Frequently Asked Questions - Medical Policy

Home Provider Part B FAQs

All FAQs are current as of the date noted next to the question.

  1. Where can I find information regarding a Wisconsin Physicians Service (WPS) Medicare Policy? (08/21/06)


  2. I called the IVR and it states non-covered services not deemed medically necessary by payee. Our coder says we are billing this correctly. So, why are you denying ? (08/20/07)


  3. Our practice requires all of our patients to have a chest x-ray before surgery. We know Medicare does not cover screening chest x-rays. Do we have to bill Medicare for the service? If we do, what should we submit on the claim? The diagnosis code that is most appropriate for these services is not listed in your Local Coverage Determination (LCD) RAD-004, "Radiologic Examination of the Chest, Including Portable." (10/01/07)


  4. I work for a physician group that has several different clinic locations. One clinic performs the radiology technical component (modifier TC). Then we send the film to one of our other clinic physicians who perform the professional component (modifier 26). Is it appropriate for one of the clinics to bill the radiology service globally? (11/14/07)


  5. Does the National Coverage Provision (NCP) PHYS-024, "Supervising Physicians in Teaching Settings," apply to Physician Assistant (PA) students or Nurse Practitioner (NP) students? (11/14/07)


  6. When can a teaching physician bill for the student's services? (11/14/07)


  7. I work for a radiology group. Recently, I noticed that the amount WPS Medicare allows for some radiology procedures is lower than the allowed amount listed on the Medicare Physician Fee Schedule. Could you please explain why WPS Medicare is reducing the allowed amount for some radiology procedures? (11/14/07)


  8. When is it appropriate for providers to use chemotherapy infusion administration Current Procedural Terminology (CPT) codes 96413 and 96415?
    96413 - Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug 96415 - …each additional hour (List separately in addition to code for primary procedure)     (11/14/07)


  9. In 2007, is Medicare accepting Current Procedural Terminology (CPT) codes 99363 and 99364? (11/14/07)


  10. If a patient is anemic prior to initiating chemotherapy, at what point does a physician determine whether the cancer or the chemotherapy caused the anemia? (11/14/07)


  11. Does Medicare cover Erythropoiesis Stimulating Agents (ESAs), Epoetin alfa (EPO) or Darbepoetin alfa (DPA), for patients who were anemic prior to starting chemotherapy? (11/14/07)


  12. If I prescribe and the patient's Medicare Prescription Drug Plan (PDP) (also known as Medicare Part D) pays for the Zostavax vaccine, may the patient bring the Zostavax vaccine to our office for administration? Will Medicare Part B cover the cost of the administration? (11/14/07)

1. Where can I find information regarding a Wisconsin Physicians Service (WPS) Medicare Policy?
  WPS Medicare policies for WI/IL/MI/MN are available on the website.
Posted: 08/21/06
 
2. I called the IVR and it states non-covered services not deemed medically necessary by payee. Our coder says we are billing this correctly. So, why are you denying ?
  According to the guidelines set by the CMS and Medicare policy, the diagnosis you are billing does not meet medical necessity guidelines. You may refer to the WPS Medicare Website for policies, which list diagnosis codes that support medical necessity for covered services. If you cannot find a policy that applies to your situation, you can also go to the CMS Website and search for procedures you are billing to see if any information is there at http://www.cms.hhs.gov/
Posted: 08/20/07
 
3. Our practice requires all of our patients to have a chest x-ray before surgery. We know Medicare does not cover screening chest x-rays. Do we have to bill Medicare for the service? If we do, what should we submit on the claim? The diagnosis code that is most appropriate for these services is not listed in your Local Coverage Determination (LCD) RAD-004, "Radiologic Examination of the Chest, Including Portable."
  Medicare does not require providers to submit claims for non-covered services (such as a screening chest x-ray performed in the absence of signs or symptoms of a medical problem) unless the beneficiary requests that they do so. If a beneficiary requests a formal claim determination by Medicare on a non-covered service, the provider should submit the service to Medicare and append modifier GY ("Item or service statutorily excluded or does not meet the definition of any Medicare benefit") to the line of service. This allows Medicare to process the claim more quickly and assign the beneficiary the responsibility for payment. Providers should also list the diagnosis code that accurately reflects the reason for ordering the chest x-ray, even if the diagnosis code is not listed in LCD RAD-004. In many cases, the most appropriate diagnosis code will be a screening diagnosis code.

For more information, please see LCD RAD-004 and the companion coding and billing article, which is available on our Website.
Posted:10/01/07
 
4. I work for a physician group that has several different clinic locations. One clinic performs the radiology technical component (modifier TC). Then we send the film to one of our other clinic physicians who perform the professional component (modifier 26). Is it appropriate for one of the clinics to bill the radiology service globally?
  In this situation, one clinic cannot bill the radiology service globally. Medicare reimburses services from the Physician Fee Schedule based on the zip code of the performing physician. When one clinic refers a radiology service to another clinic physician to interpret the service, the first physician clinic cannot bill both the technical and the professional services globally. Each clinic may bill the component they perform, or one of the clinics may bill the service they perform and bill the other component as a purchased diagnostic test.

The Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Chapter 13, Sections 20.2.4 - 20.2.4.2, provides guidelines on billing for purchased diagnostic tests. To view a copy of this publication, please refer to the CMS Website below:
http://www.cms.hhs.gov/manuals/downloads/clm104c13.pdf
Posted: 11/14/07
 
5. Does the National Coverage Provision (NCP) PHYS-024, "Supervising Physicians in Teaching Settings," apply to Physician Assistant (PA) students or Nurse Practitioner (NP) students?
  It is not appropriate to apply the guidelines in NCP PHYS-024 to the services of PA students and NP students. This NCP applies to supervising physicians and residents. The terms "interns" and "residents" include physicians participating in approved postgraduate training programs as well as physicians who are not in an approved graduate medical education (GME) program but authorized to practice in a hospital setting.
Posted: 11/14/07
 
6. When can a teaching physician bill for the student's services?
  Medicare never considers a student an intern or resident and does not pay for any service furnished by a student. In addition, for Evaluation and Management (E/M) services, Medicare limits a student's documentation to the review of systems and/or past family/social history to which the supervising physician will refer. All other billable services require the physical presence of a teaching physician or the physical presence of the resident. The teaching physician may not refer to a student's documentation of physical exam findings or medical decision making in his or her personal note. If the medical student documents E/M services, the teaching physician must verify and redocument the history of present illness as well as perform and redocument the physical exam and medical decision-making activities of the service.

For more information, please refer to the WPS Medicare National Coverage Provision (NCP) PHYS-024, "Supervising Physicians in Teaching Settings," which is available at the following address:
http://www.wpsmedicare.com/part_b/policy/phys024.pdf
Posted:11/14/07
 
7. I work for a radiology group. Recently, I noticed that the amount WPS Medicare allows for some radiology procedures is lower than the allowed amount listed on the Medicare Physician Fee Schedule. Could you please explain why WPS Medicare is reducing the allowed amount for some radiology procedures?
  The Centers for Medicare & Medicaid Services (CMS) published a Medicare Learning Network (MLN) article regarding this matter on November 16, 2006. The MLN number assigned to this article is SE0665. According to the article, the Deficit Reduction Act (DRA) of 2005 requires a payment capitation on certain diagnostic imaging procedures. The payment capitation only applies to the technical component (TC) of the imaging procedure. The DRA of 2005 limits the TC payment amount for most imaging procedures paid under the Medicare Physicians Fee Schedule (MPFS) to the amount paid under the Medicare Outpatient Prospective Payment System (OPPS). In other words, if the amount Medicare allows for a procedure under the OPPS is lower than the amount Medicare allows under the MPFS, Medicare will allow the lower OPPS amount. For these situations, instead of looking to the MPFS for pricing information, providers need to reference the payment capitation file, which is available on our Website at:
http://www.wpsmedicare.com/part_b/fees/fees.shtml

For additional information on this matter, please refer to the CMS Website below:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0665.pdf
Posted: 11/14/07
 
8. When is it appropriate for providers to use chemotherapy infusion administration Current Procedural Terminology (CPT) codes 96413 and 96415?

96413 - Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug 96415 - …each additional hour (List separately in addition to code for primary procedure)
  For services furnished on or after January 1, 2005, it is appropriate to use chemotherapy infusion administration codes for parenteral administration of nonradionuclide anti-neoplastic drugs. Chemotherapy infusion administration codes are also appropriate when physicians provide anti-neoplastic agents for the treatment of noncancer diagnoses or for substances such as monoclonal antibody agents and other biologic response modifiers. Generally, drugs such as Infliximab (Remicade ®), Rituximab (Rituxan®), Alemtuzumab (Campath®), Gemtuzumab (Mylotarg®) and Trastuzumab (Herceptin®) are considered to be in the category of monoclonal antibodies.

However, it is not appropriate to submit claims for the administration of anti-anemia drugs and anti-emetic drugs by injection or infusion for cancer patients using codes 96413 and 96415. Such services are reported using CPT codes from the range 90765-90775.

For more information regarding chemotherapy infusion administration codes, please refer to the WPS Medicare National Coverage Provision (NCP) HONC-002, "Chemotherapy and Drug Administration," at the following address:
http://www.wpsmedicare.com/part_b/policy/honc002.pdf
Posted: 11/14/07
 
9. In 2007, is Medicare accepting Current Procedural Terminology (CPT) codes 99363 and 99364?
  In 2007, CPT codes 99363 and 99364 for anticoagulant management are not reimbursable by Medicare Part B. The 2007 Physician Fee Schedule Relative Value Unit file identifies CPT codes 99363 and 99364 as Status "B" codes. The Status Code Indicator of "B" represents a bundled code. This means the payment for codes 99363 and 99364 is always bundled into payment for another service provided on the same day.

Medicare considers drug management, such as anticoagulant management, as included in the management of the patient's condition.

Erythropoiesis Stimulating Proteins
Epoetin alfa (EPO), Darbepoetin alfa (DPA)
Posted:11/14/07
 
10. If a patient is anemic prior to initiating chemotherapy, at what point does a physician determine whether the cancer or the chemotherapy caused the anemia?
  During the workup for the anemia, the physician determines if the continuing or worsening anemia is due to cancer or chemotherapy. The results of cancer may cause the anemia. Iron deficiency, bleeding, or renal disease, etc., also may cause the anemia.
Posted: 11/14/07
 
11. Does Medicare cover Erythropoiesis Stimulating Agents (ESAs), Epoetin alfa (EPO) or Darbepoetin alfa (DPA), for patients who were anemic prior to starting chemotherapy?
  WPS Medicare does not cover ESAs (EPO or DPA) for cancer-induced anemia. The anemia must be due to the chemotherapy itself, whether the chemotherapy is being used to treat cancer or another illness such as hepatitis, multiple scleroses, etc. Treatment of myeloid malignancies is an exception. Medicare considers reimbursement for ESAs (EPO and DPA) for chemotherapy-induced anemia.

When billing for chemotherapy-induced anemia, Medicare requires three diagnosis codes. The WPS Medicare Local Coverage Determination (LCD) INJ-023 instructs providers to report 285.8 or 285.9 to indicate the anemia, 995.20 to indicate the chemotherapy, and a third code to indicate the underlying condition.

For additional information on EPO and DPA, please refer to the WPS Medicare LCD INJ-023, "Erythropoiesis Stimulating Proteins Epoetin alfa (EPO), Darbepoetin alfa (DPA)," at the following links:
http://www.wpsmedicare.com/part_b/policy/inj023.pdf
http://www.wpsmedicare.com/part_b/policy/inj023_billing.pdf
Posted: 11/14/07
 
12. If I prescribe and the patient's Medicare Prescription Drug Plan (PDP) (also known as Medicare Part D) pays for the Zostavax vaccine, may the patient bring the Zostavax vaccine to our office for administration? Will Medicare Part B cover the cost of the administration?
  Yes, after the patient's Medicare PDP has paid for the Zostavax vaccine, the physician may administer and receive reimbursement for the Zostavax vaccine administration. If the Medicare PDP does not pay for the Zostavax vaccine, Medicare Part B will not pay for the administration.

The CMS created code G0377 for the administration of the Zostavax vaccine. Medicare's coverage of G0377 is effective January 1, 2007 through December 31, 2007. Providers must accept assignment when billing the Zostavax vaccine administration.
Posted:11/14/07
 


Page Last Updated: Tuesday, 04-Dec-2007 13:19:00 CST