Compliance Articles

New Medicare Screening Benefits in 2005

Reprinted from Reference Point, Winter 2005

The Medicare Modernization Act (MMA) enacted by congress in December 2003 provides for two new screening benefits that are now being implemented by the Centers for Medicare & Medicaid Services (CMS) effective January 1, 2005.

Heart Disease
As a rule, Medicare rarely covers services without signs or symptoms of disease, yet it seems they have taken the old saying about an “ounce of prevention” to heart. The final rule provides for coverage of cardiovascular screening tests for early detection of cardiovascular disease or for abnormalities associated with being at risk for that disease. Covered screening tests are:

• 80061 Lipid Panel
• 82465 Cholesterol, total
• 83718 direct HDL cholesterol
• 84478 Triglycerides

Testing should be performed as part of the lipid panel following a 12-hour fast. Appropriate ICD9 codes are:

• V81.0 Special screening for ischemic heart disease
• V81.1 Special screening for hypertension
• V81.2 Special screening, other unspecified cardiovascular conditions.

Although CMS recommends that the lipid tests be performed as a panel, each individual test will only be covered once every 5 years, whether they are performed individually or as a panel.

Diabetes
CMS defines diabetes screening tests as those furnished to an individual at risk. Risk factors for diabetes that qualify an individual for the Medicare screening benefit are listed in table 2, page 3 of this newsletter. Covered screening tests are:

• 82947 Fasting Blood Glucose Test
• 82950 Glucose; 2 hr post glucose dose
• 82951 Glucose tolerance test (GTT) of 75 grams of glucose for nonpregnant adults, three specimens (2 hour OGTT).

Note that the 3-hour OGTT is not covered by Medicare as a screening test. Frequency of testing includes one screening test per year for those who have never been diagnosed with or tested for pre-diabetes or diabetes. For patients previously diagnosed with pre-diabetes, two tests are covered annually. This benefit does not apply to patients already diagnosed with diabetes.

The appropriate ICD9 code for this benefit is V77.1, Special screening for diabetes mellitus. Use the modifier “TS” (V77.1TS ) to designate patients who have been previously diagnosed with pre-diabetes.

General Health Panels not Covered

Reprinted from Reference Point, Fall 2004

Generally speaking, the word “general” itself is like a red flag when it comes to Medicare claims. Such is the case for the General Health Panel; it will not fly with Medicare. Yes, it is approved by the AMA, but this is an example of how not every test or procedure approved by the AMA is covered by Medicare. The same holds true for tests with FDA approval or CPT code issuance; these standards do not always guarantee coverage.

A “non-covered service” is always denied coverage because either a National Decision or a Local Determination exists to exclude it; therefore it may subsequently be billed to the patient. In some instances, unless written notice of non-coverage (ABN) is issued to the beneficiary prior to rendering a specific non-covered service, the provider may be held financially liable.

The basis for most exclusions involve section 1862 (a) (1) (A) of the Social Security Act. Statutory provisions for Medicare coverage exclude “items and services that are not reasonable and necessary for the diagnosis of illness or injury or to improve the functioning of a malformed body member.” Noncovered services are either specifically excluded by Medicare law by this provision, or are excluded upon interpretation of this law as it applies to certain procedures. Non-covered procedures are most commonly excluded because they are:

1. Not yet approved by the FDA or proven safe and effective.
2. Experimental or investigational.
3. Cosmetic in nature.
4. Routine physical examinations or screenings not specifically listed as covered by Medicare.
5. Routine examinations or screenings that are covered but were performed before the designated waiting period elapsed.

The four laboratory tests below are not reimbursed by Medicare due to National Non-Coverage Decisions. So the next time you order one of these tests, let your flag wave!

• General Health Panel
• Chloride, blood
• Blood typing for Paternity testing
• Hair Analysis (except for Arsenic)

Serum Magnesium: A Look at the LMRP

Reprinted from Reference Point, Fall 2003

The Magnesium LMRP makes it this a tricky lab test to order due to the relatively few diagnosis codes that are acceptable to Medicare. As we all know too well, Medicare will exclude expenses incurred for a test that is not documented by the physician as “reasonable and necessary” for the diagnosis or treatment of the patient’s medical condition.

The only ICD-9 codes allowed for Magnesium are codes appropriate for clinical conditions of unexplained lethargy, confusion, muscle fasciculation, muscle paralysis, cardiac arrhythmias, depression, agitation, seizures, hypocalcemia, hypokalemia, and medical conditions or drug therapy known to cause hypomagnesemia or hypermagnesemia. That is only about a two and a half page list of symptoms and their associated ICD-9 codes.

Magnesium coding may seem to be just an annoying inconvenience to the physicians’ offices, but inaccurate coding can become a major compliance problem for the testing laboratory. Like skeletons in the closet, each magnesium test order coded incorrectly will eventually come back to haunt all of us. Don’t let compliance failures turn ugly! Take a few extra minutes to check the accuracy of diagnosis coding on magnesium orders, and you will help keep the “compliance monster” under control.

For a complete copy of the final LMRP for serum magnesium, go to www.astar-federal.com, or contact Julie Hayes, EMHRL Marketing Coordinator at 630-833-1400 x 41350 or jxhayes@emhc.org.

National Patient Safety Goals
How JCAHO Helps Improve Healthcare Communication

Reprinted from Reference Point, Spring 2004

Picture this situation: You’re lying in the emergency room, and a nurse is giving you an infusion. Suddenly you feel like you can’t breathe... losing consciousness.... and it sounds like everyone’s rushing around you and shouting “Code Blue!” What’s happening to you?

Earlier, the nurse took a verbal stat glucose result from the lab, and she quickly wrote down “35.0.” Thirty Five? It turns out that the lab really said “three-o-five,” not “thirty-five!” No wonder you don’t feel so well after your infusion! Thanking you’re lucky stars that you’re alive, you silently begin planning your lawsuit.

This scenario illustrates the kind of “telephone” game that can have disastrous consequences. Communication between healthcare members is so important to the safety of the patient that the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) included a verbal “readback” goal to the2003 standards. JCAHO describes goal # 2 of the six National Patient Safety Goals as “improving the effectiveness of communication among caregivers” by implementing “a process for taking verbal or telephone orders or critical test results that requires verification ‘readback’ of the complete order or test result by the person receiving it.” Specifically, this means that for all accredited healthcare providers, any verbal exchange of test orders, medication orders or critical lab results must require the receiver to write or type the information, read it back, and receive confirmation from the person who gave the information.

This standard affects the way we communicate with YOU! As an accredited healthcare organization, EMHRL takes these safety goals and standards seriously. You can help us achieve this safety goal by reading back a called result, and by being patient as your Client Service Representative reads back verbal orders to you. Together, we can continue ensuring your patients the kind of quality care and safety they depend on.

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