May 2005 Newsletter

To "Q" You In

By , Quality Assurance

Initial Preventive Physical Examination (IPPE) for new Medicare beneficiaries

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 provides for coverage under Medicare Part B of an initial preventive physical examination (IPPE), including a screening EKG for new beneficiaries, effective for services furnished on or after 1/1/05.

This physical examination is a once-a-lifetime benefit for a beneficiary and it must be performed within six months after the effective date of the beneficiary's first Part B coverage, but only if such Part B coverage begins on or after 1/1/05.

A new HCPCS code, G0344 (IPPE, face-to-face visit) will be used for billing the IPPE. As required by statute, this benefit always includes a screening EKG, which should be billed using new HCPCS codes G0366 for the full EKG service; G0367 (tracing only) or G0368 when only the interpretation and report are performed.

The MMA did not make any provision for the waiver of Medicare coinsurance and Part B deductible for the IPPE. Payment for this service would be applied to the required deductible, if the deductible has not been met.
For complete details, refer to Medlearn Matters Number MM3638 here.

Medicare B - Duplicate Claims for "Medically Reviewed" Services

Effective 7/5/05, there are important changes in the way Medicare contractors will handle claims for "medically reviewed" services. These changes affect claims containing any of the following:

• Any service which receives a denial on the basis of medically reasonable and necessary.
• Any service, for which the carrier requested, received and reviewed documentation, and then denied.
• Any service for which documentation was requested but not received.

With this change, providers may not resubmit claims denied for these reasons. Any other submissions will be considered duplicates and denied.

A Redetermination (Appeal) Request form must be submitted for the claims to be considered for payment. Requests must include copies of the original claim, the Remittance Advice Notice statement, a brief explanation of why you want the claim reviewed, and any additional information that was not originally provided. This form is available from the OH/WV Medicare website.

For additional information concerning these instructions, you may refer to the CMS website.

CMS Proposed Revisions to hospital conditions of participation (CoPs)

The CMS issued a proposed rule March 24, 2005 to requirements in the hospital Conditions of Participation (Cops). The intent of the changes, says the agency, is to reflect current medical practice standards, give hospitals and practitioners more flexibility in patient care, and reduce unnecessary regulatory burdens. The revised requirement include:

• H&P examination: Exams performed within 30 days before or 24 hours after patient admission would be required. They would also expand the number of practitioners who may perform these exams.
• Authentication of verbal orders: Verbal orders that are not in written or electronic form could be authenticated within 48 hours by someone other than the prescribing physician.
• Security of Medications: Noncontrolled drugs would be kept in a secure area but only locked down "when appropriate." All drugs and biologicals currently must be locked down in a secure area.
• Post anesthesia evaluation: Any individual trained to administer anesthesia would be able to conduct a patient's post-procedure evaluation. Currently only the person who treated the patient may make the evaluation.

CMS Recovery Audit Contractors (RAC) Demonstration Project

The CMS has announced new initiatives to provide clear guidance on Medicare billing and a new demonstration project using Recover Audit Contractors (RACs) as part of CMS' further efforts to assure accurate payments.

The demonstration will use the RACs to search for improper Medicare payments that may have been made to healthcare providers and that were not detected through existing program integrity efforts. California, Florida, and New York are the states that have been chosen for this three-year demonstration. Each RAC will begin work on claims that are at least one year old. The RACs will request claim history and medical records, if necessary, to determine if over or underpayments exist.

CMS will be holding an open door forum in the near future to discuss the Recover Audit Contractor (RAC) demonstration.