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Reimbursement Questions
Whether you are experienced or new to reimbursement, everyone has questions. This section contains those questions that come up most often. In addition, if you have questions that are not listed here, you can contact us via e-mail or call us at 1-800-553-3851 and we will assist in finding your answer.
Reimbursement - Frequently Asked Questions:
Why does Medicare ask for provider medical records?
There are three common reasons:
- The contractor is gathering information from a number of offices to develop a baseline, or an average, which is used to compare individual practice submissions.
- Your billing submission may fall outside the established baseline.
- The majority of requests are made because the contractor thinks that you might be billing non-routinely for some services. They detect a repetition, or pattern to your billing, which raises questions.
Baseline
All contractors are required to study physician's billings to Medicare using statistics and data analysis. They use the current six (6) months and the previous six (6) months of submitted charges to Medicare. This process, called profiling, is the same for all contractors. First, the contractor looks at each service billed per specialty and finds the average billing. Then the contractor looks at the national billings for the same service, same specialty and finds the national billing average. The contractor takes the two (2) averages and then develops a baseline usage, per service, per specialty. For example, family practitioners billed an average of three (3) 99214's, per month to the local Medicare contractor. Nationally, all family practitioners billed an average of three (3) 99214's, per month to the entire Medicare Program. The baseline or norm for the contractor's review of 99214's, billed by family practitioners, is three (3), per month.
Contractors will request medical records from a very small sampling of providers within the baseline to make sure that the norm is valid. Clinical staff audits or reviews (terms used simultaneously in Medicare) medical records to ensure they are complete.
Outliers
Once the baseline is established, the contractor looks at, or profiles, each practitioner who requested payment from Medicare. Their charges are compared to the baseline, per specialty, per service. As an illustration, Dr. Jones is a physician in family practice. The contractor ran Dr. Jones' profile and found that in the past six (6) months Dr. Jones average number of 99214's submitted to Medicare is six (6), per month. This average is compared to the specialty of family practice, locally and nationally. In our case, the average number of visits, locally and nationally, is three (3), per month. Dr. Jones usage or utilization of services is six (6), per month and is outside the monthly baseline of three (3). Because Dr. Jones billings are outside of the average, they are considered outliers. Since Dr. Jones billed for more services than the norm, the contractor must order medical records to see if the conditions of Dr. Jones' patients warrant the extra services. Clinical staff reviews and determines if the documentation in the medical record supports the need for more services above the average. If the medical records fully document and support the additional services, then no further action is required. However, if clinical staff determines that there isn't enough information in Dr. Jones' medical records to support the extra services, then the contractor must determine what type of action it needs to take to correct a perceived deficiency in the medical record documentation. The number of claims and potential payment dollars will determine whether the contractor will do a one-on-one educational contact, overpayment assessment of all or part of past claims, suspension of all or part of future claim submissions, or a combination of all these actions.
Pattern Billing
Because contractors are required to study practitioners' charges submitted to Medicare, they could detect a pattern in your billings during the course of their analysis. Dr. Fleming is an internist. In the course of the data review, the carrier has noticed that 90 out of 100 of Dr. Fleming's patients have arthritis and Dr. Fleming always bills a 99214 office visit for these patients. The contractor will wonder why this is happening. They will order medical records to eliminate the possibility of billing errors. Clinical staff will review the records and determine if they need to contact the provider for additional information or initiate one-on-one educational contact, overpayment assessment of all or part of past claims, suspension of all or part of future claim submissions, or a combination of all these actions.
The most common reasons for triggering a medical record request:
- The highest level of E/M code is billed routinely for the majority of patients, for example 99215 or 99233.
- The physician bills the same number of visits per patient for the majority of patients. All of Dr. Smith's patients receive four (4) visits a month, regardless of their condition.
- The exact same diagnosis is billed for the majority of patients.
- High dollar procedures are billed routinely and the billing exceeds the national norm.
- High volumes of services are billed and exceed the national norm. Dr. Pallor removes three times as many skin lesions as any other dermatologist in the country.
- The majority of billings are for non-covered or excluded services. (The contractors are required to review these billings to ensure the beneficiary is not inappropriately responsible for charges not paid by Medicare.)
- The provider consistently bills services that are coded incorrectly, for example hospital visit codes are billed, but the office is indicated as the place of service.
- The provider frequently bills for new technologies, usually using the unlisted procedure code, using 27299 or 92599.
- Referrals from other agencies, law enforcement, Internal Revenue Service, beneficiary or provider complaints.
- Once a baseline or norm for a particular specialty and service is established, providers within that norm are selected to validate the norm's accuracy.
If you should have any questions about these potential reasons for a Medicare audit, please send in your questions to the FAQ section or call PROCRITline.
Date Created: 02/27/01, Reviewed 1/24/2005
What are APCs?
APCs are Ambulatory Payment Classifications, a Medicare prospective payment system for the hospital outpatient setting. APCs were implemented in the hospital outpatient setting on 8/1/00. APCs do not impact physicians' offices. APCs are a clinically consistent groups of items and services that receive a defined payment for both the drug and the procedure.
Date Created: 11/01/00, Reviewed 1/14/2005
How is PROCRIT paid under APCs?
PROCRIT is paid under the Medicare APC system using its product specific J-code (J0885—effective 1/1/06; until then use Q0136—per 1000 units).
Date Created: 11/01/00, Reviewed 11/29/2005
Can a patient have more than one APC per clinic visit?
Yes, a patient can have multiple APCs for each hospital outpatient clinic visit. There will be a separate APC for each procedure and / or pass-through drug received.
Date Created: 11/01/00, Reviewed 1/24/2005
Will hospitals receive any payment in addition to the APC payment (Medicare portion plus patient co-pay)?
No, in general a geographically adjusted APC payment rate represents the maximum Medicare allowed amount for Medicare covered services. In rare instances when the cost of providing a drug, device or service is unusually expensive a cost outlier payment may be made to a facility.
Date Created: 11/01/00, Revised 1/24/2005
I would like to learn more about oncology reimbursement. What can I do?
In our Resources section we have several documents that will help get you started.
Date Created: 11/08/00
Where can I find reimbursement information?
You can find reimbursement information in our Billing & Reimbursement section, as well as our Resources and FAQs.
Date Created: 11/28/00
Where can I find Medicare guidelines on a specific state?
State Medicare guidelines can be found in the Billing &
Reimbursement section. Simply select your state/region from
the left-hand navigation, press the red GO button, and let PROCRITline.com do the rest.
Date Created: 11/08/00, Revised 3/8/05
Why are there typically only four indications listed on the guidelines? Carriers often list additional indications in their documentation.
PROCRITline.com lists the FDA-approved indications on the website. For additional information on the indications supported by your Carrier or Fiscal Intermediary, please refer to the Local Coverage Determinations (LCD). Links to these can be found at the top of the state guidelines pages.
Date Created: 08/26/05
What should be in Box 19 of the CMS 1500 examples?
Box 19 contains information requested by the Carrier as defined in the Local Coverage Determinations (LCD). Some documentation needs to be available upon request and does not need to be included in Box 19, or it can be attached. See the LCD for further information.
Date Created: 08/26/05
What is a G-code? They are not in the current CPT book.
The new G-codes are temporary National Level II HCPCS codes in effect until new CPT codes are to be published by the AMA in the CPT 2006. These G-codes are only for use in a physician office setting (billings submitted to Medicare Part B Carriers on the CMS 1500 claim format).
The new G-codes are required by Medicare in 2005 for reporting chemotherapy administration, parenteral administration of non-radionuclide anti-neoplastic drugs and anti-neoplastic agents provided for the treatment of noncancer diagnoses or to substances such as monoclonal antibody agents and other biologic response modifiers.
G-codes have also been created to identify additional sequential infusions as well as additional non-chemotherapy sequential intravenous pushes and intravenous chemotherapy pushes for additional drugs. Please refer to CMS Transmittal 129 dated December 10, 2004 and CMS Transmittal 148 dated April 15, 2005 for more details and the coding ground rules and modifiers that apply to the new G-codes for reporting drug administration services and procedures.
Date Created: 08/26/05
What are the new demonstration codes?
The following is from CMS Transmittal 14, published in December 2004.
These are part of a one-year demonstration project for calendar year 2005 for certain chemotherapy services furnished in an office. This was announced in the physician fee schedule regulation published in the Federal Register on November 15, 2004. The initial CR (CR 3634) released on December 10, 2004 was rescinded and replaced by Transmittal 14 because the initial CR did not include complete business requirements. You can use this link to get the actual G-codes used for the Chemotherapy Demonstration Project. http://www.cms.hhs.gov/manuals/pm_trans/r14demo.pdf
Practitioners participating in the project must provide and document specified services related to
- Assessment of Nausea and/or Vomiting (G9021-G9024)
- Assessment for Pain (G9025-G9028) and
- Assessment for Lack of Energy (Fatigue) (G9029-G9032)
Practitioners must bill the applicable G-codes for each patient status factor assessed during a chemotherapy encounter in order to receive payment under the demonstration.
A G-code for each symptom (pain, nausea/vomiting, and fatigue) must appear on the claim for payment to be made under the demonstration project. If only one demonstration G-code is reported, no payment will be made for that service.
A patient chemotherapy encounter is defined as chemotherapy administered through intravenous infusion or push. During the demonstration, an additional payment of $130 per encounter will be paid to participating practitioners for submitting the patient assessment data.
There is no separate enrollment for the demonstration. Reporting G-codes in each of the three areas automatically enrolls you in the project.
The services described by the Chemotherapy Demonstration Project G-codes are paid on an assignment basis and the usual Part B deductible and coinsurance apply.
Date Created: 08/26/05
Some of the CMS 1500 forms state "Use appropriate infusion code" in Box 24. How can I find out what this means?
In general this means you report the G-code or CPT code for drug administration service(s) as documented in a patient's medical record in Box 24 or the electronic equivalent of Box 24.
For more information, refer to the PROCRIT Full Prescribing Information including Boxed WARNINGS.
Please refer to the Dosage and Administration section of the Full Prescribing Information along with CMS Transmittals 129 dated December 10, 2004 and CMS Transmittal 148 dated April 15, 2005 to determine the appropriate CPT code for reporting the drug administration services documented in the patient's medical record.
Date Created: 08/26/05
Box 21 in the CMS 1500 form states "use appropriate chemotherapy code." Where can I find this?
Please refer to the ICD-9 coding book. An example of a typical chemotherapy code is
V58.11. The appropriate chemotherapy code means ICD-9-CM diagnosis coding that accurately reflects the patient's diagnosis and reason(s) for the encounter as they are documented in the medical record to the highest degree of specificity possible.
Date Created: 08/26/05
How are payments made for Level 1 E/M code?
Payments for a Level 1 E/M code and injection code are bundled when billed together on the same date of service.
Date Created: 08/26/05
I've heard that CMS (Centers for Medicare and Medicaid Services) is
changing the ICD-9 codes. How does this impact my billing for PROCRIT?
Effective 10/1/05, CMS has announced that codes V58.1 (chemotherapy) and
585 (Chronic Renal Failure) are obsolete. These codes are each being
replaced with new codes. For the full details of this announcement,
including a list of all codes to be made obsolete, plus the new codes, click here.
If you have questions, contact your Medicare Carrier or Fiscal Intermediary or call PROCRITline at 1-800-553-3851.
Date Created: 08/26/05
Why is the ICD (International Classification of Diseases) being revised?
The ICD is revised periodically to incorporate changes in the medical field.
Date Created: 08/26/05
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