Objectives - namas.co

2/21/2014

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Auditing Diagnostics and

Ancillary Services

Presented by R. Kevin Townsend, CMPE, CPC, CPMA

Director of Revenue Cycle Management/NAMAS Instructor DoctorsManagement, LLC

Objectives

• Review key aspects of routine diagnostic clinical

laboratory auditing

• Review key aspects of routine diagnostic imaging

auditing

• Review key aspects of other routine diagnostic

auditing

• OIG Work Plan and new CPT updates related to diagnostics

Medical Necessity AMA

• Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site, and duration; and (c) not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician, or other health care provider.”

CMS • Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that “no Medicare payment shall

be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury” Furthermore, it has been longstanding CMS policy that "tests that are performed in the absence of signs, symptoms, complaints, or personal history of disease or injury are not covered unless explicitly authorized by statute". “Screening services, such as pre-symptomatic genetic tests and services, are those used to detect an undiagnosed disease or disease predisposition, and as such are not a Medicare benefit and not covered by Medicare. Similarly, Medicare may not reimburse the costs of tests/examinations that assess the risk for and/or of a condition unless the risk assessment clearly and directly effects the management of the patient.”

• Title XVIII of the Social Security Act, Section 1862(a)(1)(D) states that “no Medicare payment may be made for any expenses incurred for items or services that are investigational or experimental.”

• 42 Code of Federal Regulations (CFR) section 410.32(d)(3) indicates “diagnostic tests are payable only when the physician who is treating the beneficiary for a specific medical problem and who uses the results in such treatment.”

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Clinical Laboratory Auditing

• Medicare Clinical Laboratory Diagnostics NCD

Manual

• http://www.cms.gov/Medicare/Coverage/Covera

geGenInfo/Downloads/manual201301.pdf

• Check regional carriers for LCD information OR

payer websites for specific medical policies.


Medicare Clinical Laboratory Diagnostics NCD Manual:

“Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statute. “

“Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified non-physician practitioner) through documentation in the physician’s office may result in denial.”



“Diagnoses documented as “probable,” “suspected,” “questionable,” “rule-out,” or “working diagnosis”

should not be coded as though they exist. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as signs,

symptoms, abnormal test results, exposure to communicable disease or other reasons for the visit.”

http://www.cms.gov/Medicare/Coverage/CoverageGenInfo/Downloads/manual201301.pdf

http://www.cms.gov/Medicare/Coverage/CoverageGenInfo/Downloads/manual201301.pdf

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“Tests for screening purposes that are performed in the absence of signs, symptoms, complaints, or personal

history of disease or injury are not covered except as explicitly authorized by statute. These include exams required by insurance companies, business

establishments, government agencies, or other third parties.”



“Tests that are not ordered by a treating physician or other qualified treating non-physician practitioner

acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary.” (i.e.

Chiropractors, Clinical Psychologists, LCSW)



“Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement

Amendments of 1988 (CLIA) certificate for the testing performed will result in denial of claims.”

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Non-covered ICD-9 Codes for ALL NCD Edits • Any code that represents “Family History of” (e.g., V16.xx Family history of

neoplasm, V18.0 Family history of diabetes, etc.)

• Personal history of contact with and exposure to potentially hazardous

body fluids (V15.85)

• Heath Supervision (V20.xx)

• General Medical Examinations (V70.xx)

• Any code that represents “Special Screening”


Common Labs Requiring Auditor Review • CA-125

• CEA

• Glycated Hemoglobin (A1C)

• Drug Screens


CA-125 Tumor Marker

• “These services are not covered for the evaluation of patients with signs or symptoms suggestive of malignancy. The service may be ordered at times necessary to assess either the presence of recurrent disease or the patient's response to treatment with subsequent treatment cycles.”

• “The CA 125 is specifically not covered for aiding in the differential diagnosis of patients with a pelvic mass as the sensitivity and specificity of the test is not sufficient. In general, a single "tumor marker" will suffice in following a patient with one of these malignancies.”

• Same for CA 15-3, CA 27.29, CA 19-9

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Carcinoembryonic Antigen (CEA)

• “Serum CEA determinations are generally not indicated more frequently than once per chemotherapy treatment cycle for patients with metastatic solid tumors which express CEA or every two months post-surgical treatment for patients who have had colorectal carcinoma. However, it may be proper to order the test more frequently in certain situations, for example, when there has been a significant change from prior CEA level or a significant change in patient status which could reflect disease progression or recurrence.”

• “Testing with a diagnosis of an in situ carcinoma is not reasonably done more frequently than once, unless the result is abnormal, in which case the test may be repeated once.”


Glycated Hemoglobin (A1C) • “It is not considered reasonable and necessary to

perform glycated hemoglobin tests more often than every three months on a controlled diabetic patient to determine whether the patient's metabolic control has been on average within the target range. It is not considered reasonable and necessary for these tests to be performed more frequently than once a month for diabetic pregnant women. Testing for uncontrolled type one or two diabetes mellitus may require testing more than four times a year.”


Drug Screens Medicare, Medicare Advantage, and now CIGNA

require: • G0434 “Drug screen, other than chromatographic; any number of drug

classes, by CLIA waived test or moderate complexity test, per patient encounter” (per encounter - cups or dipsticks, etc.). MUE edit of 1 unit

• G0431 “Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter”. MUE edit of 1 unit.

Other Commercial and Some Medicaids: • 80104 “Drug screen, qualitative; multiple drug classes other than

chromatographic method, each procedure”. CPT Assist Dec. 2010. “New code 80104 more accurately reflecting the resources used in a multiplex test kit as compared to multiple runs using a single class methodology.” 1 unit – waived testing

• 80101 “Drug screen, qualitative; single drug class method (eg, immunoassay, enzyme assay), each drug class” Multiple units – moderate or high complexity testing.

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Obsolete or Unreliable Diagnostic Tests

•Amylase, blood isoenzymes, electrophoretic, •Chromium, blood, •Guanase, blood, •Zinc sulphate turbidity, blood, •Skin test, cat scratch fever, •Skin test, lymphopathia venereum, •Circulation time, one test, •Cephalin flocculation, •Congo red, blood, •Hormones, adrenocorticotropin quantitative animal tests, •Hormones, adrenocorticotropin quantitative bioassay, •Thymol turbidity, blood, •Skin test, actinomycosis,

•Skin test, brucellosis, •Skin test, psittacosis, •Skin test, trichinosis •Calcium, feces, 24-hour quantitative, •Starch, feces, screening, •Chymotrypsin, duodenal contents, •Gastric analysis, pepsin, •Gastric analysis, tubeless, •Calcium saturation clotting time, •Capillary fragility test (Rumpel-Leede), •Colloidal gold, •Bendien's test for cancer and tuberculosis, •Bolen's test for cancer, •Rehfuss test for gastric acidity, and •Serum seromucoid assay for cancer and other diseases

Imaging Auditing General Radiography/Imaging Concepts • Anatomy, number of views, and interpretation are the core elements of imaging

audits • “Routine, screening, pre operative or periodic examinations in the absence of

symptoms, signs or disease states as represented by Covered ICD-9-CM Codes will not be reimbursed [Section 1862(a)(1)(A) of the Social Security Act].”

• “Following a stable chronic condition, generally one examination in a twelve-month period will be considered appropriate. In acute or subacute conditions or when new symptoms or findings are documented, more frequent examinations will be considered for reimbursement and are subject to medical necessity review.”

Imaging Auditing

Bone Mass Measurement (Bone Density) http://www.cms.gov/Regulations-and-

Guidance/Guidance/Transmittals/downloads/R70BP.pdf

Approved for:

• “estrogen-deficient and at clinical risk for osteoporosis…will document in her medical record why he or she believes that the woman is estrogen-deficient and at clinical risk for osteoporosis”

• “An individual with vertebral abnormalities as demonstrated by an x-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture.”

• “An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to an average of 5.0 mg of prednisone, or greater, per day, for more than 3 months.”

• An individual with primary hyperparathyroidism. • An individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug

therapy.

“The following BMMs are noncovered under Medicare because they are not considered reasonable and necessary under section 1862(a)(1)(A) of the Act. • Single photon absorptiometry (effective January 1, 2007). • Dual photon absorptiometry (established in 1983).” (Requires dual energy x-ray or DEXA)

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R70BP.pdf





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Other Diagnostics Auditing Pulmonary Function Testing (PFT)

E&M on same day may not be allowed

• Medicare recovery auditors have identified

overpayments associated with evaluation and

management (E&M) services (CPT codes

99211-99213) for pulmonary diagnostic

procedures. These overpayments occurred

due to claims billed without modifier 25 on the

same date of service as a pulmonary

diagnostic, therapeutic, or monitoring

procedure (94010-94799). For practices

providing PFTs, remember:

If a physician in attendance for a pulmonary

function study obtains a history and performs a

physical exam related to the pulmonary

function testing, separate reporting of an E&M

service is not appropriate.

If the physician performs a significant,

separately identifiable E&M service unrelated

to the performance of the pulmonary function

test, the physician may report an E&M service

with modifier 25.

If the E&M was not separately identifiable, then

the physician should not bill the E&M service. MLN Matters No. SE1315

Diagnostics Supervision Medicare Benefit Policy Manual – Chapter 15 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf

• “Direct Supervision - in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.” (level 2 MPFSD)

• “Nurse practitioners, clinical nurse specialists, and physician assistants are not defined as physicians under §1861(r) of the Act. Therefore, they may not function as supervisory physicians under the diagnostic tests benefit (§1861(s)(3) of the Act). However, when these practitioners personally perform diagnostic tests as provided under §1861(s)(2)(K) of the Act, §1861(s)(3) does not apply and they may perform diagnostic tests pursuant to State scope of practice laws and under the applicable State requirements for physician supervision or collaboration.”

• Examples: Urodynamics, some advanced imagining, etc.

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/B0128.pdf

Other Diagnostics Auditing

EMG/NVC • Codes 95860, 95861, 95863, 95864, 95867, 95868, 95869,95870, 95885, 95886, and

95887 (EMG) require level 6a supervision, which means the service must be performed personally by the physician or a physical therapist who is certified by the American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysiologic clinical specialist AND is permitted to provide the service under state law.

• Codes 95905,95907, 95908, 95909, 95910, 95911, 95912, 95913 and 95937 require level 7a supervision which means the services must be personally performed by a physician, or by a physical therapist with ABPTS certification, or by a physical therapist lacking certification but under the direct supervision of a physician, or by a technician with certification under the general supervision of a physician.

• It would be expected that the individual interpreting the test is also supervising the test, as part of the supervision involves evaluating both the quality and extent of testing performed.”

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf










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OIG Work Plan

Fiscal Year 2014 HHS OIG Work Plan Update

• According to the OIG Strategic Plan, 2014-2018, the OIG’s four goals over the next four years are: o Fight Fraud, Waste, and Abuse

o Promote Quality, Safety, and Value

o Secure the Future

o Advance Excellence and Innovation

• http://oig.hhs.gov/reports-and-

publications/workplan/index.asp#current

OIG Work Plan Portable x-ray equipment—Supplier compliance with transportation and

setup fee requirements (New 2014) • Billing and Payments. We will review Medicare payments for the

transportation and setup of portable x-ray equipment to determine whether payments were correct and were supported by documentation. We will also assess the qualifications of the technologists who performed the services and determine whether the services were ordered by a physician (e.g., doctor of medicine or doctor of osteopathy). Context—Prior OIG work found that Medicare improperly paid portable x-ray suppliers for return trips to nursing facilities (i.e., multiple trips to a facility in 1 day) and for services ordered by non-physicians that are not covered by Medicare. Medicare generally reimburses for transportation and setup of portable x-ray equipment if the conditions for coverage are met. (42 CFR § 486, §§ 486.100 – 486.110.) (OAS; W-00-14-35464; various reviews; expected issue date: FY 2015; new start)

42 CFR § 486, §§ 486.100 – 486.110. (a) Standard—referral by a physician. Portable X-ray examinations are

performed only on the order of a doctor of medicine or doctor of

osteopathy licensed to practice in the State. The supplier's records show

that:

(1) The X-ray test was ordered by a licensed doctor of medicine or

doctor of osteopathy, and

(2) Such physician's written, signed order specifies the reason an X-ray

test is required, the area of the body to be exposed, the number of

radiographs to be obtained, and the views needed; it also includes a statement concerning the condition of the patient which indicates why

portable X-ray services are necessary.

(b) Standard—records of examinations performed. The supplier makes for

each patient a record of the date of the X-ray examination, the name of

the patient, a description of the procedures ordered and performed, the

referring physician, the operator(s) of the portable X-ray equipment who

performed the examination, the physician to whom the radiograph was

sent, and the date it was sent.

http://oig.hhs.gov/reports-and-publications/strategic-plan/files/OIG-Strategic-Plan-2014-2018.pdf



http://oig.hhs.gov/reports-and-publications/workplan/index.asp






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OIG Work Plan Sleep Testing—Appropriateness of Medicare Payments for

Polysomnography

• We will identify questionable billing patterns for Medicare sleep study services provided in 2009 and 2010. Medicare payments for polysomnography increased from $62 million in 2001 to $235 million in 2009, and coverage was also recently expanded. Sleep studies are reimbursable for patients who have symptoms such as sleep apnea, narcolepsy, or parasomnia in accordance with the CMS’s Medicare Benefit Policy Manual, Pub. 102, ch. 15, § 70. (OEI; 05-12-00340; expected issue date: FY 2013; work inprogress)

OIG Work Plan Sleep Testing—Appropriateness of Medicare Payments for Polysomnography Sleep

Disorder Clinics—High Utilization of Sleep Testing Procedures • We will review the appropriateness of Medicare payments for high utilization sleep

testing procedures to determine whether they were in accordance with Medicare requirements. Our analysis of CY 2010 Medicare payments for Current Procedural Terminology (CPT) codes 95810 and 95811, which totaled approximately $415 million, showed high utilization associated with these sleep test procedures. We will examine Medicare payments to physicians, hospital outpatient departments, and independent diagnostic testing facilities for sleep testing procedures. Medicare will not pay for items or services that are not “reasonable and necessary.” (Social Security Act, § 1862(a)(1)(A).) Diagnostic testing that is duplicative of previous testing done by the attending physician to the extent the results are still pertinent is not covered because it is not reasonable and necessary under 1862(a)(1)(A) of the Act. Requirements for coverage of sleep tests under Part B are in CMS’s Medicare Benefit Policy Manual, Pub. 100-02, ch. 15, § 70. (OAS; W-00-10-35521; W-00-12-35521; various reviews; expected issue date: FY 2013; work in progress)

OIG Work Plan Sleep Testing—Appropriateness of Medicare Payments for Polysomnography

Sleep Disorder Clinics—High Utilization of Sleep Testing Procedures • The clinic is either affiliated with a hospital or is under the direction and

control of physicians. Diagnostic testing routinely performed in sleep disorder clinics may be covered even in the absence of direct supervision by a physician;

• Patients are referred to the sleep disorder clinic by their attending physicians, and the clinic maintains a record of the attending physician’s orders; and

• The need for diagnostic testing is confirmed by medical evidence, e.g., physician examinations and laboratory tests.

• Covered medical conditions: Narcolepsy, Sleep Apnea, Impotence, and Parasomnia. Chronic insomnia is not covered.

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OIG Work Plan Electrodiagnostic Testing—Questionable Billing (New in 2013) • We will review Medicare claims data to identify questionable billing for

electrodiagnostic testing. We will also determine the extent to which Medicare utilization rates differ by provider specialty, diagnosis, and geographic area for these services. Electrodiagnostic testing, which assists in the diagnosis and treatment of nerve or muscle damage, includes the needle electromyogram and the nerve conduction test. Coverage for diagnostic testing is provided by the Social Security act, § 1861(s)(2), and 42 CFR § 410.32.) The use of electrodiagnostic testing for inappropriate financial gain poses a growing vulnerability to Medicare. (OEI; 04-12-00420; expected issue date: FY 2013; work in progress)

OIG Work Plan

Diagnostic Radiology—Medical Necessity of High-Cost Tests

• We will review Medicare payments for high-cost diagnostic radiology tests to determine whether they were medically necessary and the extent to which the same diagnostic tests are ordered for a beneficiary by primary care physicians and physician specialists for the same treatment. Medicare will not pay for items or services that are not “reasonable and necessary.” (Social Security Act, § 1862 (a)(1)(A).) (OAS; W-00-12-35454; W-00-13-35454; various reviews; expected issue date: FY 2013; work in progress and new start)

OIG Work Plan Laboratory Tests—Billing Characteristics and Questionable

Billing in 2010

• We will describe billing characteristics for Part B clinical laboratory tests in 2010. We will also identify questionable

billing for Part B clinical laboratory tests in 2010. In 2008, Medicare paid about $7 billion for clinical laboratory

services, which represents a 92-percent increase from 1998. Much of the growth in laboratory spending was the

result of increased volume of ordered services. Medicare pays only for those laboratory tests that are ordered by a

physician or qualified non-physician practitioner who is treating a beneficiary. (42 CFR § 410.32(a). (OEI; 03-11-

00730; expected issue date: FY 2013; work in progress)

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OIG Work Plan Laboratory Tests—Reasonableness of Medicare Payments

Compared to Those by State Medicaid and Federal Employees Health Benefit Programs

• We will determine how the methods for establishing Medicare laboratory test payment rates vary from those of State Medicaid and Federal Employees Health Benefits (FEHB) programs. Excessive payment rates for laboratory tests can be costly for Medicare. In 2009, Medicare paid nearly $10 billion for laboratory tests. We will compare Medicare laboratory payment rates for 20 laboratory tests, representing the most frequently ordered and most costly tests in terms of total dollars paid, with those of other public payers, including State Medicaid programs and FEHB plans. (OEI; 07-11-00010; expected issue date: FY 2013; work in progress)

OIG Work Plan Laboratory Tests—Part B Payments for Glycated Hemoglobin A1C

Tests

• We will review Medicare contractors’ procedures for screening the frequency of clinical laboratory claims for glycated hemoglobin A1C tests and determine the appropriateness of Medicare payments for these tests. Preliminary OIG work at two Medicare contractors showed variations in the contractors’ procedures for screening the frequency of these tests. It is not considered reasonable and necessary to perform a glycated hemoglobin test more often than every 3 months on a controlled diabetic patient unless documentation supports the medical necessity of testing in excess of national coverage determinations guidelines. (CMS’s Medicare National Coverage Determinations Manual, Pub. 100-03, ch. 1, pt. 3, § 190.21.) (OAS; W-00-12-35455; W-00-13-35455; various reviews; expected issue date: FY 2013; work in progress and new start)

OIG Work Plan Claims Processing Errors—Medicare Payments for Part B

Claims With G Modifiers (New in 2013)

• We will determine the extent to which Medicare improperly paid claims from 2002 to 2011 in which providers entered GA, GX, GY, or GZ service code modifiers, indicating that Medicare denial was expected. Providers may use GA or GZ modifiers on claims they expect Medicare to deny as not reasonable and necessary pursuant to CMS’s Claims Processing Manual. They may use GX or GY modifiers for items or services that are statutorily excluded. A recent OIG review found that Medicare paid for 72 percent of pressure-reducing support surface claims with GA or GZ modifiers, amounting to $4 million in potentially inappropriate payments. (OEI; 02-10-00160; expected issue date: FY 2013; work in progress)

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ABN

• Test • Reason • Cost (within $100 or 25% of actual cost) • Advanced Beneficiary Notice • Current form (CMS-R-131 (03/11))

New of 2014

• New Drug Assays o 80155 Caffeine

o 80159 Clozapine

o 80169 Everolimus

o 80171 Gabapentin

o 80175 Lamotringine

o 80177 Levetiracetam

o 80180 Mycophenolate

o 80183 Ozcarbzepine

o 80199 Tiagabine

o 80203 Zonisamide

New of 2014

• Change to Spine Views o 72040 Radiologic examination, spine,

cervical; 2 or 3 views

o Eliminated confusion from “3 or less”.

Report 72020 for single view.

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Presented by:

R. Kevin Townsend, CMPE, CPC, CPMA Director of Revenue Cycle Management/NAMAS Instructor

DoctorsManagement, LLC [email protected]

(800) 635-4040

Thank You!

mailto:[email protected]

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