Pulmonology Coding Alert

Are you already eligible to bill for COVID-19 vaccinations? Should you skip billing Medicare Advantage for your vaccine services? The answer to both of these questions can vary based on your circumstances, and you should know the nuances that will allow you to most accurately report these 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 pulmonology practices.

Question 1: What Do MACs Need for Prior Authorizations?

One way that many pulmonology 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.”

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.

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

CMS advises Medicare Advantage 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.

No particular modifiers are necessary — you can just bill the code as-is,” she said. “This is for COVID only; this does not include the flu or pneumonia vaccines.”

Question 6: Why Are Claims Denying for Invalid Patient Information?

If you’ve ever gotten a claim denied for invalid patient information and you’re sure you submitted the correct Medicare Beneficiary Identifier (MBI) to the payer, you’re not alone, Tripp said.

“We get this question a lot, especially with the new MBI,” she noted. If this happens, you should first verify the patient’s name spelling and that the patient’s name and MBI match, she said.

One way this can happen is if a patient loses their Medicare card. In the past, they’d get a new card with the same ID number on it as they had before (which was their Social Security number). However, with the MBI, if a patient loses their card, Medicare will send them a new card with a totally new MBI on it, she added.

Another problem that can occur happens because two of your patients may have the same name, so your system may pull up the wrong MBI if you just input the patient name into your system.

“Make sure you know their government name,” she said. “You may call a patient by one name, but their official name may be something different.” You can use your Part B MAC’s MBI lookup tool if necessary, if you have their name, birth date, and Social Security number. Customer service will protect patient information and will not release a patient’s MBI to you if you call your MAC, she noted.

Question 7: Our Physician Rendered Postop Care Only, But Our Claims Are Being Denied.

It happens from time to time: Patients may go to another city for a surgery, such as a lung resection, and then return to their hometown, where your pulmonologist will handle the postoperative care. Getting paid for postop care only can be tricky, Tripp noted.

In these cases, physicians other than surgeons who are providing postoperative care should use modifier 55 (Postoperative management only) for procedures with global periods of 10 or 90 days, Tripp said. “Report the date of surgery as the date of service (DOS), not when you first saw the patient.” For instance, perhaps the patient had surgery on Jan. 1, but you didn’t see them until Jan. 9. The DOS is Jan. 1, not Jan. 9, she said. “Indicate the ‘assumed’ and ‘relinquished’ information in item 19 of the claim form, she noted.

“The receiving physician must provide at least one service before billing any part of the postoperative care,” she noted. “So, if the patient had surgery on Jan. 1, you can’t bill us on Jan. 2 for the postop care. You have to wait to see the patient first before doing that.”

The surgeon who performed the surgery may forget to put modifier 54 (Surgical care only) on their claim. “They may have relinquished the postop care to your physician, but they forgot to bill their surgery claim with the 54 modifier, so when that comes in, we have no idea whether the surgeon relinquished their care until you bill your claim,” Tripp said regarding the payer’s perspective. “By this time the surgeon has already gotten paid, not only for the surgery but also for the postop. They got paid for the entire global package.”

To correct this, you must contact the surgeon and let them know they made an error and received the money for the postop care. They will have to send a correction to the insurer’s overpayment recovery department so they can recoup that portion of the claim. “They have to bill it with the 54 modifier and we can adjust the claim and recoup our money back and once that’s done, you’ll be able to bill your claim for the postop care,” she said. “Make sure you’re working closely with the surgeon’s office, and that they’re getting their info in as soon as possible, because even though they got paid for the postop care, your claim is being rejected for a billing error, so you’re on a time limit to get that claim into us within a year from the DOS so you can get your payment.”

If the surgery occurred in another state, indicate that in block 19, she advised. Some issues stem from the fact that the surgery was in one state and the postop care was in another, which should be made clear to the MAC so the processors know to verify that the out of state provider billed the claim correctly as well.