05/02/2018

"Ask MSHO"

May 2018, Frequently Asked Questions

Question:  I am SO happy WPS Medicare has increased the High Dollar Review threshold to $10,000.  We were wondering if this is based on the charges or on the approved amount.

Answer: We recently verified with a member office who’s charge was above $10,000 and reimbursement was under $10,000 and they did not hit the edit for High Dollar Review.  Based on this, I would say that the edit triggers the High Dollar Review based on the approved amount.

Question:  If the provider office meets the "incident to" requirements, is it necessary to put the NPI of the midlevel provider anywhere on the claim?

Answer:  Currently, it is not necessary to put the NPI of the rendering midlevel provider anywhere on the claim when the billing/supervising physician is submitting the service under Medicare's incident to concept. 

Question: With a physician in the suite and available, a midlevel provider sees an established patient in follow-up for chemotherapy previously ordered by the MD and addresses an issue related to the chemotherapy treatment, ie: expected side effect from the chemotherapy.  We want to confirm that the visit would qualify for "incident to".

Answer: If the service that the midlevel provider performs is an integral part of the plan of care that was initially established by the billing/supervision MD, the service would qualify for "incident to" as long as all incident to criteria is met.  The plan of care/treatment plan set by the physician must be followed by the midlevel practitioner. When the midlevel makes a change to that plan, the midlevel services are no longer incident to. This is also the case for the "oh, by the way" situations for which the midlevel is now addressing treatment that is not already under the billing/supervision physician's plan of care.  In such a case, incident to no longer applies.   

Question:  If a midlevel sees an established patient “incident to” but during the visit the patient has a new problem.  The Midlevel discusses the problem with the MD who is in the suite and available and documents the MDs decision-making.  (example: provide the patient with a prescription for an antibiotic - addressing their cold/flu symptoms).  Is it appropriate to bill this visit as "incident to" or would it be necessary to bill this visit under the NPI of the midlevel since she has addressed a "new" problem outside the side effects of the patient’s chemo.

Answer:  For the situation described, it is not appropriate to bill the visit as an "incident to" service.  The service is no longer incidental to the physician because a "new" problem was addressed during the Mid-level visit.  The Mid-level must bill the service under his/her own NPI/PTAN. The Mid-level should choose the CPT code based on the medically necessary services documented in the patient's medical record.

Question: Would you mind clarifying the proper use of 96368 for billing in chemotherapy.  Can we bill for the 96368 if they are a therapeutic drug and a chemotherapy drug going to the same access site???   Can we only bill the 96368 when they are concurrent and going to different access sites?  I have gotten so many different answers and feel that you could answer this question once and for all.   

Answer: I used to call it "Concurrent Confusion" - because it is challenging to understand.  If you have a therapeutic drug, in a SEPARATE BAG, hanging at the same time as another drug - (concurrently) - then you can use the code. 

The AMA defines a concurrent infusion as one in which two drugs are simultaneously infused or multiple infusions are provided through the same intravenous line. Note: Multiple substances mixed in one bag are considered to be one infusion, not a concurrent infusion, and you should not use the 96368 in this situation.

The concurrent CPT/Charge is limited to unit of one regardless of the duration of the concurrent infusion.

Question:  Just wondering if you had any tips or suggestions for discharging a patient while undergoing treatment.  I would be sending her a certified letter stating the reason we can no longer care for her along with the names and phone numbers of other oncologists in town (not sure if this needs to be done or not due to the circumstances of discharge).  Without saying too much, she is regularly under the influence of narcotics and Dr. feels he cannot properly treat her as she tends not to show up on a regular basis, and when she does, she is no condition for chemotherapy.  We have never discharged a patient during treatment and just want to make sure we are covering our basis.  Thanks.

Answer: I recommend that you review this article. I believe you will find answers to your questions about discharging the patient.  CLICK HERE