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Issue #105 - July 15, 2008 
AAPC EdgeBlast
Congress Overrides Vetoed Medicare Bill
by Bill Finerfrock, AAPC lobbyist

Last night both houses of Congress overrode President Bush's veto of the H.R. 6331, stopping the 10.6 percent pay cut to Medicare providers that was effective July 1.

When signing the veto, President Bush said "Taking choices away from seniors to pay physicians is wrong."

There was much jubilation among the medical community July 9 as the Senate passed legislation (H.R. 6331) to stall a 10.6 percent cut to doctorsí Medicare reimbursement rates for the next 18 months. Under the Medicare Improvement for Patients and Providers Act of 2008, effective Jan.1, physicians would continue to receive a 0.5 percent payment update, and the Medicare physician fee schedule (MPFS) payments would go up by 1.1 percent on Jan. 1, 2009.

The House (who voted in favor of the bill 355-59 on June 24) and the Senate (who voted in favor of the bill 69-30) had enough votes to override the veto. Shortly after receiving word of the presidentís veto, the House yesterday voted 383-41 to override it. The Senate quickly followed suit.

PQRI Participants Receive Over $36 Million
August will be a good month for some 56,700 health care professionals who reported quality information to Medicare under the 2007 Physician Quality Reporting Initiative (PQRI). The Centers for Medicare & Medicaid Services (CMS) announced July 15 that participants would divvy up more than $36 million in bonus payments.

More information about the PQRI program is available on the CMS Web site.

CMS Releases 2009 OPPS Proposed Rule
The Centers for Medicare & Medicaid Services (CMS) proposes to update payment rates paid under both the Outpatient Prospective Payment System (OPPS) and the ASC Prospective Payment System (ASC PPS) for hospital outpatient department (HOPD) services and ambulatory surgical center (ASC) services for 2009.

The proposed rule includes a 3.2 percent annual inflation update to Medicare payment rates for most services paid under the OPPS, such as general acute care hospitals, inpatient rehabilitation centers, inpatient psychiatric facilities, long-term acute care hospitals, community mental health centers, children’s hospitals, and cancer hospitals. According to CMS, this would result in hospitals receiving $28.7 billion in 2009 for OPPS services furnished to Medicare beneficiaries and $3.9 billion to Medicare participating ASCs.

More payment changes
CMS also proposes to change how it pays for imaging services when a patient receives multiple services during one session. CMS suggests making one payment for particular multiple services performed in a single hospital session. CMS also wants to apply this policy to computed tomography (CT) and magnetic resonance imaging (MRI) services.

Expect tighter standards
To qualify for the full OPPS payment update, facilities must meet quality reporting requirements. CMS proposes to add four new imaging efficiency measures to the seven existing quality measures for 2010, and is looking for public comment on 18 additional measures.

Speak now or forever hold your peace
CMS will accept comments on the proposed rule until Sept. 2. It will release the final CY 2009 OPPS/ASC payment rule no later than Nov. 1.

Visit CMS for more information on the OPPS and the ASC PPS.

Read the complete CMS July 3 press release.

Sleep Apnea Patients Rest Assured
You may now be able to receive compensation for continuous positive airway pressure (CPAP) therapy for adult Medicare patients diagnosed with obstructive sleep apnea (OSA) using a home sleep test (HST).

Caution: Diagnostic tests ordered by anyone other than the treating physician are not considered reasonably necessary by CMS.

This revision is a national coverage determination (NCD) that affects carriers, fiscal intermediaries, and administrative law judges. This NCD came into effect March 13 and will be implemented Aug. 4.

Prior to this latest NCD, the use of CPAP was only covered when confirmed by polysomnography (PSG) and ordered by a licensed treating physician performed in a sleep laboratory.

New HST Portable Monitoring G Codes are:

  • G0398 Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation
  • G0399 Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation
  • G0400 Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels

To read the specific criteria for coverage, read CMS transmittal 86 and the related MLN Matters article.

For billing guidelines for capped rental items (including CPAP), refer to section 240.4 of the NCD Manual, pub. 100-3, and chapter 20, section 30.5 of pub. 100-04 of the Medicare Claims Processing Manual.

Therapy Cap Exceptions Come to End
Outpatient therapy service providers should no longer submit claims with the KX modifier Requirements specified in the medical policy have been met for services on or after July 1. The exceptions to outpatient therapy caps expired June 30, according to TrailBlazer.

Providers can access the accrued or remaining amount of therapy services from the Medicare beneficiary eligibility inquiry and response transactions.

For Common Working File (CWF) users, the system returns the applied amount. See Change Request (CR) 4115.
For users of the HETS 270/271, the system returns the remaining amount. See page 18 of the 270/271 user guide.

Patients reaching their limits on outpatient therapy services may obtain medically necessary therapy services exceeding the caps if the services are furnished and billed by the hospital outpatient department. An Advance Beneficiary Notice (ABN) is recommended, but not required for services that exceed therapy caps.

New Quarterly Updates to PUF Available
Some contractor/carrier numbers included in the 2008 annual Ambulance Fee Schedule Public Use File (PUF) may be outdated. You can access a quarterly update to the PUF file on the CMS Web site.

CMS Develops Tool for
Locating DMEPOS Contractors

Medicare will soon implement a new program that may change the way your Medicare patients get certain medical equipment and supplies. The first phase of the new program began July 1.

CMS is developing an online contract supplier “locator tool” that will contain up-to-date information on Medicare contract suppliers in your area. Visit the CMS Web site for more information regarding the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program.

Coding Tips
Make the Most of Integumentary Coding
Paul Cadorette, CPC-H-ORTHO, CPC-P-ASC

Two of the most common problems affecting revenue are untimely dictation and incomplete documentation. The result is physician queries, delayed billing, increased accounts receivable (AR), and negative cash flow issues.

Excision of lesions, for example, are often documented wrong and improperly coded. When documenting procedures such as this, remember the following:

  1. The greatest size (diameter) of the lesion should be documented first.
  2. The physician should then indicate the margin given around the lesion. The margin is the shortest distance from the lesion to the edge of the skin ellipse.

Documentation should read something like this: The lesion was 2 cm in diameter and excised in an elliptical fashion with a 2 mm margin around this lesion (2 cm + .2 cm + .2 cm = 2.4 cm).

Physicians also have their own interpretation of closure codes. Simply stating layered closure does not constitute an intermediate repair. CPT® Assistant Aug. 2006 says “wounds that require closure of subcutaneous tissue or more than one layer of tissue beneath the dermis should be coded as intermediate repairs,” indicating the physician should document closure of subcutaneous tissue and skin to meet documentation guidelines.

Adjacent tissue transfers are another area where considerable revenue can be lost. The components necessary for accurate coding are:

  1. The size of the primary defect must be known. This is the defect created when a lesion is excised. For example, if the defect is 3 cm x 3 cm your primary defect is 9 sq cm.
  2. You also must know the size of the secondary defect. This is the defect created during the formation of the flap, which is usually the same size of the primary defect or larger. For example, if the created flap to fill the primary defect measures 3.2 cm x 3.5 cm, the total size equals 11.2 sq cm.

The total transfer is then 9 sq cm + 11.2 sq cm = 20.2 sq cm. This enables you to report the next highest CPT® code, which might lead to a higher reimbursement.

RAC Opens Door to Certified Coders
By Penny Sparks, CPC

One of the improvements to the recovery audit contractor (RAC) permanent program is to require each RAC to hire certified coders as well as a physician medical director. As stated in The Medicare Recovery Audit Contractor (RAC) program: An Evaluation of the 3-Year Demonstration, June 2008, CMS will begin implementing the RAC permanent program this summer with a limited number of states. The law states the national program—meant to protect the Medicare Trust Funds from improper payments—must be implemented by Jan. 1, 2010.

Medical News
New Source for Determining Chemo Drug Coverage
CMS recently announced additional updates to the information it uses in determining which drugs may be covered under Medicare Part B when used to treat patients undergoing cancer treatment through chemotherapy.

CMS will add Elsevier Gold Standard’s Clinical Pharmacology compendium to the list of Medicare anti-cancer treatment compendia.

FDA Approves Xience V Stent
The U.S. Food and Drug Administration (FDA) recently approved the new drug-coated Xience V stent, made by Abbott Laboratories, CNBC reports.

New On the Market: Generic Nausea Injection
APP Pharmaceuticals announced July 3 that it received final approval from the FDA to market its granisetron hydrochloride injection for chemo-induced nausea—the generic equivalent of the Hoffmann-LaRoche’s Kytril® injection.

Neonates Lack Pain Management
Newborns in ICU often undergo painful and stressful procedures without analgesic therapy, according to a study in the July 2 issue of the Journal of the American Medical Association (JAMA).

Do You Use Epocrates? UnitedHealthcare Wants To Know
UnitedHealthcare is conducting a brief survey to assess physician use of Epocrates for prescription drug formulary information. Epocrates is a service that offers formulary information, clinical information, and other prescribing tools. Survey results will be used to evaluate UnitedHealthcare’s continuing support for this service.

Participate today in the 5 minute survey.

For more information about United Healthcare’s use of Epocrates, visit and follow the links to Tools & Resources/Health Information Technology/Epocrates Drug and Formulary Reference.

Coding Job Links
AAPC Job Database

AAPC Employment Forums

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
Congress Overrides Bill
PQRI Participants
2009 OPPS Proposed Rule
Sleep Apnea Patients Rest
Therapy Cap Exceptions
Quarterly Updates to PUF
DMEPOS Contractors
Coding Tips
Medical News
Coding Job Links
Test Yourself Online

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