In The News - Rose & Associates- Health Care Consultants

Are you planning to participate in the Physician Quality Reporting Initiative (PQRI)? If so, you can perform a “test” of your billing system with your Medicare carrier prior to the original reporting date of July 1, 2007.

You simply bill code G8300 on any of your claims(s) submitted to Medicare in item 24D of the CMS-1500 Claim form (or electronic equivalent). A charge of $0.00, or $0.01 if your system cannot submit a “no charge,” should be submitted with the “G” code.

Physicians may now bill the patient for the additional work involved in implanting astigmatism-correcting and presbyopia-correcting intraocular lenses (IOLs) when performed in conjunction with conventional cataract surgery. The ambulatory surgery center or hospital may bill for extra work involved and/or the cost differential in these premium lenses and the $150 already included in the facility fee for a conventional IOL.

The final implementation instructions from the Centers for Medicare and Medicaid Services (CMS) indicate that physicians and facilities (ASCs and hospitals) should use code V2788 when billing Medicare or the patient for the extra work and/or IOL differential involved in implanting the premium IOLs. This is the same code that was developed for the presbyopia-correcting IOLs, and no other code is being developed at this time.

There is a new diagnosis code for floppy iris syndrome. Diagnosis code 364.81 will be effective October 1, 2007, with the release of the 2008 ICD-9CM coding book.

The Centers for Medicare & Medicaid Services (CMS) released updates to the Ambulatory Surgical Center (ASC) payment system for calendar years 2007 and 2008.

The proposed rule (with comment) published in the November 24, 2006 Federal Register describes changes to the amounts and factors used to determine the payment rates for hospital outpatient services as well as revisions to the current list of procedures that are approved in a Medicare-approved ambulatory surgery center. The proposed rule calls for Ambulatory surgery centers to be paid at 62% of the Hospital Outpatient Department (HOPD) rate with a 3-year phase in beginning January 1, 2007.

In 2007, ASCs are paid the current ASC facility fee payment or the Hospital Outpatient Department (HOPD) rate, whichever is lower.

The six ophthalmology codes affected are:

In addition, 14 additional procedures were added to the ASC list of covered procedures in 2007 but no ophthalmology procedures are included. By 2009 the new ASC payment system will expand the list of covered procedures to include all surgical services, other than those that impose a significant risk or require an overnight stay in the hospital.

In 2008, the proposed rule calls for ASCs to be paid a 50/50 blended rate of the 2007 facility fee payment and the 62% HOPD rate. In 2009, the 62% ASC payment rate will be fully implemented. Beginning in 2010, the ASC conversion factor will be updated by the Consumer Price Index for Urban Consumers (CPI-U). As a result of MMA, ASC payment rates were frozen until 2009.

Legislation has been introduced calling for the full reduction to be at 75% of the HPD rate beginning with the 50/50 blended rate in 2008 and carrier through 2009 with regular updates of the facility fee payments in order to remain current with the industry payment standards.

Whether or not the legislation will have an affect remains to be seen, but at least CMS knows we are out there fighting for higher ASC reimbursements.

The Office of the Inspector General (OIG) released its 2007 Work Plan. The Work Plan provides CMS with information and advice concerning fraud, waste, and abuse to government programs. This year's work plan contains several issues that affect ophthalmology such as:

The 2007 OIG Work Plan and audit reports were discussed in detail in the November/December 2006 issue of our newsletter, The Messenger .

On June 30, 2006, the Food and Drug Administration (FDA) approved Lucentis (ranibizumab injection) for the treatment of patients with neovascular (wet) age-related macular degeneration (AMD). According to the FDA release, Lucentis is the first treatment, when dosed monthly, that can maintain the vision of more than 90 percent of patients with this type of AMD.

The FDA release also indicated that approximately one-third of patients in clinical trial had improved vision at 12 months. In a single study carried out for 24 months, these findings have been maintained with continued monthly dosing. The most commonly reported adverse side affects included conjunctival hemorrhage, eye pain, floaters, increased eye pressure and inflammation of the eye. Serious adverse events were rare and often related to the injection procedure including endophthalmitis, intraocular inflammation, retinal detachment, retinal tear, and increased eye pressure and traumatic cataract.

How do you bill for Lucentis? It will take a while for the FDA approval to filter down to the Medicare carriers. Since there is no HCPCS drug code or not otherwise classified code (NOC) assigned to Lucentis at this time, payment should be based on 106% of the wholesale average cost or invoice price. You should increase your charge to Medicare accordingly.

Until a procedure code can be assigned, we recommend you bill the drug with code J3490, Unclassified drug. The name of the drug, the NDC number, and the dosage administered should be included in item 19 (or EMC equivalent) of the CMS-1500 claim form.

The patient should be given an advance beneficiary notice (ABN) indicating that this procedure could be denied as not medically necessary and financially responsible for the charges if denied.

Avastin has gained widespread use in ophthalmology for treating patients with age-related macular degeneration (AMD). Since the drug is not FDA approved for use in ophthalmology, it is considered an off-label use of the drug under Medicare guidelines and will be denied as investigational/experimental. Payment for the injection, code 67028, is left up to carrier discretion depending on whether or not the Medicare carrier has an off-label drug use policy in place. Some carriers are now starting to request that Avastin be billed with the not other classified drug code, J3490, since J9035 does not adequately describe the reformulated drug used in ophthalmology.

For those carriers who do have a policy in place, they will most likely deny the injection as not medically necessary and the Avastin as investigational or experimental. If the carrier does not have a policy in place, they may very well pay for the injection, but not the drug. As with any new treatment, physicians should contact their Medicare carrier to see if there are any specific billing guidelines they should follow.

We recommend you bill both the injection and the drug to Medicare to ensure there is no question regarding coverage and what drug was actually administered. If you do not bill the drug on the same claim form, Medicare might inadvertently pay for something that is otherwise non-covered.

CMS announced coverage of an innovative type of intraocular lens known as “Reduced Spherical Aberration” intraocular lenses. These new lenses, manufactured by Advanced Medical Optics (AMO), have been given new technology intraocular lens (NTIOL) status which is valid for a period of 5 years. For dates of service on or after February 27, 2006, ambulatory surgery centers may bill Medicare an additional $50 over and above the Group 8 ASC facility fee payment when one of the NTIOL lenses is implanted in conjunction with medically necessary cataract surgery. The new intraocular lenses are Tecnis® Models Z9000, Z9001, and ZA9003.

It is not clear at this time if Medicare intends to use the next series of “Q” codes for billing these new NTIOLs. If so, then the ASC would bill Q1003 on the same claim as the cataract surgery code. Be sure to check your Medicare newsletters or carrier website to make sure this is the code Medicare intends to be used when billing these new NTIOLs.

The Centers for Medicare and Medicaid Services (CMS) issued a program transmittal clarifying the use of CPT modifier -25 to identify a significant, separately identifiable evaluation and management (E&M) service. The Change Request revises the Medicare Claims Processing Manual in response to a recommendation by the Office of Inspector General’s study on the use of the -25 modifier. The study found that monies were improperly paid for claims submitted with this modifier. The majority of the errors were for inadequate supporting documentation.

As a reminder, the -25 modifier is only appended to the office visit when the medical record supports the billing of a “significant, separately identifiable” evaluation by the physician on the same day as a minor surgery. As long as the chart documents an examination above and beyond the usual pre- and post-operative work of the minor surgery, you will be able to bill separately for the office visit. Of course, the “above and beyond” must be medically appropriate and necessary to begin with.

For examples of when and when not to use the -25 modifier, refer to the July/August, 2006 issue of our newsletter, The Messenger .