ASFA 2016 Reimbursement Guide
Therapeutic Apheresis: A Guide to Billing and Securing Appropriate Reimbursement (2016 Edition)
This ASFA publication is a comprehensive manual on reimbursement for those who practice in the field of apheresis and those involved in billing for apheresis procedures.
Update: Medicare Corrects Photopheresis Coverage Policy
Now Pays Claims with New GVHD-Related Diagnosis Code
The Medicare program has updated its extracorporeal photopheresis (ECP) coverage policy to ensure that ECP is covered and paid for treatment of chronic graft-versus-host disease (cGVHD) following outpatient peripheral blood or umbilical cord stem cell transplant procedures.
Effective July 1, 2013, ICD-9-CM 996.88 has been added as a covered diagnosis code for Medicare beneficiaries ECP used to treat patients with cGVHD whose disease is refractory to standard immunosuppressive drug treatment.
Please share this information with claims processing managers/supervisors at your institution.
Your hospital coders must utilize one of the two following diagnosis codes for Medicare coverage and payment of ECP used to treat patients with drug-refractory cGVHD:
996.85 Complications of transplanted organ, bone marrow
996.88 Complications of transplanted organ, stem cell(s) from peripheral blood or umbilical cord
These two diagnosis codes describe the underlying cause of cGVHD. Please note that CMS has elected not to require use of more specific cGVHD-descriptive codes (ICD-9-CM 279.50, 279.52, 279.53) that were added to the ICD-9-CM classification system in 2009. Of course these specific codes for cGVHD may be included as well, but again your GVHD-related ECP claims must include either ICD-9-CM 996.85 or 996.88for Medicare coverage and payment.
Note: ICD-9-CM 996.88 is anticipated to migrate to ICD - 10-CM T86.5 October 2014.
Your claims managers can contact your Medicare Administrative Contractor (MAC) or Medicare Regional Office with any questions or issues concerning resubmission of denied ECP claims, including questions about timely filing limits.
The American Society for Apheresis Announces the Clarification of 1992 National Medicare Coverage Determination
(Vancouver, Canada - February 16, 2011) The American Society for Apheresis is pleased to announce the clarification of 1992 National Medicare Coverage Determination.
For years, language inserted in the 1992 National Coverage document (NCD) for Medicare has been confusing to apheresis professionals.
The confusion can be found in the Medicare National Coverage Determinations Manual Chapter 1, Part 2 (Sections 90 – 160.26) - Coverage Determinations: section 110.14 - Apheresis (Therapeutic Pheresis). It pertains to the last sentence in that section.
Specifically, the sentence "All nonphysician services are furnished under the direct, personal supervision of a physician.”
The confusion is the result of the juxtaposition of the words direct and personal. Direct implies the non-physician personnel have a direct reporting and oversight relationship to the apheresis physician who is immediately available to them. The word "personal” suggests an alternative interpretation. Specifically, some suggest this implies that the physician is in the apheresis patient suite during the entirety of the process overseeing the nonphysician personnel.
On occasion, Medicare contractors have denied payment for apheresis services based upon the lack of evidence that the apheresis professional was personally present to the patient during the entirety of the procedure. Others have reported that they have been compelled to arrange service coverage in order to eliminate any chance of being perceived as non-compliant leading to inefficient use of resources.
In order to help clarify this situation, ASFA’s Public Relations and Advocacy committee submitted a request for clarification to CMS.
The CMS section responsible for this portion of the 1992 NCD convened internally and with their contract medical directors to address this issue. They clarified the intent of the wording as follows:
"The intent of "direct, personal" was more generic with reference to "personal", and means literally the regulatory definition of "direct" supervision. It was not intended to require the more recent regulatory definition of "personal supervision" in 42 CFR 410.32(b)(3)(iii)”.
Moreover, CMS stated that "There was no definition of "personal" supervision until after 1997”.
This is good news for apheresis professionals as provision of "direct”supervision of nonphysician personal during a plasma exchange is customary.
So what is the precise definition of direct?
For services furnished in the hospital or CAH (critical access hospital) including an on campus or off campus outpatient department of the hospital, direct supervision is defined at 42 CFR 410.27(a)(1)(iv).
As of 1/1/2011, "direct supervision” means that the physician or nonphysician practitioner must be immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician or nonphysician practitioner must be present in the room when the procedure is performed."
Quoting directly from the Medicare Benefit Policy Manual, chapter 6, (Rev 137, 12-30-10),
"Immediate availability” requires the immediate physical presence of the supervisory physician or nonphysician practitioner. CMS has not specifically defined the word "immediate” in terms of time or distance. However, examples of a lack of immediate availability would be situations where the supervisory practitioner is performing another procedure or service that he or she could not interrupt, or where he or she is so physically far away from the location where services are being furnished that he or she could not intervene right away. The hospital or supervisory practitioner must judge their relative location to ensure that they are immediately available. Therefore, a supervisory practitioner may supervise from a physician office or other nonhospital space that is not officially part of the hospital campus as long as he or she remains immediately available”.
For services in a physician's office, direct supervision is defined in 42 CFR 410.32(b)(3). Please note the subtle difference.
"Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed."
The Public Relations and Advocacy committee encourages all members to becomefamiliar with the 1992 NCD section pertaining to apheresis. Though the confusion to direct and personal is clarified, proper practice also includes:
- A physician (or a number of physicians) is present to perform medical services and to respond to medical emergencies at all times during patient care hours;
- Each patient is under the care of a physician; and
- All nonphysician services are furnished under the direct, personal supervision of a physician.
Note: Directive #3 has now been clarified.
The ASFA Public Relations and Advocacy committee would also like to report that working with CMS was very efficient and very helpful.
Please Note: A press release announcing the Clarification of 1992 National Medicare Coverage Determination, was successfully distributed via an online visibility engine on February 16, 2011 and can be viewed at http://www.prweb.com/releases/2011/02/prweb5069984.htm
For further information, contact:
John Barclay, BSc, MBA
American Society for Apheresis
570 West 7th Avenue, Suite 400
Vancouver, BC, Canada V5Z 1B3
About the American Society for Apheresis:
The American Society for Apheresis (ASFA) is an organization of physicians, scientists, and allied health professionals whose mission is lead the field of apheresis through patient and donor care, research, education and advocacy.