Part B Insider (Multispecialty) Coding Alert

Published on Sun Dec 05, 2004 PDF

Watch out for pitfalls in new demo project, PT provision

The 2005 Physician Fee Schedule contained a few provisions intended to soften the blow of sharp cutbacks. But those consolation prizes could be booby-trapped.

In particular, Medicare will pay $130 a day for a demonstration project in which physicians will ask chemotherapy patients about nausea, fatigue and pain. The Centers for Medicare & Medicaid Services has yet to issue billing details, but some experts are wary.

CMS hasn't yet made clear what sort of documentation you'll have to produce to prove the doctor really asked the patient the required questions, notes Deborah Kamin, senior director of cancer policy and clinical affairs with the American Society of Clinical Oncology. If the feds decide to audit charts of providers who bill for this service, they could demand huge repayments and possibly hand down penalties if they don't find enough evidence.

ASCO is working to develop a non-burdensome approach that will protect providers from this liability, says Kamin. This approach hopefully will be useful to researchers looking into which interventions help chemotherapy patients mitigate their side effects.

Separately, CMS is encouraging providers to bill for a high-level evaluation and management visit if they have to manage complications from chemotherapy. Many providers question whether the carriers will be educated to pay these claims, or whether too many high-level E/M claims will put them in the fraud-hunters' crosshairs. CMS will provide guidance to the carriers, so they'll understand when to pay these claims, Kamin says.

"CMS of course has to be a good steward of the taxpayer dollars," notes Kamin, so she expects the feds to be scrutinizing how providers use these new benefits, but she believes they won't punish innocent physicians.

Meanwhile, doctors who provide physical therapy in their offices should pay attention to a little-noticed provision in the new Fee Schedule , says attorney Rebecca Burke with Powers Pyles Sutter & Verville in Washington.
 
Starting in March, you won't be able to employ someone to provide PT on an incident-to basis, unless that person meets the education requirements for a physical therapist. "They actually have to be physical therapists even though they don't have to be lic-ensed," Burke explains.
 
In the past, doctors have em-ployed athletic trainers, PT assistants or people whom they'd trained in-house. Billing for these people would constitute false claims next year, she warns.