Saturday, March 26, 2016

CPT Modifier 1P

Description for 1P:
Medical reasons

Guidelines for 1P Modifier:
In general, PQRI quality measures consist of a numerator and a denominator that permit the calculation of the percentage of a defined patient population that receive a particular process of care or achieve a particular outcome.
  • Where a patient falls in the denominator population but specifications define circumstances in which a patient may be excluded from the measure’s denominator population, CPT Category II code modifiers 1P, 2P, and 3P are available to describe medical, patient, or system reasons, respectively, for such exclusion
  • CPT modifier 1P: the quality measure was not applied due to medical reasons
  • This modifier is only valid with some measures
  • This modifier may only be reported with the CPT Category II codes for quality measures. It does not apply to HCPCS codes for quality measures.
  • Refer to each individual quality measure for specific indications for this modifier

HCPCS Modifier AQ

Description for AQ:
Physician providing a service in a health professional shortage area.

Guidelines/Instructions for AQ:
Submit HCPCS modifier AQ in the following instances:

  • When you provide services in ZIP code area that does not fall entirely within a designated full county HPSA bonus area
  • When you provide services in a ZIP code area that falls partially within a full county HPSA but is not considered to be in that county based on the USPS dominance decision
  • When you provide services in a ZIP code area that falls partially within a non-full county HPSA
  • When you provide services in a ZIP code area that was not included in the automated file of HPSA based on the date of the data run used to create the file
  • When services are provided in areas that were eligible for the HPSA bonus on December 31 of the prior year but were not on the automated ZIP code list 
  • Designated HPSAs change periodically, so it is important to verify that services fall in a HPSA before submitting claims. 
Do not submit HCPCS modifier AQ in the following instances:
  • You are submitting a technical-only component code (e.g., CPT code 93005)
  • The service was not rendered in a HPSA
  • The service was performed by someone that does not meet the definition of a physician (psychiatrists are included in the definition of a physician)
To determine if you qualify to automatically receive the bonus payment, you can review the information provided on the CMS website (refer to the link above). If the ZIP code of the location where you render services does not appear there, check the Palmetto GBA website for HPSA designations to determine if the location where you render services is within a HPSA bonus area, but still requires the submission of the HCPCS modifier AQ. The most current source of HPSA designations is the HRSA website. Physicians may use the HRSA website designations when making the decision on whether or not to include HCPCS modifier AQ on their claims.

HCPCS Modifier Q6

HCPCS Modifier Q6 Services furnished by a locum tenens physician

Guidelines/Instructions for Q6:
Guidelines Submit HCPCS modifier Q6 to indicate that services were provided under a locum tenens arrangement.

Locum tenens background:
  • Physicians may retain substitute physicians to take over their professional practices when they are absent for reasons such as illness, pregnancy, vacation or continuing medical education
  • These substitute physicians, known as 'locum tenens' physicians, generally have no practice of their own and move from area to area as needed
  • The regular physician generally pays the substitute physician a fixed per diem amount. The substitute physician's status is that of independent contractor, rather than employee, and his/her services are not restricted just to the physician's office.
  • Services of non-physician practitioners (e.g., CRNAs, NPs and PAs) may not be billed under the locum tenens or reciprocal billing reassignment exceptions. These provisions apply only to physicians.
The regular physician may submit a claim under the locum tenens arrangement using his/her own National Provider Identifier (NPI) and, if assignment is taken, receive payment for covered visit services if the following conditions are met:
  • The regular physician is unavailable to provide the visit/services
  • The Medicare patient has arranged or seeks to receive the visit/services from the regular physician
  • The regular physician pays the locum tenens physician for his/her services on a per diem or similar fee-for-time basis
  • The substitute physician does not provide the visit/services to Medicare patients over a continuous period of longer than 60 days
  • The regular physician identifies the services as substitute physician services with HCPCS modifier Q6 (services furnished by a locum tenens physician). Until further notice, the regular physician must keep on file a record of each service along with the substitute physician's NPI.
  • If postoperative services are furnished by the substitute physician, the services cannot be submitted with HCPCS modifier Q6 since the regular physician is paid a global fee
  • If services are provided by a substitute physician over a continuous period of longer than 60 days, the regular physician must submit the first 60 days with HCPCS modifier Q6
  • The substitute physician must submit for the remainder of the services in his/her own name
  • The regular physician may not submit and receive direct payment for services over the 60-day period
  • A new period of covered visits can begin after the regular physician has returned to work
For a medical group billing under the locum tenens arrangement, it is assumed that the locum tenens physician is paid by the regular physician.
  • The term 'regular physician' includes a physician who has left the group and for whom the group has hired the locum tenens physician as a replacement
  • A physician who has left a group, and for whom the group has engaged a locum tenens physician as a temporary replacement, may still be considered a member of the group until a permanent replacement is obtained
Exception to the 60-day limitation for locum tenens billing:
  • Section 116 of the Medicare, Medicaid and SCHIP Extension Act of 2007 extended the exception to the 60-day limit on substitute physician billing for physicians being called to active duty in the Armed Forces for services furnished from January 1, 2008, through June 30, 2008. Section 116 of Public Law 110-173 extended the accommodation of physicians ordered to active duty in the Armed Forces, enacted by Public Law 110-54, by striking 'January 1, 2008,' and inserting 'July 1, 2008'.
  • Essentially, both legislative acts allow a physician being called to active duty to bill for the services furnished by a substitute physician for longer than the 60-day limitationHC

Sunday, February 7, 2016

Difference Between 58 and 78 Modifier

Modifier 58, Staged or related procedure or services by the same Physician or other Qualified Health care Professional during the postoperative period.

When to Use modifier 58

Modifier 58 is used to identify those situations when a procedure or services may be staged(planned). While a return to the operating room for a related procedure
may be commonplace, a staged (planned) procedure or services may not be as routine. I will try to clarify the intent when to
exactly use modifier 58 with the procedure code. As per the CPT coding guidelines, Modifier 58 is assigned for any subsequent procedure,
Which is planned or has to be performed with the related original procedure. Following three key points should be remembered before
appending modifier 58 to the procedure codes.

Modifier 78

Unplanned return to the operating / procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period

Sunday, January 17, 2016

Secondary diagnosis is must ambulance service

Effective with services rendered October 1, 2015 and later, ALL ambulance transports require dual diagnoses.  Providers should report the primary diagnosis as the most appropriate ICD-10 code that adequately describes the patient’s medical condition at the time of transport.  In addition, a secondary diagnosis must be reported which reflects the patient’s need for the ambulance service and ambulance personnel at the time of transport.  In order for claims to be processed and paid in a timely manner it is important that claims submitted for ambulance services contain both the primary and secondary diagnosis.

Please refer to the Ambulance Local Coverage Article A54574 for a list of “suggested” ICD-10 codes that may be reported as a primary diagnosis. Please note that the list of diagnosis codes provided in A54574 is not an all-inclusive list. Other valid ICD-10 diagnoses codes that accurately describe the patient’s condition at the time of transport may be reported as a primary diagnosis.  Please refer to the Ambulance Local Coverage Determination (LCD) Policy for a list of four covered secondary diagnosis codes (Z codes).  The secondary diagnosis code should reflect why the transport is reasonable and necessary.  If the transport is not reasonable and necessary the LCD provides a non-covered Z code.

Saturday, January 16, 2016

Inpatient Hospital Payment Rate Impacted by the Consolidated Appropriations Act, 2016

Inpatient Hospital Payment Rate Impacted by the Consolidated Appropriations Act, 2016

On Friday, December 18, 2015, President Obama signed into law the Consolidated Appropriations Act, 2016.  Section 601, Modification of Medicare Inpatient Hospital Payment Rate for Puerto Rico Hospitals modifies the payment calculation with respect to operating costs of inpatient hospital services of a subsection (d) Puerto Rico hospital for discharges on or after January 1, 2016.

CMS is currently revising the Inpatient Prospective Payment System (IPPS) FY 2016 Pricer to reflect the new payment calculation requirement.  The amount of the payment with respect to the operating costs of inpatient hospital services of a subsection (d) Puerto Rico hospital for inpatient hospital discharges on or after January 1, 2016, will be based on 0 percent of the applicable Puerto Rico percentage and 100 percent of the applicable Federal percentage. In addition, the IPPS FY 2016 Pricer will include conforming changes to certain FY 2016 IPPS operating rates and factors that result from the application of the new Puerto Rico hospital payment calculation requirement, which are applicable to all IPPS hospital discharges on or after January 1, 2016. We will also incorporate the revised IPPS rates into the Long-Term Care Hospital (LTCH) Pricer, as they are used for certain LTCH claims payments.

To allow sufficient time to develop and test, CMS will implement the IPPS and LTCH Pricers on April 4, 2016. Medicare Administrative Contractors (MACs) will reprocess IPPS inpatient claims from Puerto Rico and all other IPPS hospitals with a discharge date on or after January 1, 2016. The MACs will also reprocess LTCH claims with a discharge date on or after January 1, 2016, due to the impact of this change.  Puerto Rico hospitals (as well as all other IPPS and LTCH hospitals) do not need to take any action. CMS expect to reprocess claims no later than June 30, 2016.

Wednesday, January 6, 2016

Provider enrollment application fee amount for 2016

Provider Enrollment Application Fee Amount for CY 2016

On December 3, CMS issued a notice: Provider Enrollment Application Fee Amount for Calendar Year 2016 [CMS–6066–N] ( Effective January 1, 2016, the CY 2016 application fee is $554 for institutional providers that are:

Initially enrolling in the Medicare or Medicaid program or the Children's Health Insurance Program (CHIP)Revalidating their Medicare, Medicaid, or CHIP enrollmentAdding a new Medicare practice location

This fee is required with any enrollment application submitted from January 1 through December 31, 2016.