March 7, 2024
The following policies received their annual review with no changes:
The following policies received their annual review with the updates noted below:
Contract Exclusions/Disallowed Charges – Inpatient and Outpatient Facility Services
Added and/or modified the following sections to provide for additional clarification on non-reimbursable services:
- Nursing care:
- Incremental Therapy Charges (e.g., PT, OT, ST)
- Dietary and related nursing services
- Medical and Psychiatric social services
- Bedside respiratory and pulmonary services
- Outpatient services billed while patient is Inpatient
- Equipment which are a required component of a specific level of care room charge:
- Oximetry Monitors
- Fluoroscopy/Ultrasound/Vascular Access Guidance”
- Equipment considered required component of specific service and/or procedure
- Perfusion equipment and supplies in OR when billed in conjunction with perfusionist time increments
- Medical/Surgical Supplies:
- Supplies considered integral to patient care (e.g., wipes, swabs, bed pans, etc.)
- Catheter Guidance/Guidewires
- Respiratory Services:
- Ventilatory support management and maintenance
- Bedside respiratory and pulmonary services (ex. management of nebulizers/breathing treatments, mechanical chest physiotherapy, swallow testing, IPPB therapy)
- Nebulizer treatments
- Radiology:
- Ultrasound guidance for vascular access
- Contrast materials (ex. Gadoteridol, LOCM, Gastrogafen, Gadoterate, Iohexol)
- Radiopharmaceuticals (ex. Technetium Tc-99m)
- Pharmacy Services furnished to patients or other departments:
- Contrast materials, topical anesthetics, irrigation fluids
- Radiopharmaceuticals (ex. Technetium Tc-99m)
Medicare Indicator Status B and Status T Services Reimbursement
In the Policy section, paragraph three, added further clarification on when a Status T code is/is not reimbursed
Modifier 53 – Discontinued Procedure
In the Policy section, in paragraph three, added the third and fifth bullets of when appending modifier 53 to a service is not appropriate.
Modifier 73-Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to Administration of Anesthesia
In the Policy section, expanded the fifth paragraph with bulleted examples of when appending modifier 73 to a service is not appropriate.
Modifier 74-Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure after Administration of Anesthesia
In the Policy section, added the fifth paragraph with bulleted examples of when appending modifier 74 to a service is not appropriate.
Modifier 78-Unplanned return to the Operating Room by the Same Physician for a Related Procedure During Post-operative period
Removed references to modifier 76 for an unplanned return to the OR for a repeat of the same original surgical procedure in the global period of the original surgery.
National Drug Code (NDC) Billing Guidelines-Outpatient Facility Claims
The following updates and clarifications were made to sections of the Policy statement:
- Removed the “ME-Milligrams” unit of measurement from the entire policy
- In the subsection “How to Submit an NDC on a Claim Form” added the third bullet
- In the subsection “2) Paper Claim Guidelines (UB-04/CMS-1450), added bullet five under Field 43-Descriptions
- Expanded the last subsection in the Policy to include “Administered” drugs and added clarification on how to bill for administered drugs (modifier JZ) and wasted drugs (modifier JW) on the facility claim form
National Drug Code (NDC) Billing Guidelines-Professional Claims
The following updates and clarifications were made to sections In the Policy statement:
- Removed ALL references to “ME-Milligrams”
- In the subsection “How to Submit an NDC on a Claim Form”, added the third bullet
- In the subsection “Paper Claim Guidelines (CMS-1500)”, added the fifth bullet in the second paragraph
- Expanded the last subsection in the Policy to include “Administered” drugs and added clarification on how to bill for administered drugs (modifier JZ) and wasted drugs (modifier JW) on the facility claim form
Physical Medicine and Rehabilitation Services
The following updates and clarifications were made to sections of the Policy statement:
- Clarified the maximum number of units for the Supervised Modalities, Constant Attendance Modalities, Therapeutic Procedures and Physical/Occupational Therapy Evaluation and Re-Evaluation sections.
- In the Plan of Care Modifiers section, added third paragraph urging providers to review the Annual Therapy Code list
- In the Codes/Coding Guidelines section, under the Constant Attendance Modalities, added new code 97037 which is effective January 1, 2024
- In the Unit Billing for Timed Codes section, revised the second and third paragraphs on determining the halfway point of time for codes noted in the policy
Place of Service Codes
Removed the Exceptions effective 01/01/2024 when POS 10 was changed from “F-Facility” RVUs to “NF-Non-Facility” RVUs for all providers.
Unlisted, Non-Specific and Miscellaneous Procedure Codes
In the Table of Unlisted codes in the Policy section, added the following:
- Added the bullet “Recommendation of a comparable code” to each section in the table
- Added code examples to the section “ALL OTHER UNCLASSIFIED/NOT OTHERWISE SPECIFIED/ MISCELLANEOUS HCPCS CODES”
Medically Unlikely Edits (MUEs)/Maximum units of service
This policy explains the establishment of maximum daily units on CPT and HCPCS procedure codes that are enforced by the claim editors.