06/05/2018

ASK MSHO

June 2018, Frequently Asked Questions

Question:  When we get a drug at no cost but need to bill for the administration, is there any direction from Medicare on how to do this?

Answer: The best place to go for this answer is the Medicare Claims Processing Manual, Chapter 32—Billing Requirements for Special Services—Section 67.2 at:  CLICK HERE

Also, consult Transmittal 4013 at:  CLICK HERE

Question:  Our physician wants to submit some data to NCCN so they will include an indication in their Guidelines/Compendia.  Can you tell me where to submit this request, what is needed and how long the process takes?

Answer:   CLICK HERE to review information from the NCCN website on how to submit a request to NCCN Guidelines Panels (which also includes the Compendia).

As far as the timeline, NCCN meets regularly (weekly) to review requests and update the Guidelines/Compendia however, this is done by cancer site so your request may take some time to be reviewed by the panel depending on the timing of their meetings. 

CLICK HERE to visit the NCCN Guidelines Panels Meeting Schedule.

Question: CMS had published a National Coverage Determination (NCD) for ESAs which said that CKD and MDS would be non-payable indications.  I know our Medicare contractor published that they will not be implementing the edits and that CMS was going to be updating the NCD but since that NCD was to go into effect on April 1, we are concerned that we may have payments taken back in the future!  Have you heard anything on this?  Has CMS released a new NCD?

Answer: CMS has not released a revised NCD nor have they published anything additional.  The American Society of Hematology is in the process of contacting CMS to get an update and to be sure that CKD and MDS are a payable benefit for Medicare patients.  Keep an eye on this newsletter for further updates!

Question: I am looking for some information on Advanced Care Planning, specifically who can perform the service.  Can you help?

Answer:  

CLICK HERE to go to the advanced care planning FAQ link from CMS.  I believe the answer to your question is clearly stated in FAQ #4.  

4. Who can perform ACP services?

As we said in the CY 2016 FPS final rule (80 Fed. Reg. 70956), the services described by CPT codes 99497 and 99498 are appropriately provided by physicians or using a team-based approach provided by physicians, nonphysician practitioners (NPPs) and other staff under the order and medical management of the beneficiary’s treating physician. The CPT code descriptors describe the services as furnished by physicians or other qualified health professionals, which for Medicare purposes is consistent with allowing these codes to be billed by the physicians and NPPs whose scope of practice and Medicare benefit category include the services described by the CPT codes and who are authorized to independently bill Medicare for those services. Therefore, only these practitioners may report CPT codes 99497 or 99498. The ACP services described by these codes are primarily the provenance of patients and physicians; accordingly we expect the billing physician or NPP to manage, participate and meaningfully contribute to the provision of the services in addition to providing a minimum of direct supervision. The usual PFS payment rules regarding ‘‘incident to’’ services apply, so that when the services are furnished incident to the billing physician or practitioner all applicable state law and scope of practice requirements must be met and there must be a minimum of direct supervision in addition to other incident to rules.

Question: I am looking for information from CMS related to unspecified diagnosis coding. Do you know if this type of information is available?

Answer:  Yes, CMS released a GEM (general equivalency mappings) MLN Booklet which has information on reporting unspecified codes. When billing for office visits, it can make sense but I would caution you on using unspecified codes when billing for chemotherapy treatments as most all drug reimbursement is tied directly to the patient’s diagnosis. CLICK HERE to review the MLN Booklet.