The Centers for Medicare & Medicaid Services (CMS) is changing the payment status indicator for CPT® code 90662 Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use from “E” (not paid under the Outpatient Prospective Payment System (OPPS)) to “L” (not paid under OPPS; paid at reasonable cost; not subject to deductible or co-insurance) in the October 2010 Integrated Outpatient Code Editor (IOCE).

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Under the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) is expanding Medicare coverage of evidence-based tobacco cessation counseling. Effective Jan. 1, 2011, any smoker covered by Medicare can receive tobacco cessation counseling from a qualified physician or other Medicare-recognized practitioner.

Current Medicare policy covers tobacco counseling only for individuals diagnosed with a recognized tobacco-related disease or for those who show signs or symptoms of such a disease.

“Today’s decision builds on the existing preventive services that are available to Medicare beneficiaries,” said CMS Administrator Don Berwick, M.D. “Giving older Americans and persons with disabilities who rely on Medicare the coverage they need for counseling treatments that can aid them in quitting will have a positive impact on their health and quality of life. As a result, all Medicare beneficiaries now have more help to avoid the painful—and often deadly—consequences of tobacco use.”

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The Centers for Medicare & Medicaid Services (CMS) is considering changes to the Medicare coverage policy for ventricular assist devices (VAD) as destination therapy in end-stage heart failure patients.

In a proposed decision memo dated Aug. 19, CMS proposes removing the requirement that patients must have a body size greater than 1.5 m² and raising the peak oxygen-consumption threshold from 12 mL/kg/min to 14 mL/kg/min.

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The Centers for Medicare & Medicaid Services (CMS) issued a reminder Aug. 24 to health care providers, health plans, clearinghouses, and vendors about the approaching compliance dates for the transition to the Accredited Standards Committee X12 Technical Reports Type 3, Version 005010 (Version 5010) electronic health care transaction standards. Beginning January 2011, entities covered under the Health Insurance Portability and Accountability Act (HIPAA) should be ready to test with their trading partners the functionality of the entities’ practice management and/or other related software featuring Version 5010 standards.

That date is right around the corner. Are you ready?

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Effective Nov. 6, physicians separately can report implantable tissue markers (HCPCS Level II A4648 Tissue marker, implantable, any type, each) and implantable radiation dosimeters (A4650 Implantable radiation dosimeter, each) in Medicare Part B claims.

To receive payment for these miscellaneous supplies, codes A4648 and A4650 must be billed in conjunction with one of the following CPT^® codes:

19499 Unlisted procedure, breast

32553 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous intra-thoracic, single or multiple

49411 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous intra-abdominal, intra-pelvic (except prostate), and/or retroperitoneum, single or multiple

55876 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple

If one of the above CPT® codes is not paid on the same claim (or in history) with the same date of service, payment will be denied.

No policy change has been made for hospitals paid under the Outpatient Prospective Payment System (OPPS), Inpatient Prospective Payment System (IPPS), or ambulatory surgical centers (ASCs) paid under the ASC Payment System. Current Medicare policy continues to instruct Medicare contractors not to separately reimburse claims for HCPCS Level II codes A4648 or A4650 to hospitals and ASCs paid under these payment systems.

Refer to the Centers for Medicare & Medicaid Services (CMS) Transmittal 745, Change Request (CR) 6968, issued Aug. 6, for further clarification of this physician payment policy in Pub. 100-20 of the Medicare Claims Processing Manual.

Effective Jan. 1, 2011, the Centers for Medicare & Medicaid Services (CMS) will establish durable medical equipment prosthesis, orthotics and supplies (DMEPOS) specialty code B5 for ocularists.

The American Society of Ocularists defines an ocularist as a “carefully trained technician skilled in the arts of fitting, shaping, and painting ocular prostheses.” In addition to creating ocular prostheses, the ocularist shows the patient how to handle and care for them, and provides long-term care through periodic examinations.

Patients who need to be referred to an ocularist usually fall into the following categories:

• Recent enucleation/evisceration
• Problems with an existing prosthesis
• Blind eyes requiring a scleral shell
• Congenital anophthalmia/microphthalmia

Patients with existing ocular prostheses often need to be referred to the ocularist for problems with either the surface condition of the prosthesis or problems with the fit of the prosthetic eye or scleral shell.

Services provided by the ocularist include:

• Cleaning
• Polishing
• Enlargement
• Reduction
• Replacement

Due to the requirements of most insurance policies, a written prescription from the referring physician or other appropriate eye care specialist often is required.

Palmetto GBA recently amended its Cataract Surgery Local Coverage Determinations (LCDs) to reflect a focus on the adult patient and a more complete description of functional status.

In response to comments the J1 Part A/B Medicare administrative contractor (MAC) received, the title of the final policy was amended to appropriately reflect the adult patient population. Palmetto GBA also removed the specific Snellen visual acuity threshold from the final LCD. The reporting requirement of the “best corrected” Snellen visual acuity remains, however. As does the expectation that the medical records supporting the cataract extraction identify the activity limitations (e.g., in self-care and mobility) and participation restrictions (e.g., in interpersonal interactions and relationships and community, social and civic life) are also reported.

These terms may be new to physicians, hospitals, and ambulatory surgical centers (ASCs) providing cataract surgery but are reflective of long-standing concepts included in such well-established instruments like the National Eye Institute’s Visual Functioning Questionnaire – 25 (VFQ – 25).

To provide guidance to physicians, hospitals, and ASCs on how best to communicate functional status for patients requiring cataract extraction, Palmetto GBA has incorporated the concepts of the International Classification of Functioning, Disability and Health (ICF) taxonomy into the final version of the LCD.

Below is a case scenario demonstrating the value of going beyond diagnosis by using the concepts of the ICF. Please note that while Palmetto GBA is encouraging physicians and hospitals providing cataract surgery to consider the conceptual framework of the ICF, Medicare does not require the reporting of the ICF codes. Read more »

An Office of Inspector General (OIG) review suggests physicians correctly code the place of service (POS) in Medicare Part B claims only 10 percent of the time. This pattern of incorrectly coded claims for nonfacility services resulted in Medicare overpaying physicians an estimated $13.8 million in 2007, the OIG concludes in a July report.

Of the 100 services the OIG sampled, 90 of the services were coded as having been performed in a nonfacility location, when 60 of the services were actually performed in hospital outpatient departments and 30 were performed in ambulatory surgical centers (ASCs).

The OIG provides in the report this example of incorrect coding:

“A carrier paid a physician $374 for performing a spinal pain injection procedure coded as having been performed in his office. Our analysis showed that the physician actually performed this procedure in a hospital outpatient department and that a fiscal intermediary had reimbursed the hospital for the overhead portion of the service. If the claim had been coded correctly, the physician would have received a payment of $96, which would not have included overhead costs. As a result of the incorrect coding, the physician was overpaid $278.”

The OIG report recommends for the Centers for Medicare & Medicaid Services (CMS) to immediately reopen the claims associated with the 484,118 nonsampled services and work with the physicians who provided the services (and more than likely miscoded the POS) to recover any overpayments.

For complete details, read the OIG July 2010 report; and for POS codes and definitions, refer to CMS Pub. 100-04, Medicare Claims Processing Manual, chapter 26, section 10.5.

Twenty-one U.S. senators sent a letter dated Aug. 5 to the Centers for Medicare & Medicaid Services’ (CMS) Administrator Donald Berwick, M.D., asking for the agency “to use its existing discretionary authority to make an important modification to the ASC payment system.”

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By G. John Verhovshek, MA, CPC

Certain circumstances call for practices to discard unused portions of drugs. For instance, Botox® (onabotulinumtoxin A) currently has a shelf life of only four hours when reconstituted. If the entire vial isn’t used within that time, the only option is to discard the remaining supply.

This waste is not necessarily money down the (proverbial) drain, however. You may report drug waste for those drugs the billing entity paid for and provides. For example, you wouldn’t bill waste for provider-administered drugs the patient purchased from a pharmacy. Nor would you report waste for drugs supplied by a facility. Read more »