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Part B Insider (Multispecialty) Coding Alert

PHYSICIAN NOTES:

Medicare Coding Nightmares Prevent Patients From Receiving Diagnostic Tests

Published on Thu Jul 14, 2005

No updates expected until 2008, study says

If you're feeling as though Medicare reimbursement complexities are keeping you from providing the tests your patients need, you're not alone.

At a time when policymakers are trying to cut back on Medicare spending for imaging tests, one new study says that Medicare is already making it too difficult to provide important tests. Quality measures such as the Health Plan Employer Data and Information Set (HEDIS) and evidenced-based clinical guidelines both push the importance of early diagnostic testing, according to "The Value of Diagnostics," a study by the Lewin Group and commissioned by the Advanced Medical Technology Association, or AdvaMed.

The report cites studies that found providers underused critical diagnostic tests. For example, underuse of diabetes, cardiac and some cancer screenings caused 34,000 avoidable deaths in 2004 alone, according to the National Committee for Quality Assurance. But Medicare coding remains a barrier to providing tests - it can take 14 to 26 months to obtain a new CPT Code for a diagnostic test, and there's no uniform method for making coverage determinations for diagnostics. Also, the Clinical Laboratory Fee Schedule hasn't been updated for inflation in 13 of the past 15 years, and won't be updated again until 2008.

The Lewin report urges Medicare to standardize lab payments and simplify the process of assigning codes and coverage.

  •  Here's your chance to weigh in on pancreas transplantation alone (PTA). The Centers for Medicare & Medicaid Services opened a national coverage determination process on July 29 to consider whole organ PTA for diabetes patients who don't have end-stage renal failure. Medicare covers whole organ pancreas transplants only after or in conjunction with a kidney transplant.

    The Office of Health Technology Assessment's 1994 report on potential PTA coverage lacked sufficient evidence, CMS says. On July 1, 2005, the Departmental Appeals Board ruled that CMS didn't have enough information to exclude coverage for all PTA procedures.

    You have until Aug. 29 to submit comments on PTA coverage by going to     www.cms.hhs.gov/coverage.

  •  Physicians may provide better routine preventive care depending on where their income comes from, as well as their type of practice, according to a study published in the July 27 Journal of the American Medical Association. Medicare receive less preventive care than national goals, and practices that relied on Medicaid for less of their income were more likely to provide diabetic eye exams, mammograms, colon cancer screenings, and influenza and pneumococcal vaccinations. The size of a physician's practice also affected the level of preventive care. To read the study, go to http://jama.ama-assn.org/cgi/content/abstract/294/4/473.

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