Medicare Compliance & Reimbursement

If you simply can’t wait until Jan. 1 to access new codes, the Centers for Medicare & Medicaid Services (CMS) has a gift for you, with two new orthotics codes that you can use effective Oct. 14. The new codes for prefabricated knee orthoses were published in CMS Transmittal 3016, which was issued on Aug. 8, and are as follows:

• K0901: Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf 
  
• K0902: Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf
  

These new codes are payable as leg braces, which are defined as “Rigid or semi-rigid devices which are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body,” CMS explains in the Transmittal.

To read Transmittal 3016, visit www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3016CP.pdf.

MAC Clarifies Modifier 22 Submissions

If you consider yourself modifier 22’s biggest fan, chances are high that your MAC is taking notice. Part B MAC NGS Medicare sent out a clarification on Aug. 6 noting that using modifier 22 requires you to maintain documentation that supports the “substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, etc.).”

In addition, NGS says that when you submit claims with modifier 22 (Increased procedural services) appended, “you may attempt to explain justification on the electronic comment field,” on which you explain why you have appended the modifier and what additional work the physician performed to warrant its use.

“Please note that having this information up front does speed up the processing time for these claims and will save mailing costs for providers,” NGS advises. You can add the information in box 19 of the CMS-1500 form or attach records to your claim.

Hint: If, however, you are appending modifier 22 to an E/M code, don’t expect any consideration at all. This is an inappropriate use of the modifier, NGS adds.

Home Health Coders: Now’s The Time to Eliminate Manifestation Codes as Primary

Incorrect diagnosis code reporting could bounce your claims back to you when new edits hit. You may be looking ahead to ICD-10 implementation, but perhaps you should be paying more attention to ICD-9 in the meantime.

Why? On Jan. 1, the Centers for Medicare & Medicaid Services (CMS) will implement edits that will return home health agency claims that contain a manifestation code as primary. Under ICD-9 coding conventions, a manifestation code may only be listed after the code for its underlying condition.

“An analysis of Outcome Assessment and Information Set (OASIS) records and claims for CY 2011 revealed that some agencies were not complying with the coding guidelines when reporting the primary diagnosis, in particular with regards to certain codes that require the underlying condition be sequenced first followed by the manifestation,” CMS says in Change Request 8813. “Given the concerns regarding compliance with coding guidelines, CMS is adopting edits to ensure greater compliance of coding guidelines for primary diagnosis codes.”

Do this: “The principal diagnosis reported on the home health claim shall be the ICD-9-CM code that is most related to the current home health plan of care,” CMS instructs. “HHAs shall not submit manifestation codes as the primary diagnosis.”

The CR is at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1405OTN.pdf. 

Learn Hospice Drug Reporting Lessons From New MAC Tool

CMS may have fixed the claims system glitch affecting hospice claims with infusion pump charges, but hospice providers are still running into plenty of other problems when it comes to reporting drugs on claims.

Home Health & Hospice Medicare Administrative Contractor CGS is offering a helping hand on the matter. The MAC’s new Hospice Prescription Drug Reporting Table quick resource tool “was developed to provide information on how to report prescription drugs on hospice claims,” CGS says in a message to providers.

“Keep this tool handy to ensure the appropriate billing information is submitted based on how the drug is administered,” the MAC says.

For example: “The 0250 revenue code line only requires a valid value (i.e., whole number) because the actual units (quantity) are reported in the NDC field,” the tool explains. “Providers can report a unit of ‘1’ or any other value that may assist them internally.”

The tool is at www.cgsmedicare.com/hhh/education/materials/pdf/hospice_presdrugreportingtable.pdf.