Part B Insider (Multispecialty) Coding Alert

Published on Wed Jul 26, 2006 PDF

Doctor who followed carrier advice not guilty of false claims

You may have to transition to the ICD-10 diagnosis coding system by October 2010, if a health information technology (HIT) bill becomes law.

H.R. 4157, the Health Information Technology Promotion Act, was scheduled for a floor vote in the House of Representatives on July 27. At press time, the bill still included a provision requiring providers to move from ICD-9 to ICD-10 within the next four years. Health plans say they need until 2012 to move to ICD-10, but legislators are concerned the ICD-9 system is too out of date.

H.R. 4157 would also provide grants for implementing HIT over the next three years--and create a loophole in the Stark physician self-referral law for providers who helped doctors install HIT. A controversial provision that would have required hospitals to disclose their costs for procedures was removed, allowing the bill to go forward.

In other news:

- A doctor who billed Medicare for pulmonary stress tests (94620) as part of a pulmonary rehabilitation program wasn't guilty of fraud, the U.S. District Court for Nevada ruled (04-CV-0589-RCJ-LRL). The government sued R.D. Prabhu, accusing Prabhu of billing for just the stress tests because Medicare doesn't pay for pulmonary rehabilitation. The government also claimed Prabhu's documentation was inadequate, and he failed to perform the required spirometry test along with 94620.

The court ruled that Prabhu's services were consistent with vignettes published by the American Medical Association and noted that the carrier had instructed him to bill 94620 when he provided pulmonary rehabilitation. -Reasonable persons can disagree about billing requirements,- the court added. The government's own witness, as well as Noridian medical director William Mangold, both agreed that Medicare has always paid for pulmonary stress tests as part of pulmonary rehab.

-  Medicare's National Plan and Provider Enumeration System (NPPES) will be down for scheduled maintenance August 2-3, returning to operation August 4, said the Centers for Medicare & Medicaid Services.

-  CMS announced steps to improve coverage for people with both Medicare and Medicaid, including incentives for people to buy long-term care insurance and rules governing the transfer of assets to prevent inappropriate use of Medicaid. The new program will also improve coordination of care for dual Medicare-Medicaid eligibles.

-  Medicare should use outpatient data to set prospective payment rates for iodine and palladium, two radioactive sources used in brachytherapy, the Government Accountability Office recommended in a new report (GAO-06-635).