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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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.

The 2011 Outpatient Prospective Payment System (OPPS)/Ambulatory Surgical Center (ASC) payment system proposed rule, released July 2 by the Centers for Medicare & Medicaid Services (CMS), proposes payment system changes and 2011 payment rates. The proposed rule also would implement several health care reform law provisions, including some pertaining to certain inpatient hospital services, graduate medical education costs, and physician self-referral rates, which did not make it into the 2011 Inpatient Prospective Payment System (IPPS) proposed rule, published May 4. Read more »

The July 2010 update to the Ambulatory Surgical Center (ASC) payment system adds seven new ancillary service codes and eight new surgical procedure codes. ASC staff also should note that the payment rates for three codes were incorrect in the April 2010 ASC DRUG file.

New Ancillary Service Codes

Seven new HCPCS Level II codes have been created for drugs that are payable as covered ancillary services for dates of service on or after July 1. The following new separately payable drug and biological codes and their payment rates are included in the July 2010 ASC DRUG file.

*C9262 is discontinued after June 30 and replaced by Q2025 effective July 1.

CPT® Code Payment Indicator Change

Effective April 1, the payment for CPT® code 90670 Pneumococcal conjugate vaccine, 13 valent, for intramuscular use will change from ASC PI=Y5 (non-surgical procedure/item not valid for Medicare purposes because of coverage, regulation and/or statute; no payment made) to ASC PI=K2 (drugs and biologicals paid separately when provided integral to a surgical procedure on ASC list; payment based on Outpatient Prospective Payment System (OPPS) rate). The payment rate effective April 1 is: $106.70. Suppliers who think they may have received an incorrect payment determination between April 1 and June 30 should request contractor adjustment of previously processed claims.

New Surgical Procedure Codes

Seven new Category III CPT® codes have been created for surgical procedures that are payable for dates of service on or after July 1. and one new HCPCS Level II surgical procedure code has been created and is payable for dates of service on or after March 23.

The following new separately payable codes and their payment rates are included in the July 2010 ASC Fee Schedule (ASCFS) file.

*Temporary office-based status

Updated Payment Rates

The corrected payment rates that follow appear in the revised April 2010 ASC DRUG file effective for services furnished on April 1 through implementation of the July 2010 update (July 6).

Medicare contractors will adjust claims for these three HCPCS Level II codes that have dates of service on or after April 1 through July 1, and were originally processed prior to the installation of the revised April 2010 ASC DRUG File, only if brought to their attention.

MLN Matters MM7008 notifies providers submitting claims payable under the ASC payment system to Medicare of these important changes.

The Medicare manual and previous guidance stipulates that physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives who operate within the scope of practice under state law may order and perform diagnostic tests. That much was clear, but then the 2010 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) final rule implemented a few changes to this policy. New guidance from the Centers for Medicare & Medicaid Services (CMS) helps clarify any misconceptions providers may have about Medicare’s current policy for physician supervision of diagnostic and therapeutic services provided to hospital outpatients.

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The Ambulatory Surgery Center Association (ASCA) — a membership and advocacy organization for ASCs — will no longer manage eight state ASC groups, reports Outpatient Surgery Magazine in its May online edition. Although an official statement has not yet been made by the association, “Sources are calling it a business decision made at ASCA’s annual meeting in Anaheim, Calif., [held May 19-22],” according to Outpatient Surgery Magazine Editor-in-Chief Dan O’Connor.

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A federal jury ruled that Tuomey Healthcare System acted in violation of the Stark Law and may order the Sumter, S.C. hospital to pay as much as $44.8 million in damages. Read more »

The Medicare Payment Advisory Commission (MedPAC) released its March 2010 “Report to the Congress: Medicare Payment Policy” on March 1. The report contains annual rate adjustment recommendations for Medicare’s various fee-for-service (FFS) payment systems.

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