11/06/2018

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November 2018, Frequently Asked Questions

Question: It there a guideline, whether it be FDA or another entity, stating that I need a co-signer when a Medical Assistant administers Neulasta? 

Answer: The rule for Physician Extenders, Nurses, and Medical Assistants is that they must be working "within their scope of care" and that is regulated by the state (and sometimes isn't black and white). But nothing about a "co-signer".  Anyone documenting the medical record must sign (authenticate) the medical record themselves.

For Medical Assistants in Michigan, here is a link to the information this state has: CLICK HERE

So, it appears that the Medical Assistants scope includes:
Preparing and administering medications as directed by a physician
Authorizing prescription refills as directed

And that confirms what I have been able to find out previously - they fall under the physician direction.  Additionally, when the Medical Assistant Society asked specifically what tasks are delegable legally to Medical Assistants according to Michigan Law, they received the following opinion: (you will find this on the website I referenced above)

"There is no language in Michigan law that more specifically delineates what tasks are delegable
by physicians to medical assistants. Nevertheless, it is my legal opinion that this language permits physicians to delegate a reasonable scope of clinical tasks (including venipuncture; intramuscular, intradermal, and subcutaneous injections; and measuring vital signs) to knowledgeable and competent unlicensed professionals such as medical assistants working under their direct/onsite supervision in outpatient settings. Tasks which constitute the practice of medicine, or which state law permits only certain health care professionals to perform, however, may not be delegated to unlicensed professionals such as medical assistants."

Question: One of our physicians gave chemotherapy to a patient that was admitted as inpatient rehab.  Medicare paid us and then came and took their money back stating we cannot bill due to overlap inpatient hospital stay.  I did a redetermination with Medicare and sent the records from the hospital where the patient’s wife signed him out to come to our office to receive treatment. I received another denial from Medicare stating that Part A should be billed.  Is this correct?  Is there anything we can do?

Answer:  CMS IRF information is found in the Medicare Benefits Manual, Chapter 1 - however, it was difficult to find information on Part B payments when a patient is in an IRF and what constitutes an "interrupted stay" or "discharge and readmission".  However, on an NGS Medicare webcast site I found:
 
·       If an IRF arranges a service for a patient and the patient returns to the IRF by midnight of the same day, the IRF must pay the facility for the services and should bill the services on the IRF account.

·       When the patient is away from the IRF beyond midnight of the day the patient left, the IRF should code the time away as an interrupted stay. The other facility’s claim can be submitted to and processed by Medicare.

So, in your scenario you will need to contact the IRF and bill them for your services and they have to bill CMS.

Question: I have a question on billing for a drug and waste, using Imfinzi as an example.  This drug is available in 500 mg. vials and 120 mg. vials.  As an example, we had a patient that received a dosage of 900 mg. Can you review the below scenarios to see if there would be any issue with using the 8-120 mg. vials instead of the 500/120 mg vials.
 
We could use 1-500 mg. vial and 4-120 mg. vials and the waste would be 80 mg.
We could also use 8-120 mg vials and the waste would be 60 mg.

Answer:  Medicare policy states:
If the provider must discard the remainder of a single-use vial or other package after administering the prescribed dosage of any given drug, Medicare may cover the amount of the drug discarded along with the amount administered. The following elements must be followed in order for the discarded amount to be covered.

1.     The vial must be a single-use vial. Multi-use vials are not subject to payment for any discarded amounts of the drug.
2.     The units billed must correspond with the smallest dose (vial) available for purchase from the manufacturer(s) that could provide the appropriate dose for the patient.
3.     The left-over amount must actually be discarded and may not be used for another patient, regardless of whether or not that other patient has Medicare.

Question: What is a “step edit”? 

Answer: "Step therapy means trying less expensive options before "stepping up" to drugs that cost more. ... Prior authorization and step therapy ensure that medically sound and cost-effective medications are prescribed appropriately."
 
So, if there are two drugs that do the same thing, equally effectively... the payer can require you to use the less expensive vs you having the choice to choose what you want.

Question: Are there any Medicare guidelines for using an electronic signature when ordering medications?

Answer:  In a MLN fact sheet (ICN 905364, May 2018), the Centers for Medicare & Medicaid Services (CMS) provide the following guidelines for using an electronic signature:

• Systems and software products must include protections against modification, and you should apply administrative safeguards that correspond to standards and laws.
• The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the attested information You should check with your attorneys and malpractice insurers before using alternative signature methods.
• Part B medications, other than controlled substances, may be ordered through a qualified e-prescribing system.
• Medications incident to durable medical equipment (DME), other than controlled substances, may be ordered through a qualified e-prescribing system.

Question: Can you explain the Medicare CERT Program?

Answer: The Centers for Medicare & Medicaid Services (CMS) implemented the Comprehensive Error Rate Testing (CERT) program to measure improper payments in the Medicare fee-for-service (FFS) program. CERT selects a random sampling of claim types to request and review medical documentation to determine if the services were paid appropriately. If the criteria for coverage are not met, or the provider fails to submit medical documentation to support the claim, the payment is recouped from the provider, and an error is assessed to the contractor for that paid claim.

Question:  If a patient receives a push of benadryl before treatment, then has a reaction during treatment and is given another push of benadryl, can we bill for the second therapeutic push if it is more than 30 minutes from the first push?

Answer:  Depends.  To bill for more than one push same therapeutic drug > 30 min apart, you must bill as a facility (CMS1450) .  Those that bill as private practice (CMS1500) cannot. 

Below are the CPT codes:

• 96375 – “each additional sequential intravenous push of a new substance/drug”
• 96376 – “each additional sequential intravenous push of the same substance/drug provided in a facility"
  • “Do not report 96376 for a push performed within 30 minutes of a reported push of the same substance or drug”