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For newsletter archives, click here NEWSLETTER - JULY 2007Medicare Proposed Rule for 2008CMS Press Release:The Centers for Medicare & Medicaid Services (CMS) projects that it will pay approximately $58.9 billion to 900,000 physicians and other health care professionals in calendar year (CY) 2008, under a proposed rule released today that would revise payment rates and policies under the Medicare Physician Fee Schedule (MPFS). This proposed rule is a further step in Medicare’s efforts to ensure that payment policies provide incentives to improve the quality of care. “This proposed rule builds on the changes the Centers for Medicare & Medicaid Services made last year to pay more appropriately for practice expenses and to transform Medicare into an active purchaser of higher quality services, rather than just paying for procedures” said acting CMS Administrator Leslie V. Norwalk, Esq. “It also includes an important new initiative to encourage the use of electronic prescribing to improve the speed and accuracy of care furnished to beneficiaries, as well as proposals for additional quality measures for use in the Physician Voluntary Reporting Initiative in 2008.” The Tax Reform and Health Care Act of 2006 (TRHCA) directed that quality measures in future years be developed through the notice and comment rulemaking process. In this proposed rule, CMS outlines measures from seven categories for inclusion in the 2008 Physician Quality Reporting Initiative (PQRI), provided that the measures are either endorsed by the National Quality Forum (NQF) or adopted by the AQA Alliance. The 2008 proposed measures include existing measures from the AQA Starter Set, other measures from the NQF Ambulatory measure set, and new quality measures currently being developed with input from American Medical Association (AMA) Physician Consortium for Performance Improvement (physician measures), the Pennsylvania Quality Improvement Organization (QIO) (non-physician and structural measures), and the American Podiatric Medical Association. The proposed rule would also retain the 2007 PQRI measures to the extent that they have been NQF endorsed. As required by the sustainable growth rate (SGR) formula specified in the Medicare statute, the estimated update to the physician fee schedule for 2008 is -9.9 percent. “For the past 5 years, Congress has intervened to prevent the implementation of the negative updates resulting from this formula,” said Ms. Norwalk. “CMS will continue working with Congress as well as physician groups to identify payment methods that help improve the quality and efficiency of care in a way that is cognizant of the costs to taxpayers and to Medicare and its beneficiaries. The Medicare program needs to compensate physicians appropriately for the services they provide to people with Medicare. But how the program pays also matters. We think the early work on the PQRI program is one of those reforms that could help lead us to a point where we can promote better quality care and more efficient care.” The proposed rule would make a number of changes to payments for specific services paid under the MPFS. For example, the proposed rule would adopt the recommendation of the American Medical Association’s Relative Value Update Committee (RUC) that would increase the value of the work component of anesthesia services by 32 percent. In addition, it would adopt the recommendations of the RUC with regard to more than 50 procedures which were included in the 2007 five year review of work, but for which a decision was deferred until the 2008 proposed rule. CMS is proposing to revise the methodology for determining the average sales price (ASP) for Part B drugs by defining bundled arrangements and requiring that drug manufacturers allocate bundled price concessions proportionately to the dollar value of units of each drug sold under the bundled arrangement when reporting ASPs. This proposal will help the ASPs to better reflect the true costs incurred by physicians when purchasing Part B covered drugs. The CMS proposal is in response to MedPAC’s January 2007 report to Congress, suggesting that CMS policy on reporting discounts might need to change over time. In addition it is consistent with the proposed Medicaid policy for bundled sales. CMS is also proposing to continue to pay for preadmission-related services for intravenous infusion of immunoglobulin (IVIG) under a temporary HCPCS code, G0332. This payment is for the extra resources expended in locating and obtaining IVIG products that are appropriate for the patient’s treatment, and for scheduling the patient’s infusions. This service may be billed for each visit to the physician’s office at which IVIG is administered. Other provisions in the proposed rule include:
Comments will be accepted on the proposed rule until August 31, 2007, and a final rule will be published later in the fall. The final rule will be effective for services on or after January 1, 2008. Obstetrical Ultrasounds for Mercy PatientsOB ultrasound coverage guidelines were recently discussed in Mercy News:
Medicare Carrier WebsitesMissouri: www.momedicare.com Florida: www.floridamedicare.com Illinois: www.wpsic.com/medicare Arkansas: www.arkmedicare.com Virginia: www.trailblazerhealth.com West Virginia: www.palmettogba.com Colorado: www.noridianmedicare.com Mississippi: www.msmedicare.com Kentucky: www.adminastar.com Ohio: www.palmettogba.com/palmetto/palmetto.nsf/Template/Providers/Part%20B%20Carrier/Ohio?OpenDocument Texas: www.trailblazerhealth.com/partb/tx/index.asp Indiana: www.administar.com/providers Washington and Oregon: www.noridianmedicare.com/provider California: www.medicarenhic.com South Carolina: www.palmettogba.com Draft Medicare Policies Available for CommentCurrently, there are no radiology related Draft Policies that are open for comment. Clarification of Radiologist InvolvementThere are three levels of involvement by a radiologist when an interventional procedure is performed. The highest level occurs when the radiologist performs the “surgical” portion of the procedure, the radiological supervision, and the interpretation. The next level occurs when a non-radiologist performs the “surgical” procedure and the radiologist performs the radiological supervision and interpretation. The third level occurs when the radiologist is not present at the procedure and performs the interpretation only. Please clearly dictate the level of service that was provided. Ambiguity could result in improper coding and reimbursement. Contrast ReminderThe 2007 CPT Manual states that the phrase “with contrast” found in various radiology procedure codes represent contrast that is administered intravascularly, intra-articularly, or intrathecally. Contrast administered orally, rectally, or by any other method does not qualify for “with contrast” coding. It is very important that your dictation include the route of administration for all contrast administered. Your coder cannot determine the appropriate code to bill if you do not clarify the route used. Also remember to include the name and amount of the contrast, especially if you are billing for services billed in a free standing imaging center. Depending upon the type of contrast used, it may be separately billable. Consistent WithThe AHA ICD-9 Coding Clinic states that the term “consistent with” fits the definition of a probable or suspected condition. Please be aware that any condition preceded by this wording should not be used for coding and billing purposes. If there are no other findings to code for, we will code from the reason for the test and/or the history. Other terms that fall into this category are Compatible with, Possible, Rule Out, and Suggestive of. If you are “sure” of a diagnosis, do not use these terms in your dictation. If you must use them, please be sure to also dictate the patient’s signs or symptoms so our coders have something to work with. Missouri Medicare Top Ten Denial ReasonsThe Missouri Medicare Carrier recently released a list of the top ten denial reasons for Radiology services. The top ten reasons were:
Knowing the denial reason code is just part of the battle. Next you have to figure out what it really means, why it happened to a specific claim, and how to correct it. Familiarity with and frequent visits to your Carrier’s website is a definite plus for this process. We will review each of the reasons listed above and will give some suggestions of what may have gone wrong with your denied claim. This month we will review the top five reasons. In the September issue we will review reasons six through ten. CO-18 – DuplicateFor most states, this is usually the number one denial for all specialties. First of all, you need to determine if this really is a duplicate. If it is, you have billed it in error and need to correct that in your system. If you are auto-rebilling, you need to look at your duplicate denial numbers and figure out if it is a good or bad practice for you. Rebilling anything to Medicare without making any changes on the claim will NOT get it paid. If it is really not a duplicate, then you need to look at rebilling it with a modifier to let the Medicare claims system know that is not a duplicate and should be paid. Take a look at modifiers 76 and 59 to see if they fit your scenario. CO-50 – Not medically necessaryYou will have to access your Carrier’s Local Coverage Determinations (LCD) on their website to find a solution for this one. First find the LCD that pertains to your denial. All Carrier websites have an LCD section where you can search by procedure code. Next check the patient records to see if there are any documented signs, symptoms, or diagnoses that are found both in the chart and in the LCD. You may have to check with the ordering physician if you do not have access to the patient’s record. If you find an ICD9 code that is payable per LCD and documented in the patient record, re-bill the denied line with that ICD9 code. CO/PR-31 – No Part BThis denial likely originated at the front desk of your practice or was a keying error. Look at the patient’s name and Medicare number that is on the denied claim and compare it to the copy of the patient’s Medicare card in the chart. Make sure the patient’s name and number on the claim is an exact match with the information on the copied Medicare card. No current card copy in the chart? Then it is time to call the patient and time to implement a process of always getting copies of all cards at all visits. CO-109 – Claim not covered by this payerThis patient is likely not regular fee for service Medicare. Most Carrier‘s automated phone systems will now tell you if a patient has another kind of Medicare, such as a Medicare HMO. You will need to re-bill this to the correct payer. This is another instance where it is vital to get copies of ALL insurance cards at each visit. If your front desk person just asks for the Medicare card, that may be all you get! CO-22 – Medicare Secondary PayerThis patient probably has another insurance that should be primary over Medicare. Research the chart and query your patient to see what the other insurances are. If another payer is primary you must bill them first. This is another instance where it is vital to get copies of ALL insurance cards at each visit. Information on MSP and all COB issues may be found at www.cms.hhs.gov/COBGeneralInformation and at www.cms.hhs.gov/MedicareSecondPayerandYou. Visit Our WebsitePlease visit us at www.evolutions-mbs.com where you can find information on the services we provide, and staff biographies. Take a look and see what Evolutions can do for your practice. If you have questions concerning this information, please contact:
If you would like to talk with us about what Evolutions can do for your practice, please contact:
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