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Part B Insider (Multispecialty) Coding Alert

Physician Notes:

Carrier Does Coverage Backflip, Will Reimburse 86141

Published on Sat Aug 28, 2004

Part B Carrier NHIC California reversed its previous decision and said it would cover high-sensitivity C-reactive protein (hsCRP) (86141) after all. In June 2003, NHIC said it considered hsCRP to be a screening test and therefore not reimbursable. The change came after new data showed hsCRP was related to, or somewhat predictive of, atherogenic risk for cardiovascular disease or stroke. But you have to document signs and symptoms of the disease being evaluated or diagnosed, or it will remain non-covered.

  • The Centers for Medicare & Medicaid Services released quarterly changes to the 2003 physician fee schedule. Code G0336-26 (PET imaging, brain imaging for the differential diagnosis of Alzheimer's disease versus fronto-temporal dementia) now has 1.50 work RVUs, 0.51 practice expense RVUs and 0.05 malpractice RVUs.

    G0341 now has 6.98 work RVUs, 2.73 PE-RVUs and 0.48 malpractice RVUs, G0342 now has 11.92 work RVUs, 5.32 PE-RVUs and 1.46 malpractice RVUs, and G0343 now has 19.82 work RVUs, 8.82 PE-RVUs and 2.05 malpractice RVUs. Also, a number of codes from 69440 to 69979 now have a bilateral status indicator of "0."

  • The one-year time limit to file claims can be extended without any payment reduction penalties if you can show "good cause" for the extension, CMS said in Change Request 3402.

  • A Wisconsin chiropractor will be permanently excluded from Medicaid after being turned in by the very doctor she sold her business to. Barbara Bergman pled no contest to one count of fraud Aug. 20 and was sentenced to 18 months' probation, $1,000 in fines and 100 hours of community service.

    Prosecutors say Bergman's new employer, Dr. Tony D. Hjelle, said he uncovered suspicious business records after he purchased the practice. Specifically, Bergman allegedly changed her patient treatment notes, diagnostic codes and the dates of injuries in patient records. The doctor vented his concerns to the HHS Office of Inspector General, claiming Bergman had upcoded 1,739 billings between 1999 and 2001.

  • Free samples have tripped up another physician. Lanconia, NH urologist Henry Lewis agreed to pay $100,000 to settle claims that he billed Medicare $30,000 for administering Lupron dosages that were taken from free samples, and not purchased from the manufacturer as Lewis had claimed.

  • An impressive 96.66 percent of providers are submitting electronic claims that comply with the Health Insurance Portability and Accountability Act, says CMS. The other 3.4 percent will be seeing their Medicare reimbursement delayed at least 27 days or more.

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