Email not displaying correctly? View it in your browser.
Issue #106 - August 6, 2008 
AAPC EdgeBlast
MPFS Cut Gone, Not Forgotten
With the enactment of the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 on July 15 comes several important changes. Of course, the headline news is that the 10.6 percent rate reduction to the Medicare Physician Fee Schedule (MPFS) that went into effect on July 1 is waylaid for the next 18 months. MPFS rates are now back to what they were in the first half of the year. According to the Centers of Medicare & Medicaid Services (CMS), Medicare contractors will continue to process the claims put on a 10-day hold on a first-come, first-serve basis at the reduced rate. Contractors will then automatically reprocess any claims submitted between July 1 and July 15 that were paid at the lower rates “to the extent possible.” MIPPA also ensures physicians receive a 1.1 percent increase in MPFS rates in 2009.

Here’s the rest of the story
MIPPA postpones the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program. According to Highmark Medicare Services, the July 21 accredited or applied accreditation deadline and the Jan. 14, 2009 obtaining accreditation deadline no longer apply. The Sept. 20, 2009 deadline for all DMEPOS suppliers to be accredited is still in effect. What this means is that the items included in the first round of the DMEPOS Competitive Bidding Program can now be furnished by any enrolled DMEPOS supplier in accordance with existing Medicare rules. Payment for these items will be made under the fee schedule.

The therapy caps exceptions process was also reinstated as of July 1. MIPPA extends the use of the cost to charge payment methodology for brachytherapy and therapeutic radiopharmaceuticals through Jan. 1, 2010. Outpatient therapy service providers may continue to submit claims with the KX modifier Requirements specified in the medical policy have been met for therapy services that exceed the cap. For 2008, the incurred expenses limit is $1,810 for both physical therapy and speech language pathology services combined and occupational therapy services. Once again, contractors are expected to mass adjust all claims processed using the Outpatient Prospective Payment System (OPPS) rates in effect between July 1 and July 15 “in a timely manner,” CMS reports. Further information is available on the CMS Web site.

MIPPA also continues to allow independent laboratories technical component (TC) Medicare billing of physician pathology services furnished to covered hospital patients, regardless of a beneficiary’s inpatient/outpatient status. MIPPA establishes a new moratorium extension effective for claims with dates of service between July 1 and Dec. 31, 2009. Be sure to read CMS Transmittal 1561, CR6042, dated July 25, for the latest requirements.

Ambulance fee schedule amounts for ground ambulance services will increase. The increase will be effective for claims with dates of service on or after July 1, 2008, and before Jan. 1, 2010. For covered ground ambulance transports originating in rural areas, the fee schedule amounts increase by 3 percent; and for covered ground ambulance transports originating in non-rural areas, the fee schedule amounts increase by 2 percent.

A complete summary of provisions in H.R. 6331 is available online; and MLN Matters article SE0826 is available on the CMS Web site.

Waiving Cost-Share Amounts Pays Off
The HHS Office of the Inspector General (OIG) issued a policy statement assuring Medicare providers, practitioners, and suppliers affected by retroactive increases in payment rates under MIPPA of 2008 that they will not be subject to OIG administrative sanctions if they waive retroactive beneficiary cost-sharing amounts attributable to those increased payment rates.

Legislation Requires Disclosure of
Self-Referrals for Imaging

Physicians may soon be required to disclose their financial ties to imaging services ordered under Medicare when making self-referrals. Read the full report on the Medical News Today Web site.

Greater Hospital Safety Encouraged
CMS is taking several actions to improve the quality of care in hospitals and reduce the number of “never events”—preventable medical errors resulting in serious consequences for the patient and “unnecessary costs to Medicare and Medicaid,” said CMS Acting Administrator Kerry Weems in a July 31 press release.

The inpatient prospective payment system (IPPS) rule displayed July 31 at the Office of the Federal Register adds three conditions, including one National Quality Forum (NQF) never event, to the Do Not Pay list.

The new conditions and events are:

  • Surgical site infections following certain elective procedures, including certain orthopedic surgeries, and bariatric surgery for obesity
  • Certain manifestations of poor control of blood sugar levels
  • Deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures

Beginning Oct. 1, Medicare will require hospitals to include a complication code in diagnostic related groups (DRGs) documenting whether a given complication was present on admission. Medicare will then determine whether the complication developed due to hospital mistakes—and if so, it won't pay for care related to such mistakes.

CMS has posted three National Coverage Analysis (NCAs) addressing Medicare’s coverage of surgery on the wrong body part, surgery on the wrong patient, and wrong surgery on a patient. Additional details about open NCAs are available on the tracking sheets found on the coverage Web site.

Medicare Increases SNF Payment Rates
Medicare payment rates to nursing homes will increase by $780 million next year, CMS announced July 31. The boost in payments is the result of a 3.4 percent increase in the annual market basket calculation of the cost of goods and services included in a skilled nursing facility (SNF) stay. A copy of the final rule is available on the CMS Web site.

Cash-in on E-prescribing
In an effort to accelerate the adoption of health IT and reduce drug errors, CMS will provide incentive payments to eligible healthcare professionals who are e-prescribing. According to a July 21 report posted on the Web site, the initiative will be a 2 percent incentive payment in 2009 and 2010; a 1 percent incentive payment in 2011 and 2012; and a 0.5 percent incentive payment in 2013.

Eligible health care professionals not e-prescribing by 2012 will receive a reduction in payment unless otherwise exempt. To qualify for exemption, a health care professional must prove compliance would result in significant hardship.

CMS Clarifies CPAP Coverage
CMS Transmittal 91, CR6048, dated July 25, rescinds and replaces Transmittal 86, CR6048, dated July 3. To avoid any misinterpretations, there was a verbiage correction in subsection C of the manual text. All other information remains the same.

Special Open Door Forum: PQRI
CMS, along with the American Academy of Ophthalmology (AAO), will host a Special Open Door Forum on Aug. 14, from 2-3:30 p.m. (EDT) to discuss participation in the 2008 Physician Quality Reporting Initiative (PQRI). The forum’s purpose is to encourage PQRI participation and provide simple steps physicians can use to collect and report quality data to be eligible for an incentive payment from CMS. To participate in the conference call ODF, dial in at 1-800-837-1935, and use reference conference ID number 56800644.

Coding Tips
Critical Info About Critical Care Coding
Pay close attention to how you code critical care visits (CPT® codes 99291-99292) as CMS has replaced all previous critical care payment policy language and added general Medicare evaluation and management (E/M) payment policies impacting payment for critical care services.

Look for changes made regarding calculation of critical care time and clarifications in language related to time spent reviewing or discussing patient information and off the unit/floor and split/shared service discussions.

For a detailed explanation of changes, read CMS transmittal R1548CP and MLN Matters article MM5993 on the CMS Web site.

New Hemophilia Clotting Factor and HCPCS Code
Effective for outpatient claims with dates of service on or after April 1, 2008, Health Care Procedure Code System (HCPCS) Level II code Q4096 Injection, Von Willebrand factor complex, human, ristocetin cofactor (not otherwise specified), per I.U. VWF:RCO VWF complex, NOS is payable for Medicare.

Local carriers and MACs will process non-institutional blood clotting factor Part B claims. Hospitals subject to the Outpatient Prospective Payment System (OPPS) will be paid the ambulatory payment classification (APC) for the clotting factors; and SNFs will be paid based on cost.

Read the CMS transmittal 1564, CR6006, on which this report is based, on the CMS Web site.

DPNA for SNF Billing Requirements Revised
CMS is updating Denial of Payment for New Admissions (DPNA) instructions. Effective Jan. 1, 2009, a SNF must use occurrence span code 80 for reporting prior same-SNF stay dates when a SNF that is under a payment ban needs to submit a claim for a Medicare beneficiary readmission that is not subject to the payment ban. For a summary of additional changes made to Chapter 6, Section 50 of the Medicare Processing Manual, see MLN Matters article MM6116 on the CMS Web site. For a more comprehensive explanation, read CMS transmittal 1555.

SNFs May Be Entitled to Reimbursement
Changes made to the Medicare Common Working File (CWF) for SNF consolidated billing as written in CMS transmittal CR5757 no longer apply to claims on or after Jan. 5, 2009. Transmittal 1554 revises CR5757, which implemented the changes that were later found to negatively impact therapy professionals. According to MLN Matters article MM6128, Medicare contractors will only reopen and re-process incorrectly denied claims that are brought to their attention.

CCI 59 Modifier Reminders
According to Highmark Medicare Services, Comprehensive Coding Initiative (CCI) edits may be bypassed by reporting modifier 59. Watch out: Incorrect reporting of modifier 59 may get you a CCI denial.

Modifier 59 indicates a distinct procedural service and should only be used to identify procedures or services not normally reported together, but are appropriate under the circumstances. When appropriate, the secondary, additional, or lesser procedure(s) or service(s) must be identified by adding modifier 59 to the Column 2 code. Do not report modifier 59 with the primary procedure.

New Hospice Discharge Code
For claims with dates of service on or after Jan. 1, 2009, hospices should report the condition code H2 on claims when Medicare beneficiaries are discharged for cause according to the hospice’s documented policy addressing discharges for cause. Discharge for cause identifies a discharge from the provider’s care, not from the Medicare hospice benefit. For details, read transmittal 1558, CR6115, dated July 18, on the CMS Web site. is Quick Reference
The UnitedHealthcare Online Web site could save you time and money. It’s designed to make administrative tasks easier as well as provide you with comprehensive online resources and information developed in part by the American Medical Association (AMA), the Medical Group Management Association (MGMA), and numerous state and specialty societies. Take a tour to find out more.

Medical News
NCD Determines PT/INR Monitoring Covered
For services furnished on or after March 19, 2008, Medicare will cover the use of home prothrombin time tests adjusted to the International Normalized Ratio (PT/INR) monitoring for chronic, oral anticoagulation management for patients with mechanical heart valves, chronic atrial fibrillation, or venous thromboembolism (inclusive of deep venous thrombosis and pulmonary embolism) on warfarin. This addition/revision is a national coverage determination (NCD) found in the Medicare National Coverage Determinations Manual, Chapter 1, Part 3 (Sections 170 – 190.34), Coverage Determinations.

Applicable HCPCS Level II codes are:

  • G0248     Demonstration, at initial use, of home INR monitoring for patient with mechanical heart valve(s) who meets Medicare coverage criteria, under the direction of a physician; includes: demonstrating use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient ability to perform testing
  • G0249      Provision of test materials and equipment for home INR monitoring to patient with mechanical heart valve(s) who meets Medicare coverage criteria; includes provision of materials for use in the home and reporting of test results to physician; per 4 tests
  • G0250      Physician review, interpretation and patient management of home INR testing for a patient with mechanical heart valve(s) who meets other coverage criteria; per 4 tests (does not require face-to-face service)

With the July 2008 OCE and MPFS updates, the descriptors of these codes are changing to reflect the revised coverage policy. The new descriptors reflect the expanded NCD criteria and are effective March 19; however, they have not been posted on the CMS Web site yet.

For requirements and other details, read CMS Transmittal 90, dated July 25, MLN Matters article MM6138, and NCD 190.11 on the CMS Web site.

PreGen-Plus Not Covered
Following reconsideration of the current NCD for colorectal cancer screening, CMS says it will not expand the colorectal cancer screening benefit to include coverage of PreGen-Plus, a commercially available screening DNA stool test. CMS says the Food and Drug Administration (FDA) has determined this test requires premarket review and approval. CMS says a subsequent request for reconsideration will be considered once FDA approval is obtained. You can read all about this NCD in CMS Transmittal 89, and in the MLN Matters article MM6145.

Microvolt T-wave Alternans Not Covered
CMS reconsidered the NCD on microvolt t-wave alternans (MTWA) diagnostic testing and has determined not to extend coverage to the modified moving average (MMA) method because it is not deemed reasonable and necessary. The current policy remains in place providing for coverage of MTWA testing for the evaluation of patients at risk for sudden cardiac death only when the spectral analysis method is used. For complete details, read CMS Transmittal 88, CR6154, dated July 25, and NCD 20.30 on the CMS Web site.

Coding Job Links
AAPC Job Database

AAPC Employment Forums

Test Yourself Online
The Test Yourself questions can be accessed online at Once you go there and take the test, you can automatically grade your answers, correct any mistakes, and have your CEUs automatically added to your CEU Tracker for submission.

Featured Items
MPFS Cut Gone
Waiving Cost-Share
Disclosure Self-Referrals
Hospital Safety
SNF Payment Rates
Cash-in on E-prescribing
CPAP Coverage
Open Door Forum
Coding Tips
Medical News
Coding Job Links
Test Yourself Online

EdgeBlast Sponsors

The AAPC EdgeBlast is offered as a benefit to members and we hope you find the information useful. If you'd rather not receive future EdgeBlast issues, please log in to our member area and change your e-mail preferences.

2233 S Presidents Dr., Suite F | Salt Lake City, UT 84120 | (801) 236-2200

Copyright © 2008 AAPC - All rights reserved. CPC®, CPC-H®, and CPC-P® are registered trademarks of the AAPC.

CPT® codes Copyright 2007 American Medical Association. All Rights Reserved. CPT® is a trademark of the AMA. No fee schedules, basic units, relative values or related listings are included in CPT®. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.