|
Meetings & Forums
Calendar
PRIT - Past Issues |
Physician Regulatory Issues Team (PRIT)
Active Issues
Jump to an issue by selecting from the following choices:
Payment for CPT 79900, Brachytherapy Updated Oct 6, 2004
Same Specialty Referral Denials Updated Sept 30, 2004
E&M; Services Associated with Screening Colonoscopies
Ordering of POVs Updated Oct 6, 2004
Bariatric Ambulance Service Updated: Oct 14, 2004
Cardiac Rehab Supervision Updated: Sept 27, 2004
Security of Anesthesia Carts Updated Oct 6, 2004
Anesthesia Billing Issue
History and Physicals by Podiatrists Updated Oct 6, 2004
Provider Enrollment
Outpatient Mental Health Treatment Limitation
Use of Macros in Teaching Documentation
Post Anesthesia Reports Updated Oct 6, 2004
Chemotherapy Codes Issue
Reenrollment
Verbal Orders Updated Oct 6, 2004
| Past Issues |
Payment for CPT 79900, Brachytherapy |
[back to top] |
Issue |
Status |
|---|---|
| Providers are uncertain how to code for the radioisotopes used in Brachytherapy services with the upcoming elimination of CPT 79900. |
September 29: This issue was brought to the PRIT by Radiation Oncologists and the Coalition for the Advancement of Brachytherapy. We are currently investigating possible solutions. October 1: Coding changes will be announced in the physician rule which will allow these supplies to be billed using code Q3001. |
Same Specialty Referral Denials |
[back to top] |
Issue |
Status |
|---|---|
| Denials of payment for consultations because ordering and consulting physicians are from the same specialty. |
This issue came to the PRIT from the American College of Cardiology on September 13th. Some of their members have had trouble with denial of payment for consultations because the consultant is identified in the Medicare database as being of the same specialty as the referring physician. September 29: Medicare does not prohibit consultations in the same group practice whether the physicians represent multi-specialties or a single specialty. Circumstances could arise which would necessitate care by physicians of the same specialty (and in the same group practice). This issue involves two policy areas, consultations and concurrent care. The consult must be medically necessary; requested by an appropriate source seeking the advice or opinion of another professional, and the consultant must report the results of the consultation to the requesting professional. For the exact details, please read the CMS manuals at: www.cms.hhs.gov/manuals/102_policy/bp102c15.pdf www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf We would like to hear from providers who are having problems with denials despite this guidance. |
E&M; services associated with screening colonoscopies |
[back to top] |
Issue |
Status |
|---|---|
| The American College of Gastroenterology has asked the PRIT if there are circumstances under which Medicare might pay for a preprocedure visit for a patient scheduled for a screening colonoscopy. | The PRIT is discussing the issue with subject matter experts and has suggested several possible resolutions with the college. |
Ordering of POVs |
[back to top] |
Issue |
Status |
|---|---|
| The PPAC asked the PRIT to find out why authority to order POVs was restricted to a few medical specialties. |
A draft regulation is currently undergoing internal review which will remove the specialty requirement. August 13: The PRIT is reporting this issue to the PPAC on 8/30/04. September 9: The regulation is in the final approval process. October 4: Regulation is still on track for publication very soon. |
Bariatric Ambulance Service |
[back to top] |
Issue |
Status |
|---|---|
| Ambulance transports of morbidly obese patients require added staff and resources that are not reflected in Medicare's payment. |
This issue was brought to the PRIT by the Ambulance Open Door forum on June 16th. July 8: We are still developing a database of background information for this issue in preparation for an internal discussion. August 3: We’ve contacted representatives of the ambulance community and have been provided with a few statistics but we still need more information. September 16: Data received indicated that this is not an issue of concern to most of the ambulance community. We have a meeting on 9/30 with ambulance representatives. October 5: We have asked the industry for further cost data, we have not seen evidence to date that this is a pressing issue for most providers. October 14: The American Ambulance Association has surveyed their members on this issue and is now sharing this data with CMS. We expect to receive a copy of the survey in the next week. |
Cardiac Rehab Supervision |
[back to top] |
Issue |
Status |
|---|---|
| There is debate about whether Emergency physicians should be permitted to supervise Phase II cardiac rehab under some circumstance. |
April 23: This issue was brought to the PRIT by a hospital in Oregon. We are currently examining options. June 16:The OIG will soon publish a report on this subject. We cannot formulate a new regulation until that report is released. July 14: While internal development at a policy proceeds we still are awaiting the final OIG report. August 3: OIG report slated for release in August or September. August 16: OIG report slated for publication in September. September 14: We spoke to the ACC CAC and they reinforced the importance of this issue to their members. The Committee on Technology and Innovation is addressing the issue seriously but an interim fix may be possible. |
Security of Anesthesia Carts |
[back to top] |
Issue |
Status |
|---|---|
| CMS requirements exceed JCAHO and some state survey organization requirements. |
This issue was brought to the PRIT by the ASA May 10, 2004. We are currently researching the background. July 9: Unfortunately changing this requires rulemaking not just a manual change. We are working on a proposed rule which will be published for comment in about 4 months. August 13: The Hospital Condition of Participation is now in the final approval process. October 6: One of 4 PRIT issues which will be resolved in the soon to be released Hospitals Conditions of Participation. |
History and Physicals by Podiatrists |
[back to top] |
Issue |
Status |
|---|---|
| Podiatrists have asked that Medicare allow them to perform H&Ps; on hospital inpatients. |
CMS is considering a change to the Hospital Condition of Participation that would permit Podiatrists to perform this service. August 13: The Hospital Condition of Participation are now in the final approval process. October 6: One of 4 PRIT issues which will be resolved in the soon to be released Hospitals Conditions of Participation. |
Reenrollment |
[back to top] |
Issue |
Status |
|---|---|
| Provider Reenrollment should not interfere in any way with the provider's ability to bill Medicare during the enrollment process. |
This was a resolution of the PPAC on February 24, 2004. The PRIT will work with our Division of Provider and Supplier Enrollment to insure that we comply with this resolution. CMS is developing software to allow providers to reenroll online. CMS will not require reenrollment until that software is running. April 2: We hope to have a web enabled reenrollment process by early 2005. June 10: CMS will not require reenrollment until an online reenrollment system is functioning and the current enrollment crisis is resolved. August 30: The PPAC strongly recommended that reenrollment software be thoroughly beta tested before implementation. |
Provider Enrollment |
[back to top] |
Issue |
Status |
|---|---|
| Providers across the nation have noted that applications for provider numbers take longer to process than they used to creating serious economic problems for the affected practices. |
Feb 23rd, 2004: Work on the PECOS server has improved its reliability. The server was only down 90 minutes in the past week. An update of PECOS, just installed, has new features that will allow applications to be processed as soon as essential data points have been completed. Nonessential fields can be completed as the provider submits the information. March 2nd: Five teams consisting of CMS specialists and representatives from the PECOS contractor visited five carriers during the first week in March to address any local problems with enrollment. March 14th: A new server was installed which should resolve remaining reliability problems. CMS sent 5 teams out to visit the carriers and check on their progress with the enrollment backlog. April 2nd: Eleven carrier site visits have been completed. The PECOS server now accommodates 330 simultaneous users and further upgrades are being preformed. The backlog is no longer growing and should begin to decline now. The Director of the Office of Financial Management requires all members of the team to meet with him every Thursday to report on progress and the workload report. May 11th: CMS approved additional funding for all carriers that requested it to hire part time staff to clear the backlog. May 27th: Backlog is dropping weekly by 5%. CMS has given the carriers funding to hire additional staff. We also are developing a database to facilitate the importation of data from the old carrier database to PECOS. Bob Loyal (Director of Provider Enrollment) spoke to the PPAC on May 17 on the enrollment problem. July 14: The PECOS backlog continues to shrink. The carriers have hired additional staff to work on the backlog. A transitional database will soon be installed which will allow the enrollment staff to import data into the PECOS database when providers are only modifying an existing UPIN. Although the backlog might have been expected to increase this month due to new residency graduates applying for UPINs it has gone down. This is probably due to increased staffing in the enrollment offices and software improvements. August 20:CMS will report on PECOS to the PPAC on 8/30/04. Highlights of that report will be posted here. September 8: The enrollment backlog is being reduced by about 2% to 3% per week. At this rate we will have returned to pre-PECOS levels by mid October. Please note: If there are providers whose applications have not been processed and who are experiencing cash flow issues or other hardships, please let CMS know. We will work with the appropriate contractor to expedite the processing of their application. Contact person: Allen Gillespie, agillespie@cms.hhs.gov |
Outpatient Mental Health Treatment Limitation |
[back to top] |
Issue |
Status |
|---|---|
| When should physicians bill the M0064 code versus the CPT code 90862? |
The Physicians Open Door Forum asked the PRIT to address this issue. We are looking at when the outpatient mental health limitation should be applied to 90862.
May 20: CMS intends to clarify this policy through a manual issuance rather then through the Physician Rule. The expected date of issuance will be announced as soon as we know. |
Use of Macros in Teaching Documentation |
[back to top] |
Issue |
Status |
|---|---|
| Are teaching physicians permitted to use Macros when dictating or typing their portion of the medical record? |
CMS will release instructions very soon.
July 14: A CMS official will be meeting with the AAMC to achieve consensus on this issue. August 20:The AAMC is soliciting input from their members on this issue and will submit comments for inclusion on the physician rule. September 2: The PRIT discussed this issue with the AAMC before the PPAC meeting and we will work with them to formulate a policy as soon as they survey their members. |
Post Anesthesia Reports |
[back to top] |
Issue |
Status |
|---|---|
| Current CMS policy, with respect to inpatients, is unclear as to whether a different anesthesiologist (who did not administer the anesthesia) may perform the post anesthesia recovery unit (PACU) evaluation and report. |
This issue involves the Medicare Hospital Conditions of Participation. CMS' Office of Clinical Standards and Quality is actively reviewing this issue as well as others in the Conditions of Participation. The new Medicare CoP should be released in a few months. May 11th: This issue originated with the SACCR and has been effectively addressed in the upcoming Hospital CoP. July 7: Still waiting for internal clearance of the Hospital Conditions of Participation. August 13: Due to the volume of regulations and the MMA, this process has been delayed but we still expect the Hospital Conditions of Participation to be released before 2005. October 6: One of 4 PRIT issues which will be resolved in the soon to be released Hospitals Conditions of Participation. |
Verbal Orders |
[back to top] |
Issue |
Status |
|---|---|
| Burdened by the requirement that verbal orders in the hospital must be signed by the individual physician giving the order |
This issue involves the Medicare Hospital Conditions of Participation. CMS' Office of Clinical Standards and Quality is actively reviewing this issue as well as others in the Conditions of Participation. Current guidance can be found in the CMS response to the AHA letter. The new Medicare CoP should be released in a few months.
July 7: Still waiting for internal clearance of the Hospital Conditions of Participation. August 13: Due to the volume of regulations and the MMA, this process has been delayed but we still expect the Hospital Conditions of Participation to be released before 2005. October 6: One of 4 PRIT issues which will be resolved in the soon to be released Hospitals Conditions of Participation. |
Anesthesia Billing Issue |
[back to top] |
Issue |
Status |
|---|---|
| Anesthesiologists feel clarification is needed in how to appropriately bill for a case which is started by a supervised anesthetist and completed by the supervising anesthesiologist. |
The PRIT has a proposed resolution acceptable to the ASA. In March, the AANA and ASA have met together to discuss this issue. The AANA will discuss the proposal at the AANA Practice Committee meeting in April. June 10: The AANA and ASA have jointly proposed a solution that has been presented to our staff for review. August 13: Internal review is proceeding favorably and we hope for resolution in the near future. |
Chemotherapy Codes Issue |
[back to top] |
Issue |
Status |
|---|---|
| Should use of the Chemotherapy codes 96400-96450, 96542, 96545 and 96549 be permitted for some nononcologic drugs when the complexity of the infusion is equivalent to that of a cancer drug? |
An internal working group began consideration of this issue in October of 2003. A change of the Medicare Carrier Manual would be required to implement this proposal. The CPT manual would permit it without modification. At a November 4th internal meeting we concluded that we needed to see the final version of the Medicare reform bill before we could resolve this issue. April 6: Since Section 303 of the Medicare Modernization Act requires CMS to both use "existing processes" and to gain input from the medical community, we have decided to refer this issue to a subcommittee of the CPT editorial committee. At this time, members of that subcommittee are being selected. April 27: The CPT subcommittee had their first meeting today to discuss refinement of code descriptors. May 25: The CPT subcommittee met via conference call today and has decided to hold two public forums to discuss the issue. These forums will be held June 21st and 22nd. July 14: CPT drug administration workgroup met and plan to make a proposal to the CPT Editorial Panel in August so that codes can be valued by the RUC in September. August 30: Read the document regarding the AMA CPT subcommittee recommendations to PPAC (adobe pdf 26Kb). |
| Note: This page includes links to specialized data and multimedia files. Viewing these files requires the use of a third-party plug-in or viewer. For more information or to test whether your computer can read these files, visit our File Formats and Plug-Ins page. |
Last Modified on Friday, October 15, 2004
Centers for Medicare & Medicaid Services