OIG Work Plan for Orthotics

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1 OIG Work Plan for Orthotics February 1, 2018 We recently heard that the government will be focusing audits on off the shelf orthotics. We have tried to find information but have not been successful. Are you able to direct us? Yes, and thanks for reaching out. The OIG Work Plan (updated January 2018) includes off the shelf orthotics, focusing specifically on three items. Several Medicare Intermediaries conducted reviews during The carriers findings may have contributed to the OIG adding off the shelf orthotics to the Work Plan. A key finding was lack of documentation of medical necessity in the patient s record. The OIG will review billing trends for and will be focusing on claims without an encounter in the 12 months prior to the orthotic claim. L1833 (Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf) L0650: Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf as an area of focus L0648 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces

2 intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf Now is a good time to review internal documents related to all DME products. You will also want to read Sarah Wiskerchen s article in the November 2017 AAOS NOW Dispensing DME in Orthopaedics for Medicare if you have not already done so. of 02/01/18. Splint Application and L- codes January 18, 2018 We are having a discussion in our office about how to report the application of off-the-shelf braces that are dispensed in our office. The nurses are adding splint application codes to the encounter forms, such as and 29515, but the coder only wants to report the HCPCS supply code. Which method is correct? The coder is correct in this case. The splint application CPT codes are used when a physician or provider such as a PT or OT creates a splint from raw materials, such as plaster,

3 fiberglass, padding, and ace bandages. Examples include sugar tong splints and thumb spica splints, among others. The HCPCS codes used for reporting off-the-shelf braces, also called prefabricated orthotics, include the fitting of the item, so a splint application code would not be separately reportable. Even orthotics that do require custom fitting would not support separate reporting of a splint application, as the HCPCS definitions for those codes include the language includes fitting and adjustment. of 01/18/18. Bone Marrow Aspirate Harvesting for Platelet Rich Plasma January 4, 2018 Our physicians are asking us to report and 0232T when they harvest bone marrow aspirate from the iliac crest for platelet rich plasma and inject it during another procedure. Is this correct? If not, can we report 0232T? What if the only service performed is a PRP injection using bone marrow aspirate?

4 You ve asked two questions, so we ve provided two parts to our answer: CPT Category III code 0232T was introduced in 2010 for reporting injection of platelet rich plasma to a targeted site; the code definition includes all harvesting, preparation, and image guidance for the service. In August 2010 the AAOS published guidance in AAOSNow which explained The new code is to be used only when PRP is performed in a complete separate patient encounter from a surgical procedure. Based on this direction, when PRP is injected during another procedure, whether using drawn blood or bone marrow aspirate, it is not separately reportable with the primary surgical service. If PRP injection is the only service performed, then 0232T is the correct code. In recent years some physicians have begun using bone marrow aspirate harvested from the iliac crest instead of drawn blood for PRP preparation, and reporting the harvesting using CPT code The May 2012 edition of CPTAssistant clarified that 0232T is the only code reportable for PRP injection, whether performed using drawn blood or harvested bone marrow aspirate. In 2018 the definition of was changed to reflect that it should be used only for diagnostic bone marrow aspiration. New code should be used when bone marrow aspiration is performed for bone grafting, for spine surgery only, via a separate incision. of 01/04/18.

5 CMS Reimbursement Reduction for CR Technology in 2018 December 1, 2017 My physician read that we will be paid less for radiology services in 2018, and that we need to use a special modifier because we use CR technology. Do you know anything about this? Yes, that is correct. Medicare will institute a 7 percent reduction in reimbursement for the technical component (TC) of x-rays taken using computed radiology (CR) beginning January 1, This reduction will be in place till 2022, and then increase to a 10 percent reduction. Computed radiography technology is defined as cassette-based imaging that utilizes an imaging plate to create the image involved. For reporting, CMS created modifier FY (X- ray taken using computed radiography technology/cassette-based imaging), which should be appended to the X-ray service reported either globally (without any modifiers) e.g FY, or the x-ray code with the TC modifier appended, indicating only the technical component is being reported for reimbursement e.g TC,FY. The technical component of musculoskeletal X-ray codes ranges from 63% to 78% of the global value, so the practice should expect reimbursement from 94.5% to 95.6% of the standard allowable. (100% x 37% for professional portion) + (93% x 63% for

6 technical portion) = 95.6% (100% x 22% for professional portion) + (93% x 78% for technical portion) = 94.5% of 12/01/17. Why am I Receiving a Denial When I Report a Joint Injection and a Trigger Point Injection on the Same Date of Service? November 2, 2017 Our orthopaedic surgeon performed and clearly documented a joint injection to the right shoulder and a trigger point injection bilaterally to the trapezius muscle. We are receiving denials when we report CPT code and on the same claim form? Are you able to assist us in understanding if we have coded correctly or how to appeal? You are correct to question this denial! There is no clinical reason for this denial assuming your documentation and medical

7 necessity supports reporting CPT and as defined in your scenario. If the payor is Medicare, or a payor who follows NCCI rules, the answer has to do with NCCI edits between the code combinations. Several years ago, Medicare identified coding patterns where the 2055x series of codes were reported during the same session as joint or other musculoskeletal surgical injections. In doing their due diligence, Medicare found in record review that the 2055x series was being incorrectly reported for the administration of a local anesthetic prior to the definitive injection. In the KZA orthopaedic coding workshops the surgical package and administration of local anesthesia is discussed as the rationale for the creation of this edit. This is an example where the use of modifier 59 (distinct procedure modifier) has a role in claims reporting! Report: linked to the shoulder diagnosis linked to the appropriate diagnosis to support the trigger point injection We are confident the denial, while not identified in your question, was for a bundled or service integral to another procedure on the same day. It is not uncommon for the Center for Medicare and Medicaid Services (CMS) to implement edits when a pattern of incorrect code combinations are identified. The following statement is found in the January 2017 NCCI Guidelines (CHAPTER IV SURGERY MUSCULOSKELETAL SYSTEM): Injections of local anesthesia for musculoskeletal procedures (surgical or manipulative) are not separately reportable. For example, CPT codes (therapeutic injection of carpal tunnel, tendon sheath, ligament, muscle trigger points) should not be reported for the administration of local anesthesia to perform another procedure. The NCCI contains

8 many edits based on this principle. If a procedure and a separate and distinct injection service unrelated to anesthesia for the former procedure are reported, the injection service may be reported with an NCCI-associated modifier if appropriate. of 11/02/17. Assistant Surgeon Payments October 19, 2017 We are seeing payers ask for payment back when we use Modifier 80 for assistant surgeon. Is there a reason why they would take the payment back? Without additional information it is difficult to respond to your inquiry. First, Medicare has a list of surgical CPT codes where payment will be considered for an assistant surgeon. Some codes will be paid without documentation submitted, some codes will be considered for payment if documentation of medical necessity is present and other codes will not be considered for payment at all (e.g. when less than 5% of the codes have an assistant surgeon reported). It is helpful to review this as a first step to understanding the denial. If the code allows an assistant and the service is still denied, documentation needs to be reviewed. An assistant

9 surgeon does not create a separate operative note for his/her role as an assistant. The primary surgeon is responsible for documenting the name and credentials of the assistant surgeon, and the work performed and medical necessity of the assistant must be documented in every operative note when services for the assistant are reported. Payors are no longer always paying claims when the assistant s name is the only information reported. of 10/19/17. Billing Incident-to October 5, 2017 Whose NPI number do we bill under when a PA sees the patient in the office under the Incident-to rules for Medicare? We bill under the NPI number of the physician who is assigned to the PA. Is that correct? No, when billing Incident-to, bill under the NPI number of the physician in the office who is supervising. The guidelines are very clear that the physician must be present in the office suite. The PA s visit must be billed under the physician who is in the office suite at the time the PA is managing the care of the patient not the physician the PA is assigned.

10 of 10/05/17. Moderate sedation Denials. How do we get paid for 99153? September 21, 2017 We are billing the new moderate sedation codes, but are getting denied on the second 15 minutes, Almost all our patients have sedation for more than 15 minutes. What are we doing wrong? The answer depends on your place of service! The codes you are referencing are listed below. Code or are paid without a problem. It s code that is the issue. When Medicare valued these new codes as part of the Medicare Physician Fee Schedule, and have work and total RVU s assigned. Code 99153, for the second 15 minutes, (or a minimum of 23 minutes total of sedation) does not have professional work RVU value assigned; thus in a Facility setting Medicare will not pay, as there is no physician work and Incident-To does not apply in a Facility setting. In a private practice (Non Facility) Medicare will pay for these additional minutes performed by the physician employed staff as Incident-To services are met assuming the physician

11 continues to provide direct supervision. To recap: In a Facility Setting, Medicare considers all physician work for moderate sedation to be covered by CPT codes and In a Non Facility setting, Medicare will reimburse the private practice assuming Incident-To rules are met. CPT Code Description Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient s level of consciousness and physiological status; initial 15 minutes of intra-service time, patient younger than 5 years of age initial 15 minutes of intra-service time, patient age 5 years or older each additional 15 minutes intra-service time (List separately in addition to code for primary service) of 09/21/17.

12 Billing Medicare Patient Admittance September 7, 2017 I was consulted to see a Medicare patient in the emergency room (ER) by the Emergency Department physician. When I arrived, the patient was still in the ER but had been admitted to the hospitalist and was waiting for a bed. Since the patient is Medicare and has been formally admitted you would report CPT codes for this consultation service, even though the patient is physically in the ED. Keep in mind Medicare does not pay for inpatient or outpatient consultations. of 09/07/17. Global Period for Surgery. Is it billable? August 24, 2017 A Medicare patient of mine presented to the Emergency Room

13 with an infection at the surgical incision site from a surgery that I did 4 weeks ago. The surgery has a 90 day global. I was on vacation so my covering physician saw the patient and admitted her. The procedure has a ninety day global period. Is the covering physician able to report an E/M code for this visit? The patient did not have surgery but an I&D at the bedside. This visit is not considered billable by you or the covering physician (same or different group practice) as it is inclusive to the global surgical package. The I&D is also not reportable as the procedure was performed in the ER and not an approved operative suite. of 08/24/17.

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