Medicare Compliance & Reimbursement

Stop using the obsolete QV modifier for PET scans.

If you like your carrier's Local Coverage Determination (LCD) for a particular service, now you can encourage Medicare to adopt it nationally.

New LCDs may be eligible to become National Coverage Determinations starting on June 19, according to Transmittal 147, dated May 19. The Centers for Medicare & Medicaid Services will decide which LCDs to make into NCDs, based on: their net impact on clinical health outcomes, whether current national utilization patterns seem unreasonable or unnecessary, quality, access to care, and impact on the national Medicare payment error rate.

In other new transmittals, the CMS says:

· You shouldn't bill for Pegfilgrastim (J2505) based on the number of MGs you provide. Rather, you should bill one unit for each 6 MGs, according to May 12 Transmittal 949.

· Stop using the QV modifier for PET scans in a clinical trial. You should use the QR modifier instead, in cases where the patient has a neurodegenerative disease and receives a PET scan as part of an approved clinical trial, CMS says in Transmittal 956, dated May 19. The QR modifier also works for certain cancers where a PET scan is covered in a clinical trial.

· All carotid artery stenting procedures that are performed in Food & Drug Administration-approved post-approval studies must have approval directly from the FDA, CMS said in Transmittal 951, dated May 12. For studies that extend to[?] previously-approved studies, you must obtain a letter from the FDA stating that the extension study is scientifically valid and will generate valid clinical data.

· CMS gives instructions to the carriers on how to "crosswalk" National Provider Identifiers (NPIs) to existing Medicare or other provider numbers in the run-up to the May 23, 2007 effective date for NPIs, in May 12 Transmittal 948. A single NPI may be crosswalked to a single legacy number. Multiple NPIs may be crosswalked to a single Medicare number, and a single NPI may be crosswalked to multiple Medicare numbers.