Part B Insider (Multispecialty) Coding Alert

Published on Thu Aug 07, 2003 PDF

Carriers Plan Massive Take-Backs

The Food and Drug Administration only just approved the first drug-eluting stent last April, and it's already getting providers into trouble.
  
The Centers for Medicare & Medicaid Services said hospitals could start billing for drug-eluting stents using HCPCS G0290 and HCPCS G0291 effective July 1, according to Trans-mittal A-03-051. Those codes reimburse about $5,000 each, or nearly three times the codes the hospitals had been using for outpatient stent insertion prior to July 1: 92980 and 92981.
  
But many physician coders misunderstood the CMS instruction and thought they had an open invitation to start billing G0290 and G0291 as well. One physician coder says she was told to use the two "G" codes, plus the -26 modifier to indicate the professional component of the service. Several coders report using the   G codes.
  
According to the American College of Cardiology, the two G codes are only for hospitals, and the two CPT codes are for physicians.
  
"There was conflicting information from the carriers and the government," says Karen Salowitz, coder with Heart and Vascular Center of Arizona in Phoenix. But it makes sense for hospitals to be paid more for drug-eluting stents than for regular stents because of the cost of the drugs and the stents themselves, Salowitz says.
  
On the other hand, "there's no more skill involved" in placing a drug-eluting stent than a regular stent for a physician, she says.
  
"For the physician to bill the G code would now be considered fraudulent," says Terry Fletcher, a healthcare coding consultant in Laguna Niguel, Calif. "CMS is getting really upset."
  
Because the carriers aren't up to speed on this issue yet, physicians will receive payment for the two G codes, she adds. Then the carriers will have to ask for a refund or offset the physicians' later checks. "It's an accounting nightmare," she says.
  
Nor do physicians need to bill with the -26 modifier to show the professional component, because stent placement is "not a two-component system."