A Report for the:
MEDICARE CARRIER ADVISORY COMMITTEE
OAKLAND, CA JULY 19, 2006
CUA REPRESENTATIVE
JEFFREY KAUFMAN MD, FACS

Update provided on the proposed change to the Least Costly Alternative (LCA) policy regarding LHRH agonists that would include Trelstar along with Zoladex, Lupron, and Eligard but limit application to those drugs with at least 20% market share and limit cross walking rates to those with similar injection frequencies: implementation of policy delayed pending legal review from CMS to challenge from attorneys for two of the largest pharmaceutical companies regarding the basis for a LCA policy and the specifics of this particular draft regarding how to define 20% market share, etc.

Agreement secured that a new policy on nerve conduction studies will not impact EMG studies on the external urinary sphincter since that issue is already covered by a policy on urodynamics and its CPT code is different from those listed in the new policy.

Article on stolen physician identity reviewed since physician ID numbers used fraudulently leave physician open to many charges including IRS claims that tax is owed on payments made to that ID number even if physician maintains he never received any money. Caution was given about allowing clinics to use a physician’s ID number without doctor’s involvement. Review also made on current fraud investigations, the dominance of Southern California above all other regions nationally in fraud and abuse charges providing profile and examples of current types of fraudulent claims.

Urology specific inquiry was made regarding denial of claims to a San Jose CUA member with Medicare explanation code -49 indicating “these are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam” even though the codes were for evaluation and management of BPH, urinary frequency and urgency and the bills included cystoscopy, bladder ultrasound and uroflow testing. NHIC’s Carrier Medical Director indicated the code -49 is now also used by the fraud edit division when an abusive pattern of billing is identified and fraud investigation is initiated. The hold on all payments precedes a formal finding of fraud that would close down all bills from a health care provider or a patient. The investigation may occur when a patient’s identification number is compromised (stolen, duplicated, abused, misused, etc) leading to denied payment to all innocent physician providers until CMS is able to sort out which claims are legitimate and which are fraudulent. Alternately, the investigation may involve a physician who is billing in a manner so out of step with others that it raises questions about the legitimacy and honesty of his claims. Unfortunately, this reason for denial of claim is not made known to those other physicians providing care honestly to the patient since the official Medicare Part B Billing Manual simply lists the explanation of -49 as unpayable because Medicare does not routinely cover screening evaluations or well-being exams unless specifically provided for by law. The provider who asked for CUA assistance was referred to Kathy O’Donnell in the fraud edit division of the local Medicare carrier NHIC in Chico at 530-896-7030 for help sorting out his claims.

Based on a request from CAC member Jeffrey Kaufman MD, the Medical Director reviewed new regulations from CMS regarding billing for E&M Consultation codes effective January 1, 2006. The definition of a consultation service was reviewed distinguishing it from other evaluation and management services because it is provided by a physician whose opinion is requested by another physician. The request and the reason for the consultation must be documented by the referring physician in his record and after consultation is provided, a written report of the findings and recommendations shall be provided to the referring doctor. Details of the new regulations involving consultations followed by treatment as distinguished from a simple transfer of care were discussed. Codes for follow up consultation services have been deleted. A request for second opinion by the patient or family has been deemed not to be a “consultation” request and will only be paid as an initial new patient visit.

One requested by another physician is a simple “consult” and codes for a Confirmatory Consult have been deleted. Requests for preoperative clearance have been specifically qualified as new or established patient visits rather than a consult just as a request for postoperative care by a surgeon to an internist or other specialist are no longer considered a “consult”.

Many of these new regulations are counter-intuitive to practicing physicians, run contrary to long standing patterns of practice and understandings of the common definitions of a “consult”, defy the assumptions on which various codes and reimbursement levels were established and appear to be an attempt by CMS to re-write CPT coding structures in an attempt to cheat physicians out of proper reimbursement. Since these new regulations were issued by CMS central, they are not open to individual interpretation or selective implementation by the various local carriers. However based on extensive discussion at the CAC meeting, several physicians were designated to draft a letter of comment to the local carrier Medical Director to be forwarded to CMS asking that the new definitions and regulations be reconsidered. Dr. Kaufman is partnering in that ad hoc committee with physicians representing the California neurosurgical society, CMA and California allergy specialists in drafting that letter. For the present, urology specialists must insure that consults are requested by the referring physician who documents the request and reason in his chart and must respond with a copy of their consultation in writing back to the referring physician which includes his findings and recommendations. While it is unlikely that any bills for consultation services will be audited, it remains the physician’s responsibility to insure that all elements of the new regulations are adhered to. More discussion on this will follow in the future.

Submitted,

Jeffrey Kaufman MD, FACS
CUA Medicare CAC representative