CMS proposed a test this week for a new Medicare Part B prescription drug plan that would replace its previous policy of paying physicians and outpatient hospital departments the average sales price (ASP) plus 6%.
CMS will require revenue code and HCPCS code reporting for rural health clinics starting April 1. CMS created more questions than answers during the recent Rural Health Open Door Forum call and in the guidance published in the last few months. This article will help sort through the issue.
Q: Last week you talked about the MAC editing for medically necessary services related to the local coverage determination (LCD). What do we do if we have a situation where we believe that the list of covered diagnoses is not complete? How do we get our MAC to consider that information? We placed a call, but nothing has happened and we’ve received no response.
One of several issues involving CMS receiving inconsistent provider data has arisen due to differing MAC guidance on whether providers should report a nonchemotherapy vs. chemotherapy injection code when injecting monoclonal antibodies and/or biologic response modifiers.
Q: We are having difficulty getting our patient financial services group to route claims back to us that hit edits for lack of a medically necessary diagnosis. We have found one procedure-to-diagnosis pairing that is faulty because it is a crossover from a local coverage determination (LCD) that has multiple procedure codes related to a procedure. One of the procedure codes happens to be on this claim, but as a standalone procedure and not as part of the service described by the LCD. How do we get them to understand that the edit is not always correct for the individual situation?
