April 5, 2008

NYSRS HEALTH INSURANCE, COMPENSATION & CAC REPORT 

MEDICARE UPDATE

IMPORTANT NOTICE:

The Centers for Medicare & Medicaid Services (CMS) announced that National Government Services (NGS), formerly known as Empire Medicare Services, has been awarded the contract for the Medicare Administrative Contractor (MAC) for Part A and Part B Medicare fee-for-service claims for hospital, skilled nursing home, physician, and home health services in New York and Connecticut (Jurisdiction 13). The MAC structure allows CMS to combine the fiscal intermediary and carrier functions under one contract. NGS currently has the contract for Part A services and some Part B services in New York, and Part A services in Connecticut. Hospitals should not experience any changes in their interaction with NGS due to this announcement.

“Details on the logistics” will follow.

Rules RE:  3-D Codes

Choosing and documenting the codes:  76376 vs 76377

Requirement for 76376 – An independent workstation is not required.  The physician asks the technologist for 3-D images and then supervises the image creation.

Requirement for 76377 – An independent workstation is required along with doing & documenting by the radiologist, i.e. the physician, “supervises or creates the 3-D image and adjusts the projection for optimal anatomy and pathology visualization.  In the January 2006 issue of the JACR, recommendations include documentation of medical necessity, a specific order, and a section of the report that indicates “what it showed independent of the originating exam.”

Note:  Global reimbursement for 76377 is 35% higher than 76376; however, breaking this down to TC and Professional component, reimbursement is 5% higher for the technical component and almost 500% higher for the professional component!!!

Radiology Coding Alert 2008, Volume 10, No. 5, p. 33-35

CMS Denial Rate in 2006: Of the 10 most frequently denied codes, two are from RADIOLOY:

71020, CHEST X-RAY, two views – 5.47% National Denial rate.

71010, CHEST X-RAY, single view – 5.78% National Denial rate.

Part B News February 25, 2008, Volume 22, No. 8,  p. 5

DEXA Scans

CMS denial rate in 2006 was 12.6% in 2006 --- almost $70 million!

Key reason:  LACK OF DOCUMENTED MEDICAL NECESSITY AND/OR APPROPRIATE CODING.

As of 1 January 2007, DEXA codes 76075-76076 were replaced with 77080-77081 with the addition of a new code, 77082 for vertebral fracture assessment.

According to Part B News, “common ICD-9 codes that Medicare considers justification for 77080, the most common DEXA test, include:

· 255.0 – Cushing’s syndrome

· 733.00-733.09 – various types of osteoporosis

· 733.90 – disorder of bone and cartilage, unspecified.

Part B News March 3, 2008, Volume 22, No. 9,  p. 4

CMS prior determination of eligible services - ? by March 24, 2008

Prior determination may allow you to ask your CMS carrier if it will pay for certain ‘expensive services’ performed more than 50 times per year.  Of the ten most expensive services performed more than 1,000 times in an office setting in 2006, the following were listed:

·   77301 – Radiotherapy dose plan, imrt

·   22521 – vertebroplasty, lumbar

·   22520 – vertebroplasty, thoracic

Part B News March 24, 2008, Volume 22, No. 12,  p. 6

NEW ABN FORM

May start to use NOW but mandatory by September 1, 2008.

Key changes include:

1. Consolidates and replaces ABN-G and ABN-L

2. Can be used in place of the Notice of Exclusion from Medicare benefits form, NEMB

3. Contains a mandatory field for cost estimates of services being performed

4. Adds a new option to allow beneficiaries to choose a service for which they will pay out-of-pocket, without having a claim submitted to Medicare.

Part B News March 17, 2008, Volume 22, No. 11,  p. 1-3

Code Changes in 2008– Reported in January and reprinted again

         CTA codes now INCLUDE images obtained prior to contrast injection.

         New codes for:

                   CTA – 70496-70498, 71275, 72191, 73706, 74175, 75635

                   Brain imaging (particularly imaging for brain death) – 78600-78607

                   Chest Tubes – 32421, 32422, 32550, 32551, 32560

                   Ureteral Stent Removal – 50385, 50386

                   Thyroid Cyst Aspiration        - 60300

                   Renal Tumor Ablation – 50593

Radiology Coding Alert 2007, Volume 10, No. 2, p. 12

MRI Contrast Payment – Reported in January and reprinted again

You can now bill for contrast media used for MRI.  This was previously included in the MRI Practice Expense relative value.  Therefore, in addition to the CPT code for MRI, you can use the appropriate HCPCS code for contrast (typically Q9952-Q9954).  The Radiology Coding Alert indicates that additional information can be obtained in,

“MLN Matters article MM5677 (www.cms.hhs.gov/MLNMattersArticles/downloads/MM5677.pdf).

Radiology Coding Alert 2007, Volume 10, No. 2, p. 13

Additional information can be accessed by reading the original articles referenced above.

Home Page Information:

http://www.ghimedicare.com/

http://www.umd.nycpic.com/

http://www.gao.gov

Coding 

Upstate Medicare –

http://www.umd.nycpic.com/billtips.html#ICD-9-CM and then select, ICD-9-CM Coding for Diagnostic Tests

Respectfully submitted,

Arthur J. Segal, M.D., F.A.C.R.

Chairman, Medical Insurance and Compensation Committee / NYSRS CAC Representative