March 2010

AMDA’s National Day of Recognition for Long-Term Care Physicians is Introduced in Congress

On March 2, Senator Saxby Chambliss (R-GA) and Representative Phil Gingrey (R-GA) introduced a concurrent resolution (S.Con.Res 52 & H.Con.Res 244) calling for the designation of  March 20th as the National Day of Recognition of Long-Term Care Physicians. The resolution originated from the Georgia Medical Directors Association (GMDA) that introduced AMDA resolution A 09 entitled “National Day of Recognition for Long term Care Physicians in Honor of Dr. William Dodd”.

A concurrent resolution, such as this one, is a formal statement that must be passed by both houses of the Congress, stating the opinion of Congress or permitting some action that does not require the President's approval. The resolution is now in the proper committees and will hopefully be up for vote in the coming weeks.

“It is appropriate that Long-Term Care Physician's Day be on Dr. Billy Dodd's birthday, March 20th. He was a community physician who recognized that residents of nursing homes were patients with complex medical problems. Physicians needed to be involved in establishing the standards of management and clinical care for our most vulnerable elderly. We all can see in the succeeding decades how right he was. This recognition day will encourage the other team members in our nursing facilities to celebrate their physicians' contributions.” said former GMDA executive director Perry Kemp.

To tell your Senator and/or Representative to show their support for the S.Con.Res 52 & H.Con.Res 244 visit http://www.amda.com/advocacy/legal/links.cfm

Providers Report Problems with Claims Containing – AI Modifier

CMS issues further clarification

AMDA has learned that some providers have reported that their claims are being rejected because the paper claims containing the –AI modifier, used to identify the principal physician of record for an evaluation and management (E/M) service, is being misread as A1 or AT. Starting January 1, 2010, the Centers for Medicare & Medicaid Services no longer recognized consultation service codes and instructed providers to use the –AI modifier to identify the physician of record and to distinguish the E/M service from a consultation service. The error occurs on paper claims and providers have to resubmit the claim if it is rejected in order to get reimbursed. 

Meanwhile, CMS issued further clarification regarding billing without consultation services. CMS issued MLN Matters SE1010 that provides answers to some popular questions being asked about the coding change. CMS states that there is no direct crosswalk between the old consultation service codes and the inpatient E/M codes (e.g., 99304-99306), however, CMS instructs providers to “report the most appropriate available code to bill Medicare for services that were previously billed using the CPT consultation codes”.  Further CMS states that “providers may bill the initial nursing facility care CPT codes, where those codes appropriately describe the level of service provided.” However, when those codes do not apply, providers are instructed to “bill the E/M code that most closely describes the service provided”. 

While previously Medicare carriers interpreted that to mean that providers can bill subsequent visit codes (99307-99310) or 99499 (Unlisted E/M service), CMS now states that it will instruct Medicare carriers to “find fault with providers who report subsequent hospital care CPT code in cases where the medical record appropriately demonstrates that the work and medical necessity requirement are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay”.  Likewise, CMS states that it expects coding for 99499 to be “unusual”.

CMS has suggested that providers check with their local Medicare carriers for specific rules regarding billing without consultation services. AMDA will continue to work with CMS to ensure that long-term care providers receive clear instructions on how to handle the new coding rules. Please check AMDA’s Health Policy Advisor for any further clarifications on consultation coding rule change.

21% Medicare Payment Cut Postponed until April 1

The U.S. Senate passed H.R. 4691, the "Temporary Extension Act of 2010," by a vote of 78-19 on Tuesday night. The bill included provisions that resulted in a one month delay of the 21% physician payment cut that was scheduled to take place on March 1. The cut is now extended until April 1st.

The bill, which was passed by the House of Representatives on February 25th, encountered opposition on the Senate floor from Senator Jim Bunning (R-KY). The Senator repeatedly objected to unanimous consent votes on the legislation because he wanted to find ways to finance the bill, so that it wouldn't add to the deficit. Additionally, the bill extends the therapy cap exceptions process through March 31, 2010, retroactive to January 1, 2010. Outpatient therapy service providers may now submit claims with the KX modifier, when an exception is appropriate, for services furnished on or after January 1, 2010 through March 31, 2010

Although, another short term fix is now in affect, there are other proposals in the works that would implement other short-term patches to the sustainable growth rate (SGR) formula. Some proposals would postpone cuts for 90 days, 7 months, or through the end of 2010. Senate Majority Leader Harry Reid (D-NV), has a measure to provide full-year extension of Medicare payments to physicians as well as extensions to other expired benefits.

AMDA, along with the American Medical Association and others, continue to press for permanent repeal of the SGR and will continue to monitor Congress as they try to find a solution.

Using Modifiers, Place of Services Codes in the Nursing Home Setting

Coding for evaluation and management services (E/M) services can be complex and it is only further complicated with the rules for using modifiers. In the nursing home setting, two popular modifiers, -25 and -24, are used to supplement regular nursing home E/M visits (99304–99318). Generally, modifiers are two digit codes that are used in instances to distinguish payment for two different services by the same physician, otherwise prohibited by the National Correct Coding Initiative (NCCI), is appropriate.

There are a total of 31 modifiers that clarify circumstances of a given patient encounter, service, or procedure that qualify for exceptions to NCCI rules. Five of the thirty-one modifiers apply directly to E/M coding (-24, -25, -32, -52 and -57). An additional modifier, -AI, has been added to indicate the principal physician of record and to distinguish from a consultation service being performed. The Centers for Medicare & Medicaid Services deleted consultation codes (99251-99255) starting January 1, 2010.

Other modifiers are used in various areas of medicine, surgery, anesthesia, the lab, pathology, and radiology. In order to use these modifiers correctly and receive additional payment providers must follow certain guidelines when using modifiers.

Examples of Popular Modifier Use in Nursing Facilities

Modifier –AI Principal Physician of Record

Starting January 1, 2010, CMS no longer recognized consultation codes for Medicare part B payment. Practitioners who bill consultation codes are instructed to use initial visit codes (99304-99306) or bill for the most appropriate code that could describe the service being provided. For further instructions, please visit www.cms.hhs.gov/MLNMattersArticles/downloads/SE1010.pdf. Therefore, physicians who bill nursing home E/M services must now used modifier –AI in addition to the E/M code to identify physician of record and to distinguish the service from a consultation service.

The following is an example of service that requires an –AI modifier:

A new resident is admitted to a nursing home.  The attending physician performs 99306, Initial Nursing Facility Care, comprised of a comprehensive history, comprehensive examination and medical decision making of high complexity.  The '-AI' modifier would be appended to the visit to identify the service as being provided by the admitting physician of record.  For subsequent visits, the 'AI' modifier is not necessary. A consultant performing an initial consult, comprising a comprehensive history, comprehensive examination and medical decision making of high complexity would also use CPT 99306, but without a modifier.

Subsequent visits by either the admitting physician of record or consultant would be submitted without modifiers.

Modifier -24 – Unrelated E/M Service by the Same Physician During a Postoperative Period
Providers can add modifier -24 when there is a need to indicate that an E/M services was performed during a postoperative period(s) for a reason unrelated to the procedure. Most procedures have a defined post-operative procedure time that could range between zero and ninety days. If providers perform an unrelated E/M visit during what is considered the post-operative timeframe for that procedure, providers must use -24 to indicate a separate E/M visit. Clear documentation that the E/M visit is unrelated to the procedure must follow.

The following is an example of a service that requires a -24 modifier:

The resident is seen for a removal of benign lesion of left forearm 2.0 cm. The physician performs 11402 “Excision-Benign lesions (Excised diameter 1.1 to 2.0 cm)”. Five days later seen at request of family for increasing lethargy; or annual history and physical; or discharge. Physician would use modifier-24 to report the service.

Modifier -25 – Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure or Other Service

Providers can add modifier -25 when providers need to indicate a separately identifiable and significant E/M service. The separate E/M service must be beyond the service that would be required during the usual preoperative or postoperative service. Documentation must be present that shows the necessity for a separate and significant E/M service. While the term “significant” is not defined directly, the E/M service performed must be a billable service if performed separately. Providers are encouraged to check the documentation guidelines for the relevant E/M codes. Please see AMDA’s Guide to Long Term Care Coding, Reimbursement and Documentation for help with documentation.

In addition, modifier -25 may be appropriate when the physician evaluates a patient and determines that a procedure is necessary. Thus, a separate diagnosis is not required to appropriately use the -25 modifier.  If however, there are two unique diagnoses evaluated on the same E/M visit, the modifier is still appropriate.

The following example illustrates the use of Modifier -25:

A resident is seen for a laceration of the arm.  The physician  performs 12001 "Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less." 

The resident then reports a cough and a separate, significant E/M service is performed to evaluate the cough.  The modifier -25 would be used.

 The physician can begin the note by writing, "A separate and significant E/M service was performed to evaluate a cough..."

• The -32 is used for services related to mandated consultation and/or related services (e.g., third party payer, governmental, legislative or regulatory requirement).
• The -52 modifier is used when the original service or procedure is reduced or eliminated at the physician’s discretion.
• The -57 modifier is used when a E/M service resulted in the initial decision to perform surgery.

Using Place of Service Codes: SNF v. NF

Separate, but as important, place of service codes (POS -31 and -32) are used to report the site of services (skilled nursing facility versus nursing facility) setting. The -31 code is used to report services provided to a patient whom the facility is reviewing payment under Medicare Part A (Medicare Stay, Part A stay), while -32 is used for patients who do not have Part A SNF benefits, patients who are in a nursing facility, or in a non-covered SNF stay.

Using Modifiers to Report Hospice Services

For hospice services, two popular modifiers, -GW and –GV, are used to report services. According to Centers for Medicare & Medicaid Services (CMS) Claims Processing Manual (Pub 100-04 Chapter 11) the –GW modifier is used to report services unrelated to the hospice patient’s terminal condition. The –GV modifier is used to for services rendered for care related for terminal illness performed by a physician who is not associated with the hospice.

Additional resources on coding are available on the AMDA Web site at http://www.amda.com/advocacy/cptcentral/index.cfm.

If you have additional questions regarding modifiers or other long-term care coding please visit AMDA’s Ask the Expert page. Note: Ask the Expert Service is for AMDA Members Only.

For more information on how to become an AMDA member please visit http://www.amda.com/membership/benefits.cfm.

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