It isn’t every day a Medicare administrative contractor (MAC) says it will cover a procedure that has neither a specific CPT® code describing it nor any concrete proof that the medical intervention is even useful. On July 16, however, Palmetto GBA did exactly that when it posted a policy update for percutaneous endovascular cardiac assist procedures and devices.
Effective for dates of service on or after Sept. 1, 2011, the jurisdiction 1 Part B MAC will cover the percutaneous insertion of an endovascular cardiac assist device and the device itself.
Coverage will be allowed for (but not exclusively) the following ICD-9-CM codes:
- Cardiogenic shock, reported with 785.51
- Severe decompensated heart failure with threatening multi-organ failure, represented by one of the following:
- 428.21 Acute systolic heart failure
- 428.23 Acute or chronic systolic heart failure
- 428.41 Acute combine systolic and diastolic heart failure
- 428.43 Acute or chronic combined systolic and diastolic heart failure
- 429.4 Functional disturbances following cardiac surgery
- 997.1 Cardiac complications, not elsewhere classified
When submitting a claim to Palmetto for an endovascular cardiac assist procedure, report CPT® 33999 Unlisted procedure, cardiac surgery and enter “Impella” or “Tandem Heart” in item 19 of the CMS-1500 claim form or its electronic equivalent.
Source: Palmetto GBA
July 26th, 2012
Confusion regarding which services qualify for the Health Professional Shortage Area (HPSA) 10 percent bonus is mounting, Palmetto GBA says. “Submitting HPSA modifiers on claims that do not qualify for the HPSA incentive payment may result in erroneous incentive payments and a referral to the Zone Program Integrity Contractor (ZPIC) for fraud and abuse investigation,” the Medicare contractor warns.
To curtail abuse, Palmetto says it will be “suppressing” HPSA payments for providers with four or more quarters of erroneous billing of the AQ modifier.
Palmetto also posted important HPSA claim filing rules and requirements on its website, with a reminder, “It is vital that you determine whether the service qualifies for a HPSA bonus payment prior to submitting a claim.”
June 18th, 2012
Billing and coding guidelines for prostate molecular marker claims submitted to Palmetto GBA have changed. The Part B Medicare administrative contractor (MAC) for jurisdiction 1 (American Samoa, California, Guam, Hawaii, Nevada, and Northern Mariana Islands) has determined the service to be medically unnecessary and will not reimburse physicians for HOXD3, PTEN, and ERG molecular markers.
Among other considerations, patients should be informed that molecular markers are not covered under Medicare, and an Advanced Beneficiary Notice (ABN) for the service should be retained on file.
Complete instructions for how to submit a claim to receive a service denial were posted June 1 on Palmetto’s website.
There reportedly has been a high incidence of crossover claims being rejected. According to Palmetto GBA, many physician offices and durable medical equipment (DME) suppliers are receiving provider notification letters from their servicing Medicare administrative contractor (MAC) or carrier that includes an H40142 error code and the description “Discharge date (DTP-01=096) was not expected because this claim is not for inpatient services.” (more…)
March 16th, 2012
Treatment of endometrial hyperplasia with the insertion of a hormone-containing intrauterine device (IUD) is an accepted method to manage endometrial hyperplasia for patients with abnormal uterine bleeding who are unable to tolerate, or at high risk for complications of, oral megestrol, states Palmetto GBA in its February 2012 Medicare Advisory.
The jurisdiction 1 Medicare administrative contractor (J1 MAC) says it will reimburse IUD insertion services for patients who meet these criteria effective for dates of service on or after Feb. 1, 2012.
For proper reimbursement, do not report CPT® code 58300 Insertion of intrauterine device (IUD) for endometrial hyperplasia treatment with an IUD for a Medicare patient. Medicare does not allow payment for contraceptive devices or medication, and the claim will be auto-denied.
Palmetto advises providers to, instead, bill the following information to avoid unnecessary claim denials:
- CPT® code 58999 Unlisted procedure, female genital system
- ICD-9 codes 621.30-621.34
- Enter “hormone IUD” in the comment/narrative field
Read the Medicare Advisory report for other important coding information pertaining to fee-for-service providers who submit Medicare Part B claims to Palmetto GBA.
JF MAC Noridian Administrative Services recently updated its IUD (Hormone-Eluting) for Endometrial Hyperplasia local coverage determination (LCD), as well, to include coverage for treatment of endometrial hyperplasia with the insertion of a hormone-containing IUD. Guidance is the same with one exception: In item 19 of the CMS-1500 form or the electronic equivalent, enter ”hormone IUD for endometrial hyperplasia.”
February 10th, 2012