Medicare Compliance & Reimbursement

Watch out for possible reductions in reimbursement.

With many issues of the Affordable Care Act still a mystery, coders and providers by and large are taking the "wait and see" approach to specifics on how the law will affect their day to day job functions. But there are a few key areas where the impact is clear.

Preventive services: If patients "have a new health insurance plan or insurance policy beginning on or after September 23, 2010," certain preventive services must be covered when delivered by a network provider. For these services, the patient is not responsible for a copayment, co-insurance, or meeting the deductible. According to the preventive services fact sheet at www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html, some of the covered services your practice may see include:

• One-time abdominal aortic aneurysm screening for certain men with a history of smoking
• Aspirin use
• Blood pressure screening
• Cholesterol screening
• Tobacco use screening and cessation interventions.
• Coverage for pre-existing conditions: U.S. citizens and legal residents may qualify for pre-existing condition

Coverage for pre-existing conditions: U.S. citizens and legal residents may qualify for the Pre-Existing Condition Insurance Plan if they have been uninsured for at least six months and have been denied health insurance because of a pre-existing condition. By 2014, additional reforms are planned to keep insurance companies from refusing to sell coverage or renew policies because of pre-existing conditions.

ACOs: The ACA creates voluntary Accountable Care Organizations (ACOs). An ACO is a group of providers, hospitals, and others who coordinate to improve a Medicare patient's care. This coordinated care approach has left some coders wondering whether it will change how their practice is structured.

MPPR: Generally speaking, the ACA and the Medicare physician fee schedule (MPFS) are different entities. For instance, "The Sustainable Growth Rate (SGR) formula is not addressed in the ACA and is not affected by the ruling," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

But you may be acquainted with the ACA-related Multiple Procedure Payment Reduction (MPPR). The MPPR has been in place for several years. The proposed 2013 Medicare physician fee schedule includes a plan to reduce reimbursement by 25 percent for certain cardiovascular services performed on the same date. The reduction would apply to the technical component only of second and subsequent services. Affected services include angiography, nuclear medicine, ECG, echocardiography, device evaluations, and vascular studies.

Consider this example from the proposed rule: Suppose you provide the professional and technical components of these codes on the same date:

• 78452, Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
• 93306, Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography.

Under the proposed rule, Medicare would reimburse you for 100 percent of 78452 professional component and technical component. You also would receive 100 percent of the professional component fee for 93306. But 93306 technical component reimbursement would be reduced by 25 percent.

This reimbursement cut is tough to take, especially when you consider that over the past four years, the trend toward combining services typically performed together under a single code (instead of reporting a separate code for each service) has brought lower reimbursement, says Terry A. Fletcher, BS, CPC, CCS-P, CCS, CEMC, CCC, CMSCS, CMC, of Terry Fletcher Consulting in Laguna Beach, Calif. The list includes echocardiography, heart caths, nuclear medicine, and lower extremity peripheral vascular.

MPFS resource: For the full list of codes subject to the proposed MPPR rule, see pages 103-105 of this file: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/Downloads/2013-PFS-Proposed-Rule-CMS-1590-P_2012-16814_PI.pdf.