Internal Medicine Coding Alert

Published on Sat Aug 01, 1998 PDF

Internal medicine practices can now receive separate Medicare payments for fecal occult-blood screening exams (G0107) performed on the same day as another E/M service, according to a recent update from AdminaStar Federal, the company contracting with HCFA to administer the Correct Coding Initiative (CCI). CCI is the software program that HCFA carriers use to determine whether codes are appropriately billed. This program also stands as the administrations final word on correct coding policy.

Several screening exams and preventive services, including colorectal screening services, became eligible for Medicare coverage on the first of this year

Subscriber Benefits: To receive a list of preventive services and screening exams now covered by Medicare (Doc.# IMCA 898-1001) call 800/508-2582.

However, in April, HCFA announced that it would not pay for four of these codes when they were billed on the same day as another E/M service performed on the same patient by the same physician. AdminaStar Federal released edits to version 4.1 of CCI which bundled these codes in with the E/M service.

The four excluded codes were:

G0101: cervical or vaginal cancer screening; pelvic and clinical breast examination.

G0104: colorectal cancer screening; flexible sigmoidoscopy (start of coverage date, Jan. 1, 1999).

G0105: colorectal cancer screening; colonoscopy on individual at high risk; and (start of coverage date, Jan. 1, 1999).

G0107: colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations.

ASIM Pushes for Removal of Edits

The American Society of Internal Medicine (ASIM), the nations largest medical specialty organization, strenuously objected to the edits. In a letter to AdminaStars CCI project coordinator, Linda Deitz, dated June 8, 1998, ASIMs executive director, Alan Nelson, MD, urged HCFA to delete the edits.

It is inappropriate to consider each of these services/procedures to be a component of an E/M service because the screening service/procedure and the E/M service are, according to code definition, performed for inherently different reasons, Nelson wrote.

For example, argues Nelson, an internist may see a patient to evaluate and treat shoulder joint pain, and on the same visit, realize the patient is eligible for and could benefit from a fecal occult-blood screening test. For the patients convenience, the physician would take a stool sample and perform the test with the patient still in the office. The physician would then code the evaluation for shoulder joint pain as a mid-level E/M service and the screening service, which is unrelated to the joint pain, as G0107.

ASIM fails to understand how the CCI can view a screening fecal-occult blood test as a component of a medically necessary E/M service for acute shoulder joint pain, he writes.

HCFA must have bought the argument, at least up to a point, says Brett Baker, ASIMs third party relations specialist, because last month, the administration instructed its carriers to allow separate payments for one of the four codes (G0107).

Should You Appeal, Resubmit or Wait?

Internal medicine practices have two options when it comes to recouping the reimbursement for fecal occult-blood screens that were performed after January 1, 1998 on the same day as a patients E/M visit.

First, says Baker, you can wait.

The carriers are supposed to reprocess any affected claims, he states. However, they first have to run an audit and come up with the number of claims that were affected.

Since that process may take a considerable amount of time,
Baker says some practices might want to consider a second option--resubmitting the claim or appealing its denial--despite the additional work.

Appealing or resubmitting may actually be faster, he explains.

Baker acknowledges that ASIM originally instructed internal medicine practices to hold all claims for G codes performed on the same day as a separate E/M service until HCFA issued billing instructions.

We were waiting on instructions from the carrier about whether they were going to reprocess them, he says. Also, we were hopeful they would say, Were going to take out these edits for the other covered screenings, which were also mentioned in the letter.

That has not yet happened, and Baker says ASIM understands that practices need to be reimbursed for the services they have provided.

Note: ASIM is continuing to push for the deletion of the other CCI edits that bundle the other screening services in with an unrelated E/M service. Internal Medicine Coding Alert will update you as changes take effect.