Avoiding Physician Self-Referral Violations Starts with a Code List

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

Executive Editor at AAPC
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.
Renee Dustman
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About Has 653 Posts

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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