MLN Matters Number: MM6397
Related Change Request (CR) #: 6397
Related CR Release Date: March 4, 2009
Effective Date: January 1, 2009
Related CR Transmittal #: R1691CP
Implementation Date: April 6, 2009
Provider Types Affected
Physicians, non-physician practitioners, and providers submitting claims to Palmetto GBA for professional services provided to Medicare beneficiaries that are paid under the Medicare Physician Fee Schedule (MPFS).
Provider Action Needed
This article is based on Change Request (CR) 6397 which amends payment files that were issued to contractors based upon the 2009 Medicare Physician Fee Schedule (MPFS) Final Rule. Physical therapists should pay particular attention to the 'Background Section' regarding the billing of canalith repositioning procedures.
Background
Section 1848(c)(4) of the Social Security Act authorizes the Secretary to establish ancillary policies necessary to implement relative values for physicians’ services.
Canalith Repositioning
In the 2009 MPFS Final Rule, the Centers for Medicare & Medicaid Services (CMS) discussed a newly created CPT code 95992 that describes canalith repositioning procedures. CMS indicated that, prior to the new CPT code; this service was billed by physicians as part of an Evaluation and Management (E/M) service, and by other practitioners, primarily therapists, using existing codes. CMS assigned the code a status indicator of B (bundled), and stated that bundling this code is most appropriate because this service is currently being paid for as part of an E/M service. However, since therapists also provide this service and they cannot bill for E/M services, they should continue to bill CPT code 97112 for this service.
2009 Physician Quality Reporting Initiative (PQRI) Program
CMS identified a technical problem affecting twenty quality-data codes (QDCs) used for reporting thirteen quality measures through the claims-based method for the 2009 Physician Quality Reporting Initiative (PQRI). These 20 QDCs are new codes for the 2009 PQRI. The CPT II codes and the 2009 PQRI measures affected are listed below.
|
CPT II Code
|
Measure #
|
Measure
|
|
3250F
|
99
|
Breast Cancer Resection Pathology Reporting: pT
Category (Primary Tumor) and pN Category (Regional
Lymph Nodes) with Histologic Grade
|
|
3250F
|
100
|
Colorectal Cancer Resection Pathology Reporting: pT
Category (Primary Tumor) and pN Category (Regional
Lymph Nodes) with Histologic Grade
|
|
3570F
|
147
|
Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy
|
|
3016F
|
173
|
Preventive Care and Screening: Unhealthy Alcohol Use –
Screening
|
|
3455F
|
176
|
Rheumatoid Arthritis (RA): Tuberculosis Screening
|
|
4195F
|
176
|
Rheumatoid Arthritis (RA): Tuberculosis Screening
|
|
4196F
|
176
|
Rheumatoid Arthritis (RA): Tuberculosis Screening
|
|
3470F
|
177
|
Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
|
|
3471F
|
177
|
Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
|
|
3472F
|
177
|
Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
|
|
1170F
|
178
|
Rheumatoid Arthritis (RA): Functional Status Assessment
|
|
3475F
|
179
|
Rheumatoid Arthritis (RA): Assessment and Classification
of Disease Prognosis
|
|
3476F
|
179
|
Rheumatoid Arthritis (RA): Assessment and Classification
of Disease Prognosis
|
|
0540F
|
180
|
Rheumatoid Arthritis (RA): Glucocorticoid Management
|
|
4192F
|
180
|
Rheumatoid Arthritis (RA): Glucocorticoid Management
|
|
4193F
|
180
|
Rheumatoid Arthritis (RA): Glucocorticoid Management
|
|
4194F
|
180
|
Rheumatoid Arthritis (RA): Glucocorticoid Management
|
|
4148F
|
183
|
Hepatitis C: Hepatitis A Vaccination in Patients with HCV
|
|
4149F
|
184
|
Hepatitis C: Hepatitis B Vaccination in Patients with HCV
|
|
0529F
|
185
|
Endoscopy & Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps –
Avoidance of Inappropriate Use
|
|
4267F
|
186
|
Wound Care: Use of Compression System in Patients with
Venous Ulcers
|
In most instances, the technical problem has caused line items containing any of the QDCs listed above to reject/return as unprocessable. In those circumstances, the eligible professional (EP) received a message other than N365 indicating that the procedure code was not accepted for reporting proposes. Since this is an issue that affects claims-based PQRI reporting only, the reporting of quality measures through registries is not affected.
CMS is actively working with the Palmetto GBA to address this issue. All carriers will be able to accept the affected codes within the next three weeks. Once this has been accomplished, submission of the affected CPT II codes will result in the normal N365 message on the remittance advice indicating that the code has been accepted for reporting purposes.
In order to minimize any adverse impact on EPs for determination of satisfactory reporting for affected measures, CMS will exclude from the reporting denominator all cases for dates before which the Palmetto GBA could accept the affected CPT II codes, unless inclusion of cases for such dates is more favorable to the EP. In view of this, EPs have the option to seek correction of 1st Quarter (i.e., January 1, 2009 – March 31, 2009) QDC submissions which were returned as unprocessed if desired, but EPs would not be required to seek correction for the affected codes. The two basic options for EPs are:
A. Do not seek correction of the submitted codes which were returned unprocessed.
As indicated above, CMS will exclude from the determination of satisfactory reporting cases for dates prior to the date the Palmetto GBA can process the relevant codes. Thus, EPs are not required to seek correction of claims. On the other hand, EPs who have begun to submit codes for the affected measures should continue to submit such codes. The beginning of acceptance of the codes will be apparent when the N365 message is noted on the remittance advice. The 2009 reporting period will not be changed and the EP who qualifies for the incentive based on the listed or affected measures will receive the 2% incentive payment with respect to the entire reporting period.
B. Seek correction of the submitted codes that were returned unprocessed.
In certain circumstances, EPs may desire to seek correction of the unprocessed claims. To accomplish this, EPs who have already billed and included any of the listed QDCs for dates of service January 1, 2009, and after and received a message other than N365 on their remittance advice, can call Palmetto GBA and request a correction beginning April 1, 2009. In this case the EP should be prepared to give specific claim information to Palmetto GBA, such as, the internal control number (ICN), the beneficiary’s health insurance claim number (HIC), dates of service and the QDCs. EPs who began reporting the affected measures using the Measures Group Consecutive Method during the first three months of 2009 may find that it is worthwhile to pursue correction.
Note: PQRI reporting and performance rate analysis for ONLY the affected measures will initially be performed after excluding cases for the first three months of 2009. If an EP does not qualify based on this calculation, then the EP’s claims without excluding claims for the first 3 months of 2009 will be evaluated. Thus, the determination of satisfactory reporting will be evaluated both ways for all EPs who report on the relevant measures.
Other specific changes included in the April Update to the 2009 MPFSDB are detailed in Attachment 1 of CR 6397. That CR is available at www.cms.hhs.gov/Transmittals/downloads/R1691CP.pdf. Key changes, however, are summarized as follows:
These Current Procedural Terminology /Healthcare Common Procedure Coding System (CPT/HCPCS) codes are assigned a Procedure Status = M as follows:
- CPT codes: 0529F, 0540F, 1170F, 3016F, 3250F, 3455F, 3470F, 3471F, 3472F, 3475F, 3476F, 3570F, 4148F, 4149F, 4192F, 4193F, 4194F, 4195F, 4196F and 4267F
- HCPCS codes: G8489, G8490, G8491, G8492, G8493, G8494.
These CPT codes are assigned a Procedure Status = I as follows:
- 0575F, 4270F, 4271F, 4279F, 4280F
Physicians/providers should also note the following:
|
CPT/HCPCS Code/Modifier
|
Action
|
|
93351 Global
|
Long Descriptor: Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with physician supervision
Short Descriptor: Stress tte complete
|
|
93351 HCPCS modifier TC
|
Long Descriptor: Echocardiography, transthoracic, real-time with
image documentation (2D), includes M-mode recording, when
performed, during rest and cardiovascular stress test using
treadmill, bicycle exercise and/or pharmacologically induced
stress, with interpretation and report; including performance of
continuous electrocardiographic monitoring, with physician
supervision
Short Descriptor: Stress tte complete
|
|
CPT code/modifier 93351 26
|
Long Descriptor: Echocardiography, transthoracic, real-time with
image documentation (2D), includes M-mode recording, when
performed, during rest and cardiovascular stress test using
treadmill, bicycle exercise and/or pharmacologically induced
stress, with interpretation and report; including performance of
continuous electrocardiographic monitoring, with physician
supervision
Short Descriptor: Stress tte complete
|
Descriptor Changes
The long descriptor has been revised for the following codes:
|
HCPCS Code
|
Revised Long Descriptor
|
Revised Short Descriptor
|
|
G0248
|
Demonstration, prior to initiation of home INR monitoring, for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of 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’s ability to
perform testing and report results
|
N/A
|
|
G0249
|
Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart
valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the
home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests
|
N/A
|
|
G0250
|
Physician review, interpretation, and patient management of home INR testing for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets
Medicare coverage criteria; testing not occurring more frequently than once a week; billing units of service include 4 tests
|
N/A
|
Change in Procedure Status for CPT code 0085T
Effective for claims with dates of service on and after December 8, 2008, the Heartsbreath Test used to predict heart transplant rejection is nationally non-covered. CPT code 0085T, breath test for heart transplant rejection, is assigned procedure status of N and is no longer payable by Medicare.
April Update to the 2009 Medicare Physician Fee Schedule Database (MPFSDB)
Effective April 6, 2009, for services performed on or after January 1, 2009, the Centers for Medicare and Medicaid Services (CMS) have made changes to the following codes on the 2009 Medicare Physician Fee Schedule Database (MPFSDB).
Ohio MPFSDB Updates
|
Note
|
HCPCS Code
|
Modifier
|
PAR Amount
|
Non-PAR Amount
|
Limiting Charge
|
|
|
G0270
|
|
$25.03
|
$23.78
|
$27.35
|
|
#
|
G0270
|
|
$23.36
|
$22.19
|
$25.52
|
|
|
G0392
|
|
$2031.45
|
$1929.88
|
$2219.36
|
|
#
|
G0392
|
|
$489.82
|
$465.33
|
$535.13
|
|
|
G0393
|
|
$1528.82
|
$1452.38
|
$1670.24
|
|
#
|
G0393
|
|
$311.49
|
$295.92
|
$340.31
|
|
Note
|
CPT Code
|
Modifier
|
PAR Amount
|
Non-PAR Amount
|
Limiting Charge
|
|
|
93351
|
|
$242.40
|
$230.28
|
$264.82
|
|
|
93351
|
HCPCS modifier TC
|
$145.86
|
$138.57
|
$159.36
|
|
|
93351
|
CPT modifier 26
|
$96.54
|
$91.71
|
$105.47
|
West Virginia MPFSDB Updates
|
Note
|
HCPCS Code
|
Modifier
|
PAR Amount
|
Non-PAR Amount
|
Limiting Charge
|
|
|
G0270
|
|
$24.17
|
$22.96
|
$26.40
|
|
#
|
G0270
|
|
$22.68
|
$21.55
|
$24.78
|
|
|
G0392
|
|
$1854.87
|
$1762.13
|
$2026.45
|
|
#
|
G0392
|
|
$479.54
|
$455.56
|
$523.89
|
|
|
G0393
|
|
$1390.47
|
$1320.95
|
$1519.09
|
|
#
|
G0393
|
|
$304.46
|
$289.24
|
$332.63
|
|
Note
|
CPT Code
|
Modifier
|
PAR Amount
|
Non-PAR Amount
|
Limiting Charge
|
|
|
93351
|
|
$225.08
|
$213.83
|
$245.90
|
|
|
93351
|
HCPCS modifier TC
|
$131.59
|
$125.01
|
$143.76
|
|
|
93351
|
CPT modifier 26
|
$93.49
|
$88.82
|
$102.14
|
South Carolina MPFSDB Updates
|
Note
|
HCPCS Code
|
Modifier
|
PAR Amount
|
Non-PAR Amount
|
Limiting Charge
|
|
|
G0270
|
|
$24.56
|
$23.33
|
$26.83
|
|
#
|
G0270
|
|
$22.93
|
$21.78
|
$25.05
|
|
|
G0392
|
|
$1,976.23
|
$1,877.42
|
$2,159.03
|
|
#
|
G0392
|
|
$469.52
|
$446.04
|
$512.95
|
|
|
G0393
|
|
$1,489.81
|
$1,415.32
|
$1,627.62
|
|
#
|
G0393
|
|
$300.07
|
$285.07
|
$327.83
|
|
Note
|
CPT Code
|
Modifier
|
PAR Amount
|
Non-PAR Amount
|
Limiting Charge
|
|
|
93351
|
|
$232.32
|
$220.70
|
$253.81
|
|
|
93351
|
HCPCS modifier TC
|
$138.18
|
$131.27
|
$150.96
|
|
|
93351
|
CPT modifier 26
|
$94.14
|
$89.43
|
$102.84
|
# These amounts apply when service is performed in a facility setting.
Limiting charge applies to unassigned claims by non-participating providers.
All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2008 by the American Medical Association.
Additional Information
The official instruction, CR 6397, issued to Palmetto GBA regarding this change may be viewed at www.cms.hhs.gov/Transmittals/downloads/R1691CP.pdf (PDF, 199 KB).
If you have any questions, please contact our Provider Contact Center at our toll-free number (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092 (South Carolina Part B).
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2008 American Medical Association.