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Issue 4, Vol. 5
June 2007

Partners in
Healthcare
Improvement

Charlene Nutter
Senior Consultant
(614) 227-4852
cnutt@qmcg.com

The Quality Management
Consulting Group, Ltd.
100 S. Third St.
Columbus, OH 43215
Ph: (614) 227-4848
Fx: (614) 227-2390
Email: info@qmcg.com

July 2007 OPPS Update

Transmittal 1259 (Change Request 5623) was published outlining the July 2007 OPPS payment changes. These changes are also addressed in MLN Matters Number MM5623. The coding changes are addressed below:

Comprehensive List of Brachytherapy Source Payable as of July 1, 2007
Below is coding information for all brachytherapy sources payable as of July 1, 2007. Please note that CMS has added the term “non-stranded” to the descriptors for all sources that are described as “per source”, other than iodine-125, palladium-103 and cesium-131 for which CMS has separate stranded or non-stranded codes. All changes, i.e., new codes and descriptors and changes to existing code descriptors are noted in bold.

Newly Approved Drug Eligible for Pass-Through Status as of July 1, 2007
The following drug has been designated as eligible for pass-through status under the OPPS effective July 1, 2007:

New HCPCS Drug Codes Separately Payable Under OPPS as of July 1, 2007
The following seven HCPCS drug codes will be made effective July 1, 2007. These HCPCS codes will be separately payable under the hospital OPPS. The payment rates for these drugs can be found in the July 2007 update of OPPS Addendum A and Addendum B which will be posted on the CMS website at the end of June.

Billing for Zometa and Reclast under the OPPS as of July 1, 2007
Effective July 1, 2007 hospitals should report one of two HCPCS codes for zoledronic acid, i.e., J3487 for Zometa and Q4095 for Reclast.

Drug HCPCS Code J1567 Not Reportable Under the Hospital OPPS as of July 1, 2007
HCPCS code J1567 will no longer be recognized by Medicare effective July 1, 2007. Therefore, HCPCS code J1567 will no longer be reportable under the hospital OPPS. To report those drugs previously reported under HCPCS code J1567, refer to HCPCS codes Q4087, Q4088, Q4091 or Q4092.

Any changes to your hospital’s charge description master should be made and effective July 1, 2007.

Modifier -59

CMS recently published MLN Number SE0715 to clarify the existing policy for using modifier -59. The primary purpose of modifier -59 is to indicate that 2 or more procedures are done at different anatomic sites or during different patient encounters. This modifier should only be used if no other modifier more appropriately describes the relationship of the 2 or more procedure codes.

The article reminds us that modifier -59 along with any other modifier should not be used to bypass an NCCI edit, but the criteria should be met according to the modifier’s definition.

Modifier -59 is often misused when listed in relation to part of the definition that reads, “different procedure or surgery”. Modifier -59 cannot be used for this edit based on 2 CPT codes describing different procedures/surgeries. However, if these 2 surgeries are performed at separate anatomic sites or separate patient encounters on the same date of service, modifier -59 may be reported. From an NCCI perspective, the definition of different anatomic site includes different organs or different lesions in the same organ. It does NOT include treatment of contiguous structures of the same organ.

It is recommended that billers not have the responsibility of appending modifiers to a CPT code. In each instance the medical record documentation should be reviewed to ensure a modifier is appropriate and the appropriate modifier is used.

Discarded Drugs from Single Use Vial/Package

Change Request #5520 discusses a revision to the Medicare Claims Processing Manual regarding discarded drugs from a single use vial or single use package.

The change request noted that:

1. CMS encourages us to schedule patients so that drugs can be used in the most efficient, clinical appropriate manner.
2. If after administering a single dose/quantity of a drug of biological to a Medicare patient, the provider must discard the remainder of the single use vial or other single use package. CMS provides payment for the amount of drug or biological administered and the amount discarded up to the total amount of the drug or biological as noted on the vial or package label.

Medically Unlikely Edits (MUE), Effective July 1, 2007

On July 2, 2007 CMS will install Version 1.2 of the medically unlikely edits.

An MUE is defined as an edit that tests claim lines for the same beneficiary, same HCPCS code, same date of service and provider against a certain number of units of service.

When a claim is submitted to a fiscal intermediary with units of service that exceed the MUE criteria, the claim will be returned to the provider. Other services on the claim will be paid.

Providers are reminded that:

1. An appeal process will not be allowed for claims RTP as a result of a MUE
2. Providers may appeal MUE criteria by forwarding a request to the FI
3. Excess charges due to units of service greater than the MUE may NOT be billed to the beneficiary. This is provider liability.

Revised Advanced Beneficiary Notice (ABN)

The start of a second public comment period for the revised revisions of the ABN was published in the Federal Register May 25, 2007. Currently CMS maintains 2 versions of the ABN (a general ABN and a lab-specific ABN). CMS is now proposing to combine these 2 versions into a single ABN. Comments must be received by Sunday, June 24th.