Corporate Compliance

Note from Hugh

Medicare Insider, January 22, 2008

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As reported below, CMS issued a number of operationally focused transmittals last week, including the much anticipated January 2008 OPPS update transmittal. That transmittal is particularly significant because it provides instructions for operationalizing many of the changes announced in the 2008 OPPS Final Rule.

CMS also released a set of three transmittals last week relating to coverage and billing for drugs used to treat anemia, in particular, erythropoiesis stimulating agents, or "ESAs."  Among other things, these transmittals will require hospitals to develop and implement processes for:

  1. Determining whether patients receiving ESAs meet the current Medicare coverage requirements applicable to ESAs.
  2. Reporting the patient's "most recent" hematocrit or hemoglobin level on Medicare claims for ESAs used for any purpose and other anti-anemia drugs used in the treatment of cancer.
  3. Reporting the appropriate "ESA modifier" (EA, EB, or EC) on non-ESRD ESA claims, based on the clinical reason for the patient's anemia.

While the transmittals provide a lot of new information, I suspect that they will also result in a number of additional questions from hospitals. Hospitals wrestling with implementation of these new requirements may want to plan on participating in CMS's next Hospital Open Door Forum conference call, which is scheduled for January 31. I suspect that the new ESA-related requirements will be discussed on that call. We will provide the dial-in information for the January 31st call in next week's Medicare Weekly Update.

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