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X{EPSU} Modifiers

The Medicare National Correct Coding Initiative (NCCI) has Procedure to Procedure (PTP) edits to prevent unbundling of services, and the consequent overpayment to physicians and outpatient facilities. The underlying principle is that the second code defines a subset of the work of the first code. Reporting the codes separately is inappropriate. Separate reporting would trigger a separate payment and would constitute double billing. 

CR8863 discusses changes to HCPCS modifier -59, a modifier which is used to define a “Distinct Procedural Service.” Modifier -59 indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled. 

The -59 modifier is the most widely used HCPCS modifier. Modifier -59 can be broadly applied. Some providers incorrectly consider it to be the “modifier to use to bypass (NCCI).” This modifier is associated with considerable abuse and high levels of manual audit activity; leading to reviews, appeals and even civil fraud and abuse cases. 

The primary issue associated with the -59 modifier is that it is defined for use in a wide variety of circumstances, such as to identify: i) Different encounters; ii) Different anatomic sites; and iii) Distinct services.

The -59 modifier is 

Infrequently (and usually correctly) used to identify a separate encounter; 
Less commonly (and less correctly) used to define a separate anatomic site; and 
More commonly (and frequently incorrectly) used to define a distinct service. 

The -59 modifier often overrides the edit in the exact circumstance for which CMS created it in the first place. CMS believes that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment. 

CR8863 provides that CMS is establishing the following four new HCPCS modifiers (referred to collectively as -X{EPSU} modifiers) to define specific subsets of the -59 modifier: 

XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter, 

XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure, 

XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner, and 

XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service.

CMS will continue to recognize the -59 modifier, but notes that Current Procedural Terminology (CPT) instructions state that the -59 modifier should not be used when a more descriptive modifier is available. While CMS will continue to recognize the -59 modifier in many instances, it may selectively require a more specific - X{EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers. The -X{EPSU} modifiers are more selective versions of the -59 modifier so it would be incorrect to include both modifiers on the same line. The combination of alternative specific modifiers with a general less specific modifier creates additional discrimination in both reporting and editing. As a default, at this time CMS will initially accept either a -59 modifier or a more selective - X{EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged. 

However, please note that these modifiers are valid even before national edits are in place. MACs are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier, when necessitated by local program integrity and compliance needs. 

Reference: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8863.pdf

Power Mobility Device (PMD) Prior Authorization Demonstration Project

The Centers for Medicare & Medicaid Services (CMS), in its effort to reduce waste, fraud, and abuse in the Medicare fee-for-service program, is conducting a three-year demonstration to ensure that Medicare only pays for power mobility devices (PMDs) that are medically necessary. This demonstration began with orders written on or after September 1, 2012. The demonstration will be conducted in Arizona, California, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Maryland, Michigan, Missouri, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Tennessee, Texas, and Washington.

The prior authorization process allows the physician/practitioner (submitter) to send a prior authorization request for a PMD before the supplier delivers the device to the beneficiary’s home. Documentation supporting coverage of the PMD should be submitted to the appropriate durable medical equipment Medicare administrative contractor (DME MAC) for an initial decision.

A physician/practitioner can bill G9156 after he/she submits an initial prior authorization request to partially compensate physicians for the additional time spent in submitting the prior authorization request.

This demonstration will help ensure that no Medicare payments are made for PMDs unless a beneficiary’s medical condition warrants the equipment under existing coverage guidelines. Moreover, the program will assist in preserving a Medicare beneficiary’s right to receive quality products and help protect them from unexpected financial liability.

PMDs includes power wheelchairs and Power-Operated Vehicles (POVs) that a beneficiary uses in their home (42 CFR 410.38(c)). Power wheelchairs are four-wheeled motorized vehicles that are steered by operating an electronic device or joystick to control direction and turning. POVs are three- or four-wheeled motorized scooters that are operated by a tiller. PMDs are classified as items of Durable Medical Equipment (DME) for Medicare coverage purposes. 

Power Operated Vehicles (POVs or scooters): Under the Mobility Assistive Equipment (MAE) National Coverage Determination (NCD), POVs may be medically necessary for beneficiaries who cannot effectively perform Mobility-Related Activities of Daily Living (MRADLs) in the home using a cane, walker, or manually operated wheelchair. 

Power Operated Vehicles (POVs or scooters): Under the Mobility Assistive Equipment (MAE) National Coverage Determination (NCD), POVs may be medically necessary for beneficiaries who cannot effectively perform Mobility-Related Activities of Daily Living (MRADLs) in the home using a cane, walker, or manually operated wheelchair. 

Power (Motorized) Wheelchairs: Under the MAE NCD, power wheelchairs may be medically necessary for beneficiaries who cannot effectively perform MRADLs in the home using a cane, walker, manually operated wheelchair, or a POV/scooter. In addition, the beneficiary must demonstrate the ability to safely and effectively operate the power wheelchair. Most beneficiaries who require power wheelchairs are non-ambulatory and have severe weakness of the upper extremities due to a neurological or muscular condition.

For more information:



PV-PQRS Registration Open Until September 30

The Physician Value-Physician Quality Reporting System (PV-PQRS) Registration System is open for authorized representatives of group practices to register to participate in the PQRS Group Practice Reporting Option (GPRO) for CY 2014 via Qualified PQRS Registry, Electronic Health Record Incentive Program (EHR)or Web Interface (limited to groups with 25 or more eligible professionals (EPs) only). In general, if a group practice has 25 or more EPs, then the group can elect to supplement its PQRS reporting mechanism with the Consumer Assessment of Health Providers and Systems (CAHPS) for PQRS survey. However, if the group practice has 100 or more EPs and has selected the Web Interface reporting mechanism for 2014, then the group is required to report the CAHPS for PQRS survey. Group practices that have elected or are required to report the CAHPS for PQRS survey may choose to include their performance on the 2014 CAHPS for PQRS survey in the calculation of the group’s 2016 Value-Based Payment Modifier (VM). If a group does not register to participate through the PQRS GPRO, CMS will calculate a group quality score for the 2016 VM if at least 50 percent of the eligible professionals within the group report measures individually and meet the criteria to avoid the 2016 PQRS payment adjustment. The group does not have to register for this 50% threshold option.

Group practices of 10 or more EPs who don’t participate in PQRS in 2014, either as a group or by having at least 50% EPs reporting as individuals, will be subject to a -2% VM downward payment adjustment in 2016.

The PV-PQRS Registration System will close on September 30, 2014. Access the PV-PQRS Registration System at https://portal.cms.gov using a valid Individuals Authorized Access to the CMS Computer Services (IACS) User ID and password. 

CMS Issues Hospital Inpatient Payment Regulation

The final rule issued on August 4 by CMS adopts improvements in the quality of care that limit payment for hospital acquired conditions (HACs) and readmissions. The rule, which updates Medicare payment policies and rates for inpatient stays at general acute care and long-term care hospitals (LTCHs) for FY 2015, builds on the administration’s efforts for better hospital patient outcomes and slowing the long-term health care cost growth.

The rule also supports price transparency by reminding hospitals of the Affordable Care Act requirement to post or otherwise make their charges available to patients and the public.

“Today’s policies further support our efforts to continue improving the care our Medicare beneficiaries receive while also cutting the growth of Medicare costs,” said CMS Administrator Marilyn Tavenner. “This final rule builds on our recent efforts to improve hospital performance while giving hospitals the clarity and resources they need to deliver the best possible patient care.”

CMS announced that the payment rate update to general acute care hospitals will be 1.4 percent in FY 2015. The rate update for long term care hospitals will be 0.9 percent. The difference in the update is accounted for by different statutory and regulatory provisions that apply to each system. 

The final rule also summarizes ideas received from stakeholders on an alternative payment methodology for short stay inpatient cases that also may be treated on an outpatient basis.

Improving Patient Care

Hospital Value-Based Purchasing Program: The Hospital Value-Based Purchasing (VBP) Program, which was established by the Affordable Care Act, adjusts payments to hospitals under the Inpatient Prospective Payment System (IPPS) based on the quality of care they furnish to patients. For FY 2015, as directed by the law, CMS is increasing the applicable percent reduction, the portion of Medicare payments available to fund the value-based incentive payments under the program, to 1.5 percent of the base operating diagnosis-related group (DRG) payment amounts to all participating hospitals. CMS estimates that the total amount available for value-based incentive payments in FY 2015 will be approximately $1.4 billion.

Hospital Readmissions Reduction Program: The maximum reduction in payments under the Hospital Readmissions Reduction program will increase from 2 to 3 percent as required by law. For FY 2015, CMS will assess hospitals’ readmissions penalties using five readmissions measures endorsed by the National Quality Forum. CMS estimates that hospital readmissions in Medicare declined by a total of 150,000 from January 2012 through December 2013.

Hospital Acquired Condition Reduction Program: CMS is implementing the Affordable Care Act’s Hospital Acquired Condition Reduction Program. Beginning in FY 2015, hospitals scoring in the top quartile for the rate of HACs (i.e. those with the poorest performance) will have their Medicare inpatient payments reduced by one percent. This new program builds on the progress in this area achieved through the existing HAC program, which is currently saving approximately $30 million annually by not providing additional Medicare 
payment for treatment of certain conditions that are reasonably preventable when those conditions are acquired after the beneficiary has been admitted to the hospital for a different condition.

Quality Reporting Programs: The rule’s changes to Medicare quality incentive programs will continue to encourage high quality care while decreasing the time and effort it takes for providers to report the information. It will also align certain reporting requirements in both the Electronic Health Record (EHR) Incentive Program and the Hospital Inpatient Quality Reporting (IQR) Program. 

The final rule revises measures for the Hospital Inpatient Quality Reporting, LTCH Quality Reporting and PPS-Exempt Cancer Hospital Quality Reporting Programs.

Wage Index - Updated Labor Market Areas

The law requires that Medicare adjust its inpatient hospital payment for area differences in the cost of labor—an adjustment known as the wage index. CMS is revising the labor market areas used for the wage index based on the most recent Office of Management and Budget (OMB) Core-Based Statistical Area delineations that are based on 2010 Census data.In order to mitigate potential negative payment impacts due to the adoption of the new OMB delineations, CMS is adopting a one-year transition during FY 2015 that would be based on a 50/50 blend of the former wage index and the new wage index. The new wage index will take effect in full in FY 2016. This will be for all hospitals that would experience a decrease in their wage index exclusively due to the implementation of the new OMB delineations, and a three-year transition for the relatively few hospitals currently located in an urban county that would become rural under the new OMB delineations.

Final rule strengthens tie between payment and quality improvement

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Will Medicare contractors accept the CPT consultation codes when Medicare is the secondary payer?

Medicare will also no longer recognize the CPT consultation codes for purposes of determining Medicare secondary payments (MSP). In MSP cases, providers must bill an appropriate E/M code for the E/M services previously reported and paid using the CPT consultation codes. If the primary payer for the service continues to recognize CPT consultation codes for payment, providers billing for these services may either: 

Bill the primary payer an E/M code that is appropriate for the service, and then report the amount actually paid by the primary payer, along with the same E/M code, to Medicare for determination of whether a payment is due; or 

Bill the primary payer using a CPT consultation code that is appropriate for the service, and then report the amount actually paid by the primary payer, along with an E/M code that is appropriate for the service, to Medicare for determination of whether a payment is due. 

Reference: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1010.pdf

CMS Launches Next Phase of New Quality Improvement Program

On July 18, CMS awarded additional contracts as part of a restructuring of the Quality Improvement Organization (QIO) Program to create a new approach to improve care for beneficiaries, families and caregivers. QIOs are private, mostly not-for-profit organizations staffed by doctors and other health care professionals trained to review medical care and help beneficiaries with complaints about the quality of care and to implement improvements in the quality of care available throughout the spectrum of care. The new contracts being awarded to fourteen organizations represent the second phase of QIO restructuring. The awardees will work with providers and communities across the country on data-driven quality initiatives. These QIOs will be known as Quality Innovation Network (QIN)-QIOs.

QIN-QIO projects will be based in communities, health care facilities and clinical practices. They will drive quality by providing technical assistance, convening learning and action networks for sharing best practices, collecting and analyzing data for improvement. HHS National Quality Strategy (NQS) and the CMS Quality Strategy provide the framework for the contracts along with the companion, recommendations, and priorities.

Specifically, each QIN-QIO will work on strategic initiatives such as reducing healthcare associated infections, reducing readmissions and medication errors, working with nursing homes to improve care for residents, supporting clinical practices in using interoperable health information technology to enable the exchange of essential health information to improve the coordination of care, promoting prevention activities, reducing cardiac disease and diabetes, reducing health care disparities and improving patient and family engagement. QIN-QIOs will also provide technical assistance for improvement in CMS value based purchasing programs, including the physician value based modifier program.

As a result of the changes, some hospitals and providers will now work with a different QIO than in the past. The new QIN-QIO contracts were competitively awarded. The restructured program will continue to ensure that the entire country participates in strategic initiatives and that local practices are considered. The first phase of the restructuring – which CMS announced on May 9, 2014 –allows two Beneficiary and Family-Centered Care (BFCC) QIO contractors to perform the program’s case review and monitoring activities separate from the quality improvement activities performed by QIN-QIOs. CMS will introduce the program changes with the beginning of its five year, 11th Statement of Work – the QIO contracts cycle – on August 1, 2014.

For more information please visit: http://cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/2014-07-18.html?DLPage=1&DLSort=0&DLSortDir=descending

CPT 90999 for Isolated Ultrafiltration

Recently, Novitas reviewed services reporting Isolated Ultrafiltration for Management of Fluid Overload in Cardiac Disease. Following the review, it was determined that HCPCS code 90999, Unlisted Dialysis Procedure, Inpatient or Outpatient is the most accurate HCPCS code to report for this service.

Effective for dates of service on or after August 14, 2014, claims for ultrafiltration for management of fluid overload in cardiac disease should be reported with HCPCS code 90999. Consistent with the current process for Not Otherwise Classified (NOC) codes, payment for these services will be determined by the Contractor. Please refer to the Local Contractor Pricing Webpage for additional information regarding the determination of fees.

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