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Issue #108 - September 3, 2008 
AAPC EdgeBlast
Join the Feedback Group Town Hall Meeting
The Centers for Medicare & Medicaid Services (CMS) will hold its annual Medicare Provider Feedback Group (MPFG) Town Hall meeting Sept. 22, from 2 p.m. to 4 p.m. EDT. Topics will include an overview of the goals and objectives of the MPFG efforts to gather feedback from individual Medicare providers and suppliers, the possible next version of HIPAA standards for claims and other transactions (5010), Medicare administrative contract transitions, recovery auditing, and more.

Attendees are given an opportunity to present their individual views and opinions on selected fee for service (FFS) Medicare topics. CMS will also solicit input from the audience on how it can improve communications to better serve Medicare FFS providers and suppliers.

The meeting will be held at CMS’ headquarters in Baltimore, Md., and will also be teleconferenced. This meeting is free and open to all FFS providers and supplier, but you must register. Registration began Aug. 29, and will close Sept. 17 at 5 p.m. EDT.

On or after Sept. 19, you can download the meeting agenda and discussion materials from the Provider area of the CMS Web site.

Read the notice posted at the Federal Register Aug. 22 for more details.

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Get Online Technology Guidance
CMS is offering a new resource to providers intended to facilitate the process of getting new technologies to Medicare patients and providers. In The Innovator’s Guide to Navigating CMS, you’ll find explicit coverage, coding or payment changes for new treatment options, and the availability of medically appropriate technologies.

Look for this guide, produced by the CMS Council for Technology and Innovation (CTI), on the CMS Web site.

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October 2008 Update to MPFS Released
The October update to the Medicare Physician Fee Schedule (MPFS) is out. CMS is amending payment files issued to contractors based on the 2008 final rule in an Aug. 22 transmittal.

Medicare contractors are to give providers 30 days notice before implementing the changes outlined in CR 6180. The implementation date for these changes is Oct. 6 and current MPFS rates are (unless otherwise noted in the transmittal) retroactive Jan. 1.

Contractors are instructed to adjust payment for or retroactively pay only those claims brought to their attention.

Included in the October Update to the 2008 MPFS are the following changes:

CPT® code  Action
15878 Bilateral Indicator = 1 (150 percent payment adjustment applies)
15879 Bilateral Indicator = 1 (150 percent payment adjustment applies)
92557 PC/TC Indicator = 9 (PC/TC doesn’t apply)
92567 PC/TC Indicator = 9 (PC/TC doesn’t apply)
93660–26 Multiple Procedure Indicator = 2 (Standard payment adjustment rules for multiple procedures apply)

(Standard payment adjustment rules for multiple procedures apply)

Changes made to HCPCS Level II codes G0398-G0400 are retroactive to March 13. And an editorial change was made to the long descriptor for HCPCS Level II code G0250.

Refer to CR 6180 on the CMS Web site for more information on the changes to the 2008 MPFS database.

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HHS Proposes Protection Regulation
To increase awareness of and compliance with laws protecting health care providers from being coerced into performing specific medical procedures conflicting with their religious or moral beliefs, HHS has placed a new proposed regulation on public display in the Federal Register.

Laws already exist to prohibit discrimination against health care providers who refuse to participate in controversial medical procedures, such as abortions and sterilizations. The U.S. Department of Health and Human Services (HHS), however, believes a large segment of the health care industry is unaware of these laws.

Specifically, the proposed rule would:

  • Clarify that non-discrimination protections apply to institutional health care providers as well as to individual employees working for recipients of certain funds from HHS;
  • Require recipients of certain HHS funds to certify compliance with laws protecting provider conscience rights;
  • Designate the HHS Office for Civil Rights as the entity to receive complaints of discrimination addressed by the existing statutes and the proposed regulation; and
  • Charge HHS officials to work with any state or local government or entity that may be in violation of existing statutes and the proposed regulation to encourage voluntary steps to bring that government or entity into compliance with the law. If, despite the Department’s efforts, compliance is not achieved, HHS officials say they will consider all legal options, including termination of funding and the return of funds paid out in violation of the nondiscrimination provisions.
The proposed regulation is available on the HHS Web site. The Aug. 21 display in the Federal Register triggers a 30-day public comment period. Refer to the proposed rule for commenting instructions.

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OIG Says Medicare Overpaid for Generic Drugs
The Medicare payment amount for irinotecan hydrochloride—an injectable drug used to treat patients with colorectal cancer—exceeded the average manufacturer price (AMP) by 145 percent in March 2008, according to an August 2008 report from the HHS Office of Inspector General (OIG). The OIG estimates that this price disparity cost Medicare in excess of $6.5 million in just that one month.

In March, the average sales price (ASP) for brand name irinotecan (HCPCS Level II code J9206 Irinotecan injection, 20 mg) was $126.31, and the OIG-calculated AMP was $51.59.

The Food and Drug Administration (FDA) approved the first generic version of irinotecan on Feb. 20, and generic irinotecan went on the market in March. That same month, generic irinotecan accounted for 86 percent of sales. The AMP for generic irinotecan was $40.66—nearly a third of the brand-name product’s average price. Anyone who purchased generic irinotecan in March received a Medicare payment approximately $85 more than the AMP, according to the OIG report.

The OIG contributes the disparity among ASPs and AMPs for drugs on the standard two-quarter lag time between when sales occur and when sales become the basis for Medicare payment amounts.

When the ASP exceeds market price by 5 percent, Section 1847(d)(3) of the Social Security Act (the Act) states that the secretary of HHS may disregard the ASP for the drug when setting reimbursement and substitute payment amounts for the drug with the lesser of the widely available market price, or 103 percent of AMP.

Instead of using this authority, the OIG recommends in the report that CMS explore options to expedite the process of setting the Medicare payment amount to ensure the ASP of drugs with newly available generic versions accurately reflect market prices.

CMS concurred with the OIG, but also reported that in third-quarter the Medicare payment amount for brand name irinotecan was $74.75—a 40 percent decrease—thus “demonstrating that the ASP methodology reflects market-based prices over time.”

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Coding Tips
CMS: Physicians!  Refer Not to Thyself
CMS has instructed Medicare contractors to use new claim adjustment reason code 213 beginning Jan. 1, 2009 when denying claims based on non-compliance with the physician self-referral prohibition. And the agency is turning to hospitals for information.

As written in the 2009 IPPS final rule, Section 1877 of the Act prohibits a physician from referring a Medicare patient for certain designated health services (DHS) to an entity with which the physician (or immediate family member(s)) has a financial relationship. A “financial relationship” includes both ownership/investment interests and compensation arrangements such as contractual arrangements.

CMS intends to send an information collection instrument, referred to as the Disclosure of Financial Relationships Report (DFRR), to 500 hospitals to identify noncompliance and practices. Participating hospitals have 60 days from the date on the cover letter or email transmission of the DFRR to complete the report. CMS originally estimated the time to complete the DFRR to be 31 hours, but has since changed this estimation to 100 hours. CMS has also increased the estimated costs associated with completing the DFFR from $1,550 to $4,080 per participating hospital.

Read MLN Matters article MM6131, on which this report is based, or CR 6131, for more information and a list of DHSs. And, of course, there are always exceptions to every rule. You’ll find these exceptions listed in Section 1877 of the Act.

Comment »

Medical News
CDC: Biggest Measles Year Since 1996
There have been more cases of measles in the United States this year than since 1996, according to a Centers for Disease Control and Prevention (CDC) media advisory. Dr. Anne Schuchat, Director of the National Center for Immunization and Respiratory Diseases at CDC, during the Aug. 21 audio webcast said “the CDC has received reports of 131 cases so far this year.”

These cases, which include outbreaks in Washington and Illinois, stem from importations brought to the U.S. from other countries—Europe, in particular. When a U.S. citizen who hasn’t been vaccinated travels abroad or a foreigner visiting the U.S. brings the virus into the states, the virus then spreads to others who are not vaccinated. Schuchat says the affected are typically home schooled children or children who haven’t been vaccinated due to religious or philosophical reasons. Infants too young to be vaccinated are also at risk.

The recommended age for receiving the measles vaccination is 12 to 15 months old—six to 11 months if an infant will be traveling internationally, with two more doses after 12 months of age.

CPT® codes  Description
90705 Measles virus vaccine, live, for subcutaneous use
90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use
90708 Measles and rubella virus vaccine, live, for subcutaneous use
90710 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use

You can read the full transcript on the CDC Web site.

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New Imaging Technique on the Horizon
A new imaging system being licensed by GE Healthcare is said to enable surgeons to see and remove diseased tissue with little or no damage to normal surrounding tissue. The new imaging system, called FLARE (Fluorescence-Assisted Resection and Exploration), highlights cancerous tissue in the body using special chemical dyes, called NIR fluorophores.

Researchers say they have already used the FLARE to successfully visualize organs and body fluids of mice and map the lymph nodes of pigs in real time. Human clinical trials have not yet begun in the United States.

To learn more about this new technology, read the Medical News Today and Technology Review stories on which this report is based.

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FDA Approves Nausea Prevention Drug
The FDA has approved a new oral formulation of ALOXI(R) (palonosetron hydrochloride) made by Eisai Corporation of North America and its partner Helsinn Healthcare SA for the prevention of chemotherapy-induced nausea and vomiting (CINV) (Medical News Today, Aug. 24).

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New Dx and Tx Guidelines for Allergy
New guidelines for diagnosing and treating allergic rhinitis were released this month, just in time for the crush of fall allergy sufferers seeking relief from their allergist/immunologists (Medical News Today, Aug. 18). “The Diagnosis and Management of Rhinitis: An Updated Practice Parameter” is featured in the August edition of the Journal of Allergy and Clinical Immunology (JACI).

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FDA Approves New Chorea Treatment
The FDA announced Aug. 15 that it has approved Prestwick Pharmaceuticals Inc.’s new drug Xenazine (generic name tetrabenazine) for the treatment of chorea in people with Huntington's disease, heralding the first treatment to receive U.S. approval for any of the disease’s symptoms (Medical News Today, Aug. 18).

Chorea, once called St. Vitus’ Dance, is characterized by brief, irregular contractions that appear to flow from one muscle to the next. This neurological feature is a primary symptom of Huntington’s disease but can be caused by drugs, metabolic disorders, endocrine disorders, and vascular incidents.

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Featured Items
Join the Feedback Group
Technology Guidance
October 2008 Update
Protection Regulation
Medicare Overpaid
Coding Tips
Medical News
Coding Job Links
Test Yourself Online


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