Endo Docs Gaming the System, Study Says

A study presented at Digestive Disease Week in Chicago last year suggests that physicians may be deliberately performing endoscopies on different days to avoid bundling—and the attendant reduction of payment—by Medicare payers, reports Internal Medicine News.

Researchers identified 12,905 Medicare beneficiaries who underwent both a colonoscopy and diagnostic upper endoscopy procedure within 180 days of each other. Nearly two-thirds of all procedures were bundled; the remaining procedures (approximately 37 percent) were separated from each other by a median of just 26 days, and approximately 30 percent of procedures not performed on the same day were separated by four or fewer days.

“The lack of bundling was unlikely to be explained by clinical necessity,” commented lead investigator Dr. Hashem B. El-Serag. Rather, El-Serag believes physicians making clinical choices may have been influenced by purely financial concerns.

Providing related endoscopic services on the same day is more convenient, efficient, and cost-effective, but there is a financial disincentive for physicians to embrace this approach. Medicare pays less when two endoscopic procedures are reported for the same patient on the same day. For example, reimbursement for a diagnostic upper endoscopy is approximately $75 when bundled; the payment nearly doubles ($150) if the procedure is reported independently.

The study stopped short of making recommendations to prevent such unbundling of endoscopic services, but lead researcher El-Serag did caution, “The financial implications to the health care system and the increased adverse events in patients are likely to be large.”

December 30th, 2011

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Updated IOCE Includes Substantial Changes

Medicare contractors received updated instructions and specifications in December for the January 2012 Integrated Outpatient Code Editor (IOCE). They’ll use version 13.0 to edit claims paid under the Outpatient Prospective Payment System (OPPS) and non-OPPS for hospital outpatient departments, community mental health centers, and for all non-OPPS providers; and for limited services when provided in a home health agency not under the Home Health Prospective Payment System or to a hospice patient for the treatment of a non-terminal illness.

The update includes a number of ambulatory payment classifications (APCs) and HCPCS Level II and CPT^® code changes, most of which are effective Jan. 1, 2012, and all of which outpatient facilities should be aware.

APC Changes

There are 28 new APCs, 25 deleted APCs, 26 APCs with description changes, and 15 APCs with status indicator changes.

New APCs range from 00331 Combined abdomen and pelvis CT without contrast to 09366 EpiFix wound cover.

Deleted APCs begin with 00245 Level I cataract procedures without IOL insert and end with 09364 Porcine implant, Permacol.

Many of the description changes to APCs are meant to enhance specificity and some greatly change the meaning of the code. Here are a few examples:

Other description changes have little or no effect. For example:

As for status indicator changes: With the exception of APC 00668, which went from ‘S’ to ‘T,’ APCs 01236, 01238, 01290, 01296, 01297, 09249, 09250, 09251, 09252, 09253, 09255, 09256, 09360, and 09363 went from a status indicator of ‘G’ to ‘K.’

Code Changes

Added to the January I/OCE are six HCPCS Level II ‘G’ codes for preventive screening services. The following codes are effective Oct. 1, 2011:

Deleted from the IOCE, effective July 1, 2011 is HCPCS Level II code S3628 PAMG-1 rapid assay for ROM.

For the complete list of HCPCS Level II and CPT^® procedure codes that are either added or deleted effective Jan. 1, 2011, and for description and status indicator changes and other code edits, please see the Centers for Medicare & Medicaid Services’ (CMS) Transmittal 2370.

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J4 MAC Issues Billing Instructions for Denosumab

Beginning Jan. 1, 2012, a new HCPCS Level II code has been assigned to the drug denosumab. Formally C9272 Injection, denosumab, 1 mg, denosumab should now be reported with J0897 (description remains the same).

The drug denosumab has two brand names with two different indications:

Prolia® - indicated to treat osteoporosis in women after menopause.

Xgeva® - indicated for the prevention of skeletal-related events in patients with bone metastases from solid tumors.

When billing Prolia for patients with postmenopausal osteoporosis, TrailBlazer Health Enterprises instructs providers to report ICD-9 diagnosis code 733.01 Senile osteoporosis on the claim. And when billing Xgeva for patients with bone metastases from solid tumors, providers should report ICD-9 code 198.5 Bone and bone marrow on the claim.

TrailBlazer, Medicare administrative contractor for jurisdiction 4 (J4-MAC), further instructs providers to indicate in the comment section of the claim which drug is being administered, Prolia or Xgeva.

Remember: The medical record must clearly demonstrate the patient has been diagnosed as indicated on the claim.

“Utilizing the recommended diagnosis code in situations where medical records do not support the reported diagnosis  is not appropriate,” TrailBlazer warns.

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Medicare Covers Screening for Depression

Medicare recently added annual depression screening as a covered preventive service, in accordance with the Affordable Care Act. Effective Oct. 14, 2011, adult Medicare patients may receive depression screening once every 12 months in the primary care setting without a copay or deductible.

Requirement: The provider must have in place staff-assisted depression care supports who can advise the physician of screening results and who can facilitate and coordinate referrals to mental health treatment.

Report: The type of service is 1 and the HCPCS Level II code is G0444 Annual depression screening, 15 minutes.

Another thing to consider is whether your organization qualifies as a “primary care setting.” According to MLN Matters article MM7637, effective for claims with dates of service on or after the implementation date (April 2, 2012), contractors will pay for annual depression screening only when provided at the following places of service:

11 – Office
22 – Outpatient hospital
49 – Independent clinic
50 – Federally qualified health center
71 – State or local public health clinic
72 – Rural health clinic

Limitations: Places of service that are not considered a primary care setting include: emergency departments (EDs), inpatient hospitals, ambulatory surgical centers (ASCs), independent diagnostic testing facilities, skilled nursing facilities (SNFs), inpatient rehabilitative facilities, and hospice. Also, treatment options—such as self-help materials, phone calls, etc.—are not included under this Medicare Part B benefit.

For further depression screening coding and billing guidance, read the complete MLN Matters article on the Centers for Medicare & Medicaid Services (CMS) website.

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2012 MPFS Final Rule Cuts Imaging Payments, Redistributes RVUs

The release of the 2012 Medicare Physician Fee Schedule (MPFS) final rule brings an expansion of the multiple procedure payment reduction policy for Medicare, as well as modifications to the Physician Quality Reporting System (PQRS) and other changes.

Congress acted on Dec. 23, 2011 to stall a 27.4 percent cut in Medicare payments that would have gone into affect Jan. 1, 2012. The legislation extends current payment rates for the first two months of 2012, by which time Congress will have to act once again to prevent drastically lower reimbursement for Medicare physicians. A permanent fix to the sustainable growth rate (SGR) formula that determines Medicare payments is widely desired.

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