The old "new patient" conundrum
In its most recent Medicare Quarterly Provider Compliance Newsletter (PDF download) the Centers for Medicare and Medicaid Services (CMS) highlighted an issue that apparently continues to be a problem for some physicians. Namely, when is a patient "new" for purposes of billing evaluation and management (E/M) services?
CMS defines a "new" patient in Chapter 12 Section 30.6.7 (PDF download) of the Medicare Claims Processing Manual as "a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years." This is essentially the same definition as in Current Procedural Terminology (CPT), which states, "A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years." CPT defines "professional services" as "those face-to-face services rendered by a physician and reported by a specific CPT code(s)."
A simple way to determine if a patient is new is to ask yourself this question: "Have I (or another physician of my specialty within our group practice) provided a face-to-face service to this patient within the past 3 years?" If the answer is no, then the patient is new to you for purposes of coding and billing the E/M service that you are providing to him or her. If the answer is yes, then you must consider the patient established. Determination of whether the patient is new or established should not be made solely on whether the chart presented was new. Coding or charge entry staff should search for past billing records using the patient's social security number and date of birth, and if a billing record is found, contact the appropriate staff to compare the charts and determine if the patient is established.
While some of your patients may be new, this issue is not, and apparently, it continues to sufficiently confuse some physicians that CMS felt it necessary to remind folks about the definitions involved. CMS issues the Medicare Quarterly Provider Compliance Newsletter to help physicians and their billing staffs understand the claims submission problems found by Medicare contractors and how to avoid certain billing errors and other improper activities when dealing with the Medicare. In light of that, you may want to check your own understanding of the new patient issue and related coding and billing practices, lest this become a compliance issue in your practice.
Facing the new face-to-face requirement for Medicare home health services
Did you know that Medicare will soon begin enforcing a requirement that a physician who certifies a patient as eligible for Medicare home health services must see the patient either within 90 days prior or 30 days after the start of home health care? If not, read on. If so, you may still want to read on for more information.
As an outgrowth of section 6407 of the Patient Protection and Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) is requiring that a physician who certifies a patient as eligible for Medicare home health services must see the patient. The law also allows the requirement to be satisfied if a non-physician practitioner (NPP) sees the patient, when the NPP is working for or in collaboration with the physician. The provision was effective as of Jan. 1, 2011, but CMS agreed in December to delay enforcement until April 1, 2011.
The provision requires that, as part of the certification form itself, or as an addendum to it, the physician must document that the physician or NPP saw the patient, and document how the patient’s clinical condition supports a homebound status and need for skilled services. As noted, the face-to-face encounter must occur within the 90 days prior to the start of home health care or the 30 days after the start of care. When a physician orders home health care for the patient based on a new condition that was not evident during a recent visit, the certifying physician or NPP must see the patient within 30 days after admission.
The new requirement includes several features intended to accommodate physician practices. In addition to allowing NPPs to conduct the face-to-face encounter, Medicare will allow a physician who attends to the patient but does not follow the patient in the community, such as a hospitalist, to certify the need for home health care based on their face-to-face contact in the hospital and to establish and sign the plan of care. Medicare will also allow such physicians to certify the need for home health care based on their face-to-face contact with the patient, initiate the orders for home health services, and “hand off” the patient to his or her community-based physician to review and sign off on the plan of care. Finally, in rural areas, the law allows the face-to-face encounter to occur via telehealth, in an approved originating site.
The American Academy of Family Physicians and others are advocating with CMS to extend the enforcement date to no earlier than July 1, 2011, based on confusion with and resistance to the paperwork obligations for physicians, still evolving policy interpretations and guidance on the part of CMS, and the simple need for more time to ensure that physicians and NPPs understand the rule. A decision by CMS on this request is still pending, so as of now, April 1, 2011, remains the key date.
CMS has made additional guidance available via an article (PDF download) on the Medicare Learning Network web site. Additionally, CMS has posted frequently asked questions and answers regarding this requirement in the Spotlights section of the Home Health Agency Center section of the CMS web site.
Drug screening codes have changed
There are now two drug screening codes for reporting use of a multiplexed screening kit that tests for multiple drugs or drug classes. The Centers for Medicare & Medicaid Service published new HCPCS code G0434 for the multiplexed drug screening to differentiate these tests from those that are more complex. CPT followed with new code 80104 for the same purpose. The descriptors for these new codes follow:
• G0434, "Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter (add modifier QW if you have CLIA certificate of waiver)"
• 80104, "Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure"
Use the G code for Medicare claims, and use the CPT code for other claims. The Medicare Clinical Laboratory Fee Schedule shows an average fee of $20.67.
CMS explained in MLN Matters publication SE1105 (PDF download) that refining the drug screen testing codes and revising the descriptors was done to avoid unnecessary or excessive utilization of code G0431 for relatively simple point-of-care tests that screen for multiple substances. In addition to introducing code G0434, code G0431 was changed from “Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class” to “Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter.” If your practice has received denials for claims with dates of service on or after Jan. 1, 2011, that use code G0431QW for tests conducted with the kits listed in MLN Matters publication MM7266 (PDF download), corrected claims should be submitted with code G0434QW. For dates of service on or after April 1, 2011, claims that use code G0431QW will be denied.
Also effective Jan. 1, 2011, code G0430 has been deleted and replaced with code G0434. Therefore, the code G0434QW replaces G0430QW.
G0434 should be used to report very simple testing methods, such as dipsticks, cups, cassettes and cards, that are interpreted visually or with the assistance of a scanner, or that are read utilizing a moderately complex reader device outside the instrumented laboratory setting (i.e., non-instrumented devices). This code should also be used to report any other type of drug screen testing using test(s) that are classified as Clinical Laboratory Improvement Amendments (CLIA) moderate complexity test(s), keeping the following points in mind:
• G0434 includes qualitative drug screen tests that are waived under CLIA as well as dipsticks, cups, cards, cassettes, etc., that are not CLIA-waived.
• Laboratories with a CLIA certificate of waiver may perform only those tests cleared by the Food and Drug Administration (FDA) as waived tests. Laboratories with a CLIA certificate of waiver should bill using the QW modifier.
• Laboratories with a CLIA certificate of compliance or accreditation may perform non-waived tests. Laboratories with a CLIA certificate of compliance or accreditation should not append the QW modifier to claim lines.
• Only one unit of service for code G0434 can be billed per patient encounter regardless of the number of drug classes tested and irrespective of the use or presence of the QW modifier on claim lines.
Note that the "per encounter" reporting for G0434 doesn't prevent reporting when a patient is tested in two different settings, such as when a patient tested in the physician's office in the morning later reports to the emergency department and receives a second test.
The MLN Matters publication mentioned earlier (MM7266) also provides a listing of the drug kits that should be reported using the new code G0434 with the QW modifier to signify the test's waived status. Each quarter CMS publishes a list of all test products with CLIA-waived status. Providers may use this list to determine if a particular test product can be appropriately performed by a laboratory with a CLIA waiver and is eligible to be billed using the QW modifier. However, the currently displayed list is from Jan. 5, 2010. You can view the most recent list as provided to the Medicare contractors in Medicare CR7266 (PDF download).
If you are unsure about Medicare coverage of drug screening tests, this information is available from the Medicare Coverage Database and the Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report dated January 2011. I found local coverage determinations for qualitative drug screens posted by National Governments Services Inc., First Coast Service Options Inc., and Palmetto GBA by searching the term "drug screen" in the Medicare coverage database.
I may have just set the record for the most links in a Getting Paid blog, but I'm sure my drug screen would come out clean. I just like to provide the sources for further information and to help you and your staff keep up with these ever-changing codes and coverage decisions.