Medicare Reform Advisor, December 21, 2004

Dec. 21, '04 Vol. 1, No. 41 Weekly news and analysis

SUBSCRIBE
to Medicare Reform Advisor

© 2004 HCPro, Inc.

First quarter average sales price data finalized
CMS officially set the payment amounts it will use in the first quarter of 2005 to pay for Part B covered drugs. Click here to access the file and sales price breakdown by drug. The payment amounts are 106% percent of the average sales price (ASP) calculated from data based on 2004 third quarter sales that drug manufacturers submitted to CMS. In most cases, there are not substantial changes between second- and third-quarter price data, a CMS spokesperson said. Overall, the affect on providers' revenue is similar to those reported in the physician payment rule using second quarter data from 2004. "We are encouraging groups representing Medicare Part B drug purchasers to identify ways in which purchasers, particularly small and rural purchasers, can obtain the most favorable drug prices possible," according to a CMS statement.

Back to top

Injection payment changes
If a patient comes in for an injection that Medicare covers, CMS will only pay for the injection service starting January 3, the agency announced in an e-mail to the press December 17. Injection services for codes 90782, 90783, 90784, 90788, and 90799 from the Physician Fee Schedule are not paid for separately when physicians are paid for any other physician fee schedule service furnished at the same time, according to the announcement. Starting January 3, CMS will pay separately for these five injection services only if no other physician fee schedule service is being paid. However, CMS will pay separately for cancer chemotherapy injections (for CPT codes 96400-96549) in addition to the visit furnished on the same day. In either case, the drug is separately payable. All injection claims must include the specific name of the drug and dosage. Identification of the drug enables CMS to pay for the services.

Source: CMS. Contact the editor for the reference and instructions.

Back to top

Compliance revisions for ESRD patient injections
When an end-stage renal disease (ESRD) beneficiary is given a renal-related injection outside the ESRD facility or provider setting, the patient's monthly capitation payment (MCP) physician or his or her staff must administer the injection incident to the physician's services, according to revision 397, which CMS issued December 16. For example, if Dr. Jones is Mrs. Smith's MCP physician and Dr. Jones is unable to furnish the regular Epogen injections that Smith needs three times a week, Dr. Jones must pay the physician who administers the injections. The administering physician, Dr. Miller, would submit claims for the injectable and any necessary supplies. In this case, the Medicare carrier would allow reasonable monthly reimbursement for Miller (e.g., $3 for the cost of supplies, such as syringes and needles). There is no additional payment allowed for the physician or his or staff, such as an office nurse.

Back to top

Billing instructions for three cardiovascular tests
Billing instructions for three cardiovascular tests Providers may get paid starting in January for offering three cardiovascular screening blood tests: total cholesterol test, cholesterol test for high density lipoproteins, and triglycerides test. Perform the three tests as part of a panel and only following a 12-hour fast. Providers may order individual tests; however, they can order each test no more than once every five years, according to billing rules Medicare released Friday under Transmittal 408 (see below for complete instructions). Section 612 of the Medicare-reform law required coverage for cholesterol and other lipid or triglycerides levels for this purpose. Meanwhile, the Department of Health and Human Services has the authority to cover other screening blood tests for other indications associated with cardiovascular disease or an elevated risk for that disease, including indications measured by noninvasive testing. Additional blood tests may only be covered for a particular indication if the United States Preventive Services Task Force recommends them for that purpose and they are determined appropriate through a subsequent national coverage determination.

Billing instructions
Providers and suppliers that bill for the cardiovascular screening benefit must point the screening diagnosis codes (V81.0, V81.1, V81.2) to the line item service. Medicare will pay for the three tests under the Medicare Clinical Laboratory Fee Schedule. To facilitate claims processing, labs must include in the diagnosis section of the claim the diagnosis code that provides the highest degree of accuracy and completeness in describing the diagnosis.

Editor's note: For hospitals in Maryland, CMS contractors will pay for cardiovascular screening blood tests on a claim-by-claim basis (codes 80061, 82465, 83718, 84478), according to the state's cost containment plan.

The following are acceptable codes for cardiovascular screening blood tests:

1. 80061 Lipid Panel
2. 82465 Cholesterol, serum or whole blood, total
3. 83718 Lipoprotein, director measurement; high density cholesterol (HDL cholesterol)
4. 84478 Triglycerides

The above are acceptable when the diagnosis code reported is one of the following:

1. V81.0 Special screening for ischemic heart disease
2. V81.1 Special screening for hypertension
3. V81.2 Special screening for other and unspecified cardiovascular conditions

Contacts:
You may contact any of the following at CMS with questions before January:

Joyce Eng 410/786-4619 (Coverage)
Joan Proctor-Young 410/786-0949 (Carriers)
Taneka Rivera 410/786-9502 (Fiscal intermediaries)

Back to top

CMS issues clinical trial billing opportunity
Payment instructions were released late last week to help providers get paid for the routine costs of clinical trials involving investigational device exemption category A (experimental) devices. Coverage for services starts on January 1. Refer to section 310.1 of the Medicare National Coverage Decision Manual for examples of routine costs. See below for billing instructions. Category A devices remain uncovered. The payment instructions come as a result of the provisions under section 731 (b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), which authorized Medicare to cover the routine costs. To qualify for payment, providers must document that they used the device for a life-threatening condition. CMS contractors consider this "a stage of a disease in which there is a reasonable likelihood that death will occur within a matter of months or in which premature death is likely without early treatment."

Billing instructions
Physicians billing for routine costs in a clinical trial where a category A device is used for a patient with a life-threatening condition must place the investigational device exemption (IDE) number of the category A device on Form CMS-1500 paper claim in Item 23. Physicians who bill electronically must place the IDE number on the 2300 IDE number REF segment, data element REF02 (REF01=LX) of the 837p. Hospitals must place the category A IDE number on the 837i electronic claim format in 2300 IDE number REF segment, data element REF02 (REF01=LX). If billing on Form CMS-1450 paper form, the IDE number must be in Form Locator 43.

Contacts
You may contact any of the following at CMS with questions before January:

JoAnna Baldwin (coverage policy), 410/786-7205, jbaldwin@cms.hhs.gov
Joe Bryson (Part A claims processing), 410/786-2986, jbryson2@cms.hhs.gov
Vera Dillard, (Part B claims processing), 410/786-6149, vdillard@cms.hhs.gov

Source: Transmittal 131, change request 3548

Back to top

7,400 providers to rate contractors
CMS will send 7,400 providers a survey in January in a new Medicare initiative to collect data on provider satisfaction and perceptions about fiscal intermediaries and carriers. Providers will rate their contractor in seven categories: communications, inquiries, claims processing, appeals, enrollment, medical review, and reimbursement. CMS may end up using some of this data to make changes and assess contractors. There will be two survey options, a Web-based version and a hardcopy providers may mail in. Call 888-863-3561 or e-mail MCPSS@westat.com for details. You can go to www.cms.hhs.gov/providers/mcpss/default.asp for more information.

Back to top

Results of '05 managed care reimbursement poll
HCPro surveyed 228 physicians recently about managed care policy changes as a result of Medicare reform (see below for a glimpse at the data). Contact editor Bryan Cote for information on purchasing exclusive market research for your own specialty areas and therapeutic categories, including impact analysis for your drugs.

Have any of your managed care organizations announced any of the following for 2005?

NOTE: Respondents were asked to check all that apply.

• Increased payments for infusion and injection procedures -- 11%
• Lowered average wholesale price reimbursement -- 33%
• Recategorized infusables or injectables from a medical to a prescription benefit -- 11%
• Created tiered formularies for office-based infusables and injectables -- 22%

Back to top

Bryan Cote
Executive Editor
860-232-6367
E-mail address: bcote@hcpro.com