Pediatric Coding Alert

Juggling two fee schedules for one calendar year could drive the most patient pediatrician to pull his or her hair out. The 2002 Medicare Physician Fee Schedule (PFS) is in effect until March 1. Therefore, CMS implemented various rules for processing claims incurred during the interim period. These guidelines include not paying for claims containing new CPTcodes and reimbursing at the 2002 rate during the interim period. So, pediatricians will have to hold claims containing 2003 codes until March and wait until July for payment adjustments.

The CMS Web page includes program memorandum AB-02-181, which explains the schedule's implementation for 2003. The memo directs payers to reimburse claims for services in January and February 2003, and processed before March 1, at the 2002 Physician Fee Schedule rates except for new 2003 codes. Effective March 1, carriers should pay claims including those submitted with January and February dates of service at the 2003 rates. The Holding Game:
Follow Directions or Collect Interest For claims that contain new codes submitted for services performed Jan. 1 through Feb. 28, insurers will hold claims until March 1 and then pay the services at the 2003 payment rate. CMS encourages physicians and practitioners "not to submit the new calendar year 2003 PFS HCPCS codes for services performed during the months of January and February 2003." If the insurers suspend clean claims, however, CMS requires them to pay interest, if applicable. Therefore, Medicare's directives are inconsistent. The agency tells physicians to hold claims with new HCPCS codes until March 1, but offers incentives for submitting them before that date. In July, CMS will issue automatic adjustments for services with January and February 2003 dates of service that are billed with 2002 HCPCS codes but paid at the 2003 rates. Physicians do not need to take further action to receive the adjustment payments. Following is a schedule of dates and activities: Jan. 1-Feb. 28 Submit claims with 2002 codes. Carriers will reimburse for services using the 2002 rates. Hold claims with 2003 codes. 2003 rates will apply for all other services (that is, services not paid under the fee schedule) effective Jan. 1. Medicare participation enrollment period ends on Feb. 28. March 1 New 2003 HCPCS codes that are paid under the PFS (about 203 codes) are effective. Process any held claims that contain new HCPCS codes. Medicare will start paying for all claims under the 2003 payment rate. July 2003 CMS will issue adjustments for incremental payment of January and February 2003 services billed with 2002 HCPCS codes that are processed after Feb. 28, as well as adjustments based on changes in participation status.