Part B Insider (Multispecialty) Coding Alert

Published on Sun Apr 09, 2006 PDF

Medicare Advantage plans win 4-percent pay hike next year

Medicare will no longer pay for transcatheter placement of intracatheter stents (37216) as of March 17, according to a new transmittal.

The Centers for Medicare & Medicaid Services released more changes to this physician fee schedule , in Transmittal 897, dated March 29. Among other things, CMS clarified that 37216 will have a status code of "R," and carriers should adjust their systems to "reflect a non-coverage status" for this code.

Also, gastric restrictive procedure code 43842 will have a status code of "A" and also will be non-covered by Medicare, CMS says.

The new transmittal revises descriptors for new Category II modifiers 1P and 2P, and adds another modifier, 3P. Also, the transmittal applies type of service (TOS) code "1" to codes G0941-G0944, instead of TOS code "Q," as previously stated. And 0144T-0145T will have a TOS code of "4."

In other news:

• CMS released "average sales price" files setting your payments for Part B drugs for the quarter beginning April 1. You can read these files at www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/02_aspfiles.asp.

• Independent dialysis facilities are having no trouble obtaining darbepoetin alfa at costs below the Medicare reimbursement amount in the past two years, the HHS Office of Inspector General said in a new report (OEI-03-06-00200). The facilities were able to purchase darbepoetin alfa for $2.59 per microgram, and Medicare pays between $3.01 and $3.54 per mcg.

• Medicare Advantage (MA) plans are lowering costs and also saving beneficiaries money, CMS announced, including those beneficiaries who are prescription drug plan users. CMS announced it would increase payment rates for MA plans by around 4 percent next year, at a time when physicians will be lucky to obtain another pay freeze next year.

• You can continue to use surrogate Unique Physician Identification Numbers (UPINs) when billing for doctors, non-physician practitioners and equipment suppliers. CMS rescinded Change Request 4177, which had banned the use of surrogate UPINs on claims.

• Carriers should keep a log of any potential fraud and abuse they refer to the Program Safeguard Contractors, CMS instructs in Transmittal 144, dated March 31. CMS will track any disclosures made to law enforcement through the CMS Privacy Officer.

• CMS revised the CMS-1500 billing form to make room for the new National Provider Identifier (NPI) in Transmittal 899, dated March 31.

• CMS is expanding glaucoma screening coverage for Hispanic Americans, and March 24 Transmittal 895 tells carriers how to notify you when age requirements aren't met.