DRG Coding Advisor-Reimbursement Roundup
ASCs get pay hike
Ambulatory surgical center (ASC) facilities received a small pay hike as of Oct. 1. These new rates are in effect until the new ambulatory payment classification pay system goes into effect next year.
The new ASC rates are: Group 1/$317; Group 2/$425; Group 3/$486; Group 4/$699; Group 5/ $683; Group 6/$794; Group 7/$949; Group 8/ $934.
Medicare covers insulin pumps
The Health Care Financing Administration (HCFA) now covers insulin infusion pumps for seniors with Type I diabetes, which affects about 5% to 10% of the estimated 16 million Americans with diabetes.
The agency, however, declined to also cover insulin pumps for Type II diabetic seniors, saying the devices had yet to be shown effective for these patients.
"Making the insulin pump available to Medicare beneficiaries will improve the quality of their lives. The infusion pump offers them a choice to better control their condition so that they are more active and productive," said HCFA Deputy Administrator Michael Hash.
Medicare to garnish some payments
As part of its get-tough program, HCFA on Sept. 21 published a proposed rule giving it power to "offset" Medicare payments to providers whom it says have been overpaid by Medicaid and have not yet refunded the money.
Crackdown on home oxygen therapies
HCFA has launched a crackdown on improperly documented certificates of medical necessity (CMN) for home oxygen equipment.
A recent Office of Inspector General audit of medical records and billing documentation for home oxygen therapy found one-quarter of oxygen CMNs were either inaccurate or incomplete. Indeed, 27% of the claims reviewed lacked proper documentation, confirming test results recorded on the CMN. Even more suspicious, 13% of beneficiaries reported they never used their portable oxygen systems.
In response, HCFA has agreed to target oxygen claims for focused medical review.
Magistrate nixes 'down payment' challenge
A lawsuit by 11 provider specialty organizations challenging the propriety of HCFA's decision to use 1998 rather than 1992 as the base year for calculating the so-called "down payment" — which kicks off a four-year transition to Medicare's new relative value unit-based physician fee schedule — recently took a blow when a federal magistrate reviewing the case recommended to the U.S. District Court in Chicago that the agency's action was reasonable.
The hospital-intensive specialties backing the lawsuit argue that HCFA did not have the authority to take the action it did and that the law required the earlier 1992 time frame be used as the base year.
The difference between the two dates translates into nearly $500 million in additional payments to primary care-oriented doctors during base year transition, which mainly came out of the pockets of surgical specialties. Also, the later date acts as a multiplier, increasing future payments to office-based practices at a faster rate than if 1992 was used.
While awaiting the U.S. District Court's final decision, specialty groups are also waging what some consider to be an uphill battle to convince Congress to delay implementation of the practice expense transition process.
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