Medicare Compliance & Reimbursement

Wondering whether insurers are actually checking medical necessity for your procedures? One recent case suggests that they are watching carefully.

A New Jersey-based otolaryngologist was sentenced last week to two years in prison for defrauding his insurer of over $725,000, an April 9 DOJ press release says. The physician admitted filing false claims for about 900 nasal endoscopies that he purported to have performed on a single patient over several years.

The physician continued to file claims for services he said he performed on the patient even after the patient left the practice, and for dates of service when the doctor was out of the country.

In addition to prison time, the physician must also pay restitution of $725,156 and surrendered his medical license, the DOJ release notes. To read the complete news brief, visit www.justice.gov/usao/nj/Press/files/Stein,%20Dr.%20Michael%20Sentencing%20News%20Release.html.

Although we have to wait until autumn to find out which new CPT® codes are in store for 2013, the same is not true for HCPCS codes. CMS updates these on a quarterly basis, and recently released the list of codes that will go into effect on July 1.

• Q2034--Influenza virus vaccine, split virus for intramuscular use (Agriflu)
• Q2045--Injection, human fibrinogen concentrate, 1 mg
• Q2046--Injection, aflibercept, 1 mg
• Q2047--Injection, peginesatide, 0.1 mg (for ESRD on dialysis)
• Q2048--Injection, doxorubicin hydrochloride, liposomal, doxil, 10 mg
• Q2049--Injection, doxorubicin hydrochloride, liposomal, imported lipodox, 10 mg
• S1090--Mometasone furoate sinus implant, 370 micrograms

Practices that frequently report 33249 (Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead[s], single or dual chamber) with HCPCS code C1882 (Cardioverter-defibrillator, other than single or dual chamber [implantable]) shouldn't be looking in the mailbox for a reimbursement check anytime soon.

That's because CMS has advised all MACs and fiscal intermediaries (FIs) to hold claims billed together for these dates of service between Jan. 1, 2012 and June 30, 2012. "The procedure-to-device edit files included in the January 2012 and April 2012 Integrated Outpatient Code Editor (I/OCE) do not allow the device described by C1882 to satisfy the edit in place for CPT® code 33249," an April 10 CMS email states. The issue will be corrected in time for the July I/OCE issuance, at which point these claims will be processed.