Part B Insider (Multispecialty) Coding Alert

Published on Wed Jun 27, 2007 PDF

'Medical home' could improve outcomes for minority patients

The Centers for Medicare & Medicaid Services (CMS) will crack down on coverage for erythropoiesis stimulating agents (ESAs) used to treat anemia in patients who receive dialysis for end stage renal disease (ESRD). Since CMS last updated its coverage, the Food & Drug Administration issued a -black box- warning, saying that large doses of ESAs are risky for ESRD patients with hemoglobin levels above 12 g/dL.

Effective next January, Medicare will continue to pay the same for ESAs for patients with hemoglobin of between 10 and 12 g/dL. But for patients whose levels rise above 13 g/dL, you should reduce the patient's dosage by 25 percent and append the GS modifier. This modifier shows that the provider has reduced the patient's ESA dosage in response to the hemoglobin/hematocrit level. And if the hemoglobin is above 13 for more than three months, the provider should reduce dosages by 50 percent.

CMS also says it won't pay for dosages of epoetin alpha (Epogen) over 400,000 IUs per month, or higher doses of darbepoetin alpha (Aranesp) than 1200 mcg per month. 

In other news:

- Savannah, GA physician Rafael Razuri pled guilty to conspiracy to commit health care fraud, along with his co-defendant, a chiropractor. Prosecutors charged that Razuri conspired to bill more than $5 million in fraudulent physical therapy claims and defraud private insurers by creating fake records of car accident victims, according to the Associated Press.

- CMS reopened its Clinical Trial Policy (CTP) for more public comment. The proposed new policy in-cludes a process for Coverage with Evidence Development (CED), and clarifies that some items are considered routine costs, which would be covered even outside a clinical trial. For more, go to www.cms.hhs.gov/mcd/viewdraftdecisionmemo.asp?id=210.

- If your patients are confused about the Physician Quality Reporting Initiative (PQRI), you can provide them with copies of a new Medicare letter to patients available online at www.cms.hhs.gov/PQRI, CMS announced. (Go to the -Overview- page and scroll down to -Downloads.-) CMS also clarified that you can't get credit for PQRI codes if you use modifiers that aren't allowed for those codes.

- The much-ballyhooed -medical home- model, which pays a physician to coordinate all of the care for chronically ill patients, could actually im-prove the quality of patient's care, according to the Commonwealth Fund-s 2006 Health Care Quality Survey. Not only that, but the medical home could reduce or eliminate the gap between white and minority patients.