Part B Insider (Multispecialty) Coding Alert

Published on Thu Jul 12, 2007 PDF

Learn the new reason codes and rescue your crossover claims

You should be contacting your member of Congress during the August recess to protest Medicare's new coverage decision on the use of erythropoiesis stimulating agents (ESAs) to treat anemia in cancer patients, the American Society of Clinical Oncology (ASCO) urges.

Among the problems with the new policy: It restricts ESA coverage when a patient's hemoglobin goes above 10 grams per deciliter, which is different from the Food & Drug Administration-s (FDA-s) guidelines. The policy allows dose escalation of 25 percent for hypo- or non-responders, which also goes against FDA guidelines. And it says you should discontinue ESA treatment if the hemoglobin rises by more than one g/dL in two weeks. This could result in patients needing weekly blood draws to assess the hemoglobin rise in any two-week period.

In other news:

- Watch out for new reason codes that will explain why a supplemental insurer rejected your crossover claim from Medicare, according to MLN Matters article SE0728. These include 000100 (Duplicate claim), 000200 (Claim for provider ID/state should have been excluded), 000300 (Beneficiary not on eligible file), 000600 (Incorrect claim count) and 000700 (HIPAA error).

- Quality Improvement Organizations (QIOs) will focus more on helping you improve outcomes and less on investigating you, if some influential senators get their way. Senate Finance Committee Chair Max Baucus (D-MT) and ranking member Charles Grassley (R-IA) have introduced legislation that would move QIOs- investigatory duties to new Medicare Provider Review Organizations (PROs).

- Houston physician Ira Klein didn't just defraud payors of $10 million by billing for services he didn't provide. He also allegedly schemed to murder an assistant U.S. Attorney, a Federal Bureau of Investigation agent and Klein's wife, according to the authorities.

Klein, who specialized in treating patients with hepatitis C, would provide drugs for patients to self-administer but bill as if he administered the drugs in his office. In jail awaiting trial, he offered other inmates $250,000 to kill his wife and the two federal officials. Klein faces 11 years in prison.

- Medicare has revised the CMS-1500 claim form, so now your rendering physician's NPI should go in box 24J of the form, and your group's NPI should go in box 33A, officials from the Centers for Medicare & Medicaid Services (CMS) said at a provider Q&A call. There's a new MLN matters article on the CMS-1500 form online at www.cms.hhs.gov/MLNMattersArticles/downloads/SE0729.pdf.