Medicare Compliance & Reimbursement

You've heard other offices rave about the latest equipment that treats intractable conditions -- but you could be stuck with denials if you make a purchase without doing your homework first.

Warning: Manufacturers' sales reps may make vague promises about Medicare reimbursement. For example, they'll promise that Medicare will cover a new technology in most parts of the country. But you walk on dangerous ground if you go solely by the manufacturer's general guidelines.

Find out whether your own Medicare carrier covers a new technology, says Jacqui Jones, office manager for Benjamin F. Balme, MD, PC in Klamath Falls, Ore. Check on your private payers, Medicaid, and state workers' compensation insurer as well, she advises. With new technologies, your carrier may wait until the evidence is overwhelming before jumping on the bandwagon.

Be proactive: "We always research the codes ourselves first to see if we have the correct code and then we call our payers and see if they pay for these codes before we even purchase the equipment," says Rhonda Hardison, CPC, coder with the Head and Neck Center in Baton Rouge, La. "We don't want to purchase something we won't get paid for. We put a lot of research into these equipment purchases before we sign on the dotted line."

Even if you find out that your Medicare contractor will reimburse, read the fine print too -- most payers will only reimburse in limited cases. Don't take a manufacturer's coding advice as the final word either.

Many manufacturers honestly seek to inform their buyers of the latest coding updates, but you're still never 100 percent sure until you check with your MAC firsthand. Other manufacturers may mislead you into thinking you will collect more reimbursement than you realistically can because they want to sell their product.

"I would not advise blindly trusting the manufacturer's advice," says Margaret T. Atkinson, BS, CPC, RMC, business manager with Centennial Surgery Center in Voorhees, N.J.

Not only might the manufacturer erroneously advise you to unbundle codes, but "in some cases, use of the device may trigger clinical policies which means there may be limiting diagnosis supporting coverage," Atkinson says. "In the case of the bladder neurostimulator, the patient must have undergone other treatments and failed, and this must be documented in addition to the limiting covered diagnosis. If the practice is not aware of this, the device will not be covered and they are stuck with cost ramifications or trying to collect from the patient (as long as the denial does not prohibit that, i.e.: a deemed experimental procedure)."

Even if you've had a great history with your manufacturers and suppliers, it can't hurt to confirm any coding advice with your MACs. "We haven't had too many bad experiences, but enough to know we need to double check the recommended coding advice from the manufacturer," Jones says. "Some splints or braces come with the HCPCS code on the package, and a lot are correct but some might be outdated HCPCS codes or not recognized by Medicare."

Example: Synvisc, an injectible drug often used to treat arthritis, has its own J code "but it has been changed from unspecified to its own assigned code, back to unspecified and then back to an assigned HCPCS code," Jones says. Therefore, you should always follow your payer's advice.

Do this: You should take the manufacturer's recommendation as a starting point, but look through your coding book for other options.