Molecular Genetic Testing NEW CODES- Updated 012312
CMS published two transmittals with information regarding these codes and how to report them on claims. This is very confusing and may be difficult to accomplish. Primarily they request the old codes and the new codes both be reported on the claim. This causes double charges. The new codes will deny, as they are considered excluded Medicare services (CMS changed to status indicator E). Refer to OPPS Transmittal: http://www.cms.gov/transmittals/downloads/R2376CP.pdf
or Lab transmittal http://www.cms.gov/transmittals/downloads/R2365CP.pdf
I have sent questions to CMS about this transmittal, no response.
012312- On the last Hospital Open Door forum, CMS stated there are no edits to prevent claims from denying if the 2012 codes are not included on the claim. Hospitals voiced concern about charging twice for both services. I expect hospitals will not report both services on claims. However, there may be payers that want the new codes verses the 2011 codes.
BCBS Kansas wants the new codes reported on claims. Triwest wants the old codes (2011) reported. Hopefully BCBS will publish a newsletter soon. This presents a problem for providers in Kansas and other states where payers want the new codes.
CMS will likely discuss this again during the next ODF scheduled for Feb 22.
Coverage for Drug Administration, when the drug is considered self-administered 012312
This also was discussed on the last ODF call. A caller questioned whether a drug administration charge (i.e. SQ/IM 96372) could be reported and covered when the drug is when the drug is considered self administrable.
The topic got confused with when a self-administered drug is covered verses a charge to ADMINISTER the drug.
CMS reference IOM 100-2 chapter 15 Section 50 K;
However, contractors should not make a determination of whether it was reasonable and necessary for the patient to choose to have his or her drug administered in the physician’s office or outpatient hospital setting. That is, while a physician’s office visit may not be reasonable and necessary in a specific situation, in such a case an injection service would be payable.
I sent an email to CMS about the ODF discussion. Hopefully they will clarify for all, as the information from the manual was not cited. I provided the manual reference.
It has been our understanding the drug administration charge can be reported as a covered service. I believe there is a misunderstanding regarding the use of value code A4 as described in the NUBC manual and with Transmittal 1790 issued in 2000. I believe CMS is stating that drugs administered during an emergency are not covered. This was changed a few years ago. Again this may be discussed during the next ODF.
2012 Drug Administration Updated 012312
CPT changed some of the instructional notes in the drug administration section. They changed wording from "per encounter" to " date of service” when referencing initial services. HOWEVER, CMS published information in the 2012 OPPS update- Transmittal R2376, released 12/29/11. The transmittal states:
6. Clarification of Coding for Drug Administration Services As noted in CR 7271, Transmittal 2141, in 2011 CMS revised Pub. 100-04, Medicare Claims Processing Manual, chapter4, section 230.2, to clarify the correct coding of drug administration services. Drug administration services are to be reported with a line-item date of services on the day they are provided. In addition, CMS noted that beginning in CY2007, hospitals should report only one initial drug administration service, including infusion services, per encounter foreach distinct vascular access site, with other services through the same vascular access site being reported via thesequential, concurrent or additional hour codes. CMS has subsequently become aware of new CPT guidance regarding the reporting of initial drug administration services in the event of a disruption in service; however,Medicare contractors are to continue to follow the guidance given in this manual. CMS manual instructions are located 100-4 Chapter 4 Section 230.2: “Drug administration services are to be reported with a line item date of service on the day they are provided. In addition, only one initial drug administration service is to be reported per vascular access site per encounter, including during an encounter where observation services span more than 1 calendar day.
In addition, only one initial drug administration service is to be reported per vascular access site per encounter, including during an encounter where observation services span more than 1 calendar day.”
Hospitals should contact all other payers to verify if they will continue to follow CMS instructions or CPT instructions. I would encourage you to insist all payers follow CMS instructions as it will be difficult to implement two sets of coding and charging rules.
012312: Note and Commentary- Hospitals may want to push for the implementation of CPT instructional guides. These will create additional revenue. If and when these are implemented, observation cases would likely receive additional revenue because an initial service can be reported per date of service. This will be applied to any case that extends past midnight. But remember for now- No changes for Medicare- continue to use the guides in the Hospital Manual- one initial per encounter and report the dates of service on the actual date the services were rendered.
WPS Part A claims- Overlapping dates of service
There are claims being held in status location SM3805. KHA contacted WPS and they stated this was some sort of system problem although hospitals have been told WPS is auditing these claims. The claims in this status location are series/repetitive services (PT, OT, ST) due to another OP claim with overlapping dates of service (lab, radiology, ER etc.). If the claims have duplicate revenue codes, they will likely be sent to RTP. These claims may be in this S/L for more than 14 days. Check your claims summary file to see how many claims are being held in this S/L. The specific claim information can be viewed from Claims Inquiry and inputting the status location S M3805.
WPS auto denial of services reported with GA modifier
A problem was identified beginning in October with automatic denials of services reported with GA modifier (ABN issued). WPS disabled the edit Nov- Per CMS the edits to auto deny these services were not to be reinstated.
Updated: Providers will need to identify these claims and file an adjustment.
Email amartin@gpha.com
