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.

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.

Medicare Part B physician payments for transforaminal epidural injection services increased from $57 million in 2003 to $141 million in 2007, according to a recent review conducted by the Office of Inspector General (OIG). That amounts to a 150 percent increase.

A gain in popularity of this magnitude prompted the OIG to conduct a review of this pain management service. In the review, the OIG states that roughly 34 percent of 433 sampled claims for transforaminal epidural injection services performed in 2007 did not meet Medicare requirements. The OIG estimates approximately $43 million in improper payments.

Physicians should prepare themselves for added contractor scrutiny of these types of pain management claims.

Transforaminal epidural injections are a type of interventional pain management technique used to diagnose or treat pain. There are two primary codes used to bill a single injection in the cervical/thoracic or lumbar/sacral area of the spine, and each primary code has an associated add-on code for use when injections are provided at multiple spinal levels. These codes are:

Physician payments vary based on the place of service (office vs. ambulatory surgical center (ASC) or outpatient department) and also the modifiers billed. For example, bilateral transforaminal epidural injections, which are performed on both the right and left side of a vertabrel level should be billed using modifier 50. The use of this modifier would increase payment to 150 percent of the base rate.

According to the OIG, “The reviewer found primarily that physicians improperly used add-on codes and bilateral modifiers.”

Medicare covers transforaminal epidural injections that are reasonable and necessary, which are those used in the diagnosis or treatment of illness or to improve the functioning of a malformed body part. To ensure payment, physicians must:

• Properly document medical care to support the service; and
• use uniform procedure codes to report all services.

Documentation should include a description of the service provided, with details such as location and frequency of injections, as well as outcomes that support subsequent injections. Diagnosis codes also must support medical necessity. Most contractors with local coverage determinations (LCDs) in place for transforaminal epidural injections also require the use of radiographic guidance (such as live X-rays), prohibit multiple pain management services on the same day, and limit frequency.

In response, the Centers for Medicare & Medicaid Services (CMS) says it intends to strengthen program safeguards, which may include medical reviews and system edits.

Read the OIG’s August review for complete details.

By Jennifer Hritsco-Murray, CPC, CANPC

Under Medicare guidelines, pain management following surgery usually is included in the surgeon’s global fee and may not be billed separately. If another physician (such as an anesthesiologist) provides pain management at the surgeon’s request, however, it’s possible to report the service independently.

Specifically, according to the American Society of Anesthesiology (ASA), CPT® recommendations, Correct Coding Initiative (CCI) edits, and the Centers for Medicare & Medicaid Services (CMS) guidelines, when medically necessary a block performed for post operative pain only (which is not a part of the anesthesia service) may be billed separately with the proper modifier. The surgeon is responsible for documenting in the patient’s medical records why post-op care was given to the anesthesiologist. Read more »

By Denis Rodriguez, CPC, CCS, CIRCC, CASCC

Arthroscopy refers to less invasive procedures in which an endoscope is placed within the joint for the performance of diagnostic and therapeutic procedures. As technology advances, procedures previously performed through large incisions are now performed arthroscopically. To accommodate this emerging technology, new arthroscopy, CPT® Category III codes, and HCPCS Level II codes, have been added over the past few years.

There are three general principles of arthroscopic coding: Read more »

The American College of Obstetricians and Gynecologists (ACOG) now recommends adolescent girls to wait until they turn 21 to have their first Papanicolau (Pap) test, with the exception of those who have HIV and others with weakened immune systems.

“Any adolescents who had one or more Pap tests with normal results before the guidelines changed in December 2009 should not be screened again until they reach age 21,” according to ACOG. “Likewise, teens who have had a previous abnormal Pap test followed by two normal test results also should wait until age 21 to be rescreened.”

ACOG maintains its recommendation that girls receive their first gynecological visit between the ages of 13-15, however; and continues to advise against human papillomavirus (HPV) testing in adolescents.

“Healthy immune systems typically eliminate HPV, the virus that causes cervical cancer, from the body,” reasons ACOG. “People with weakened immune systems, however, cannot fend off viral infections as easily or at all.”

“Adolescents have been over-treated for something that typically resolves on its own. We know that unnecessary treatments compromise the cervix and increase a teen’s risk of having a preterm birth later in life.” said Cheryl B. Iglesia, MD, chair of the Committee on Gynecologic Practice.

Guidelines state: Adolescents who have low- to high-grade precancerous lesions, 622.1x Dysplasia of cervix (uteri)—with the exception of 233.1 Cervical intraepithelial neoplasia III (CIN III)—generally should be managed by periodic observation. Rescreening can be delayed until age 21 when the Pap test results show regression of the dysplasia, but annual screening also is an acceptable alternative. Although very rare in adolescents, CIN 3 is considered a significant precancerous condition that does require treatment with cryotherapy, laser therapy, or loop electrosurgical excision.

For ACOG’s recommendations on screening and managing cervical cancer in adolescents, Committee Opinion #463, “Cervical Cancer in Adolescents: Screening, Evaluation, and Management,” is published in the August issue of Obstetrics & Gynecology.

Source: July 21 ACOG press release

Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women, including some women who have had two previous cesareans, according to American College of Obstetricions and Gynecologists (The College) guidelines, released July 21.

According to The College, the declining rate for VBAC (just 8.5 percent in 2006) reflects the restrictions some hospitals and insurers place on trial of labor after cesarean (TOLAC) as well as decisions by patients when presented with the risks and benefits.

“The current cesarean rate is undeniably high and absolutely concerns us as ob-gyns,” said Richard N. Waldman, MD, president of The College. “These VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy.”

“The College guidelines now clearly say that women with two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a TOLAC,” said Jeffrey L. Ecker, MD, from Massachusetts General Hospital in Boston, who co-wrote the guidelines document with William A. Grobman, MD, from Northwestern University in Chicago.

Approximately 60-80 percent of appropriate candidates who attempt VBAC will be successful, The College says, and a successful VBAC has fewer complications than an elective repeat cesarean.

A failed TOLAC, however, has more complications than an elective repeat cesarean. The risk of uterine rupture during a TOLAC is low—between 0.5 and 0.9 percent—but if it occurs, it is an emergency situation. The College maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean, but recognizes that such resources may not be universally available.

Hospitals that lack “immediately available” staff should develop a clear process for gathering them quickly and all hospitals should have a plan in place for managing emergency uterine ruptures, however rarely they may occur, Dr. Grobman added.

If, during prenatal care, a physician is uncomfortable with a patient’s desire to undergo VBAC, it is appropriate to refer her to another physician or center, The College advises.

Practice Bulletin No. 115, “Vaginal Birth after Previous Cesarean Delivery,” is published in the August 2010 issue of Obstetrics & Gynecology.

Updates to CPT® Category II codes posted July 2 on the American Medical Association (AMA) website include several new codes, revised short and medium code descriptors, and revisions to the Index of Alphabetic Clinical Topics. These updates, released July 1, will be implemented Oct. 1 and will appear in CPT® 2011.

Several new codes were added for reporting Parkinson’s disease. They are:

For diagostic/screening:

3700F Psychiatric disorders or disturbances assessed

3720F Cognitive impairment or dysfunction assessed

For therapeutic, preventative or other interventions:

4324F Patient (or caregiver) queried about Parkinson’s disease medication related motor complications

4325F Medical and surgical treatment options reviewed with patient (or caregiver)

4400F Rehabilitation therapy options discussed with patient (or caregiver)

For follow-up or other outcomes:

6080F Patient (or caregiver) queried about falls

6090F Patient (or caregiver) counseled about safety issues appropriate to patient’s stage of disease

With news of Provenge (sipuleucel-T) being approved April 29 by the U.S. Food and Drug Administration (FDA), the Centers for Medicare & Medicaid Services (CMS) has opened a national coverage analysis (NCA) for the autologous cellular immunotherapy treatment of prostate cancer.

Provenge 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 designed to stimulate a patient’s own immune system to respond against the cancer. Each dose of Provenge, administered intravenously in a three-dose schedule given at about two-week intervals, 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.

CMS is commissioning a technology assessment from an external entity and plans to convene a meeting of the Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) this year.

Public comments on the evidence regarding the effects of this treatment on health outcomes in patients with prostate cancer are being accepted during the initial 30-day public comment period, which began June 30. Instructions on submitting public comments can be found on the CMS Coverage Information Exchange webpage. You can also submit a public comment by clicking on the highlighted word comment in the title bar at the top of the CMS webpage.

Eleven new CPT® Category III codes were implemented July 1 by the American Medical Association (AMA). The codes were introduced Jan. 1 and will be included in CPT® 2011. Also among the updates are several new and two revised Category III codes that will be implemented in 2011 and two new and Category III codes that will appear in CPT® 2012.

New Category III codes implemented July 1 are:

0223T Acoustic cardiography, including automated analysis of combined acoustic and electrical intervals; single, with interpretation and report

0224T Acoustic cardiography, including automated analysis of combined acoustic and electrical intervals; multiple, including serial trended analysis and limited reprogramming of device parameter – AV or VV delays only, with interpretation and report

0225T Acoustic cardiography, including automated analysis of combined acoustic and electrical intervals; multiple, including serial trended analysis and limited reprogramming of device parameter – AV and VV delays, with interpretation and report

0226T Anoscopy, high resolution (HRA) (with magnification and chemical agent enhancement); diagnostic, including collection of specimen(s) by brushing or washing when performed

0227T Anoscopy, high resolution (HRA) (with magnification and chemical agent enhancement); with biopsy(ies)

0228T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level

+0229T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; each additional level (List separately in addition to code for primary procedure)

Use 0229T in conjunction with 0228T.

0230T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level

0231T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure)

Use 0231T in conjunction with 0230T.

For transforaminal epidural injections performed under fluoroscopy or computed tomography, see 64479-64484.

0232T Injection(s), platelet rich plasma, any tissue, including image guidance, harvesting and preparation when perofrmed

0233T Skin advanced glycation endproducts (AGE) measurment by multi-wavelength fluorescent spectroscopy

Category III codes o184T Excision of rectal tumor, transanal endoscopic microsurgical approach (ie, TEMS), including muscularis propria (ie, full thickness) and 0191T Insertion of anterior segment aqueous drainage, without extraocular reservoir; internal approach, into the trabecular meshwork are revised and new codes 0234T-0259T will be implemented Jan. 1, 2011.

Also of note are two new Category III codes that were accepted for 2012 at the June CPT® Editorial Panel meeting. The two new codes to be implemented Jan. 1, 2011 are:

0260T Total body systemic hypothermia, per day, in the neonate 28 days of age or younger

0261T Selective head hypothermia, per day, in the neonate 28 days or younger

These temporary codes are meant to display and track the use of emerging technologies. More information on these CPT® Category III codes can be found on the AMA website.