Medicare Compliance & Reimbursement

Don’t miss your opportunity to provide input.

The Centers for Medicare & Medicaid Services (CMS) published the Proposed Medicare Physician Fee Schedule for 2015 in the Federal Register on July 7. CMS reps said during a July 11 CMS Open Door Forum regarding the 2015 proposed fee schedule that there are many changes in the offing which could significantly modify the way you code your services, such as elimination of mammogram G codes.

The following highlights reveal some possibilities that could be in the pipeline for your Medicare payments.

• Mammography: “With respect to mammograms, we are eliminating the use of our Medicare G code for 2015, and instead propose that the CPT® code be used for all mammograms, whether film or digital,” said CMS’s Kathy Bryant during the call. “We’d use the G code values for 2015 under the proposal and add the CPT® codes to our list of potentially mis-valued codes so we’d determine how, now that we’ve combined digital and film, pricing based on the typical digital could be used to calculate the value.”

• Behavioral therapy: Under the intensive behavior therapy for obesity category, which was added in 2011, there was only an individual code, “but in this year’s proposed rule we are adding two new G codes for group treatment — one for groups of two to four and one for groups of five to ten,” Bryant said.

• Prostate biopsies: “In 2014 we modified the saturation biopsy codes to include all prostate biopsies, not just saturation biopsies,” Bryant told the forum. “After considering this, we decided it makes more 
• sense to have one code for prostate biopsies, so we’re using G0416 with the existing values and proposing to put this on the mis-valued code list so we can get more specific information on how it should be valued.”

• Epidurals: Four epidural codes were re-valued in 2014, but after receiving scores of comments on the adjusted values, CMS is placing the codes on the potentially mis-valued code list so the agency can consider bundling them with image guidance. “We are proposing to use the 2013 inputs for work, time and direct PE inputs for 2015,” Bryant said. “And one additional change — we’re proposing to prohibit billing image guidance at the same time of billing an epidural code,” Bryant said.

• Colonoscopies: “We’re proposing a change in the definition of colorectal cancer screening to include anesthesia if it is provided separately at the time of a screening colonoscopy, which would result in the effect of waiving coinsurance and deductible for those anesthesia services,” Bryant said. “The one important thing from the provider standpoint is that those services would have to be billed with a modifier so we would know how to address that issue.”

• Moderate sedation: CMS is also seeking comment on appropriate valuation of services that are currently valued with the assumption that moderate sedation is inherent to the procedure, said CMS’s Ryan Howe during the call. “Our data suggests that for a number of these codes, moderate sedation is no longer typical for the procedures that they describe and as we notice the change in practice, we are considering establishing a uniform approach to valuing all the services for which moderate sedation no longer appears inherent,” he said. CMS is seeking input regarding payment for these codes, so you should comment by Sept. 2 if you have input.