Avoiding Physician Self-Referral Violations Starts with a Code List

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  • January 15, 2019
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Avoiding Physician Self-Referral Violations Starts with a Code List

Every year, the Centers for Medicare & Medicaid Services (CMS) updates their Designated Health Services (DHS) Code List. What are designated health services, and why should you care?

The Link to Designated Health Services and the Law

By law, CMS categorizes the following as designated health services:

  • Clinical laboratory services
  • Physical therapy services
  • Occupational therapy services
  • Outpatient speech-language pathology services
  • Radiology services
  • Radiation therapy services and supplies
  • Durable medical equipment and supplies
  • Parenteral and enteral nutrients, equipment, and supplies
  • Prosthetics, orthotics, and prosthetic devices and supplies
  • Home health services
  • Outpatient prescription drugs
  • Inpatient and outpatient hospital services

Physician Self-referral Basics

The physician self-referral law prohibits a physician from making referrals for certain DHS payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship (ownership or compensation), and prohibits the entity from filing claims with Medicare (or billing another individual, entity, or third-party payer) for those referred services.
In 2017, the government recovered more than $1.6 billion in Medicare and Medicaid fraud and abuse violations, including physician self-referral violations. These violations are easily avoided by referencing the current DHS Code List.
Four DHS categories are defined in a code list that CMS maintains. The four categories are:

  • Clinical laboratory services
  • Physical therapy, occupational therapy, and outpatient speech-language pathology services
  • Radiology and certain other imaging services
  • Radiation therapy services and supplies

The CMS DHS Code List also identifies items and services that may qualify for either of the following two exceptions to the physician self-referral prohibition:

  • Erythropoietin (EPO) and other dialysis-related drugs furnished in or by an end-stage renal dialysis (ESRD) facility
  • Preventive screening tests, immunizations, or vaccines

The Code List excludes services for which payment is made by Medicare as part of a composite rate (unless the services are specifically identified as DHS and are themselves payable through a composite rate, such as home health and inpatient and outpatient hospital services). EPO and any dialysis-related drugs that are paid for under the ESRD Prospective Payment System are not DHS; ESRD-related oral-only drugs furnished in or by an ESRD facility are not paid as part of a composite rate and, thus, are DHS.
For 2019, there are many additions and deletions to the Code List.
Additions to the Physician Self-Referral List of CPT®/HCPCS Level II Codes
CLINICAL LABORATORY SERVICES
0018U Onc thyr 10 microrna seq alg
0019U Onc rna tiss predict alg
0020U Rx test prsmv ur w/def conf
0021U Onc prst8 detcj 8 autoantb
0022U Trgt gen seq dna&rna 23 gene
0023U Onc aml dna detcj/nondetcj
0024U Glyca nuc mr spectrsc quan
0025U Tenofovir liq chrom ur quan
0026U Onc thyr dna&mrna 112 genes
0027U Jak2 gene trgt seq alys
0028U Cyp2d6 gene cpy nmr cmn vrnt
0029U Rx metab advrs trgt seq alys
0030U Rx metab warf trgt seq alys
0031U Cypia2 gene
0032U Comt gene
0033U Htr2a htr2c genes
0034U Tpmt nudt15 genes
0035U Neuro csf prion prtn qual
0036U Xome tum & nml spec seq alys
0037U Trgt gen seq rgt gen seq dna 324 genes
0038U Vitamin d srm microsamp quan
0039U Dna antb 2strand hi avidity
0040U Bcr/abl1 gene major bp quan
0041U B brgdrferi antb 5 prtn igm
0042U B brgdrferi antb 12 prtn igg
0043U Tbrg b grp antb 4 prtn igm
0044U Tbrf b grp antb 4 prtn igg
0045U Onc brst dux carc is 12 gene
0046U Flt3 genie itd variants quan
0047U Onc prst8 mrna 17 gene alg
0048U Onc sld org neo dna 468 gene
0049U Npm1 gene analysis quan
0050U Trgt gen seq dna 194 genes
0051U Rx mntr lc-ms/ms ur 31 pnl
0052U Lpoprtn bld w/5 maj classes
0053U Onc prst8 ca fish alys 4 gen
0054U Rx mntr 14+ drugs & sbsts
0055U Card hrt trnspl 96 dna seq
0056U Hem aml dna gene reargmt
0057U Onc sld org neo mrna 51 gene
0058U Onc merkel cll carc srm quan
0059U Onc merkel cll carc srm+/-
0060U Twn zyg gen seq alys chrms2
0061U Tc meas 5 bmrk sfdi m-s alys
0011M Onc prst8 ca mrna 12 gen alg
0012M Onc mrna 5 gen rsk urthl ca
0013M Onc mrna 5 gen recr urthl ca
PHYSICAL THERAPY, OCCUPATIONAL THERAPY,
AND OUTPATIENT SPEECH-LANGUAGE
PATHOLOGY SERVICES
{No additions}
RADIOLOGY AND CERTAIN OTHER IMAGING
SERVICES
0508T Pls echo us b1 dns meas tib
76391 Mr elastography
76978 Us trgt dyn mbubb 1st les
76979 Us trgt dyn mbubb ea addl
76981 Use parenchyma
76982 Use 1st target lesion
76983 Use ea addl target lesion
77046 Mri breast c-unilateral
77047 Mri breast c-bilateral
77048 Mri breast c-+ w/cad uni
77049 Mri breast c-+ w/cad bi
C8937 Cad breast Mri
C9407 Iodine i-131 iobenguane, dx
Q9950 Inj sulf hexa lipid microsph
RADIATION THERAPY SERVICES AND
SUPPLIES
A9513 Lutetium Lu 177 dotatat ther
C9408 Iodine i-131 iobenguane, tx
DRUGS USED BY PATIENTS UNDERGOING
DIALYSIS
{No additions}
PREVENTIVE SCREENING TESTS,
IMMUNIZATIONS AND VACCINES
81528 Oncology colorectal scr
90689 Vacc IIv4 no prsrv 0.25ml im
 
Deletions from the Physician Self-Referral List of CPT®/HCPCS  Level II Codes
CLINICAL LABORATORY SERVICES
78270 Vit B-12 absorption exam
78271 Vit b-12 absrp exam int fac
78272 Vit B-12 absorp combined
PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND
OUTPATIENT SPEECH-LANGUAGE PATHOLOGY SERVICES
64550 Appl surface neurostimulator
96111 Developmental testing
RADIOLOGY AND CERTAIN OTHER IMAGING SERVICES
0159T Cad breast mri
0346T Ultrasound elastography
C9744 Abd us w/contrast
77058 Mri one breast
77059 Mri both breasts
77776 Apply interstit radiat simpl
77785 HDR brachytx 1 channel
77786 HDR brachytx 2-12 channel
C9457 Lumason contrast agent
C9461 Choline C 11, diagnostic
G0173 Linear acc stereo radsur com
G0251 Linear acc based stero radio
RADIATION THERAPY SERVICES AND SUPPLIES
0190T Place intraoc radiation src
DRUGS USED BY PATIENTS UNDERGOING DIALYSIS
{No deletions}
PREVENTIVE SCREENING TESTS, IMMUNIZATIONS AND
VACCINES
G0389 Ultrasound exam AAA screen
G0464 Colorec CA scr, sto bas DNA
The updated, comprehensive DHS Code List, effective Jan. 1, 2019, is available on the CMS website.


Resource:
Sec. 1877. [42 U.S.C. 1395] (a) Prohibition of Certain Referrals.— https://www.ssa.gov/OP_Home/ssact/title18/1877.htm

Renee Dustman
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Renee Dustman, BS, AAPC MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 20 years experience in print production and content management. Follow her on Twitter @dustman_aapc.

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