DRG Coding Advisor-New Medicare fee schedule has coding implications
Here's the nitty-gritty of new payment policy
Medicare's new 2000 physician fee schedule final rule will have a strong impact on coding operations. Here's a summary of the major changes payment officials and coders can expect, according to the Baltimore-based Health Care Financing Administration (HCFA):
• Site-of-service differential. HCFA makes it very clear that it intends "to limit the facility rate so that it cannot be higher than the nonfacility rate for any given code."
For practice expense purposes, the rule defines facilities as hospitals, skilled nursing facilities (SNFs), and ambulatory surgical centers (ASCs). All other sites of service are considered to be nonfacility settings.
The idea is that office-based practitioners have higher operating costs than facility practices, where the hospital is already being reimbursed by Medicare for the cost of such things as clinical staff, medical supplies, and equipment.
• Mixed facility. In facilities where there is a "mixture'' of nursing home and SNF patients, HCFA also makes the physician responsible for ascertaining that there will be no Part A bill for the service in order to use the nonfacility designation.
"We do not believe that it would be an onerous task for the physician to determine at the time of service whether the patient is a SNF or a nursing home patient," HCFA says. "This information is needed to pay the bill correctly, and the physician is in the best position to obtain this information quickly."
• ASC-approved payments. Reacting to earlier confusion around this issue, HCFA clarifies that when a physician performs a procedure on the ASC-approved procedures list in an ASC, the lower facility practice expense RVUs apply. However, when a physician performs a procedure in an ASC that is not on the ASC-approved procedures list, the higher nonfacility practice expense RVUs apply.
• End-stage renal disease. Reacting to concerns about the application of the site-of-service differential to the monthly capitated payment (MCP) for end-stage renal disease services (CPT codes 90918 through 90921), HCFA agreed that site-of-service designations are not meaningful for a monthly service that may be provided in different settings for the same patient during a given month. In turn, the final rule specifies that codes 90918 through 90921 "should always be reported as a nonfacility service."
• Physicians' clinical staff in the facility setting. Despite opposition from surgical and other hospital-intensive specialties, HCFA went ahead with its proposal to no longer include any of the time a physician's personal staff spends assisting him or her in a facility setting in the practice expense payment.
HCFA says this is justified because:
— Medicare ends up paying twice for the same service.
— It is not typical practice for most specialties to use their own staff in a facility setting.
— Inclusion of these costs is inconsistent with both the law and Medicare regulations.
HCFA says it wants "to make it clear that we are not asserting that physicians never bring their own clinical staff into the facility setting or that this practice may not be more common among some specialties than among others." However, HCFA has not "seen sufficient data to convince us that the use of the physician's clinical staff in the facility setting is a typical practice."
HCFA did leave the door open for future reconsideration of this issue, saying there may be "some" clinical tasks that clinical office staff can appropriately perform for a facility patient — but scheduling tests or procedures is definitely not one of them.
But, before it revises its position, HCFA wants to see a general consensus regarding which specific tasks should be included and the time it takes to perform them.
"Once there is a general approach to this issue, we would consider recommendations for specific services," says HCFA.
• Assisted suicide. The Assisted Suicide Funding Restriction Act of 1997 prohibits the use of federal funds to furnish or pay for any health care service or health benefit coverage for the purpose of causing, or assisting to cause, the death of an individual. However, the prohibition does not apply to withholding or withdrawing medical treatment, nutrition, or hydration, or to furnishing a service to alleviate pain.
The rule conforms Medicare regulations to exclude from coverage any health care service for the specific purpose of causing, or assisting to cause, the death of an individual.
• CPT modifier -25. The global surgery payment policies described in section 4820 of the Medicare Carriers Manual apply to procedures that have global periods of 0, 10, and 90 days as shown on the physician fee schedule database.
Currently, only when a significant, separately identifiable evaluation and management (E/M) service is furnished before furnishing a procedure with a global period of 0, 10, or 90 days will the E/M service be paid in addition to the procedure.
The coding mechanism for indicating that the E/M service is not related to the surgical procedure is to append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service code.
HCFA's new rule says for procedures that have a global period indicator of "XXX,'' when a significant, separately identifiable E/M service is furnished at the same time by the same physician, the physician must append the modifier -25 to the E/M service code.
HCFA justifies this new policy by arguing every procedure has an inherent E/M component. Therefore, for an E/M service to be paid separately, a significant, separately identifiable service would have to be documented in the medical record.
"In other words, we want to prevent the practice of physicians reporting an E/M service code for the inherent evaluative component of the procedure itself," notes the final regulation.
Responding to practitioners' confusion regarding whether this new policy would apply to diagnostic tests, immunizations, laboratory, and pathology services, HCFA says it is not making a blanket requirement that modifier -25 be used with every code in a specific category of services.
Policy targets 'abuse or potential for abuse'
"Rather, we will implement this coding policy for specific HCPCS codes when we believe there is abuse or the potential for abuse in the reporting of an E/M service," HCFA says. "Before implementing an edit for a specific code combination, we will provide an opportunity for review by physician groups."
• Prostate cancer screening tests. As of Jan. 1, 2000, this section provides for Medicare coverage of an annual prostate cancer screening, digital rectal examination (DRE), and an annual screening prostate-specific antigen (PSA) test for men at least age 50 plus one day.
To qualify, the DRE screening must be performed by the patient's attending physician who is either a doctor of medicine or qualified osteopathy, or by the beneficiary's attending physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS), or certified nurse midwife.
HCFA also created two new HCPCS codes to go with the new regulation:
— HCPCS G0102, prostate cancer screening DRE, to be used for the screening DRE. Because "a DRE is a relatively quick and simple procedure, . . . we have assigned it the same value as CPT code 99211, the lowest level E/M service," notes HCFA.
Also, because a DRE is usually furnished as part of an E/M service, the agency says it would be extremely rare for a DRE to be the only service provided during a patient encounter. As such, it is also bundling the DRE into the payment for an E/M service when a covered E/M service is furnished on the same day as a DRE.
"If the DRE is the only service furnished or is provided as part of an otherwise noncovered service, such as CPT code 99397 (preventive services visit), HCPCS code G0102 would be payable separately if all the aforementioned coverage requirements are met," the rule notes.
— HCPCS G0103, prostate screening; prostate-specific antigen, to be used for the screening PSA test. The screening PSA test is priced at the same payment rate as CPT code 84153 (PSA; total) and will be paid under the clinical diagnostic laboratory fee schedule.
• Diagnostic tests. The rule removes restrictions on the areas and settings in which NPs, CNSs, and PAs may be paid for services otherwise furnished by a physician for diagnostic testing.
HCFA also specifies that when it comes to diagnostic X-rays and other diagnostic tests, no physician supervision is required for tests performed by NPs and CNSs when they are authorized by the state to perform these tests. Existing regulations are further modified to pay for diagnostic tests that a PA is legally authorized to perform under state law with only a general level of physician supervision.
The rule adds an exception removing physician supervision rules from pathology and laboratory codes in the 80000 series of the CPT payable under the physician fee schedule.
"These codes are within the scope of the Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations, and we determined it would be unnecessarily confusing to apply another separate set of supervision rules to the performance of these procedures," says HCFA. In turn, the CLIA regulations will determine the level of supervision necessary, if any, for these procedures.
Also, HCFA notes that it wants to make clear that no relative technical components are not subject to the payment reduction for services of nonphysician practitioners.
• Nurse practitioner ability to directly bill Medicare. As required by the Balanced Budget Act of 1997 (BBA), this rule authorizes qualified NPs to directly bill Medicare for performing physicians' services.
HCFA notes that it does not want to "establish qualifications . . . that would cause experienced NPs, who have been furnishing services to Medi care patients, to be barred from billing under the Medicare program because they do not possess a master's degree or national certification."
In turn, to be paid by Medicare under the new rule, a nurse practitioner must be a registered professional nurse authorized by the state to provide services and must meet one of the following criteria:
1. be certified as a nurse practitioner by a recognized national certifying body that has established standards for nurse practitioners;
2. be a registered professional nurse authorized by the state to practice and be granted a Medicare billing number as a nurse practitioner by Dec. 31, 2000;
3. apply for a Medicare billing number for the first time on or after Jan. 1, 2001, and meet the standards for nurse practitioners;
4. be a nurse practitioner who, on or after Jan. 1, 2003, applies for a Medicare billing number for the first time and possesses a master's degree in nursing and meets the standards for nurse practitioner.
NPs get grandfathered in
HCFA noted that some groups were concerned that an NP whose Medicare number expires in the future might have to meet new and more stringent qualification requirements, depending on the year he or she reapplies for a new Medicare number. The agency notes that as of Jan. 1, 2001, these new qualifications only apply to NPs applying for Medicare numbers for the very first time. Therefore, "an NP would be subject only to the qualification requirements under which he or she received the initial Medicare number."
• RVUs, pediatric service. Work RVUs for certain pediatric surgical services are adjusted to correct previous data omissions.
• RVUs, physician's interpretation of Pap smears.
To accommodate new technology, codes for a physician's interpretation of an abnormal Pap smear were revised in the November 1998 proposed version of the rule to include three HCPCS level II codes (P3001, G0124, and G0141) in addition to the CPT code 88141. In the final rule, HCFA finalizes this proposal, "making the practice expense RVUs identical for HCPCS codes P3001, G0124 and G0141."
• Physician pathology services and independent laboratories. This provision revises regulations to end payments to independent laboratories under the physician fee schedule for technical component physician pathology services furnished to hospital inpatients after Dec. 31, 2000.
Independent laboratories will still be able to bill and receive payment from their Medicare carrier for the technical component of a physician pathology service furnished to beneficiaries who are not hospital inpatients. For the technical component of physician pathology services provided to a hospital inpatient, however, the hospital would have to bill, and the independent laboratory would make arrangements with the hospital to receive payment.
• Discontinuous anesthesia time. Regulations are revised to allow anesthesiologists and certified registered nurse anesthetists (CRNAs) to add blocks of time around a break in continuous anesthesia care as long as there is continuous monitoring of the patient within the blocks of time.
In turn, anesthesiologists and CRNAs should report the total anesthesia time on the HCFA claim form as the sum of the continuous anesthesia block times. The medical record should be documented so a medical record auditor can see the continuous and discontinuous periods and can verify that the reported total anesthesia time is equal to the blocks of continuous time.
• Optometrists. The rule clarifies that Medi-care Part B pays for the medical services of a doctor of optometry just as it would any other physician. This, in turn, permits optometrists to certify and rectify a beneficiary's need for occupational therapy services.
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