Q: I have a question regarding which place of service (POS) code I should use for an orthopedic doctor who did a consultation on a patient that came through the ED. The patient has a spiral fracture of the humerus. The electronic record documents that the patient was admitted to the medical unit on January 31 but was a “boarder” in the ED until February 2, waiting on a room to be available. The orthopedic doctor saw the patient on February 1. The patient did finally receive a room assignment on February 2. In this scenario would I use POS 22 (outpatient hospital) or 23 (ED)? This patient has Medicare.
Q: Did something change with the observation services Composite APC in 2016? The director of patient financial services says we no longer receive payment for it.
Q: Our radiology department is requesting that we add a new modifier to their charge description master (CDM), modifier –CT (computed tomography [CT] services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association [NEMA] XR-29-2013 standard). They want this added to the CT scan line items, but they are not sure if it is for all of the items or only certain ones. Can you provide more information that might help us know how to proceed?
Q: Last week you talked about the MAC editing for medically necessary services related to the local coverage determination (LCD). What do we do if we have a situation where we believe that the list of covered diagnoses is not complete? How do we get our MAC to consider that information? We placed a call, but nothing has happened and we’ve received no response.
Q: We are having difficulty getting our patient financial services group to route claims back to us that hit edits for lack of a medically necessary diagnosis. We have found one procedure-to-diagnosis pairing that is faulty because it is a crossover from a local coverage determination (LCD) that has multiple procedure codes related to a procedure. One of the procedure codes happens to be on this claim, but as a standalone procedure and not as part of the service described by the LCD. How do we get them to understand that the edit is not always correct for the individual situation?
Q: I work in a behavioral health hospital and am looking for guidance relating to disclosures as part of the Clozapine REMS Program. In order for a patient to fill a prescription for Clozapine at an outside pharmacy (not our on-site pharmacy), the pharmacy is required to have a copy of the patient's latest blood draw (absolute neutrophil count). Is the patient required to sign a release of information for us to be able to send the latest blood draw results, or is sharing the results with the outside pharmacy considered part of the process when the patient is registered in the Clozapine program?
In addition, if the latest lab results contain more information than what is required for the Clozapine prescription to be filled, should we edit the results to only include what is specifically needed by the pharmacy?
A: Releasing this information is considered treatment, so the patient's authorization is not needed. Editing the results report to release only the neutrophil count would be a good practice, if it is reasonable to do that. If not, it would be acceptable to release the complete results containing the neutrophil count, since the minimum necessary requirement does not apply to treatment disclosures.
Editor's note: This question was answered by Mary Brandt. Brandt is a healthcare consultant specializing in healthcare regulatory compliance and operations improvement. She is also an advisory board member for BOH. This information does not constitute legal advice. Consult legal counsel for answers to specific privacy and security questions. Email your HIPAA questions to Associate Editor Nicole Votta at nvotta@hcpro.com.
