Part B Insider (Multispecialty) Coding Alert

Published on Mon Feb 02, 2004 PDF

If you find compliance problems through internal audits, you'd better take action on them if you want to avoid getting tagged by a whistle-blower.
 
Kerlan-Jobe Orthopedic Clinic - which includes physicians for the Los Angeles Lakers, Dodgers and Kings - learned this the hard way after Trevor Baylor, former information systems director, blew the whistle on eight years of alleged foul play. The suit charges Kerlan-Jobe with defrauding Medicare and other federal health insurance programs of millions, even after internal audits had flagged the overpayments.  
 
Prosecutors announced that the clinic, though not admitting any wrongdoing, will pay $2.65 million to settle the case. In addition, Baylor will walk away with 21 percent of the recovery.

 

 Carrier Administar Federal, which also publishes the National Correct Coding Initiative edits, says it's made a change in one crucial area. Instead of referring to "comprehensive" and "component" edits, which suggested that one code was always a component of the other, the next generation of NCCI edits will merely refer to "column 1" and "column 2" codes. The change will help to clarify that the edits also include other types of forbidden pairings, such as "misuse of the code." The next NCCI edits take effect April 1.

 

 The Centers for Medicare & Medicaid Services says the most recent NCCI edits wrongly deleted mutually exclusive code pair 90375 (Rabies immune globulin for intramuscular and/or subcutaneous use) and 90376 (Rabies immune globulin, heat-treated, for intramuscular and/or subcutaneous use). CMS added the code pair back on Jan. 16, and the NCCI edits file is now correct.

 

 Participants at the Jan. 23 Physician Open Door Forum expressed concern about the new legal requirement to remove all coding guidelines from local medical review policies, which will now be known as local coverage decisions. The LCDs will only include coverage information and no advice on coding. But CMS officials said that the carriers will have coding information instead in articles on their Web sites, and the coding advice should be easy to find from the LCDs.

In Transmittal 63, CMS gives the carriers instructions on moving from LMRPs to LCDs and instructs them to act on administrative law judge decisions invalidating LCDs within 30 days.

 

 CMS decided to reverse an earlier decision to delete codes A4644 to A4646 for low osmolar contrast material in favor of a new single code, A9525. In Transmittal 45, CMS said it had realized this change would create too much confusion, so it reinstated A4644-A4646. The replacement code, A9525, will be invalid after April 1.