Part B Insider (Multispecialty) Coding Alert

Published on Tue Mar 28, 2006 PDF

CMS aims to pay claims with correct rate within two days after budget passes

Your carrier may be denying your claims for screening colonoscopies improperly, according to one caller at the Jan. 20 physician open door forum.

The situation: Sometimes a patient comes in for a routine screening colonoscopy and the physician finds a polyp. In that case, the physician performs a polypectomy as part of the colonoscopy, but Medicare still wants you to bill using a V code for a screening colonoscopy.

But now some carriers are refusing to pay for the polypectomy with the V code, Cecile Katzoff, VP of consulting services with the American Gastroenterological Association told Centers for Medicare & Medicaid Services officials at the Jan. 20 call.

Medicare has clarified in recent years that physicians shouldn't change from a screening to a diagnostic colonoscopy just because they find a polyp. The reason for this is that Medicare only covers one screening colonoscopy every five years, according to William Rogers, a physician who heads the Physician Regulatory Issues Team at CMS.

These denials seem to result from a carrier edit that hasn't caught up with Medicare policy, Rogers says. "We're working on it," he adds.

Also revealed at the Jan. 20 open door forum:

• Part D: If you're having trouble figuring out drug formularies under the new Part D prescription drug plan, you can download a free program called epocrates--www.epocrates.com--onto your handheld or desktop computer. The software can help you figure out which drugs are first or second tier with your patient's plan, and which drugs require prior approval.

• PE-RVUs: CMS will host a town hall meeting in Baltimore on Feb. 15 to discuss reforming the system of practice-expense payments for physicians.

• Pay freeze:  Medicare aims to be able to pay the correct rate within two days after the president signs the 2006 budget. For now, CMS officials advise you to hold off submitting claims until February if you can, so you'll receive the correct payment the first time.

• NPPs: Non-physician practitioners can no longer readmit patients to skilled nursing facilities, even if they're familiar with the patient's condition. This change, in Change Request 4246, was designed to bring readmission requirements in line with admission requirements, but it will make life harder for SNFs, according to Stephanie Fielder, director of provider relations with Park Ave. Health Care Consulting in New York.