Reimbursement Roundup
Coverage extended to intestinal transplants
Procedure available at three centers
Medicare has approved coverage of intestinal transplants for beneficiaries with irreversible intestinal failure. These procedures will be available at three transplant centers recently approved by Medicare.
The transplant centers approved by Medicare to perform intestinal transplants are the University of Pittsburgh Medical Center, Jackson Memorial Hospital Transplant Center in Miami, and The Mt. Sinai Hospital in New York City. To qualify, centers must have performed 10 transplants per year with a one-year actuarial survival rate of 65%.
Patients who have total intestinal failure must receive their nutrients intravenously, a procedure called total parenteral nutrition (TPN). However, patients often are not able to tolerate long-term TPN because the process may cause liver failure, the patient’s veins become clotted, the lines to deliver the nutrients become infected, or the process causes severe dehydration.
Intestinal and multi-visceral transplantation restores intestinal function in patients with irreversible intestinal failure who cannot tolerate TPN. The procedure can be performed on the small bowel alone or in combination with various parts of the digestive tract, such as the liver, stomach, pancreas, or colon.
Intestinal transplantation is a relatively new technology that has been pioneered in this country primarily at the University of Pittsburgh School of Medicine. Fewer than 1,000 transplants have been performed in the United States, with approximately two-thirds of the patients being children.
Medicare now covers carotid artery angioplasty
Surgeons must follow FDA protocol
The Health Care Financing Administration (HCFA) has added angioplasty of the carotid artery with stent insertion, a new treatment option for the prevention of stroke, to its Medicare coverage. The treatment, however, is only covered when percutaneous transluminal angioplasty of the carotid artery is performed along with the placement of a carotid stent furnished in accordance with a Food and Drug Administration-approved protocol governing category B Investigational Device Exemption trials.
"It’s important to make new technologies in health care available to Medicare beneficiaries," says Health and Human Services Secretary Tommy Thompson. "Older Americans are especially vulnerable to stroke, and we believe this may help prevent stroke in high-risk patients."
Stroke is the third-leading cause of death in the United States and the leading cause of serious, long-term disability. Approximately 70% of all strokes occur in people ages 65 and older. The carotid artery is located in the neck and is the principal artery supplying the head and neck with blood. The accumulation of plaque in the carotid artery can lead to stroke either by decreasing the blood flow to the brain or when plaque breaks free and lodges in the brain or in other arteries to the head.
The new procedure involves inflating a balloon-like device in the narrowed section of the carotid artery to re-open the vessel. A carotid stent, a small, metal mesh-like device, is then placed in the artery to prevent it from closing and from allowing pieces of plaque to enter the bloodstream.
"This is a promising new technology that may eventually be proven to prevent stroke in certain high-risk patients who would not be amenable to surgical removal of plaque from an obstructed carotid artery," says Jeffrey Kang, MD, director of HCFA’s Office of Clinical Standards and Quality and the agency’s chief clinical officer. "What we learn from this coverage decision also will help us consider this therapy as an alternative for other patients at risk for stroke."
The current standard of care for obstructed carotid arteries is carotid endarterectomy, a surgical procedure that involves opening the artery and manually removing the plaque.
Medicare reimburses for home health assessments
Policy is new for 2001
If you haven’t done so already, now’s the time to update your files to note that Medicare now pays physicians a separate fee for activities involved in certifying and recertifying a patient’s home health care plan. Brett Baker, a reimbursement expert with the American College of Physicians-American Society of Internal Medicine, says you must use the following HCFA Common Procedure Coding System codes to bill for these services:
• Use code G0180 when certifying physician services for Medicare-covered services provided by a participating home health agency (where the patient is not present). This includes reviewing patient responses to an Outcome and Assessment Information Set assessment, reviewing initial or subsequent reports of patient status, contacting the home health agency to ascertain the initial implementation of the care plan, and documentation in the patient’s office record, per certification period.
• Use G0179 when recertifying home health agency patients. The initial certification code, G0180, must be used when patients have not received Medicare-covered home health services for at least 60 days. Recertification code G0179 must be used when patients have received covered home health services for at least 60 days and when the physician signs the certification after the initial certification.
To justify these services, you’ll need to describe and document in the patient record what you did to decide if the home health care plan was appropriate — or if the proposed care plan needs to be modified to better meet the beneficiary’s needs. "As a precaution, keep a copy of the approved care plan in the record," advises Baker.
Medicare does not require physicians to submit medical record documentation with the claim for these services. However, be prepared to provide supporting documentation if requested.
Medicare pays $73.08 for physician certification of a patient care plan (G0180) and $61.23 for recertification (G0179). These payment rates represent the national average. Payments vary slightly by geographic area. Previously, Medicare did not reimburse separately for certifying or recertifying a patient’s care plan. But "because these services were included in the 2001 Medicare physician fee schedule, physicians can be paid for services that they could not bill separately in the past," Baker notes.
As a result of these changes, you are no longer able to count time spent approving or revising a patient home health care plan as part of the 30-minute requirement of billing care plan oversight for a beneficiary’s home health services if it relates to certification or recertification. If you do spend 30 minutes or more on care plan oversight of a home health patient, this time should be reported using G0181.
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