Gastroenterology Coding Alert

Part B reps address several pressing questions.

Do you see patients for aftercare following surgery, but you have trouble collecting for your services? Have you faced denials for invalid patient information? You can find solutions to these issues if you know the specifics that will help you most accurately report the services.

That was the word from CGS Medicare’s Towanna Tripp during the payer’s January 21, 2021 “Frequently Asked Question” webinar. She revealed the answers to seven pressing community questions during the session, and we’ve got the updates most applicable to gastroenterology practices.

Question 1: What Do MACs Need for Prior Authorizations?

One way that many GI practices maximize income is to get prior authorization for many services. This allows you to confirm that your work will be reimbursed, and can typically help you determine the patient responsibility. However, Tripp said, it’s not always required.

“For Medicare Part B, all services are allowed based on medical necessity,” she said. “This means you bill your services to us, and based on the diagnosis on your claim, we’re going to decide whether to allow that service. We often get questions requesting prior authorization for advanced imaging services like CT scans or MRIs. We do not require prior authorizations for these. The only things in Part B that do require prior authorizations are certain DME services and for certain Part A outpatient department services,” she noted.

Tripp’s statement is supported by CMS. In MLN Bulletin SE0916, the agency notes, “Medicare coverage and payment for items and services is contingent upon a determination that an item and service:

• Falls within a benefit category;
• Is not specifically excluded from coverage; and
• The item or service is “reasonable and necessary” unless specifically excluded from meeting this provision.”

Question 2: What Is the Update for Code 99072?

Most practices are aware that a new code debuted for additional supplies, material, and clinical staff time during the public health emergency (PHE). However, many providers are unsure of how to report 99072 (Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease).

“CMS has not changed its position on this code,” Tripp said. “It’s treated like any other supply code — there are no RVUs for it, and therefore there’s no fee schedule amount established for it. Also, this is considered a bundled procedure code, so if you bill an office visit and 99072, we’re going to deny it as bundled. The patient is not responsible for your office supplies.”

She also indicated that CGS doesn’t expect CMS to make further changes to the guidance for this service. “As far as we know, this is going to be CMS’ final say-so about this code,” she said. “It is not separately payable to anyone — physicians or hospitals.”

Keep in mind that although CMS has declared 99072 to be bundled (not separately payable), some non-Medicare payers reimburse the code enough to make it worth inquiring with your main commercial payers about coverage.

Question 3: Who Can Bill for the COVID Vaccines?

Although not every practice has the option of receiving COVID vaccine supplies, some do, which may make you wonder whether you need to meet any specific eligibility requirements to bill these.

“If you’re already a Medicare provider and you can already give the flu and pneumonia vaccines, you can give this vaccine,” Tripp said. “You don’t need to take any additional action to administer and bill the COVID vaccine,” she noted.

If you’re a provider who doesn’t already give vaccines, but you want to (for instance, a radiation therapy center), contact your Part B MAC and ask to be separately enrolled as a mass immunizer, she said.

Question 4: How Much Money Do We Bill Medicare for the COVID Vaccine?

Although you may be tempted to create an internal fee schedule amount for the COVID vaccine, the reality is that the medication itself gets a zero charge to Medicare payers, Tripp said.

“Right now, since the government is giving away the COVID-19 vaccine for free, you will only bill for the administration code,” Tripp said. “The vaccine right now is not needed on the claim; our system is set up to accept the administration only, but if you have to bill for the vaccine, (for instance, if your state law requires you to do that), you can bill it with a charge of one cent,” she said.

Like the influenza and pneumonia vaccines, there are no deductibles or coinsurance/copayments for the COVID vaccines. Specific codes for administration of a specific vaccine can be found at www.ama-assn.org/find-covid-19-vaccine-codes. This will be updated as new vaccines are approved by FDA.

Question 5: Are the COVID Vaccine Rules Different for Medicare Advantage?

CMS advises Medicare Advantage (MA) providers to submit vaccine claims to the MAC, so many coders want to know if they should submit those claims to Medicare instead of the managed care payer.

“Yes,” Tripp said. “If you have a patient who’s enrolled in a managed care plan, much like hospice services or clinical trials, if you give the COVID vaccine to the patient, you’ll bill those administration claims to us, and we will pay that for the MA patient.