Medicare Compliance & Reimbursement

The Centers for Medicare & Medicaid Services (CMS) released its 2008 Fee Schedule earlier this month, and it spells trouble for practices that report several of the new CPT codes.

Cardiology: CMS assigned a status of "R," or "restricted," to new code 93982 for noninvasive study of implanted wireless pressure sensor in aneurysmal sac following endovascular repair. CMS restricted the code be-cause the Food and Drug Administration (FDA) currently approves these studies only at the time of an endovascular repair, and doesn't cover them for follow-up pressure studies in the office or outpatient setting.

Also troubling cardiologists is CMS' decision not to cover four more codes. In the 2008 physician fee schedule final rule, CMS states, "Upon review of the new cardiac MRI codes, we recognize that four of the new codes incorporate blood flow measurement, which remains one of the nationally noncovered indications for MRI in the Medicare program. Due to a national non-coverage determination for MRI that provides blood flow measurement, CPT codes 75558, 75560, 75562 and 75564 will not be recognized by the Medicare program."

CMS will reimburse for the other new codes in this group (75557, 75559, 75561 and 75563).

Impact: Now that the "odd" numbered codes are your only hope for collecting reimbursement for the new cardiac MRI code series, you can't afford denials for the payable codes in this range. Starting Jan. 1, if the physician indicates that he used contrast, you're limited to 75557 and 75579 -- even if the physician performed the MRI without contrast and then with contrast (which would warrant 75561 and 75563 if documented properly).

"Our current reports only tell us that contrast was used," says Yvette Hofmeister, CPC, coding analyst for OSU Internal Medicine in Ohio. "The reports will need to be altered to indicate the test results without contrast and then again with contrast, similar to a stress echo, at rest and with stress."

Substance abuse codes: CMS won't cover the two new substance abuse screening codes (99408-99409). Instead, the agency created two new "G" codes, G0396 and G0397. The G codes are very similar to the CPT codes, but they clarify that Medicare won't pay for screening. Medicare will only cover substance-abuse assessment "in the context of the diagnosis or treatment of illness or injury." CMS will instruct the carriers to pay for these codes only when reasonable and necessary.

"This situation is unusual," says Heather Corcoran, with CGH Billing in Louisville, KY. "The G codes are meant to be temporary codes, so if CPT created new permanent codes for this screening, it's odd that Medicare would refuse to pay them but would create its own codes with limited coverage."