09/11/12 Ask-the-Contractor Teleconference (ACT ... - WPS Medicare

09/11/12 Ask-the-Contractor Teleconference (ACT) Transcript
Moderator: Mary Muchow
September 11, 2012
2:00 pm ET
Operator:
Good afternoon. My name is Angie, and I will be your conference operator
today. At this time, I would like to welcome everyone to the J5 ACT
Conference Call. All lines have been placed on mute in order to prevent any
background noise.
After the speakers’ remarks, there will be a question-and-answer session. If
you would like to ask a question at this time, simply press star then the
number 1 on your telephone keypad. If you would like to withdraw your
question, press the pound key. Thank you.
Ms. Muchow, you may begin your conference.
Mary Muchow: Well, good afternoon, everyone. I’d like to welcome you to the September 11,
2012, Jurisdiction 5 Medicare Part B Ask-the-Contractor Teleconference or
ACT. My name is Mary Muchow, and I’m speaking to you today from the
WPS Medicare Office in Madison, Wisconsin. I represent Part B Provider
Outreach and Education.
On this call today, there are several people from a variety of areas within the
Medicare division. To name a few, we have provider enrollment, Medicare
internal processes, payment recovery, our policy staff is with us today as is
medical review. A representative from the Provider Research Relations
Research Specialists is joining us, as is claims and appeals, and last but not
least, Medicare Publications.
These subject matter experts are available during today’s telephone call to
provide education, program updates, to answer your questions and take
feedback. In addition, we will provide necessary follow-up to any issues that
cannot be resolved during today’s teleconference.
This particular teleconference is specific to Iowa, Kansas, Missouri, and
Nebraska providers that submit claims to Medicare Part B. We don’t have
anyone on this call today to address any Part A concerns. However, Part A
does host a number of teleconferences throughout the year. I encourage you
to take a look at our Part A J5 Training Program’s web page to choose a
teleconference that would best fit your Part A need. The action to choose that
web page will show up on the sub menu that drops down when you hover
over the Training tab that appears on the primary navigation bar on the Part A
J5 website.
Created 10/02/2012 1
http://www.wpsmedicare.com/

As you may be aware, providers may submit suggestions or topics on the
ACT advance http://www.wpsmedicare.com
request form and that’s available on our website. The form
should be filled out in its entirety and should include what specific information
that you’re looking for. The completed form can then be faxed or e-mailed to
WPS Medicare. The fax number and the e-mail address both appear on the
form itself.
Now the existing form is being updated and will soon reflect a new fax
number to which the form may be faxed. Please be certain that you discard
any old forms that you may have in your possession. The new fax number will
be on the form itself as I previously mentioned. That particular new fax
number is (618) 998-5249.
Now please keep in mind that if your request is not received by WPS
Medicare at least five days prior or in advance of the call date, we may not be
able to address your request during the ACT. These five days allow time to
consult with subject matter experts here at WPS Medicare and it allows us to
research those requests that are complex in nature.
Now remember that ACTs are designed for general inquiries, not claim
specific information. If you have a claim specific issue, please contact WPS
Medicare Customer Service as they are best equipped to help you.
To begin today’s ACT, we will address the advance requests that have been
received and after that, we’ll ask Angie to open up the lines to our questions
from all of you, our participants. We will do our best to answer all of the
questions while we are on the telephone call today. However, we may need
additional time to research additional questions or issues that are complex in
nature. If this occurs, we’ll ask you for your name and your telephone
number, and someone will get back to you within the next couple of business
days.
Today’s teleconference of this ACT is being recorded. If this causes an issue
for anyone, you might wish to keep this in mind during the question-andanswer
period. You can access a recording and a transcription of this J5 ACT
on our J5 On Demand Training web page in approximately two weeks from
this call date.
Our first advance question today received from Karen states, “Some of our
physicians would like to start giving the influenza vaccine to patients. What is
the coverage period for this service during flu season For example, is it
October through May”
The Centers for Medicare & Medicaid Services, or CMS, currently follows the
Centers for Disease Control and Prevention, or CDC’s recommendation that
the flu season begins as soon as the vaccine is available and continues
through the flu season. CMS concurs with the CDC that the beginning and
duration of the flu season cannot be precisely determined.
Just as one of our current messages on our provider home page states on
our website, “We do receive numerous phone calls this time of year asking us
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for a new pricing on the influenza vaccine.” We will not have that information
prior to notification http://www.wpsmedicare.com
by CMS. When we receive that information from CMS, we
will publish that information or that notice in the WPS Medicare eNews.
Please continue to watch eNews for this notification. Once available, the
CMS website will actually contain the pricing. It will be posted out on the CMS
website. That website location will be included in the eNews that is sent out
by WPS Medicare.
If you do not subscribe to eNews, we encourage you to sign up. Our listserv
subscribers are assured that they receive the most current WPS Medicare
information in the most expeditious manner. Now, to sign up for our eNews or
to manage your current eNews subscription, simply choose eNews, which
appears in the upper right-hand corner of each WPS Medicare web page.
Here’s a question we received from Amy: “Can an Advanced Registered
Nurse Practitioner, ARNP, supervise a registered nurse performing a stress
test This would be reported with CPT code 93015 and bill that service under
the ARNP’s or the Advanced Registered Nurse Practitioner’s provider
number.”
And the answer to that is this, the Code of Federal Regulations requires that
diagnostic tests covered by the Social Security Act and payable under the
physician fee schedule with certain exceptions that are listed in the
regulations has to be performed under the supervision of an individual
meeting the definition of a physician as listed in the Social Security Act.
It goes on to say that non-physician practitioners cannot act as supervisory
physicians under the diagnostic test benefit. You can find this information in
the CMS Medicare Benefit Policy Manual. That’s publication 100-02 Chapter
15 Section 80. Remember you can easily access CMS’ Internet-Only Manual
by choosing the link labeled Manual. It appears under the top five links
heading on the center right portion of the CMS home page. It’s available at
www.cms.gov.
Our third and last Advance Request for today’s call states, “Recently, a CMS
review on a denial suggested that the technical and professional component
on a procedure should reflect different dates if they were performed on a
different date. The request further states this is not currently the procedure of
any practice in any CMS region in the country. Is this a new regulation And if
so, please indicate where this can be found in the existing claims manual.
Further, the request we received states, it is widely known that a professional
component may be performed at a later time when the original technical
component of the procedure was performed. The professional component
report reflects the date the test was done and the date the test was read. It
has always been the understanding of the physician communities that the
dates of the technical component and the professional component need to be
identical in order to be paid. If this is not correct, then there has been a
terrible miscommunication for years because this is the usual practice of all
physicians.”
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Thank you, Paula, for submitting this request. This provides WPS Medicare a
perfect opportunity http://www.wpsmedicare.com
to address this question that does indeed come up very,
very often. WPS Medicare has always instructed that the date of service must
reflect the date that the provider actually performed the service. For services
with professional and technical components, the date of service could be
different depending on when the interpretation is performed.
This is the same message that WPS Medicare has always given to providers.
Our message has never changed. The CMS Internet-Only Manual is
Publication 100-04, the Medicare Claims Processing Manual in Chapter 26,
which is entitled "Completing and Processing Form CMS-1500 Data," it’s
actually Section 10, includes instructions for completing the Medicare claim.
Instructions for completion of Item 24A or the electronic equivalent, if you
submit claims electronically, specifically states, “Enter a six-digit or eight-digit
date for each procedure, service, or supply.”
Item 24D instructions inform the provider to enter the procedure, service, or
supply using the CMS Healthcare Common Procedure Coding System or
HCPCS code, and when applicable, show the HCPCS code modifiers along
with that HCPCS code. So based on the CMS claim form instructions found in
publication 100-04, a provider who performs the professional component of a
service will list the date that he or she performed the service in Item 24A or
the electronic equivalent and will report the appropriate HCPCS code and the
PC modifier in Item 24D.
At this time, I’d like to invite Angie to once again inform participants how they
may post their questions.
Operator:
If you would like to ask an audio question, please press star 1 on your
telephone keypad. We’ll pause for just a moment to compile the Q&A roster.
Your first question comes from the line of Barb Carter.
Mary Muchow:
Barb Carter:
Mary Muchow:
Hi, Barb.
Hello. We have a question. We are getting denials on our lesions, on one of
the codes on the lesions that does the related or qualifying claim or service
was not identified on this claim and we need help to solve that.
That is a claim-specific denial. And what you’re going to need to do with that
is call customer service. They are better equipped to help you. Those of us
that have assembled for this call, we’d love to help you, but unfortunately, we
don’t have any system access. We can’t look at your claim and look at the
other claim that pended up against it to let us know additional information and
to provide additional information on why your claim denied.
So if you’ll give customer service a call, they’ll be happy to assist you.
Barb Carter:
OK, thank you.
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Mary Muchow:
Operator:
Mary Muchow:
Amy Green:
Mary Muchow:
Amy Green:
Mary Muchow:
Amy Green:
Mary Muchow:
Amy Green:
Mary Muchow:
Amy Green:
You’re welcome.
http://www.wpsmedicare.com
Your next question comes from the line of Amy Green.
Hello, Amy.
Hi. How are you
I’m doing fine, thank you.
First, I have three questions, so I assume you probably want me to get in and
request them after this. The first question has to do with the ARNP
supervising an RN. I got the information what manual it was in but I did not
catch the chapter when you’re answering the Q&A, where you can find this
information.
OK. I’m just looking back through my notes, Amy. It is actually information in
the Medicare Benefit Policy Manual, that’s one of CMS’ internet-only
manuals. All of the internet-only manuals are available on the CMS website.
But specifically what you want to look for is Publication 100-02, the Medicare
Benefit Policy Manual. Once you access that particular manual, you can
choose Chapter 15 and then look under Section 80. And that’s where you’ll
find this information.
OK. And my other questions, you’d like me to get out of queue and request
them again then
No, go ahead, Amy.
OK. My next question was when submitting questions as a contractor, I know
that your options were e-mail or a fax the form. Obviously, you got my
question so it must have worked. I just sent it by e-mail, but there was no way
to attach the form. That form isn’t allowed to be saved. So how do people
submit that by email I just actually typed in my question.
You weren’t able to save the form, is that what you’re saying It was probably
in a…
An allowable form to be saved.
Mary Muchow: …a PDF document. You can copy and paste the information into a Word
document and send that
Amy Green:
Mary Muchow:
I tried to do it into the e-mail. I think I tried to do it into a Word document also,
and it just didn’t allow because of the type of the interactive form that it
doesn’t allow it to happen. So I didn’t know if you guys are aware of that.
OK, we are going to have to revisit that and give that some consideration.
Amy, thank you for letting us know. The other option that you have is to send
an e-mail with the information into medicareadmin@wpsic.com.
5

Amy Green:
Mary Muchow:
Amy Green:
Mary Muchow:
Amy Green:
Mary Muchow:
Amy Green:
Mary Muchow:
Operator:
Mary Muchow:
Natalie Murphy:
Mary Muchow:
Natalie Murphy:
Dr. Boren:
Natalie Murphy:
Dr. Boren:
Natalie Murphy:
Dr. Boren:
Natalie Murphy:
Dr. Boren:
Natalie Murphy:
OK.
http://www.wpsmedicare.com
And if you would put please ACT Topic Suggestion in the subject. Our staff
and Medicare administration will then know who to forward the information to.
OK, and that did work because that’s what I did and you did my questions so.
OK, terrific.
OK. My last question, and I don’t know if this is too claim specific, but it has to
do with the RAC audits that have been happening with the observation care. I
would like to give you a scenario and see what your thoughts are, is that
something that you can answer on this teleconference
I’m sorry; we’re not able to address that on this teleconference, Amy.
OK. OK, that’s what I needed to know. Thank you very much.
You’re welcome.
Your next question comes from the line of Natalie Murphy.
Hi, Natalie.
Hi. I wanted to know, I don’t have a denial but I just have a hypothetical
situation and that is when we do a VAD visit, which is the daily management
of the VAD machine in the hospital, and the patient has had a previous, say,
heart transplant. Do we a put a 24 modifier on that visit or a 79 saying I’m
related, or just bill it as a plain visit as the 93750
I’m not familiar with the … did you say VAD visit Does anyone…
Yes.
Can you please repeat that question
Let’s see, OK.
Are you saying that the person who did the VAD …
Yes. We put the VAD machine in, the ventricular assist device. OK. When we
did that, maybe we did an aortic valve replacement.
OK.
But we see them everyday.
Right.
And after that, I know the valve replacement would be 90-day global. So do
we put a 79 on the following daily visits after or…
6

Dr. Boren:
Natalie Murphy:
Dr. Boren:
Natalie Murphy:
Dr. Boren:
Natalie Murphy:
Dr. Boren:
Natalie Murphy:
A 79 is for return to surgery.
http://www.wpsmedicare.com
I’m sorry, I mean a 24 modifier.
No. What you’re describing is taking care of the patient in the typical
postoperative care.
So we shouldn’t be…
Billing, no.
Because that’s interrogation of the device in person and everyday, we see
them until they get off the machine in order to get a heart transplant.
That’s right. I believe that unless CMS gives you a zero global period, I mean,
typically, when someone has a procedure done in the hospital, it is all the
postoperative care in the hospital There are few exceptions like, a
cauterization has a zero global period. But see, I can’t remember off the top
of my head what the VAD CPT code is.
It’s 93750 and Medicare has paid. Say we don’t do a procedure and we just
insert the VAD machine and we see them daily, there’s no global for that
93750. So in that case, we do bill.
Dr. Boren: 937…
Natalie Murphy:
Dr. Boren:
Natalie Murphy:
Dr. Boren:
Natalie Murphy:
Dr. Boren:
Natalie Murphy:
Dr. Boren:
Natalie Murphy:
Dr. Boren:
Natalie Murphy:
Dr. Boren:
…50.
No, but that’s not putting the VAD.
No, we’ve already done that and everyday after we charge.
What’s the CPT code for putting in a VAD It should be a 3 something.
It is the 33979 – or a 33975, 76, 79. It depends on what type, bilateral or, you
know.
33979. OK, that has a xxx global period. I’m trying to find the CMS – xxx
global concept does not apply …
Right.
I have never heard of anyone billing.
We do it everyday, yes.
I see.
We keep them on the machine.
That is very interesting.
7

Natalie Murphy:
Dr. Boren:
Beth:
Natalie Murphy:
Beth:
Natalie Murphy:
Dr. Boren:
Natalie Murphy:
Mary Muchow:
Natalie Murphy:
Dr. Boren:
Mary Muchow:
Natalie Murphy:
Mary Muchow:
Natalie Murphy:
Mary Muchow:
Natalie Murphy:
Mary Muchow:
Natalie Murphy:
And that my question was when it’s done with, say, another procedure, I
know the other http://www.wpsmedicare.com
procedure is 90 days, but we really able to bill that VAD
visit even though it’s bumping up against the other 90-day global Do you
see what I mean
I know what you mean but…
Dr. Boren, this is Beth. I have a CPT book. And under code 93750, it does
say do not report 93750 in conjunction with 33975, 33976, 33979…
That’s insertion.
OK. So is that not what you’re saying
No. We have already put it in. And then every day after, we have to visit
them, interrogate the device in person, analyze the machine to see what it’s
doing and then we bill for that.
I will talk to the head of CCI and find out his thoughts on that. Because I have
a problem because this to me should be part of the service. But I will see if it
he looks at it the same way.
And to me, this right here, this code is a procedure and not a hospital visit.
That’s why I wondered about the modifier 79 saying it’s unrelated to the aortic
valve procedure that was done maybe at the same time. Since it’s not an E/M
code, you can’t put the 24 on this. Do you see what I mean
I would suggest that this should be something that we’d want to take a look at
and follow up on.
OK.
And have her pass that information, please.
Can you provide your contact information for us, please Perhaps, a first
name and a telephone number.
Yes. And what – how do I do that I mean, just give it to you now
Yes. If you would unless you’re in objection to doing so, you could e-mail it...
Oh, no.
…to us later.
No.
OK.
My name is Natalie.
8

Mary Muchow:
Natalie Murphy:
Mary Muchow:
Natalie Murphy:
Mary Muchow:
Natalie Murphy:
Mary Muchow:
Natalie Murphy:
Mary Muchow:
Natalie Murphy:
Mary Muchow:
Natalie Murphy:
Mary Muchow:
Natalie Murphy:
Operator:
Beth Fact:
Mary Muchow:
Beth Fact:
Mary Muchow:
OK, Natalie.
http://www.wpsmedicare.com
OK and my – do you want my phone number
Yes, please.
I mean 816, sorry, 931-3312. And I’m with Kansas City Heart & Lung
Surgeons.
Thank you, Natalie.
Thank you.
Someone will follow up with you in just a couple of days.
OK.
I think if you have an ICN example for us where we could actually look at the
claim, we could look at the codes, we could check National Correct Coding
Initiative edits a well as the information on the Medicare Physician Fee
Schedule database.
OK.
All of those tools will be of great assistance to us and I’m sure that we’ll be
able to answer your question.
OK, I’ll have several examples for you.
All right, thanks so much.
All right.
Your next question comes from the line of Beth Fact.
Yes, I apologize; I was looking at something else. I’m calling for Regional
Medical Laboratory and Pathology Laboratory Associates. I’m asking a
question for another member, it has to do with the molecular pricing and she
has asked, “It appears the new molecular codes will be priced by each MAC
until CMS has enough information and to include them on the fee schedule.
Will WPS pricing compile these and a file available for download Or will we
have to search each one individually on the WPS website”
That is something that we’re going to have to follow up on, Beth.
OK.
I don’t have anyone here to represent fees, but what you’re telling me is that
these are going to be carrier priced services.
9

Beth Fact:
Mary Muchow:
Beth Fact:
Dr. Boren:
Beth Fact:
Dr. Boren:
Beth Fact:
Dr. Boren:
Beth Fact:
Dr. Boren:
Beth Fact:
Dr. Boren:
Beth Fact:
Mary Muchow:
Beth Fact:
Mary Muchow:
Correct. The procedure codes are in the 2012 procedure manual but they’re
not in place http://www.wpsmedicare.com
as of yet. It’s for the stacking code for the molecular testing.
There was 101 of them and now, they say effective, January of 2013 that
these will go into effect and we’re trying to get our pricing within our system
and get it correct. But we don’t know where to – they’re on the fee schedule
right now but with no pricing. So we’re trying to figure out how and when that
will be available for us to be able to put in to our system.
And Beth, do you have a range of codes that you can give me
Let’s see.
One thing – Dr. Boren here. We do not price any CPT code until we have
received a claim.
Once you received the claim that is showing that it has the new molecular
code, that’s when the allowable would be considered
Correct. We have never priced CPT codes or any procedure until those are
claimed. What happened in the past is a number of manufacturers who have
come up with new ideas, new products, they want to know how much this
thing will pay so that they could decide about marketing efforts.
OK. Well, you currently have a fee schedule that we do our pricing off of. So
how was this any different
Basically, the pathology fees are typically – most of them are set by CMS.
OK.
Now…
CMS is saying the MAC will be you – I understand now what you’re saying.
You will not do anything or any pricing until it comes across and that will be
determined at that time.
Correct.
OK. And I do not have the list of the new molecular codes in front of me. I can
get that for you if you need. But I think he just answered my question as far
as…
Right. And just to clarify, what I was saying that once established, what I
could do is check to see if they would be published. But that would be only
after that claim is submitted and there is pricing eventually established. So…
Yes. It sounds more like we’re going to have to submit the claim. If for any
reason denied or what, then we would have to provide the documentation to
support it at that time.
That’s correct.
10

Beth Fact:
Mary Muchow:
Beth Fact:
Operator:
I think you answered my question, OK.
All right. Thanks, Beth.
http://www.wpsmedicare.com
Thank you.
Your next question comes from the line of Jennifer Vanwinkle.
Jennifer Vanwinkle:
Hello.
Mary Muchow:
Hi.
Jennifer Vanwinkle: Actually, my first thing is that I had submitted a topic that you guys did not
discuss.
Mary Muchow:
OK.
Jennifer Vanwinkle:
That’s the routine foot care.
Mary Muchow:
How can we help you
Jennifer Vanwinkle: We’re just trying to figure out, I’m getting many denials on patients who
are elderly that are not diabetic.
Mary Muchow:
Dr. Boren:
Male:
Mary Muchow:
Male:
Dr. Boren:
Mary Muchow:
OK.
Elderly alone doesn’t mean that you’re entitled to foot care. This is a benefit
given by Medicare by law but there are restrictions.
And physical findings that are documented in the chart, would it be a Class A
finding of amputation of a portion of their foot or, two, Class B findings or
class being Class C finding. If they have those physical findings, then they
qualify. Hello.
Yes.
So why are they being denied then If they’ve got the physical findings to
qualify them, why are the claims being denied
Perhaps, they’re not being billed correctly. I mean, you have to look at your
denial message.
Right and that’s something that customer service can help you with. If you
call them and you give them an ICN, they can look at the claim and see how
it processed, see what was reported on the claim, and then provide you with
assistance. This is claim-specific information, and I’m sorry we’re not able to
provide during this call.
Jennifer Vanwinkle: Well, more of a general question not claim-specific because sometimes
we submit a claim and they get paid on certain patients who are not diabetic
11

and then the other ones do not. And so I’m trying to understand, we submit
them all the http://www.wpsmedicare.com
same and why one gets paid and one doesn’t.
Dr. Boren:
The question is, are you really submitting them all the same Because a
number of times, people think they are the same, my field is emergency
medicine. My group complained to me about Medicare denials and they
showed me a bunch of denials that they had gotten. I asked them why they
have a box open. I forgot which one it was that needed to be filled out and
they had left that box open on a number of claims. I just asked them why
there were filling out paper claims instead of electronic. That would kind of
surprise me.
Jennifer Vanwinkle: Well, whenever – I mean, by the same claim is that – if it falls (inaudible)
then we use that same code. It can be a diagnosis of the 110.1.
Dr. Boren:
Brett:
You need to let the customer service look up the denial reason.
Hey, Dr. Boren, this is Brett, Manager of Medical Review. I believe that’s
mycotic nails and there are different exceptions for mycotic nails versus a
systemic condition, which requires a professional to trim the nail. So I would
advice going back and look because there are different requirements for both.
So if you are billing debridement for mycotic nails, there’s a certain way the
claim and needs to be submitted. If you are billing routine foot care exception
due to a systemic condition with class findings, there are other things that
need to be on that billing and again, without claim-specific information, we
can’t tell. But those are two separate exceptions, mycotic nails that need
certain things and then systemic condition with certain findings which require
professionals to do that routine foot care safely.
Jennifer Vanwinkle:
Thank you so much.
Mary Muchow:
Operator:
Mary Muchow:
Kara Lithcum:
Beth:
You’re welcome.
Your next question comes from the line of Kara Lithcum.
Hi, Kara.
Hi. I have a question regarding LCDs. My question is, we have a service that
always gets denied for medical necessity because the diagnosis we’re using
is not on the on the LCD. We eventually take this to a judge and our appeals
get overturned. So I would like to know how we can transfer that information
to get the LCD at least get it considered for a change.
Hi, this is Beth from the Policy Department. We do have an e-mail box that
will take you – the emails are addressed by the Policy department. It’s
policycomments@wpsic.com. If you’d let us know your request in an LCD
reconsideration and you’d let us know what policy it is and we have a page
on our website that will also explain the type of literature that we like to see
included with your LCD reconsideration request.
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But if you ever see a policy, we really encourage you that you fill this missing
coverage and http://www.wpsmedicare.com
you have literature to support it, we really encourage you to
submit that via the policy comment box. It will save a little work on your end
by having to take it through appeals.
Kara Lithcum:
Beth:
Kara Lithcum:
Beth:
Kara Lithcum:
Beth:
Mary Muchow:
Kara Lithcum:
Mary Muchow:
Operator:
OK. And where is that at on your website
Go to the Policy page and then on the left-hand side, you can click on and go
to our Draft Policies. And I know there’s an actual link that will bring up an e-
mail that says Policy Comments on it.
OK, I found it. OK.
And then it…
And then it lists what we need to include.
Right, exactly.
I believe there’s an actual article out there for policy reconsideration request,
and it includes a very good listing of the information or the type of information
that you have to include when sending that information in.
OK, yes. Because we do have peer reviewed evidence and I can’t imagine
why it wouldn’t change, so. OK, we will do that then. Thank you.
Thank you.
Your next question comes from the line Kristine Aprenger.
Kristine Aprenger: Hi, my question is for Provider Enrollment. I want to see what is the expected
timeframe for a provider to become approved with notice of tremendous
slowdown and we’ve been told it’s due to other revalidation applications that
they’re working.
Chere:
Hi, this is Chere with Provider Enrollment. That’s probably pretty true. CMS
gives us the timeframes of 60 days to process that in a timely manner. If
you’re having issues that it’s going over 120 days then we can certainly take
a look at them. But the revalidation has really slowed us down.
Kristine Aprenger: OK, because I know that we have some that have gone past the 60-day
timeframe now. And the odd thing is that we’ve had one provider that we’ve
submitted after the rest of them and he, like, went through within a couple of
weeks.
Chere:
So are these new provides or are they revals that you’re sending in
Kristine Aprenger: These are new provider applications.
Chere:
If you have concerns, go ahead and call the hotline, and we can try and pull it
out or something.
13

Kristine Aprenger: OK. And then the second question is, has there been any discussions about
recognizing hospitalist http://www.wpsmedicare.com
as a specialty
Mary Muchow:
Dr. Boren:
I’m not aware of anything.
Dr. Boren here. The decision to create a separate physician specialty or other
specialty right rest solely with CMS.
Kristine Aprenger: OK.
Dr. Boren:
And so there would be solely a decision by CMS.
Kristine Aprenger: All right, thank you.
Dr. Boren:
Operator:
Lauren Craig:
Carol:
Lauren Craig:
Carol:
Lauren Craig:
Carol:
Operator:
Cathy Smith:
Mary Muchow:
Cathy Smith:
You’re welcome.
Your next question comes from the line of Lauren Craig.
Hi. My question is actually policy related to the policy for application of skin
substitute. We work with the skin substitute indicated for diabetic with ulcer
and we’re just wondering if the application for the ankle would be covered
given that CPT considers the ankle to be a part of the leg.
This is Carol. Dr. Boren, unless you have anything to add, I’m going to ask
that that question be submitted in the policy comment box so that it can be
researched. Would you mind…
I’ve also researched it just a little bit on the website and it does appear that
the CPT 15271 is the payable code for podiatrist, but I do have a number of
podiatrists that are a little bit concerned, and we just want a little bit of
clarification.
I think if you put it in writing and send it in through the email so we can get it
researched. OK
That would be great. Thank you.
Thanks.
Your next question comes from the line of Cathy Smith.
Hello.
Hi, Cathy, go ahead.
I’ve got a question regarding take-backs. I believed you mentioned that in
your opening. As far as take-back requests go, can you tell me how that
process is and what information is on the remit for us to know who that take
back is being taken back from
14

Jenny:
Cathy Smith:
Jenny:
Cathy Smith:
Jenny:
Cathy Smith:
Jenny:
Cathy Smith:
Jenny:
Cathy Smith:
Jenny:
Cathy Smith:
Jenny:
Cathy Smith:
Dr. Boren:
Oh, this is Jenny with Payment Recovery Area. Are you referring to at the
bottom of the remittance notice, remark code WO
http://www.wpsmedicare.com
Probably. I do not know that it’s there. I can’t remember exactly where it is or
exactly what the information is. I have seen it. I don’t have one in front of me
now, but we are having a lot of take-backs right now because we had to go
back and correct a lot of billing errors for procedures. So we’re getting takebacks
from the remits. But we just need to know the best way to get the
information to know who that money is being taken back from.
All right. So to match up your withholdings or your offsets on your remit
notice, there’s a couple of different things you can do. Do you keep a copy of
your demand letters that you received
Yes, ma’am.
On the demand letters, all of them have an accounts receivable number or an
invoice number. If you keep that letter and then match it up to your remittance
notice, at the bottom there’s the WO. That will give you the invoice number
that matches your letter and then it will give you a patient account number if
you bill with the patient account number.
OK.
If you do not bill with the patient account number then the Medicare number
will be provided.
OK.
Another option you can do is if you have that invoice number, you could take
that into C-SNAP and you can put in the invoice number and it’ll give you the
patient’s name and date of service.
OK, good. What is the difference in getting the request for a refund Like, if
we get a request from you on a refund and it’s not on our remit versus it only
being on the remit, or is that – does that even happen
The request for refund, the letter, you’ll first receive a demand letter. Then
after 41 days or whenever that demand is offset, then the WO will appear on
your remittance notice.
OK.
It’s not at the same time. You’ll have to wait if the claim is offset.
Right. OK. All right, thank you.
Mary, I don’t want to interrupt, but to answer the question that Natalie asked
about the VAD. It is not a CCI issue unless it’s the date it was inserted.
Because on the date it’s inserted, it hits a modifier. But that would not be an
15

issue after the day of insertion. The CCI only talks about the concurrent
dates. http://www.wpsmedicare.com
Mary Muchow:
Operator:
Lisa Armstrong:
Mary Muchow:
Male:
Dr. Boren:
Male:
Dr. Boren:
Male:
Dr. Boren:
Mary Muchow:
Operator:
Jim Williams:
May Muchow:
Jim Williams:
Same provider, same date of service, same encounter.
Your next question comes from the line of Lisa Armstrong.
Hello.
Hi.
We have a question regards to ambulance transports and the day of hospital
admit. If the patient arrived at hospital A to the emergency room, is admitted
by the emergency room division. He writes the order according to the
Medicare manual and the patient is then transferred by ambulance to another
hospital that shares the same provider number after those orders are written
but it’s the same date. Is that a Part A billable or is that a Part B billable
We’d have to look that up. But I don’t think it’s payable because when it’s
considered to be like you took the person from one floor of the hospital to
another floor.
So it would the responsibility of the facility not Medicare.
Right. If it’s the same provider number, that is no different than when you take
them from the emergency department to CAT scan or something as far as
we’re concerned. I don’t think there’s any other way of looking at it if it’s –
sometimes, we have situations where you have big campuses and you could
have a different provider number on different parts. But that’s still an inter –
it’s the hospital to self transfer, not to another facility
Okay, next. Even it – because it’s – after the orders for admit are written, it
becomes the facility’s responsibility. Correct
It’s in the – if the person is in the emergency department and he is going to
another place in the hospital, it’s the same provider number.
OK.
Your next question comes from the line of Jim Williams.
Hi.
Hi.
I have a question and it might have been partially answered by someone from
another field earlier, but we are an optometrist office. I noticed one of the –
we haven’t gotten any rejections yet from Medicare but specifically on
procedure code 92250 which is a fundus photography. It looks like the LCD
got changed and it got put under a low vision coverage, I guess, which I
believe is the 32007. Have you had any feedback on how that procedure
16

code got moved under low vision services or not at this point Does any of
the make sense http://www.wpsmedicare.com
to you
Bonnie:
Jim Williams:
Dr. Boren:
Jim Williams:
Dr. Boren:
Jim Williams:
Dr. Boren:
This is Bonnie. The 99250, the fundus photography, is payable for more than
what’s in the low vision, of course and that’s why you’re not getting any
denials.
Yes. And we haven’t gotten any from you all and we don’t have any problems
with Medicare or with WPS specifically.” We’ve had a couple of – oh, come
on, brain think – Humana and Medicare replacement policies that have
refused to pay that and said, “OK.” You know they’re saying that the fundus
photography falls under low vision services and to check back with our
Medicare carrier for that LCD. Like I said, we’ve been getting paid on it and I
just, you know, while we’re doing this, I know that changed on 8/20. I’m
looking at my newest remittance advice and I see that we’ve gotten paid for it
on, you know, date of service 8/24. So I don’t know if something is out of
whack with the Humanas of the world and the Medicare replacements. How
would you go about, you know, changing that or…
But if the problem is not with us.
Right.
That I’ve enough trouble doing my own job without trying to do the job for
Humana company, so…
Yes and that’s just it. You know, they’d say, “OK, go back to your Medicare
provider or your Medicare carrier" and we don’t have any problem
whatsoever with our Medicare. They’re still being paid through because the
diabetic code is the macular degeneration code, it’s a glaucoma code, but
they’re disallowing on all those other ones and I know that’s not WPS’
problem, but they keep pointing it back at our carrier. So I guess we’ll just
kind of go their chain of command and – but I didn’t know if you guys took
that code out of general usage and just lumped it under that, you know …
It’s very difficult to have any specific CPT code in two separate policies.
Because what happens is you cannot send out a denial then based on the
policy number because the computer sees two different policies with that
CPT code. So I’m not familiar with any contractor that has a CPT code that is
in two separate policies.
I suppose it could be – I just can’t think of any because it becomes a real
systems issue when that happens.
Jim Williams:
Yes and I guess I was just worried that that’s what this would become.
Because of this fundus photography got pulled under the 32007 ad I guess
I’m just trying to read into it and say, “OK, if that is under that LCD now and
we go down and see the ICD 9 codes that support the necessity, they’re all a
low vision code.” If we look at that particular LCD.
17

Chere:
Jim Williams:
Mary Muchow:
Jim Williams:
Mary Muchow:
Jim Williams:
Mary Muchow:
Jim Williams:
Mary Muchow:
Jim Williams:
Mary Muchow:
Jim Williams:
Chere:
Operator:
Amy Green:
Mary Muchow:
Amy Green:
Well, I can tell you that Dr. Boren and I have discussed this and we are going
to put into the http://www.wpsmedicare.com
low vision policy just a statement or a phrase stating that WPS
realizes that fundus photography is used of broader ranges than included in
this policy. And that might be something that you can give to Humana or
whoever. But you would hope that they would note that themselves.
Yes, that’s what I’m thinking and the way the LCD is written, it should exclude
that procedure. But the fact that we’re still getting paid now that the new
month had started, but the effective date was 8/20 of 2012, and we’re still
getting paid on the side. I was just kind of preparing for the what if things
change.
Yes. This is Mary…
You know, start of the new month so we’re starting to get denials, we’re just
going to keep an eye on it.
Right. Your next step would then to go back to the plan.
Yes. I think that’s more of a Humana issue not…
Correct.
…and well I guess, we’ll just wait for the revision because that’s about the
only place that I can find that particular procedure code, the 92250s, within
the low vision LCD, so.
OK.
So we’ll, I guess, we’ll just kind of keep experimenting with it and if we have
problems with it in the future, get back with you on that.
All right.
OK. Thank you very much.
You’re welcome.
Question comes from the line of Amy Green.
Hi.
Hi, Amy.
I was told before that maybe the observation care was more claim specific. I
just want to give you a scenario. It’s not directly related to one claim. What
my question is, the family medicine physician admits a patient to observation
at 1:33 am. Twelve hours later on the same day, an internal medicine doctor
discharged patient. It is the same physician’s group but different specialties.
Is it correct to bill 99219, which is an initial observation care for a family
medicine physician, and 99217, which is an observation care discharge for
18

the internist, because they’re two different – with a different specialty and a
different person, http://www.wpsmedicare.com
but same group.
Brett:
Amy Green:
Brett:
Amy Green:
Brett:
Amy Green:
Brett:
Amy Green:
Brett:
Mary Muchow:
This is Brett from Medical Review. We’re going to have to research that one a
little bit more. And specifically, is it under 12 or over 12, did you say
Over 12 hours.
Over 12 hours
Yes. I’ve taken this to, like, a tier two specialist and I still – there is nothing in
the manual and so forth. We have all the guidelines from 30.6.8 from the
manual that differentiates from when it’s a different specialty.
OK and could I ask what PRRS specialist response you have received from
them
There was nothing in there because there was nothing that talks about
different specialties.
OK. We’ll research that, I’m sure you’re talking about in a different section not
so much specific to that code about providers of the same specialty, same
group are treated as one physician of the same day. But as far as – I would
need some time to do some research in regards to the observation care
codes and especially with the 12 over/under because I assume – obviously,
one is that initial observation care and then the second one would be billing
as a discharge. So I…
Right.
…need to research that a little bit more.
Amy, can we get a telephone number from you And someone will follow up
with you, please.
Amy Green: Sure. It’s (563) 584-4170.
Mary Muchow:
Could you repeat the area code, please
Amy Green: 563.
Mary Muchow:
Amy Green:
Operator:
Laurie Weber:
OK, thank you.
Thank you.
Your next question comes from the line of Laurie Weber.
Yes. I have a question about the multiple E/M codes in on a single day also.
What qualifies a different group Is that you’re billing under a different NPI or
a different tax ID number Can you clarify that for us
19

Brett:
Chere:
Laurie Weber:
Chere:
Laurie Weber:
Chere:
Laurie Weber:
Chere:
Laurie Weber:
Brett:
Chere:
Laurie Weber:
Operator:
Vicki Graham:
Brett:
Vicki Graham:
Chere:
Brett:
Mary Muchow:
Actually I’m going to throw that over to Chere.
http://www.wpsmedicare.com
Well, but are they talking about claims, like, if a patient is seen by two doctors
within the same group, it looks at the tax ID.
It looks at the tax ID not the…
Yes.
…billing group NPI.
No. No. Right.
Just the tax ID.
So if two doctors under the same tax ID saw that patient, that’s considered
concurrent care.
OK. That answers my question.
Provided they’re the same specialty.
Right, right.
Thank you.
Your next question comes from the line of Vicki Graham.
Hi. I have an ambulance question about return transfers. We live in a very
super rural area, and say, we need to transfer a patient for a broken hip. We
transferred him to see an orthopedic surgeon. They have their surgery and
then they want us to transfer him back to our facility. Is that covered by
Medicare
This is Brett. Let me just kind of ask you a few questions, we might have to
research this one. Now, when you referred to your facility, what do you mean
by that Are they coming from a nursing home Are they coming from their
home to the surgery What’s the origin
From our hospital. We have a small hospital, and we transport to a larger
hospital that has a specialist or surgeon. So will they pay for from the larger
facility to a lower level of care
No.
Generally, we only cover to the hospital where there’s a surgeon who was
able to provide those services, then they should be provided there. But if the
patient’s preference to go to a different site, then it would be the patient’s
responsibility for that transport.
Nearest appropriate facility.
20

Vicki Graham:
Operator:
Richard Farley:
Brett:
Richard Farley:
Brett:
Richard Farley:
Brett:
Richard Farley:
Brett:
Mary Muchow:
OK, thank you.
http://www.wpsmedicare.com
Your next question comes from the line of Richard Barley. Excuse me,
Farley.
Hi, I have two quick questions. There’s a code for preparation of antigens for
allergen immunotherapy, 95165, and we’ve had an allergist for about three
years and we haven’t had any problems with this code until this year. There
seems to be a medically unbelievable edit that set it like 30 and we never
prepare antigens less than 36 doses. So I’m not sure if this is a mistake or
how do we address that, or this seems like the medically unbelievable edit is
set medically unbelievably low.
This is Brett, Medical Review. Are you doing the drops
He prepared a little vial and then take (inaudible) out of that for 36 doses.
And then…
It is typical.
Does the patient take those sublingually
No, this is for injection.
We’re probably going to have to research that one.
There is information published on the CMS National Correct Coding Initiative
webpage that includes information about medically unlikely edits. It does
provide for you there on that CMS web page a contact. If you disagree with
an MUE that is established by and published by the CMS contractor, publish
them on the CMS web page. Remember that not all MUEs are indeed
published, but there is a listing of the contractor that you can go to, to present
your case if you will.
If you need that information, I don’t have a computer here in the room. I can
take your number and I can give you a call, Richard.
Richard Farley: OK. Yes, it’s (563) 589-4058.
Mary Muchow:
Richard Farley:
OK.
Then my other question is about this – and I’m not sure where this is, and the
medical director sort of forwarded to me but I’m not sure if this has been fixed
or not. But there was this talk about how you are in PECOS and if you don’t
list the referring provider just right, your claims are going to be denied and I
just want to give an example of why this is so difficult for us. It seems pretty
simple on the surface.
Then if you can give the right place to go to get the proper list. But we were
looking for a referring physician from the University of Iowa. We’re in Iowa
21

and the doctor was listed. We know this doctor by her published name at the
university but http://www.wpsmedicare.com
she’s in the PECOS or the NPPES with her maiden name and
her last name there. When we searched for her last name, it didn’t come up
because it was in there as her maiden name. And sometimes if you have MD,
that doesn’t work. And sometimes it does work and maybe you know about
these problems or don’t know about these problems, but those are the types
of reasons why we can’t find the referring doctor even in the NPPES because
the names and the search engines don’t work right.
Mary Muchow:
Richard Farley:
Mary Muchow:
Richard Farley:
Mary Muchow:
Richard Farley:
Mary Muchow:
Operator:
I would pick up the phone and call that physician and ask them for that
information. If that physician is referring patients to your office and doing
business with you, then he or she should be providing that information for you
or make it readily available for you.
OK. I don’t want to say their name but it’s like McDonalds kind of name where
– do you put a space between the C and the D or do you not And it’s really
hard sometimes so if you could find where the official list is because we found
several lists in Medicare and NPPES. Is it with the space, without the space,
with the period, without the period
Unfortunately, a lot of that is going to depend on how they fill out the
paperwork when they request their National Provider Identifier. The NPI
contractor does have a searchable database. But again, depending on how
that individual or healthcare provider or entity has gone to the NPI contractor
and filled out paperwork and how, someone from that contractor indeed
entered it into their database it might vary. The best bet is to go to that
provider that you’re doing business with and ask them for their NPI. Tell them
that you need that information to support the claim for the service that they
referred to your office.
OK. Yes, I mean, we have the NPI. It’s just that you also have to put in the
name just right. But in any event, OK, we’ll look for that.
Well, on the claim form, it’s going to be driven by the NPI that you entered
into the appropriate item number on a paper claim or the corresponding
electronic field for an electronic formatted claim.
OK. Thanks.
You’re welcome.
Your next question comes from the line of Colleen Kelleher.
Colleen Kelleher: Hi, I have just one question. Are remittance advices sent to providers who do
not accept assignment and if so, how often
Mary Muchow:
We’re going to follow up on that one, Colleen. If you can give your telephone
number, please.
Colleen Kelleher: Sure. Area code (515) 226-7423. I have asked this at customer service and
I’ve received conflicting information, so I’d just like the straight answer.
22

Mary Muchow:
Colleen Kelleher: Thank you.
OK. We will indeed follow up on that, Colleen.
http://www.wpsmedicare.com
Operator:
Cathy Smith:
Mary Muchow:
Cathy Smith:
Mary Muchow:
Cathy Smith:
Mary Muchow:
Cathy Smith:
Mary Muchow:
Cathy Smith:
Mary Muchow:
Cathy Smith:
Mary Muchow:
Operator:
Mary Muchow:
Operator:
Mary Muchow:
You have a follow up question from the line of Cathy Smith.
Hello. I had asked the question earlier about take-backs and I do have a remit
in front of me now. I just wanted to follow up on one more question. This
particular one only has a provider adjustment amount and then we do have
the FB for the forwarding balance. However, there’s also mention in the remit
on the bottom of this remit, something that I’m not familiar with, the PLB04
and PLB03. Can you explain what that is I’m not familiar with that.
I can explain what a forwarding balance is. We will get that out of the way
first. The forwarding balance…
I understand the forwarding balance. I’m just unsure about a negative value
with PLB04 or PLB03.
Is the forwarding balance amount the same as the negative that you’re
seeing of the PLB03 or 04
So that’s what I’m not familiar with. I just am not familiar with that, the PLB04
and 03 what that means. Is it the same as the forwarding balance
Based on the recommendations made in the room, they’re suggesting that
you would call customer service and they would be able to provide that
information when they pull up the claim information.
OK.
So give them a call, they’ll be happy to help you.
OK. So is there a particular number if we got questions on take-backs on the
remit or do we just call the regular customer service line
It would be the regular toll-free customer service line for providers.
OK, thank you.
You’re welcome.
And there are no further questions at this time.
OK.
Excuse me; you have a question from the line of Janine Hone.
Hi, Janine.
23

Janine Hone:
Hello. In the CPT manual under the inpatient hospital care, it says, “when the
patient is admitted http://www.wpsmedicare.com
to the hospital as an inpatient in the course of an
encounter in another site of service, for example, hospital emergency
department, all evaluation and management services provided by that
physician in conjunction with that admission are considered part of the initial
hospital care when performed on the same date as the admission.”
Now that seems pretty clear cut, but if I have one doctor in ER and another
doctor doing the admission, I bill for both of them. What my question would
be is if I have a mid-level provider, so I have a physician assistant in the
emergency room who is supervised by a doctor who the patient’s care is
transferred to, would the physician on the acute care side be able to bill for
the acute care admission, the 99222, and the emergency room care mid-level
provider be able to bill under the (993) for that
Brett:
Janine Hone:
Brett:
Janine Hone:
Brett:
Janine Hone:
Brett:
Janine Hone:
Brett:
Janine Hone:
Operator:
Mary Muchow:
This is Brett from Medical Review. Are the PA and the doctor both under the
same tax ID for group
Yes.
OK. Generally that would be considered the same physician because of the
example that if I have doctors from the same group and doctor A of the same
specialty sees the patient in the morning and then doctor B follows up in the
afternoon, those two services are combined for one service that day.
OK. So even though it says by that physician, it’s not meaning that physician.
It’s meaning the same physician group.
Yes. Same group, same specialty and generally, if that PA is being
supervised, that’s usually in the same group.
OK and so if they are two different doctors, if they’re in the same group, it
really doesn’t matter either
Same group, same specialty.
Same group, same specialty. OK.
Yes.
All right, thank you.
And there are no further questions at this time.
All right. Thank you, Angie. Before adjourning this call today, I’d just like to
remind all of you that have taken your valuable time today, if you could
please consider completing your ForeSee website satisfaction survey that
does pop up when you’re out on the website. I know we talked a lot during
this call today about all of the great information that you can find out on the
website.
24

We are very interested in your feedback on what is out on the website, what
you think should http://www.wpsmedicare.com
be out on the website, kinds of improvements you suggest.
So if you would, please take some time to fill out that survey. Be specific in
your evaluation of the website. If there’s something you feel is valuable, let us
know. Also, if you could all mention the specific tool or the web page that
you’re making recommendations to, that would be very, very greatly
appreciated.
WPS and CMS do review the results of those surveys on a regular basis. And
your feedback really does directly influence the layout, the look and feel, the
content, and other aspects of our WPS Medicare website.
Once again, I’d like to thank all of you for participating today in this
teleconference. I’d like to thank my colleagues here at WPS Medicare for
their input and feedback as well and since there are no other further
questions at this time, this will then end our ACT today. I’m sorry, someone
spoke up.
Dr. Boren:
Mary Muchow:
Dr. Boren:
Mary Muchow:
Right, Mary, Dr. Boren. One quick thing for Natalie, I have sent an e-mail to a
cardiologist medical director for his opinion on her question.
Sorry, thanks, Dr. Boren.
OK.
We have Natalie’s phone number so we will be following up then with a
telephone call to her when we receive that response. All right.
On behalf of Medicare Part B Provider Outreach and Education and all of the
WPS Medicare staff joining me and participating in this call today, I wish each
and every one of you a pleasant afternoon. Thank you very much. Good bye.
Operator:
This concludes today’s conference call. You may now disconnect.
END
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