Radiology Coding Alert

Denials will start May 1 for claims that fail Medicare’s ordering/referring provider edits.

When reporting radiology services, be sure to take these three recent Medicare announcements into account.

1. Check Both National and Local PET RP Coverage

Medicare has decided to give local MACs the power to decide whether to cover PET using radiopharmaceuticals (RPs) that aren’t specifically covered by national Medicare policies. RPs with national policies include FDG (2-deoxy-2-[F-18] fluoro-D-Glucose [fluorodeoxyglucose]), NaF-18 (fluorine-18 labeled sodium fluoride), ammonia N-13, and rubidium-82 (Rb-82).

CMS published its final decision memo for Positron Emission Tomography (PET) at www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=261.

In the memo, CMS states that Section 220.6 of the Medicare National Coverage Determination Manual will be updated to state, “For labeled uses of FDA approved radiopharmaceuticals approved after September 1, 2012, Medicare coverage for diagnostic PET imaging for oncologic uses may be considered at the discretion of local contractors for uses that are not determined by NCD.”

2. Ordering/Referring Edits Will Start May 1

CMS has announced that “Effective May 1, 2013, CMS will turn on the edits to deny Part B, DME, and Part A HHA claims that fail the ordering/referring provider edits. Physicians and others who are eligible to order and refer items or services need to establish their Medicare enrollment record and must be of a specialty that is eligible to order and refer” (MLN Matters article SE1305 www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf).

For providers who perform ordered services, Medicare recommends the following steps to prevent denials:

·         Ensure the providers who order services from you “have current Medicare enrollment records and are of a type/specialty that is eligible to order or refer in the Medicare program.” Review the MLN Matters article to see which providers are eligible to order services.

·         Check to see whether the ordering provider is listed in the Medicare Ordering and Referring File (updated weekly) at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html. You’ll need the provider’s NPI to confirm he or she is on the list.

·         Make sure the name and NPI listed for the ordering provider on your claim belong to a person and not an organization.

·         Spell the ordering provider’s name correctly on your claim, don’t use nicknames, and don’t include credentials (e.g., MD). If you still use paper claims, item 17 should list the provider’s first name and then the last name. Medicare offers the example “John Smith.”

Caution: An Advance Beneficiary Notice (ABN) would not be appropriate in cases where the claim will fail because of an ordering/referring provider edit. Such claims “would not expose the Medicare beneficiary to liability,” MLN Matters SE1305 states.

3. Update Your AAA Screening Policy

On March 8, 2013, Medicare revised MLN Matters SE0711, an article on abdominal aortic aneurysm (AAA) screening, to bring the article in line with payment rules under the Affordable Care Act.

The revision states that “There is no Part B deductible or coinsurance/copayment applied to this benefit.” Previously, no Part B deductible applied but coinsurance/copayment applied.

The service discussed is the one-time preventive ultrasound screening for the early detection of AAA covered for at-risk beneficiaries who receive a referral for the screening as a result of their “Welcome to Medicare” physical exam. The relevant code is G0389 (Ultrasound B-scan and/or real time with image documentation; for abdominal aortic aneurysm [AAA] screening).

To learn more, review the revised article online at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0711.pdf.