing finalization of the proposed G-codes for Type A (continue to use 99281-99285)



• CMS has defined an Emergency Department that is not open 24 hours per day for 7 days per week, and has EMTALA responsibility, as a Type B Emergency Department (i.e., Urgent Care Center). Type A Emergency Departments are open 24 hours per day and 7 days per week. G-codes for Type B Emergency Department are as follows:


G0380 – Lev 1 hosp type B ED visit
G0381 – Lev 2 hosp type B ED visit
G0382 – Lev 3 hosp type B ED visit
G0383 – Lev 4 hosp type B ED visit
G0384 – Lev 5 hosp type B ED visit


• Type B visits will be paid at the same rate as clinic visits (e.g., 99201-99205, 99211-99215). CMS will track the utilization of the G codes reported and update future payments as necessary to ensure that facilities are adequately reimbursed.



• Hospitals will continue to report 99291 and 99292 for Critical Care Services.

Device Dependent Codes
The list of device-dependent code edits will be updated, effective January 1, 2007. The following edits are being added:

CPT Code - Short Description - Device
19296 - Place po breast cath for rad - C1728
19297 - Place breast cath for rad - C1728
36566 - Insert tunneled cv cath - C1881
65770 - Revise cornea with implant - C1818, L8609

CMS has recently released the 2007 and 2008 DRG proposed changes. Please clink on the following link to view these documents 2007 and 2008 DRG Proposals.

2006 Proposed Changes to HOPPS

There are 427 proposed changes to the 2006 HOPPS APC status indicators. To view the entire list of proposed changes, please click here.

The Centers for Medicare and Medicaid Services (CMS) is proposing additional edits for PPS hospitals to bill for supplies with device codes that begin with HCPCS Level II codes that begin with “C”.
Additional edits have been proposed for implementation in July and October 2005. The edits will require certain procedure CPT codes to also list specific device codes or the procedure will not be paid. The devices are assigned a Status Indicator of “N”. This means they are not paid separately.

Device Code Edits Being Implemented April 1, 2005:

CPT - Short Description - HCPCS Code for Device Required on the Claim
36557 - Insert tunneled CV Cath - C1751
36558 - Insert tunneled CV Cath - C1751
36570 - Insert tunneled CV Cath - C1751 and/or C1788
36571 - Insert tunneled CV Cath - C1751and/or C1788
36581 - Replace tunneled CV Cath - C1751
36585 - Replace tunneled CV Cath - C1751 and/or
C1788 - Insertion catheter, artery - C1751
61885 - Implant Neurostim one array - C1767
35458 - Repair arterial blockage - C1885and/or C1725
35459 - Repair arterial blockage - C1885 and/or C1725
35460 - Repair venous blockage - C1885 and/or C1725
35470 - Repair arterial blockage - C1885 C1725
35471 - Repair arterial blockage - C1885 and/or C1725
35472 - Repair arterial blockage - C1885 and/or C1725
35473 - Repair arterial blockage - C1885 and/or C1725
35474 - Repair arterial blockage - C1885 and/or C1725
35475 - Repair arterial blockage - C1885 and/or C1725
35476 - Repair venous blockage - C1885 and/or C1725
35484 - Atherectomy, open - C1714 and/or C1724
35485 - Atherectomy, open - C1714 and/or C1724
35490 - Atherectomy, Percutaneous - C1714 and/or C1724
35491 - Atherectomy, Percutaneous - C1714 and/or C1724
35492 - Atherectomy, Percutaneous - C1714 and/or C1724
35493 - Atherectomy, Percutaneous – and/or C1714 and/or C1724
35494 - Atherectomy, Percutaneous - C1714 and/or C1724
35495 - Atherectomy, Percutaneous - C1714 and/or C1724
61626 - Transcath occlusion, Non-CNS - C2628 and/or C1887
92997 - Pul art balloon repr, percut - C1885 and/or C1725
92998 - Pul art balloon repr, percut - C1885 and/or C1725
92995 - Coronary Atherectomy - C1714 and/or C1724
92996 - Coronary Atherectomy add-on - C1714 and/or C1724
92982 - Coronary artery dilation - C1725 and/or C1885
92984 - Coronary artery dilation - C1725 and/or C1885
93600 - Bundle of His recording - C1730, C1731, C1733, C1766, C1892, C1893, C1732, C1894 (at least one)
93602 - Intra-atrial recording - C1730, C1731, C1733, C1766, C1892, C1893,C1732, C1894 (at least one)
93603 - Right ventricular recording - C1730, C1731, C1733, C1766, C1892, C1893, C1732, C1894 (at least one)
93609 - Map tachycardia, add-on - C1730, C1731, C1733 (at least one)
93610 - Intra-atrial pacing - C1730, C1731, C1733, C1766, C1892, C1893, C1732, C1894 (at least one)
93612 - Intraventricular pacing - C1730, C1731, C1733, C1766, C1892, C1893,C1732, C1894 (at least one)
93613 - Electrophys map 3d, add-on - C1732
93615 - Esophageal recording - C1730, C1731, C1733, C1766, C1892, C1893, C1732, C1894 (at least one)
93616 - Esophageal recording - C1730, C1731, C1733, C1766, C1892, C1893, C1732, C1894 (at least one)
93618 - Heart rhythm pacing - C1730, C1731, C1733, C1766, C1892, C1893, C1732, C1894 (at least one)
93623 - Stimulation, pacing heart - C1730, C1731, C1733, C1766, C1892, C1893, C1732, C1894 (at least one)
93631 - Heart pacing, mapping - C1730, C1731, C1733, C1766, C1892, C1893, C1732, C1894 (at least one)
33212 - Insertion of pulse generator - C1786 and/or C2620
33211 - Insertion of heart electrode - C1779
33216 - Revise eltrd pacing-defib - C1779, C1777, C1895, C1896, C1899 (at least one)
33217 - Insert lead pace-defib, dual - C1779, C1777, C1895, C1896, C1899 (at least one)
G0297 - Insert single chamber/cd - C1722 and/or C1882
G0298 - Insert dual chamber/cd - C1721 and/or C1882
G0299 - Inser/repos single icd+leads - C1722 and/or C1882
G0300 - Insert reposit lead dual+gen - C1721 and/or C1882
36260 - Insertion of infusion pump - C1772, C1891, C2626 (at least one)
36563 - Insert tunneled cv cath - C1772, C1891, C2626 (at least one)
36583 - Replace tunneled cv cath - C1772, C1891, C2626 (at least one)
63685 - Implant neuroreceiver - C1767
64590 - Implant neuroreceiver - C1767
61886 - Implant neurostim arrays - C1767
43256 - Uppr gi endoscopy w stent - C2617, C2625, C1874, C1875, C1876, C1877 (at least one)
44370 - Small bowel endoscopy/stent - C2617, C2625, C1874, C1875, C1876, C1877 (at least one)
44379 - S bowel endoscope w/stent - C2617, C2625, C1874, C1875, C1876, C1877 (at least one)
44383 - Ileoscopy w/stent - C2617, C2625, C1874, C1875, C1876, C1877 (at least one)
44397 - Colonoscopy w/stent- C2617, C2625, C1874, C1875, C1876, C1877 (at least one)
45327 - Proctosigmoidoscopy w/stent - C2617, C2625, C1874, C1875, C1876, C1877 (at least one)
45345 - Sigmoidoscopy w/stent - C2617, C2625, C1874, C1875, C1876, C1877,
45387 - Colonoscopy w/stent- C2617, C2625, C1874, C1875, C1876, C1877 (at least one)
33224 - Insert pacing lead & connect - C1900
55873 - Cryoablate prostate - C2618
33225 - L ventricular pacing lead add-on - C1900

The Centers for Medicare and Medicaid Services (CMS) requires any Medicare patient receiving a Cardioverter Defibrillator Abstraction (ICDA) as primary prevention of sudden cardiac death be enrolled in a data collection system. CMS has announced that they have an electronic tool available to Medicare participating hospitals to assist in submitting the data to a data collection system. The tool is available for download by each hospital’s Quality Net Exchange Administrator by logging onto: http://www.qnetexchange.org/icda

Beneficiaries receiving an ICD for primary prevention can be identified through the absence of ICD-9-CM diagnosis codes for secondary prevention from the claim. A patient claim with at least one of the codes listed below should appear for secondary prevention that signifies that the patient should be enrolled in a registry. Medicare Part B claims submitted on or after April 1, 2005 for implantation of an ICD for primary prevention should include a QR modifier to identify that the patient is enrolled in a registry. CMS does not have a coding mechanism for Part A claims that are similar to the QR modifier, but CMS will have the ability to mach inpatient claims to identify and review registry participation through other means.
Due to varying coding practices, providers should rely on the coverage guidance offered at http://www.cms.hhs.gov/mcd/viewimplementation.asp?id=148 to decide whether data submission is required. The following codes serve as assistance in identifying patients with previous arrhythmias (secondary prevention) however depending on coding practices may not accurately reflect the requirements for coverage:

• 427.1 Ventricular tachycardia
• 427.41 Ventricular fibrillation
• 427.42 Ventricular flutter
• 427.5 Cardiac arrest
• 427.9 Cardiac dysrhythmia, unspecified

The ICDA tool allows for on-line collection of registry information that includes patient identifiers, history, clinical characteristics, medications, ICD indications, device information, complications, and facility and provider information. This tool allows the capability of importing and exporting data utilizing existing XML standards.

CMS encourages the usage of the tool for data collection activities as it is a requirement of Medicare coverage for patients who receive the device for primary prevention of sudden onset cardiac arrest (patients without history f an arrest or arrhythmia). The ICDA tool assists CMS in making a reasonable and necessary determination for Medicare patients.

Medicare is required by section 306 of the Medicare Prescription Drug and Medicare Modernization Act of 2003 to demonstrate the use of recovery audit contractors to identify overpayments and underpayments made by Medicare contractors.

The significant components of the initiative are:

• RAC payment will be on the basis of a percent of the amount recovered
• An additional percentage will be retained for CMS management
• Duplicate payments are to be identified and recouped
• Coding errors are to be identified and recouped
• Payment policy errors are to be identified and recouped
• Underpayments will be identified to the Fiscal Intermediary, Carrier, or DMEPOS supplier for their action
• California, New York, and Florida will be the first states affected
• Contractors are to begin work in May 2005
• Cases reviewed must be at least one year old in order to allow for complete processing of the claims
• Providers will have appeal rights

• Reviewing provider policies and practices in all areas where payment by Medicare could be affected. HMI has been performing revenue cycle management for more than fifteen years.
• Performing revenue cycle audits and recommending re-billing of cases that are not accurately submitted so as to refund any Medicare overpayments and collect any Medicare underpayments. HMI has found, through experience, providers are more likely to under bill than over bill Medicare.
• Reviewing alleged overpayment cases and preparing appeals for submission by providers.

HMI has highlighted the key areas that our specialists can provide assistance in auditing/reviewing for you. Please contact HMI to discuss how we may assist your facility in setting its goals for the upcoming year.

OIG Work Plan for 2005 (Unabridged)
OIG Work Plan for 2005 (Abridged)

Need assistance in assigning the device codes in your chargemaster? HMI can help! See our Services page for details of our Pass-Through Identification Review.

CMS is making an effort to improve data that will be used to update future APC payments. Effective 01/01/04, the C codes for implantable devices, which are packaged into the APC procedure payment, are reinstated. They have found that separate coding for these devices results in improved accuracy in establishing the median costs used to set relative weights for the APCs for the procedures into which the costs of these devices are packaged.

Hospitals are strongly encouraged to separately bill devices using a device category C code or other appropriate HCPCS code for implantable devices along with the charge for the device. Complete and accurate reporting of the codes and the charges for the devices is critical to ensuring accurate relative weights and proper payment to hospitals for the procedures that use implanted devices.

For all device category C codes, both current pass-through devices as well as packaged devices, found on Addendum B on the CMS OPPS website, click here.

Remember that devices, whether packaged or paid as pass-through, are reported using revenue codes: 272, 275, 276, 278, 279, 280, 289 or 624.

For 2004, HCPCS codes G0256 and G0261 are deleted. For services furnished on or after 01/01/04, hospitals are to use the CPT codes 77778 and 55859 to bill for the procedures along with the HCPCS codes C1718 and C1720 to bill for the brachytherapy sources (seeds). Separate payments will be made for the procedures and for the seeds.

REMINDER!! Separate payment is made for the HCPCS C codes. Be sure to capture the appropriate units/number of brachytherapy seeds implanted during the procedure. If 100 brachytherapy seeds are implanted, bill 100 units of the applicable HCPCS C code.

The decision to add a new single code A9525 for low or iso-osmolar contrast material and delete codes A4644 thru A4646 effective January 1, 2004 has now been changed.

Per CMS one-time notification transmittal R45OTN, the HCPCS coding change listed above may result in incorrect coding of low osmolar contrast material. Providers should now continue to use codes A4644 thru A4646 rather than new code A9525.

Effective April 1, 2004, contractors will continue to process claims for low osmolar contrast material coded under A4644 thru A4646. Also, effective April 1, 2004, for claims received on or after April 1, 2004, code A9525 should be made invalid for Medicare claims processing purposes.

CMS notification indicates the method by which tositumomab and Iodine I-131 tositumomab (Bexxar) may be billed if covered by the Medicare program. The Bexxar therapeutic regimen is administered in two separate steps:

• the dosimetric and
• the therapeutic

When Bexxar is furnished to Medicare patients in a hospital outpatient department that is paid under OPPS, hospitals are to bill using the following HCPCS codes:

• G3001, Administration and supply of tositumomab, 450mg to bill for the infusion of tositumomab during the dosimetric/diagnostic step and to bill for the infusion of tositumomab during the therapeutic step.
• G0273, Radiopharmaceutical biodistribution, single or multiple scans on one or more days, pre-treatment planning for radiopharmaceutical therapy of non-Hodgkin's lymphoma, includes administration of radiopharmaceutical (e.g., radiolabeled antibodies) for the Bexxar dosimetric dose using Iodine I-131 tositumomab. Note that G0273 includes all scans taken during the dosimetric step. G0273 should be billed only once, no matter how many scans are performed.
• G0274, Radiopharmaceutical therapy, non-Hodgkin's lymphoma, includes administration of radiopharmaceutical (e.g., radiolabeled antibodies) for the Bexxar therapeutic dose using Iodine I-131 tositumomab.
• CPT 77300 to bill for dosimetry calculation.

When Bexxar is furnished to Medicare patients in a hospital outpatient department that is paid under the OPPS, hospitals shall NOT bill using the following codes:

• CPT codes for diagnostic administration of radiopharmaceuticals(78990 and 78999) or diagnostic scanning (78800 –78803).
• CPT codes for therapeutic administration of radiopharmaceuticals (79900), radiopharmaceutical therapy (79100, 79400), or infusion or instillation of radioelement solution (77750).

Note the following:

• Critical access hospitals and other hospital outpatient departments not paid under OPPS are to continue to utilize their current billing practices.
• The OPPS payment for HCPCS codes G0273 includes payment for all scans.
• The OPPS payment for G3001, G0273, and G0274 includes payment for both the radiopharmaceutical and administration of the radiopharmaceutical.

To view this one-time notification in its entirety, click here.

Within the Federal Register’s published FY 2004 final rule for changes to the Hospital Outpatient Prospective Payment System, CMS stated that they do not expect to implement new evaluation and management (E/M) codes and guidelines for hospitals any earlier than January 2005.

CMS is currently considering the set of proposed national coding guidelines for emergency and clinic visits recommended by the independent panel (American Hospital Association and the American Health Information Management Association). As the guidelines are developed, CMS stated that their primary concerns are:

• To make appropriate payment for medically necessary care;


• To minimize the information collection and reporting burden on facilities;


• To minimize any incentives to provide unnecessary or low quality care;


• To minimize the extent to which separately billable services are counted as E/M services;


• To develop coding guidelines that are consistent with facility resource use; and


• To develop coding guidelines that are clear, facilitate accurate payment, are useful for compliance purposes and audits, and comply with HIPAA.

Any proposed guidelines will be made available to the public for comment on the OPPS web site as soon as they are complete. The public will be notified through the listserve when these proposed guidelines become available. If you would like to subscribe to this listserve, click here and follow the directions to the hospital OPPS listserve.

CMS stated that before adoption of any coding changes or coding guidelines, ample time will be provided for comment. They will also consider the time necessary to educate clinicians and coders and for hospitals to modify their systems to accommodate new codes and guidelines. A minimum notice of between six and twelve months will be provided prior to implementation of facility evaluation and management codes and guidelines.

The starred procedure (*) issue has been addressed by the American Medical Association (AMA) and resolved in the 2004 CPT-4 coding manual. All references to starred procedures (*) have been removed from the manual.

Effective January 1, 2004, hospital laboratories are to begin utilizing modifier GY to identify laboratory tests that are performed for non-covered diagnoses listed in Medicare’s November 2002 National Coverage Determinations (NCD). This modifier should only be used if the diagnosis code is listed in the NCD as not covered by the Medicare program. Because the service/test is statutorily excluded or does not meet the definition of any Medicare benefit, the hospital is permitted to bill the beneficiary without obtaining an Advanced Beneficiary Notice (ABN).

Hospitals should not use modifier GY to indicate “not medically necessary” tests. In instances when medical necessity is not met, the hospital should obtain an ABN for tests before billing the beneficiary.

Hospitals may want to do own assessment of mammography and outpatient therapy claims since January 1, 1999. CMS discovered that the Provider Statistical and Reimbursement system (PS&R) had not been updated to reflect new mammography and outpatient therapy codes. FI’s shall be required to correct the PS&R beginning October 1, 2003 and retroactive to January 1, 1999. Although CMS and one FI had reviewed a sampling of providers (hospitals and SNF) to assess the impact of payments to these providers and was determined to be immaterial, it might be beneficial to a hospital to go ahead and perform their own review. To review the PM A-03-071, click here.

CMS representatives have been conducting national HIPAA Roundtable conference calls to address questions from the provider community about the implementation of HIPAA. If you have not had the opportunity to participate in one of the roundtable calls, then click here for Archived Roundtables.

Effective January 1, 2004, physicians providing covered services in a health professional shortage area (HPSA) will be entitled to incentive payments. This will mean that the payments will be 1.15 times the amount, which equals 1.10 percent of the amount payable under fee schedule. If the Critical Access Hospital has elected the Optional Method (Method II) and is located in a HPSA, it should notify the FI of its HPSA designation in writing. To read the updated information in section 415.22 of the Hospital Manual, click here.

CMS has published a Final Rule, September 26, 2003, on the requirements for paid feeding assistants. Most of the final rule incorporates the provisions of the proposed rule, with a few exceptions:

• Feeding assistants must complete State-approved training course before feeding residents. Training course must be a minimum of 8 hours of topics listed in 42 CFR 483.160(a).
• Long-term care facility may use a paid feeding assistant consistent with State law.
• Supervision of feeding assistants by facility RNs or LPNs is no longer to be “direct” (implying visual contact). Facilities will have to develop clear guidelines that outline RNs and LPNs required level of supervision over feeding assistants.
• Feeding assistants will be required to call for a supervisory nurse for help in emergency situations. The requirement for supervisory nurse to be in the same unit or on the floor is being removed.
• Selection criteria for residents requiring feeding assistance will be based on charge nurse’s assessment and resident’s latest assessment and plan of care.

CMS has posted a recent FAQ addressing the issue of reporting ICD-9-CM procedure codes on hospital outpatient claims.

Within the FAQ CMS states, "In order to continue operations and maintain cash flow, providers, as part of their contingency plan, could continue to report hospital outpatient services with ICD-9-CM procedure codes if required by the health plan. However, health plans must realize that reporting hospital outpatient services with ICD-9-CM procedures codes on standard claim transactions is not compliant, and that their good faith efforts to come into compliance must include the steps being taken to change this requirement."

Effective November 10, 2003, are the revisions to the guidelines set forth under Title 42 Section 489.24, Special Responsibilities of Medicare Hospitals in Emergency Cases.

The September 9, 2003 release of the final rule in the Federal Register contained numerous discussions based on comments from the provider community. Below is a summary of discussions of primary interest. To see the "full text" from the Federal Register, click here.

1. Clarify "comes to the emergency department"

• Medical screening examination - individuals are provided an appropriate medical screening examination by a qualified medical professional within the capabilities of the hospital’s emergency department. The primary purpose of the medical screening examination is to determine that a medical emergency exists, then provide necessary stabilizing treatment. CMS states that neither "triaging" nor taking only vitals signs would be considered an appropriate medical screening. The qualified medical professional should be a licensed physician or other medical professional who is determined to be qualified by applicable state rules and regulations or hospital bylaws.
• Definition of hospital property - the entire main hospital campus, including the parking lot, sidewalk, and driveway, but excluding other areas or structures of the hospital’s main building that are not part of the hospital, such as physician offices, rural health centers, skilled nursing facilities, or restaurants, shops, or other nonmedical facilities.
• Dedicated emergency department - any department or facility of the hospital (on or off campus) that meets one of the following requirements: 1) is licensed by the State in which it operates, 2) is held to the public (advertising, signs, etc) as a place that provides care on an urgent basis without requiring a previously scheduled appointment, or 3) in the preceding calendar year determined that at least one-third of all its outpatient visits were for treatment of emergency medical conditions. CMS states that if a hospital’s labor and delivery department or psychiatric unit is held out to the public as a place that provides care for emergency medical conditions on an urgent, nonappointment basis, these departments will be subject to EMTALA requirements applicable to dedicated emergency departments. CMS is revising the guidelines to remove the criteria "evaluation and treatment" and replacing with "treatment."
• Closest appropriate facility - CMS is changing to this revised language in the guidelines. The original text was "nearest hospital." CMS agreed with commenters that the new language will be more consistent with community-wide EMS protocols.
• Nonemergency services - CMS is revising the language in the guidelines to include "use of dedicated emergency department for nonemergency services. If an individual comes to a hospital's dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition."
• Prudent layperson standard - CMS believes the prudent layperson standard is necessary for both presentments inside the dedicated emergency department and elsewhere on hospital property. CMS has added the language because it reflects a standard for judging whether the hospital should have acted--it does not shift control of events to any particular individual layperson. A prudent layperson will trigger EMTALA screening when an individual, who is experiencing an emergency medical condition, may not be able to request treatment on their own behalf.
• Responsibility of hospital-owned ambulances - CMS states that an individual in an ambulance owned and operated by the hospital is not considered to have "come to the emergency department" if the ambulance is operated under communitywide EMS protocols or EMS protocols "mandated by State law" that direct it to transport the individual to a hospital other than the hospital that owns the ambulance. CMS further states that an individual in an ambulance owned and operated by the hospital is not considered to have "come to the emergency department" if the ambulance is operated at the direction of a physician who is not employed or otherwise affiliated with the hospital that owns the ambulance or if the physician's direction of the destination of the ambulance is subject to communitywide protocols that require the individual to be transported to a hospital other than the hospital that owns the ambulance. This guideline is applicable to both ground and air ambulances owned by hospitals.

2. Application of EMTALA to inpatients vs. outpatients

• Inpatients – CMS is adding language to adopt the established definition of "inpatient" in section 210 of the Medicare Hospital Manual, who are not subject to the EMTALA obligations. CMS is clarifying that a hospital, with respect to admission of a patient as an inpatient, is required to provide care to its inpatients in accordance with the Medicare hospital CoPs.
• Outpatients – CMS describes these individuals as coming to the hospital either for scheduled services (e.g. diagnostic services) or seeking care at the request of a physician (e.g. coming to the hospital from the physician office), but in either of these instances, as determined by the hospital, is not seeking treatment for an emergency medical condition. CMS states that EMTALA does not apply to any individual who, before the individual presents to the hospital for examination or treatment for an emergency medical condition, has begun to receive outpatient services as part of an encounter, as defined in 42 CFR 410.2. Outpatients, who experience an emergency medical condition after the start of outpatient services, will be cared for in accordance with Medicare CoPs.

3. On-call requirements – CMS specifies that an on-call list must be maintained in a manner that best meets the needs of the hospital's patients who are receiving services required under EMTALA, in accordance with the capability of the hospital, including the availability of on-call physicians. CMS is revising the language of Sec. 489.24 to state under paragraph (j)(3)(ii) that hospitals must "provide" rather than "insure" that emergency services are available. CMS is also revising language to state the conditions under which simultaneous call and elective surgery while on-call are permitted. CMS will expect hospitals to have written policies and procedures that outline the on-call process.

The OIG Work Plan for FY 2004 includes a study that will assess the appropriateness of Medicare billings for diagnostic tests performed in hospital emergency rooms. Medicare pays approximately $85 million a year for standard imaging (x-rays) and an additional $70 million for advanced imaging (such as MRIs and CAT scans). They will determine whether the services were medically necessary and whether the tests were interpreted contemporaneously with the beneficiary’s treatment.

The Office of Inspector General (OIG) has released a recent audit (July 16, 2003) for review of outpatient cardiac rehabilitation services. A key finding related to CMS’ physician supervision requirement for cardiac rehab programs. The executive summary included the following:

• Facility did not designate a physician to directly supervise the services provided under its cardiac rehabilitation program.
• OIG could not identify the physician professional services to which the cardiac rehabilitation services were provided “incident to.”
• Based on a the statistical sample reviewed, the OIG estimated that facility claimed and received Medicare reimbursement for outpatient cardiac rehabilitation services, of approximately $47,247, which did not meet Medicare coverage requirements, which may not have been supported by medical record documentation, or which was otherwise unallowable.