Part B Spending
Mark McClellan, CMS Administrator, released a letter that includes a detailed utilization analysis of 2004 physician services. The letter shows overall spending increased from the 12% CMS had estimated, to 15.2%. The analysis is ammunition for the administration to promote its "pay-for-performance" agenda. McClellan wants MedPAC to report what services were done appropriately, and how those services effected the condition of the patient. CMS intends to compare increases in utilization with favorable/unfavorable patient outcomes and promote, through higher reimbursement schemes, the treatment regimens that actually improve quality of care.

Services CMS is most concerned over are: established patient office visits, physical therapy, diagnostic imaging, such as MRI and echocardiograms, lab tests and drug administration (Part B). These services represented the highest contribution to the 15.2% growth in reimbursement for 2004. This increase in utilization will make it more expensive for Congress to block the expected 4.3% cut in Medicare payments expected for next year.

Certain Claims Delayed for Processing to April 18, 2005
CMS recently advised certain Medicare Part B carriers that a delay in certain claims processing would be forthcoming due to system changes.

CMS Covers Off-Label Use of Certain Colorectal Anti-Cancer Drugs
CMS announced a National Coverage Determination (NCD) covering the off-label use of certain colorectal anti-cancer drugs in identified clinical trials of colorectal cancer and other cancer types.

CMS Issues Guidelines On Physician One-Time Payment for Evaluation/Counseling
An article on Hospice Pre-Election and Counseling Services has been revised to emphasize that the medical director referenced in the article must be an employee of the hospice agency.

Having Difficulty Finding ASP Pricing on Certain Drugs?
Call and write your CMS Regional Administrator and the Carrier Medical Director when you cannot find Part B drugs in the Medicare listings. CMS's Physicians Regulatory Issues Team (PRIT) Director Bill Rogers, M.D. has stated that he is interested in hearing about drugs that aren't found in the ASP listings provided by CMS. Rogers reiterated that his team will look at the price availability of each and every drug paid under ASP (approx. 590 drug codes.)

Physicians from multiple specialties have reported their inability to purchase approximately 40 different drugs at the Medicare listed ASP prices. Among these known discrepancies are:

• J1745 (Infliximab, 10mg) ASP: $53.210
• J2920 (Methylprednisolone, 40mg) ASP: $1.916
• J7030 (Normal Saline, 1000cc) ASP: $0.984
• J7050 (Normal Saline, 250cc) ASP: $0.246
• J9245 (Melphalan hydrochloride 50mg) ASP: $368.510
• Q9943 (IVIG non-lyopholized, 1G) ASP: $56.355

Doctors still complain about the Lupron/Zoladex policy of least costly alternative. To complicate matters, there are reports of physicians being unable to purchase these drugs at ASP:

• J9202 (Goserelin acetate implant, 3.6 mg) ASP: $192.684
• J9217 (Leuprolide acetate implant, 7.5mg) ASP: $226.658

ICD-9 Coding Guidelines
Changes to the official ICD-9 coding guidelines for certain diagnoses went into effect April 1, 2005. These changes may assist in describing the complexity of the services provided. Use of the codes could help in cases of medical necessity audits. The most significant changes were related to diabetes, asthma and COPD.

Expand Levels of Conditions
It is strongly suggested that your fee ticket or office coding guide include all levels of the condition being diagnosed for more accurate ICD-9 selection for claims submission.