Part B Insider (Multispecialty) Coding Alert

Published on Tue Mar 01, 2005 PDF

And at least one carrier will now pay for Abraxane for breast cancer

If you've been providing abarelix (brand name Plenaxis) for advanced symptomatic prostate cancer, then there's good news from the Centers for Medicare and Medicaid Services.

Transmittal 532 states that Medicare will expand coverage for Plenaxis to include patients for whom gonadotropin-releasing hormone (GnRH) therapy is not appropriate, who decline surgical castration, and who present with risk of neurological compromise due to metastases, ureteral or bladder outlet obstruction due to local encroachment or metastatic disease, or severe bone pain from skeletal metastases persisting on narcotic analgesia.

In other news:

 Part B carrier Cahaba GBA says it'll cover new breast cancer drug Abraxane in cases where patients have failed on combination chemotherapy for metastatic disease or relapse. The patients should already have tried a therapy that included an anthracycline, unless this was "clinically contraindicated." Patients shouldn't have baseline neutrophil counts of less than 1,500 cells/mm3.

You should administer 260 mg/m2 of Abraxane intravenously over 30 minutes, every three weeks. Use unlisted code J9999 with the name of the drug and the dosage in item 19 of the CMS 1500 form, until the drug receives its own code. The claim should specify a primary diagnosis from the 174.0-175.9 (malignant breast neoplasm) section of the ICD-9 manual.

 Orange County, CA podiatrist Mark Douglas Little was sentenced to more than four years in prison and $675,820 in restitution to Medicare for fraudulently billing $800,000 worth of Medicare claims, the Department of Justice says.

A patient notified Medicare when she saw on her statement that the podiatrist billed Medicare for more than 70 bogus procedures. Little submitted daily or almost-daily claims for surgical procedures and casting he never provided.

 Medicare carriers may have been limiting psychiatrists' Health Professional Shortage Area (HPSA) payments improperly to cover only mental health payments, or even trying to recover alleged overpayments for non-mental health payments. Carriers may have misunderstood some Medicare manual language, according to Transmittal 524, issued April 15. Carriers should return your bonus payments and pay bonuses that they've withheld, CMS says.

 CMS will cover ultrasound stimulation for nonunion fractures, and will perform a "post-coverage analysis" of claims to evaluate the health benefits of the treatment. Medicare already covers ultrasound stimulation for patients who have had surgery, but now the program will cover patients with no prior surgery.