Part A Ask the Contractor Teleconference (ACT) Questions and Answers: January 12, 2022

Published 02/01/2022

Areka Freeman, POE Sr Provider Relations Representative
Sandra Booker, POE Sr Provider Education Consultant
Charles Canaan, POE Sr Provider Education Consultant

Areka Freeman welcomed participants to the Ask the Contractor Teleconference (ACT). The ACT is intended to open the communication channels between the provider community and Palmetto GBA. We believe this is an excellent forum to encourage dialogue between our providers and Palmetto GBA. Prior to the call, an announcement was sent out via listserv and posted on the Palmetto GBA website.

Areka Freeman introduced Sandra Booker, a Sr Provider Education Consultant to provide education regarding COVID-19. Sandra provided the audience with the following education: Positive COVID-19 Test Results Required for 20-Percent Increase to MS-DRG Weighting.

Sandra Booker then turned the call back to Areka Freeman and the Questions and Answers ortion of the teleconference began.

Questions and Answers

Areka Freeman addressed the first question.

Question: We submit claims for no transport due to patient having a secondary insurance that may pay. We expect to receive a PR remittance code so that we can then bill to the patient’s secondary plan but seem to always receive a CO which means we have to adjust the charges. Can you please tell me if there's anything specific that we need to do in order to receive the PR and not the CO remit code?

Answer: It has been determined that condition code 21 should work in this circumstance. If the provider is using condition code 21 and the claim is still not assigning the correct financial responsibility, then the provider would need to escalate the claim to have it reviewed.

Areka Freeman addressed the second question.

Question: Can you tell me where I can find a crosswalk for which revenue code goes with which HCPCS code? I have looked everywhere, and I cannot find one.

Answer: This should be in the National Uniform Billing Committee or NUBC manual. 

The goal of the NUBC Manual is to achieve administrative simplification as outlined in the Health Insurance Portability and Accountability Act of 1996. 

In the manual you can access the UB-04 billing information adopted by the NUBC by subscribing to the Official UB-04 Data Specifications Manual. This manual, copyrighted by the American Hospital Association, is the only official source of UB Data. No other publication — governmental, private, or commercial — can be considered authoritative.

Areka Freeman addressed the third question.

Question: We do institutional billing. Our facility question is we have several claims that deny for hospice as “not approved treatment” and it was always my understanding of the hospice rules that once they go under hospice the patient has to follow their rules unless they revoke and when they seek unapproved treatment, the patient becomes liable. We had some claims deny from hospice as treatment not approved and we were asked to rebill said claims with the GW HCPCS modifier. I have researched this modifier and found a guideline if you will, but it is still not clear to me and from all indications, it seems to be for physician billing and not institutional billing. Can we ger verification if this modifier can be used on institutional claims?

Answer: The GW HCPCS modifier is for professional claims, not institutional claims. If the condition treated is not related to the hospice terminal illness, condition code 07 should be appended to the claim.

Areka Freeman addressed the fourth question.

Question: For LCD38994 pain block, will claims be reviewed on a pre- or postpayment review since there is not a list of specific diagnosis codes for this policy?

Answer: Please reference this coverage article. There is a list of diagnoses in this article Billing and Coding: Epidural Steroid Injections for Pain Management.

The information in the article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Epidural Steroid Injections for Pain Management L38994.

Please note that the services addressed in this article only apply to epidural injections. Other joint procedures (e.g., sacral injections, facet joint) are not addressed.

Areka Freeman addressed the fifth question, by stating that the response will be added to the call posting.

Question: When looking at our LCD (L34573) and related billing and coding article (A56606) on Cardiac Event Detection we do not see differentiation in the medical necessity criteria for Mobile Cardiac Telemetry (CPT® Codes 93228 and 93229) and Cardiac Event Monitors (CPT® Codes 93268-93272) the way other MACs and commercial payors differentiate the two services. Can you confirm that there is not different medical necessity criteria for these two services?

Answer: Palmetto GBA’s current LCD covers both services.

If there is not different criteria, what should an ordering provider’s documentation include to support ordering Mobile Cardiac Telemetry instead of Cardiac Event Monitoring?

Here are the documentation requirements copied from the LCD.

  1. The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD (See Coverage Indications, Limitations and/or Medical Necessity). This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
  2. Records must include EKG rhythm strips with interpretation for each transmission. The date and time of each transmission, when the symptoms occurred and what the symptoms were must be documented for each transmission. The medical record should also include when the reviewing physician and the ordering physician were notified of the transmission and its results.
  3. The interpretation must be a de novo interpretation by the physician billing the interpretation, in addition to any “preliminary interpretation” by the company, hospital or other provider functioning as the receiving station, or billing the technical component of the test
  4. The CED provider's records must include the referring physician's request for the test and the indications for the test. This information should be incorporated into a formal report (interpretation) of the test.
  5. Documentation of necessity should include the referring physician's diagnostic impression, and an indication of relevant signs and symptoms
  6. The provider performing the technical component of the service must retain a written copy of the physician/nonphysician practitioner (NPP) order for the test which should include the indication(s) for the test. This provider must also maintain copies of all transmissions, documentation of actions taken, and physicians contacted, or instructions given to the beneficiary.
  7. Documentation supporting medical necessity should be legible, maintained in the patient's medical record, and must be made available to the A/B MAC upon request

Question: What date of service (DOS) is reported for these services, specifically CPT® codes 93270, 93272 and 93228?

Answer: The DOS should be the date the service was performed or in the case of an extended monitoring period the DOS would be the date the monitor is first placed (beginning of monitoring period).

Areka turned the call to the operator to poll the attendees for additional questions. Per the operator there were no additional questions. The callers were thanked for their and the next scheduled ACT was announced as April 13, 2022.