Medicare Compliance & Reimbursement

Best bet: Be prepared to submit invoices and CPT book photocopies

Myth: You can't ever bill separately for fiducial markers.

Reality: Some carriers will pay for these gold markers on occasion, and you can always appeal on an individual basis by submitting an invoice.

Many providers have faced confusion over fiducial marker coverage since CPT 2007 introduced a new code, 55876. This code, for placement of interstitial device(s) for radiation therapy in the prostate, has a note in its descriptor: "Report supply of device separately."

But just because you can report something separately doesn't mean that Medicare will pay for it, cautions Cindy Parman, principal and co-founder of Coding Strategies Inc. in Atlanta. There's no way of telling whether the Centers for Medicare & Medicaid Services (CMS) included the cost of the markers in Relative Value Units (RVUs) for 55876, she notes.

Nightmares: And indeed, practices have faced nightmares trying to obtain payment separately. Florida coder Gaye Pratt says her practice has been positioning fiducial markers in the prostate for almost a year, but Medicare hasn't been paying. She's tried coding miscellaneous supply code A4649 and supply code 99070, with no luck.

Her carrier has claimed that 55876 includes the cost of supplies. Pratt has appealed these denials, including a copy of the page in the CPT book that instructs coders to report supplies separately. She's also included the invoices from the supply company and the procedure notes. She hasn't heard back yet.

Appeal: "The best chance of reimbursement is to appeal on an individual patient basis, which is time-consuming," Parman says. "Generally, an invoice is required, and if the payor reimburses, it is the invoice amount." In other words, you won't see any mark-up for your trouble.

Fiducial markers typically cost around $40 each, and you need four of them to perform the prostate procedure. So Pratt says her practice has been out about $160 for each case.

Positive sign: So far, at least one carrier appears to have said it will always pay for the fiducial markers. The Upstate Medicare Division (UMD) in New York issued a coverage policy on April 13, 2007, stating that it'll pay for 55876, plus unlisted code 53899 for the markers. "We will continue to pay per invoice price when supplied," UMD says.

Hospitals have their own code for the fiducial markers, C1879, but it doesn't have any payment attached to it, says Parman. The American Society for Therapeutic Radiology and Oncology (ASTRO) is lobbying for a separate code--and reimbursement--for the markers.

The American Urological Association (AUA) posted a fairly gloomy Frequently Asked Question (FAQ) on its Web site recently. It instructed coders to bill 55876, plus 76942 for ultrasonic guidance for needle placement.

But the AUA added that the fiducial markers "are not reimbursable separately through Medicare." Some commercial carriers may pay for them, the AUA noted.

CMS specifically said that fiducial markers were included in the payment for intensity modulated radiation therapy (IMRT) code 77418, in the Nov. 7, 2003, Federal Register. Fiducial markers are on a list of "supplies" that are bundled for this procedure and others, Parman notes.

Controversy: When CMS issued the RVUs for 55876 in the 2007 fee schedule, the American Academy of Family Physicians (AAFP) took the agency to task in its comments on the regulation.

The AAFP noted that CMS had "deleted" a mention of one package of three gold markers because of confusion over how many markers the procedure required and the usual price of the markers.

Because of CMS' statements, whether the RVUs for 55876 include the cost of the markers is unclear, AAFP adds. "Informal discussions with Carrier Medical Director (CMD) staff cause us to believe that the cost has not been included," AAFP says.

CMS should either add the typical $160 cost of the markers to the reimbursement of 55876 or make it clear that Medicare pays for the markers separately via an unlisted supply code, the AAFP insisted.

Bottom line: If you bill for fiducial markers with 55876, using either A4649, 99070 or 53899, then be prepared to appeal and provide documentation.