Medicare Compliance & Reimbursement

Gyn-Oncs win opportunity to resubmit denied demonstration claims.

Reversal of a Centers for Medicare & Medicaid Services oversight that prevented gynecologic oncologists from taking part in this year's oncology demonstration project will now afford gyn-oncs new reimbursements.

Oncologists are using "G" codes to report on compliance with various standards of care for various cancers ...quot; including ovarian cancer. At first, CMS didn't realize that gyn-oncs treat ovarian cancer, and left them off the list of specialties that could bill for the demonstration.

After a lot of lobbying by the Society for Gynecologic Oncology, CMS finally realized its mistake and added gyn-oncs to the list in Change Request 4347.

CMS made the change retroactive to January, so gyn-oncs can resubmit denied claims for those "G" codes and receive payment, says Gary Leiserowitz, professor and chief of the gynecologic oncology division at UC Davis Medical Center.

If a physician's primary specialty isn't oncology, then that physician may have to change his or her specialty designation, CMS says in a new list of "Frequently Asked Questions" about the demonstration project. For example, a doctor with a primary specialty of internal medicine and a secondary specialty of hematology/oncology should change his/her enrollment information to list oncology as the primary specialty.

In the FAQ, CMS also explains that:

• Providers can bill the "G" codes in association with an evaluation & management visit provided on an "incident to" basis if it meets all the rules.

• When prostate cancer codes refer to "castration," it means both surgical and medical castration.

• "G" codes don't have to appear on the same claim form as the E/M visits they're tied to, but it may help. Providers must bill them on the same date, however.

• Some providers have worried that CMS will keep track of physicians who report that they don't adhere to treatment guidelines and punish them down the line. But CMS says the project is just for learning more about what guidelines physicians follow.

There may be "extenuating circumstances" where it's not appropriate to follow the guidelines that the "G" codes are reporting on, says Leiserowitz. But those guidelines are mostly so broad that "it would be pretty unusual" for people not to follow them.

As for whether CMS will track non-compliant doctors, "it depends on how much you trust the government," says Leiserowitz.