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Issue #101 - May 21, 2008 
AAPC EdgeBlast

Small Practices May Close Shop
The American College of Physicians (ACP) says if Medicare reimbursement cuts continue as planned beginning this summer, small practices will be forced to shut their doors.

The ACP is asking Congress to create a timeline to completely eliminate the sustainable growth rate (SGR) formula's use. To replace the SGR formula ACP directs Medicare to change payment policies to support patient-centered, physician-guided care management based on the patient-centered medical home model of care. One Texas internist at ACP, when referring to the cuts affects on small practices said, "The margin of profit is now thin, and the proposed greater than 10 percent cut will put us out of business. The only option will be to downsize the practice and stop seeing all Medicare patients. I would hate this, but it will be the only option I have if Congress does not reverse the proposed cuts."

On July 1, physicians face a 10.6 percent cut in Medicare reimbursements. Another 5 percent cut is anticipated on Jan. 1, 2009. The SGR formula, created in 1997, is used to calculate Medicare payments to physicians and links physician payments to overall economy growth. With the SGR formula, when growth in physician expenditures exceeds growth in the economy, the difference is subtracted from physician payments, which has led to scheduled annual cuts for six consecutive years.

View the complete article here

J9303 Affects SNF CB Enforcement
Updated HCPCS Level II codes used for skilled nursing facility (SNF) consolidated billing (CB) enforcement will be implemented on July 7 as per Change Request (CR) 6009. The affected codes are subject to the consolidated billing provision of the SNF Prospective Payment System (PPS) defined in Chapter 6, sections 10-20 of the IOM.

Retroactive to Jan. 1, HCPCS Level II code J9303 Injection, panitumumab, 10 mg has been added to the major category III A chemotherapy services FI/A/B Medicare administrative contractor (MAC) exclusion list, and it has been added to Medicare systems File 1 coding list for Carrier/A/B MAC processing.

Medicare contractors are instructed to reopen and reprocess claims impacted by this decision.

MSN Customer Service Box Updated
Your patients may have new questions about the Medicare Summary Notices (MSNs) they will be receiving. The existing procedures regarding the MSN customer service information box, beneficiary estate information, and the appeals address has been modified in CR 5889. Updates include the requirement of contractors to make changes to the customer service information box of the MSN. Medicare clarified the appeals address printed on MSNs and is requiring contractors and MACs to discontinue printing the words "for the estate of," "in the estate of," or "estate of" in the address section of the MSN before the beneficiary name.

Download PDF for complete details

Feds May Ban Aggressive Marketing
New marketing rules proposed by the Bush administration for Medicare Advantage comprehensive coverage and drug plans would curb aggressive sales tactics such as cold-calling, door-to-door solicitations, and cross-selling of non-health care products, the Wall Street Journal reports (Zhang/Fuhrmans, May, 9). According to the Journal, health insurers are criticized for "overly aggressive marketing tactics, such as enrolling seniors without explaining what they are getting into."

Some seniors are reported to be losing supplemental coverage or access to their physician because the beneficiary doesn't understand the policy, the Journal says. Since the 2006 Medicare drug benefit's launch, some beneficiaries and state insurance commissioners claim some insurance agents use incorrect information to enroll people in certain plans offering comprehensive health insurance. Go here for the comprehensive story

Revised Interactive Claim Reconsideration Request Form From UHC
For claim reconsideration requests or formal appeal for members of commercial benefit plans administered by UnitedHealthcare and Medicare benefit plans administered by SecureHorizons and Evercare, there is a revised Claim Reconsideration Request Form for immediate use by contracted physicians, hospitals, and health care professionals.

To eliminate illegible handwritten forms, the updated form has interactive fields for health care professionals to easily type and print the form. New claims should not be submitted with this form. Submit a separate form for each claim.

 There is a two stage process for claim reconsideration requests:

  • First submission (Claim Reconsideration Request)
  • Subsequent submission (Formal Appeal Request)

For details, visit the United Healthcare website

Coding Tips
ASCs: Avoid coding mistakes for GI, orthopedics, and ENT procedures. Insufficient physician documentation and coders' inadequate knowledge of anatomy are the cause of common coding mistakes in this article.

Use modifier 25 with caution. Follow these three steps to identify appropriate clinical scenarios and ensure compliance.

Stage 3 or 4 pressure ulcers: specify origin and location to reflect severity, and assign proper codes.

Call for EdgeBlast Writers
Do you have timely coding news, coding tips, or coding expertise you'd like to include in the EdgeBlast? If so, email them to We'll give you credit for any articles we use.

Medical News
Middle Class Kids Have Same Unmet Medical Needs as Poor
Nationwide, uninsured children in middle class families are just as likely to go without any health care as uninsured children in poor families, according to new research from the University of Rochester Medical Center in New York.

Compliance Breach of Celebrity Medical Records
UCLA Medical Center worker charged with selling confidential medical records of celebrities to the media.

Pain in 9-year-old's Stomach Is a Twin
A nine-year-old girl who went to a hospital in central Greece suffering from stomach pains was found to be carrying her embryonic twin.

Training to Boost MT Workforce
The Medical Transcription Industry Association of the Philippines Inc. (MTIAPI) said it will provide training in health care functions like medical records processing, medical coding, and medical billing to at least triple the industry's workforce to 32,000 people by 2010, and help increase the number of workers as overseas demand continues to rise.

Two Radical Therapies for Same Transgender Disorder
Psychologists take radically different approaches in transgender therapy for two families with toddler boys who gravitate towards feminine toys, colors, and clothes.

Coding Job Links
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Test Yourself Online
The Test Yourself questions can be accessed online at Once you go there and take the test, you can automatically grade your answers, correct any mistakes, and have your CEUs automatically added to your CEU Tracker for submission.

Featured Items
Small Practices May Close
J9303 Affects SNF
MSN Customer Service
Ban on Aggro Marketing
Interactive Claim Request
Coding Tips
Call for EB Writers
Medical News
Coding Job Links
Test Yourself Online

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