October 20, 2007

 NYSRS HEALTH INSURANCE, COMPENSATION & CAC REPORT 

MEDICARE UPDATE

Arthur J. Segal, M.D., F.A.C.R., Chairman, Medical Insurance and Compensation Committee / NYSRS CAC Representative

Reversal of Denied Technical Component Dollars by Medicare

          According to Transmittal 1295, Medicare began imposing an edit in April 2007.  Based upon this edit, technical component for imaging services was denied if the outpatient radiology exam occurred on the day of hospital admission or the day of discharge.  However, on October 1, 2007, this will be corrected.

          If denials have been received due to this edit, it is suggested that these denials should be appealed.

Radiology Coding Alert, Volume 9, No. 12, p. 93

Change Request 5675, www.cms.hhs.gov/Trnasmittal/downloads/R1295CP.pdf

Recovery Audit Contractors (RAC)

                   “CMS has hired AdvanceMed to randomly review RAC demands on physicians and other providers.”  “Unlike the RAC contractors themselves, AdvanceMed is paid per claim reviewed, not on a contingency payment system.”

         Additional information can be accessed by reading the original article referenced below.

Part B News, Volume 21, No. 39, October 15, 2007, pp. 6-7

OIG Initiatives in 2008

Look for Excessive ultrasound usage

According to Part B News, “the HHS Office of the Inspector General (OIG) wants to take a closer look at physician practices in geographic areas with ‘high rate of utilization’ for ultrasound services.”  “A Part B News analysis of Medicare billing showed Florida, Texas and New York City – including its surround suburbs--- submitted the most claims for ultrasound services in 2006.”

         Things to remember about ultrasounds according to Part B News:  (1) Choose the most accurate, specific ICD-9 code; (2) Conduct a thorough physical exam before recommending an ultrasound; (3) Make sure the procedure is properly supervised; (4) Make sure the procedure follows CPT guidelines to the letter.

Part B News, Volume 21, No. 39, October 15, 2007, pp. 3-4

OIG to look for Other Excessive usage including but not limited to:

1. Business relationships and MRI – see if relationships formed to furnish MRI’s also impact Medicare utilization.

2. Reassignment arrangements – check to see if there are a large number of reassignment arrangements for various providers.  Note: this is allegedly a response to recent billing problems in South Florida.

3. Chiropractic treatments – will look for high-frequency chiropractic services to assure ‘medical necessity.”

Part B News, Volume 21, No. 38, October 8, 2007, pp. 2-3

Additional information can be accessed by reading the original article referenced below.

Home Page Information:

http://www.ghimedicare.com/

http://www.umd.nycpic.com/

http://www.gao.gov

Coding 

Upstate Medicare –

http://www.umd.nycpic.com/billtips.html#ICD-9-CM   and then select, ICD-9-CM Coding for Diagnostic Tests

Respectfully submitted,

Arthur J. Segal, M.D., F.A.C.R.

Chairman, Medical Insurance and Compensation Committee / NYSRS CAC Representative