A lawsuit filed in federal court May 21 seeking to prevent the Federal Trade Commission (FTC) from extending identity theft regulations to physicians may be the reason behind why the Red Flags Rule didn’t go into effect June 1. The American Medical Association (AMA), American Osteopathic Association (AOA), and the Medical Society of the District of Columbia (MSDC) filed the suit on the grounds that the FTC exceeded its authority under the Fair and Accurate Credit Transaction Act of 2003.
May 28th, 2010
A new treatment therapy for men with advanced prostate cancer is being heralded as revolutionary because it the first of its kind to use a patient’s own immune system to fight the disease. Provenge (sipuleucel-T), recently approved by the U.S. Food and Drug Administration (FDA), is indicated for the treatment of asymptomatic or minimally symptomatic prostate cancer that has spread to other parts of the body and is resistant to standard hormone treatment.
Provenge is an autologous cellular immunotherapy, designed to stimulate a patient’s own immune system to respond against the cancer. Each dose of Provenge is manufactured by obtaining a patient’s immune cells from the blood, using a machine in a process known as leukapheresis. To enhance the patient’s response against the cancer, the immune cells are then exposed to a protein that is found in most prostate cancers, linked to an immune stimulating substance. After this process, the patient’s own cells are returned to the patient to treat the prostate cancer.
Provenge, manufactured by Seattle-based Dendreon Corp., is administered intravenously in a three-dose schedule given at about two-week intervals.
The Patient Protection and Affordable Care Act of 2010, or health reform law, extends a number of provisions that expired Dec. 31, 2009. The Centers for Medicare & Medicaid Services (CMS) recently released instructions to its contractors to implement three health reform law provisions that will have ambulance providers breathing a sigh of relief.
Although there is evidence ultrasound guidance improves the accuracy of knee joint injections and reduces procedural pain in some cases, there is insufficient evidence ultrasound guidance improves clinical outcomes. Consequently, Highmark Medicare Services (HMS) does not support coverage of ultrasound guidance for all knee joint injections.
A new supplier specialty code is being established as part of new Medicare Part B policy which, effective Jan. 1, deems cardiac rehabilitation (CR) programs and intensive cardiac rehabilitation (ICR) programs covered services.
The Centers for Medicare & Medicaid Services (CMS) is establishing specialty code 31 Intensive cardiac rehabilitation, effective Jan. 1, to describe the specific/unique types of medicine that physicians and non-physician practitioners (NPPs) provide to patients who have experienced one or more of the following:
- An acute myocardial infarction within the preceding 12 months;
- A coronary artery bypass surgery;
- Current stable angina pectoris;
- Heart valve repair or replacement;
- Percutaneous transluminal coronary angioplasty or coronary stenting;
- A heart or heart-lung transplant; or
- Other cardiac conditions as specified through a National Coverage Determination (NCD) (CR only).
To receive reimbursement for CR and ICR services provided to Medicare patients, physicians, and NPPs must be enrolled in Medicare under supplier specialty code 31 and the services must be provided in a physician’s office—type of service code (TOS) 11—or hospital outpatient setting (TOS 22). ICR programs also must be approved by CMS through the NCD process.
Program requirements include the following components: 1) physician-prescribed exercise each day CR and ICR items and services are furnished; 2) cardiac risk factor modification; 3) psychosocial assessment; 4) outcomes assessment; and 5) an individualized treatment plan detailing how components are utilized for each patient. The individualized treatment plan must be established, reviewed, and signed by a physician every 30 days.
CR sessions are limited to a maximum of two 1-hour sessions per day up to 36 sessions furnished over a period of up to 36 weeks, with the option for an additional 36 sessions at Medicare contractor discretion over an extended period of time. ICR sessions are limited to 72 1-hour sessions, up to six sessions per day, over a period of up to 18 weeks. Append modifier KX Documentation on file to line items that exceed the maximum number of allowed sessions to indicate there is documentation on file supporting the need for further treatments.
Report CR services without continuous monitoring using CPT® 93797 Physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session); report CR services with continuous monitoring using CPT® 93798 Physician services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session).
ICR services with exercise are reported with HCPCS Level II code G0422 Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session; ICR services without exercise are reported with HCPCS Level II code G0423 Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise, per session.
CMS instructs physicians to append modifier GA Waiver of liability statement on file to the procedure code if an Advanced Beneficiary Notice (ABN) is on file for the patient or modifier GZ Item or service expected to be denied as not reasonable and necessary if an ABN isn’t on file.
For detailed information regarding CR and ICR policy and claims processing, see the 2010 Medicare Physician Fee Schedule Final Rule with Comment Final Rule (pages 62004 – 62005), published in the Federal Register on Nov. 25, 2009. Also see MLN Matters article MM6850 and CMS Transmittal 170, Change Request (CR) 6850, issued May 21.