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Note from Hugh

Medicare Weekly Update, November 13, 2007

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In an attempt to clarify the coding and billing requirements applicable to colorectal screening services, I'm afraid that CMS may have inadvertently created some additional confusion for hospitals.

As discussed below, on November 2, CMS issued a special edition MLN Matters article addressing the coding and billing guidelines requirements applicable to cases in which an abnormality is biopsied or removed during a screening colonoscopy or a screening flexible sigmoidoscopy. The article addresses cases in which an asymptomatic patient presents for a screening colonoscopy or a screening flexible sigmoidoscopy, and a lesion or growth (e.g., a polyp) is discovered, and the lesion or growth is biopsied or removed. This is important because the coding and billing of these cases determines whether the procedure is paid as a screening procedure or a non-screening procedure.  That affects, among other things, the payment rate, deductible and co-insurance applicable to the procedure (see a related MLN Matters article).

The confusion relates to whether the guidelines set forth in the article apply to hospital claims as well as physician claims. It seems to me that the guidelines should apply to both the hospital and the physician claims for these cases. Consistent with that line of thinking, the article states that the "provider types affected" by the article include "providers submitting claims to . . . Fiscal Intermediaries." 

However, the article then goes on to indicate that the guidance is based on language included in the 2007 Medicare Physician Fee Schedule final rule (which generally does not apply to hospital claims). Furthermore, all of specific coding and billing guidance provided in the article is based on billing using the CMS-1500 claim format. There is no guidance provided for hospitals, which bill using the UB-04 claim format. This is problematic for hospitals because there are significant differences between the data fields used for CMS-1500 billing and UB-04 billing.

Where does this MLN Matters article leave hospitals? In the absence of any further guidance for CMS, hospitals will have to contact their local FI or MAC to determine whether the special rules for coding and billing these cases apply to hospitals and, if so, how the rules should be applied to hospital claims using the UB-04 billing format.

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