07/10/2018

ASK MSHO

July 2018, Frequently Asked Questions

Question:  It is my understanding that in order to treat two sites with SBRT you need to keep the treatments to five or less. If the physician has two plans and two separate lesions, but treats these on alternate days that total more than five fractions, can we bill SBRT charges? 

Answer: CPT instructions for CPT code 77373 (SBRT treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions) include the possibility of treating multiple sites of disease in one treatment course. Therefore, if the sum of the treatment days for all of the sites treated during a single course of therapy exceeds five; it is not appropriate to charge CPT code 77373 for SBRT delivery.

Question:  I know there has been a CMS MUE issue with Opdivo, J9299.  The MUE has been less than what we were giving our patient, 480 mg – 480 units.  I understand that the MUE was updated on July 1st but, if we bill our May or June claim will we get paid or will we have to appeal?  

Answer: The MUE for Opdivo to 480 units was included in the 3rd quarter CMS MUE update effective 7/1/18.  In early March the FDA approved the nivolumab (Opdivo) dosing schedule to include the 480 mg infused every 4 weeks.  At that time the MUE was limited to 440 units.  All claims denied for MUE limits prior to July 1, 2018 and need(ed) to be appealed with a copy of the package insert and patient documentation.  This has been successful.  Be sure to contact Bristol-Myers Squibb if you have any problems.  The good news is that any claims with dates of service July 1st or later should process clean.

Question: I have a practice that states they only stock certain sizes of certain medications – the larger vial size and they can bill for waste. I say this should not be done per guidelines.  A  practice must minimize waste and use the lowest combination on market to do so. So, they need to stock assorted sizes if on market and use them in combination to minimize waste. If the FDA issues a shortage bulletin all bets are off we can use larger vials and bill for waste, I tell my practices to keep a copy of the bulletin in case of an audit.   Do you agree?

Answer: You are correct.  If the drug is available in a smaller size, then under the Medicare guidelines, you must purchase the smallest vial and minimize waste.

CMS Online Manual, Chapter 17, Drugs and Biologicals, Section 40 - Discarded Drugs and Biologicals - states:

"The CMS encourages physicians, hospitals and other providers and suppliers to care for and administer drugs and biologicals to patients in such a way t hat they can use drugs or biologicals most efficiently, in a clinically appropriate manner."

Here is a link to the online manual:  CLICK HERE

Here is a link to a great article on that JW modifier and mentions the same thing: CLICK HERE

As far as shortages or unavailability - you should keep a record to be able to show, under audit, that the "smallest" vial was not available at the time the patient received their treatment.

Question: If we are giving a chemotherapy drug IV, not IV Push, but only for a total time of 10 minutes, are we to bill the IV Push code (96409) or are we to bill first hour IV code (96413)?  For drugs given IV that take longer than 15 minutes to administer are we to bill the 96413 code?  Do you have any resources that we can find documentation for this issue?

Answer:  

You would bill for a push, even though you gave an infusion. 

 If you review your AMA CPT, Administration section, with the exception of hydration (which requires 31 minutes), you will find:

“When reporting codes for which infusion time is a factor, use the actual time over which the infusion is administered.  Intravenous or intra-arterial push is defined as: (a) an injection in which the healthcare professional who administers the substance/drug is continuously present to administer the injection and observe the patient, or (b) an infusion of 15 minutes or less.” 

Question: When can we accept the new Medicare beneficiary cards?

Answer:  Medicare is mailing the new Medicare cards in phases by geographic location to beneficiaries. Ask your Medicare patients for their new Medicare card when they come for care. The Centers for Medicare & Medicaid Services (CMS) have several sources of information about the new cards for providers and patients alike. Here’s one for providers: CLICK HERE

Question:  Can modifier JW be assigned when the dose administered is less than the HCPCS billing unit?

Answer: CMS does not use fractional billing units to pay for Part B drugs. Therefore, the JW modifier should not be used when the actual dose of the drug administered is less than the HCPCS billing unit.