Guidance for Avoiding Code G2211 Denials
The Centers for Medicare and Medicaid Services (CMS) have implemented edits, which instruct the MACs to deny these types of claims. These denials are not related to NCCI edits.
HCPCS code G2211 is a new E/M O/O add-on code used to report visit complexity when reported with CPT® codes 99202-99205 and 99211-99215. The O/O E/M visit complexity add-on code G2211 is not payable when reported with the O/O E/M visit appended with payment modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service). Separately identifiable visits performed on the same day as minor procedures (such as 0- or 10-day global procedures) have “resources sufficiently distinct from costs associated with furnishing standalone O/O E/M visits to justify different payment.”
ACR Revises Statement on Contrast Supervision Requirements
On February 26, 2024, the American College of Radiology (ACR) Committee on Drugs and Contrast Media released a revised statement, clarifying ACRs stance on direct supervision requirements for contrast studies. ACR states that direct supervision requires one of the following to be onsite; a radiologist, other physician (including radiology residents and fellows), or qualified person. In addition to acting under the general supervision of a physician, the radiologist, other physician, or qualified person must:
The ACR also reminds readers that remote supervision “should comply with all federal/state law or regulations and local, institutional, site and facility policies, guidelines, or rules related to telemedicine.” Whenever contrast is administered, remote general supervision should be available and “include the standard post administration monitoring as dictated by all federal/state law or regulations and under local, institutional, site, and facility policies, guidelines, or rules.” The timeliness and availability of emergency response systems should also be considered. While the revised statement from the ACR is intended to provide more flexibility to imaging facilities, readers should also refer to authoritative guidance in the Medicare Benefit Policy Manual, Chapter 6, Section 20.4.4 regarding direct supervision in the hospital outpatient setting. The Medicare Benefit Policy Manual acknowledges that “trained ancillary staff and technicians are the primary operators of some specialized diagnostic testing equipment, and while in such cases CMS does not expect the supervisory physician to operate this equipment instead of a technician”. CMS does include the following criteria to be met.
New Guidance from the HHS Regarding Hospital Interpretive Guidelines for Informed Consent
The Department of Health and Human Services (HHS) issued new guidance to the nation’s teaching hospitals and medical schools regarding Hospital Interpretive Guidelines for Informed Consent.
Specifically, requiring written informed patient consent for breast, pelvic, prostate, and rectal exams – especially if the patient is anesthetized – for educational and training purposes performed by medical students, nurse practitioners and/or physician assistants. Informed patient consent includes the patient’s right to “refuse consent for sensitive examinations conducted for teaching purposes and the right to refuse to consent to any previously unagreed examinations to treatment while under anesthesia.” Requirements related to informed consent for hospitals are found throughout the Hospital Conditions of Participation (CoPs). According to HHS, this new guidance was released to reinforce hospitals’ compliance to obtain written informed patient consent relating to medical professionals performing sensitive examinations, especially those under anesthesia. Federal regulations previously identified obtaining consent for exams related to surgeries but did not provide the level of detail pertaining to medical students. CMS surveyors are required to make sure each hospital’s patient informed consent policy, processes, and forms contain information to allow patients or their representatives to make fully informed decisions about their patient care. If hospitals do not obtain written informed patient consent, they may be ineligible for Medicare and Medicaid program participation. In addition, they may be subject to investigations and fines if they violate patient privacy laws under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule. Six topics added to ACR Influential Imaging Appropriateness Criteria®
Expert panels made up of leaders in radiology and other specialties develop and review these guidelines annually. The ACR AC currently makes up the most comprehensive evidence-based guidelines for the selection of diagnostic imaging, protocols for radiotherapy, and image guided interventional procedures.
The ACR released six new topics and revised six topics in an update to its ACR AC on April 9, 2024. The ACR AC guidelines are meant to assist physicians in ordering correct services and limit healthcare waste. There are now 239 diagnostic and interventional topics and 3,900 clinical scenarios covered in the guidelines. A narrative, evidence table, and literature search summary are included in each topic. The six new topics include:
The six revised topics include:
The ACR AC website has an interactive AC portal that can be used to access the AC topics, variants, clinical scenarios, and recommendations. The site also allows for feedback and comments on any topic. Users can comment on existing AC content here and suggest new AC content here. Additionally, the Journal of the American College of Radiology (JACR), together with the ACR AC Patient Engagement Subcommittee published patient summaries intended to improve patient comprehension of appropriate tests for their encounter. These summaries are written by patients, for patients, in a language that is easy for the layperson to understand. Patient-friendly summaries can be found here. HHS Issues Final Rule for 340B Administrative Dispute Resolution Process
On April 19, 2024, the Department of Health and Human Services (HHS) issued its final rule to establish a 340B Administrative Dispute Resolution (ADR) process under the 340B Drug Pricing Program (340B Program) as required by the Affordable Care Act. The purpose of the 340B Program ADR process is to assist hospitals and other covered entities, and manufacturers in resolving disputes involving overcharging, duplication of discounts, or drug diversion (examples include dispensing 340B drugs at ineligible sites; to ineligible patients; by ineligible providers; and/or failure to monitor and correct inventory). This final rule is effective June 18, 2024.
Historically, HHS has encouraged covered entities and pharmaceutical companies to work together to resolve 340B Program disputes in good faith. HHS recognizes that most disputes are resolved in a timely manner without third party intervention. The 340B ADR process is not meant to replace good faith efforts, but rather provide assistance when those good faith efforts have failed to resolve disputes in a timely, consistent, and fair manner. HHS issued this final rule to revise the current ADR process by modifying the regulations under the 2020 final rule. Specifically:
In addition, HHS finalized the provision for the automatic transfer of any pending claims to the new process. This means the petitioner will not have to resubmit claims under the new process and will ensure the continuity of the 340B ADR process for those parties involved in claims disputes under the 2020 final rule. These claims will be first in the queue to be reviewed after the effective date. Radiology Group must pay $3.1M to Settle False Claims Act Violations
The Radiology Group, LLC, an Atlanta-based teleradiology firm, has agreed to pay $3.1 million to settle a False Claims Act lawsuit for fraudulent billing practices. This firm, which provides nationwide services to hospitals, urgent care centers, and primary care providers, improperly billed government healthcare programs for work done by contractors in India. In a press release, the U.S. Attorney’s Office asserted that:
As part of the settlement, The Radiology Group has admitted to and accepted responsibility for the violations. Defendants potentially jeopardized patients’ health by taking shortcuts when it came to ensuring that important radiological tests were done and reviewed properly,” Naomi Gruchacz, Health and Human Services, Office of Inspector General, special agent in charge, said. “Individuals and entities that participate in the federal healthcare system are required to obey the laws meant to preserve the integrity of program funds and the provision of appropriate, quality services to patients.”
All rights reserved. No part of this newsletter may be reproduced in any form whatsoever without written permission from the publisher. This newsletter may reflect coding information from the 2024 Physician’s Current Procedural Terminology (CPT® Manual). CPT is a registered trademark of the American Medical Association. CPT® five-digit codes, nomenclature and other data are copyright 2023 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT®. This product should not be considered a substitute for the codes, cross-references and exclusions located in the CPT® Manual. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.
Comments are closed.
|
DO YOU HAVE A QUESTION?
WE HAVE AN ANSWER. Office: 512.583.2000
Fax: 512.583.2002 |
FOLLOW THE LATEST INDUSTRY TRENDS
|
CELEBRATING 25 YEARS
|
@2024 Revenue Cycle Coding Strategies. All rights reserved.