Part B Insider (Multispecialty) Coding Alert

Published on Thu Jun 14, 2007 PDF

Backing of patients trying to bail out of Medicare Advantage plans

Effective July 1, Part B carriers will no longer pay for J7611-J7614 for nebulized drugs albuterol and levalbuterol, according to MLN Matters article MM5645.

New way: You should now use Q4093-Q4094 when billing for inhalation solution that your practice purchases and provides for a nebulizer treatment (94640) and for pre/post spirometry (94060). Make sure to mark J7611-J7614 as non-payable in your system. Think of Q4093 as replacing J7611-J7612 and Q4094 as replacing J7613-J7614, advises Christine Martin, office manager at Fremont Pulmonary Care in Nebraska.

Important: Medicare no longer pays for compounded inhalation solutions as of July 1. So you should make sure to obtain a signed Advance Beneficiary Notice (ABN) before providing a compounded solution--one that is mixed, combined or altered for an individual. That way, the patient will be responsible for payment.

In other news:

- Don't be surprised if you encounter patients having trouble disenrolling from private Medicare Advantage plans -quot; a big problem for agencies in securing payment for home health services.

Seniors have the right to withdraw from the plans if they were misled or given incorrect information about benefits. But a recent report from the Lexington Herald-Leader suggests that problems persist as seniors try to get their benefits back on track.

-[H]undreds- of elderly residents have contacted the Medicare Rights Center because they cannot disenroll from a private MA plan purchased -as a result of misleading sales tactics,- the paper reports.

- A Medicare pilot project to reward physician groups for meeting quality targets has paid off so far, says the Centers for Medicare & Medicaid Services (CMS). All 10 of the practices taking part in the Physician Group Practice Demonstra-tion have met at least seven out of 10 benchmarks for diabetes care. And two groups have met all 10 benchmarks.

- But a new poll of 1,851 physicians commissioned by the Alliance for Specialty Medicine found that 36.3 percent of doctors don't support the Physician Quality Reporting Initiative (PQRI), with another 31.6 percent calling themselves -neutral.- Less than a third were supportive or -very supportive.- But 61.3 percent said they would take part in the PQRI. The vast majority of doctors--83.8 percent--said the PQRI should be delayed until CMS is sure it works.

- Almost a quarter of claims  for negative-pressure wound therapy pumps didn't meet Medicare coverage criteria, according to new report from the HHS Office of Inspector General (OEI-02-05-00370). Medicare spent $21 million in 2004 on medically unnecessary wound therapy.