Part B Insider (Multispecialty) Coding Alert

Your carrier may follow the example of TrailBlazer

If TrailBlazer Health Enterprises is your carrier, you should go back and look at your evaluation and management claims right away to see if they meet the carrier's new guidelines.

TrailBlazer's Medical Director Deborah Patterson announced Sept. 9 that the carrier has created new guidelines for auditing E/M claims, according to Quinten Buechner with ProActive Consultants in Cumberland, WI. The guidelines are different than the national standards, and other carriers may follow TrailBlazer's lead, Buechner warns.

TrailBlazer has set up a complicated and confusing "points" system for medical decision-making (MDM). It gives points based on whether the problem is new or established, the number of diagnoses, the treatments prescribed, and other factors such as drug management or hospital admissions.

Also, TrailBlazer has said it won't give credit for the review of systems (ROS) if the physician merely writes relevant positives and negatives followed by "all other systems negative."  (Stay tuned: Next week's PBI will cover in more detail these guidelines and tips for how to deal with them.)

In other news:

• A medical assistant in a Manchester, NH physician practice pleaded guilty to two counts of Medicaid fraud, and received a three-month jail term and a suspended prison term of one to three years. Prosecutors say Chelsea Tessier accessed patients' medical records and phoned in fake prescriptions for her own use.

• Medicare is saving nearly four times as much as Congress had expected on Part B prescription drugs. Your payments have been cut $4.1 billion from 2004 to 2008, instead of the $0.9 billion Congress expected. And your payments will drop $15.7 billion for 2004 to 2013, instead of the $4.2 billion Congress predicted, according to a new study that PriceWaterhouseCoopers prepared for the Community Oncology Alliance.

• Your carrier will have to provide you with decent customer service and accurate claims processing and pay claims on time--or else the Centers for Medicare & Medicaid Services will come down on it, according to proposed carrier performance standards for 2006, published in the Sept. 23 Federal Register.

• Part B carrier AdminaStar Federal agreed to pay the federal government $6 million to settle allegations that AdminaStar interfered with Medicare evaluations and overcharged the program, the Department of Justice has announced.  From 1991 through 1998, AdminaStar's employees purportedly altered claims information and Medicare files and hung up on customer service phone calls to improve the company's evaluation scores on its Medicare operations administration in Kentucky.