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Ask the Expert
| Article Date: 5/31/2007 |
Payment for Blood Collection
Q. All of the sudden, Medicare stopped paying for blood draws. Is this a nationwide change?
A. The good news is that Medicare still pays a measly $3.00 for blood draws, but the CPT code was changed from G0001 to 36415, so I suspect you’re using the wrong code or sending the patient elsewhere to get the blood drawn. Medicare only pays the person who actually extracted the specimen from the patient.
Venipuncture is one of the most commonly billed Medicare codes (about 70 million claims per year with a denial rate of less than 5%) and has consistently reimbursed $3.00 for the last 15 years. Although the laboratory community has been petitioning for a reimbursement raise for venipuncture to about $5.50, so far Uncle Sam isn’t budging.
Doctors Screening for Drugs, Alcohol
Q. Did Medicare recently start paying for in-office drug and alcohol screening tests?
A. No. This month, Medicare and Medicaid introduced two new HCPCS codes: one for drug and alcohol screening, and the other for brief intervention and counseling, to encourage physicians to identify and treat people with substance use disorders. Unfortunately, the screening tools the government is paying for are “questionnaires”!
About 22 million Americans have substance abuse problems; of these, only about 10% are in treatment. The vast majority of the rest are closet members of DAMM (Drunks Against Mad Mothers).
This new benefit sounds almost as good as the “Welcome to Medicare” exam, huh? Unfortunately, even though questionnaires are cheap, doctor’s time isn’t and questionnaires don’t give real answers like urine and blood test kits. A typical question session goes like this:
Physician: “Harry, do you take drugs”?
Patient: “Never, doc. Now can you please refill my Ambien? It works so much better than Jack Daniels alone”.
Screening tests for drugs and alcohol – real ones, not questionnaires- should be covered by Medicare at least for emergency and trauma centers, since 40% to 60% of all patients admitted to trauma centers are loaded on some substance or another. Regrettably, in over 30 states, insurers deny payment for patients injured while under the influence, so some facilities won’t test for fear of losing payment from third party payers (non-Medicare/Medicaid).
Monitoring Patients on Accutane
Q. I have several patients on Accutane and need to monitor their liver and lipid functions in addition to performing a pregnancy test. Currently, we do only the pregnancy test in house. Is there a CLIA-waived product to do all these tests?
A. Check out Cholestech Corp’s new dermatology kit for use in monitoring the key health indicators of Accutane patients. The kit features a CLIA-waived lipid and liver screening system, which enables physicians prescribing Accutane to obtain laboratory-accurate blood results during routine office visits in under five minutes with a simple finger stick. Each kit also includes 25 QuickVue Urine hCG pregnancy test kits. For more information, visit www.cholestech.com.
Pulse Oximetry Payments
Q. My managed care plans won’t pay for either pulse oximetry or urine dipstick testing. It’s just considered part of the office visit. Is this right?
A. The biggest plan in the nation, Aetna, recently capitulated to pressure from state medical societies and agreed to reprocess previously denied claims from back to May 1, 2006 and pay up for these services separately. This new policy is available to participating physicians on Aetna’s website: www.aetna.com/provider/medical_claim_payment.html.
RIA Testing
Q. A local medical supply salesperson suggested doing thyroid and other immunoassays in my office using radioimmunoassay (RIA) equipment rather than an immunoassay instrument. The cost per test is much, much lower on an RIA instrument and the radioisotopes are in such small quantities that they’re negligible. What other considerations should I be aware of before making a decision?
A. Not since disco died has using nukes for thyroid and other hormone testing been popular. Nowadays, most labs (except notably those in Teheran) use immunoassay, which unlike RIA, doesn’t require a license from the Nuclear Regulatory Commission!
From a safety standpoint, just picture little Johnnie wandering back to the lab area, checking out that cool scintillator and taking a swig of plutonium or 14C. That scenario isn’t too far fetched. National headlines recently described a lawsuit stemming from a child who drank phenol from a styrofoam cup that was left sitting on the exam room counter. The final nail in RIA’s coffin: it’s high complexity under CLIA, so a real lab tech is required. Immunoassay testing is moderately complex under CLIA so a high school grad with documented training may perform immunoassays.
Billing for PT-INRs
Q. We have a coumadin clinic and do lots of CLIA-waived PT-INRs. We normally bill for both for the test and for a non-physician office visit (CPT 99211). I understand that there are 2 new codes and that we can’t use 99211 anymore. The test really isn’t very profitable without 99211. What do you know about this?
A. I’ll try to explain something that doesn’t make any sense at all, but consider the source. Uncle Sam announced two new CPT codes that went into effect on 1/1/07:99363 - Anticoagulation management for an outpatient taking warfarin, physician review and interpretation of International Normalized Ratio (INR) testing, patient instructions, dosage adjustment (as needed), and ordering of additional tests; initial 90 days of therapy (must include a minimum of 8 INR measurements)
99364 - Anticoagulation management for an outpatient taking warfarin, physician review and interpretation of International Normalized Ratio (INR) testing, patient instructions, dosage adjustment (as needed), and ordering of additional tests; subsequent 90 days of therapy (must include a minimum of 3 INR measurements)
As with virtually any federal program, I bet you’re wondering: “where’s the rump rocket”? Well, here it is: neither of these codes pays anything! What are the Medicare folks at CMS thinking? Oh, let’s just add a bunch of new paperwork for physicians without paying them anything for it…the new CPT codes are not recognized by Medicare as separately billable services! On the other hand, you can bet your bottom dollar that private (non-Medicare) payers are recognizing these codes…whether or not they’re paying for them is questionable. Check out your insurance company communications and let us know here at “Ask the Expert”, if they’re paying and what amount. Then, we’ll share it with our readers.
The good news is that physicians should continue to bill both for the test (CPT85610) and the E&M code, such as 99211 (reimbursement averages $21) when a nurse (or other office personnel) runs the test and performs a short history and physical. If the physician performs the H&P, a higher E&M code can be billed. So, nothing has really changed in terms of PT-INR reimbursement.
Doubting Thomas’ can contact the PT-INR manufacturer to obtain a Fact Sheet, drafted by their high-paid corporate attorneys, to substantiate what I said above.
Autoclave Versus Dishwasher
Q. I wrote to you last month about using kitty litter to clean up biohazardous spills rather than buying spill kits and in your response, you intimated that I’m cheap. Well, I am thrifty and proud of it. Assuming you want some more fodder for your column, here’s another practical suggestion: use your dishwasher to sterilize reusable vaginal speculums. It works just as well as an autoclave!
A. You’re not from around here, are you? Thanks for the suggestion, but I’m picturing some high-powered, Johnny Cochran-type attorney shooting rapid-fire questions at you on the witness stand: Attorney: 'Now, Dr. X., tell the jury how you knew that the instrument you used on my poor client….whose life will never be the same (wipes a few tears from his eyes for effect) was clean?
Dr. X: Duh…..
Attorney: Then, isn’t it true that the AIDS virus could have been crawling all over that speculum?
I would politely decline refreshments from cups that went through that dishwasher, if offered. Finally, check out the actual CDC requirements for disinfecting semi-critical instruments at http://www.cdc.gov/ncidod/hip/enviro/guide.htm. These Infection Control Guidelines say that reusable items that contact patient’s mucous membranes must be sterilized or receive high-level disinfection before reuse. One last thought would be to switch to disposable speculums….they melt in the dishwasher!
Defibrillator Safety
Q. We’re considering getting an automated external defibrillator for our urgent care clinic, but reports of malfunctions have dominated the medical journals lately. How can I access a report of the most reliable models?
A. First, I applaud you for acquiring this technology. Now that some states require defibrillators in public buildings, and Congress has approved money for rural communities to buy them, almost 200,000 AEDs a year are being sold into ambulatory medical facilities.
Over the past decade, one in five AED’s were recalled because of the potential for malfunction, and those that failed were associated with 370 deaths. This may sound alarming, but if taken in context that the devices have saved tens of thousands of lives, the benefits far outweigh the risk of malfunctions.
These recalls are a problem, but one that can be overcome by performing the same type of maintenance on AEDs that we do on, say, fire extinguishers or lab equipment –follow the manufacturer’s instructions for use and maintenance, have occasional drills and pay attention to recall notices.
For more information, check out Recalls and Safety Alerts Affecting Automated External Defibrillators. JAMA.2006; 296: 655-660
Bogus Alcohol Gel Products
Q. One of my office staff attended an OSHA seminar (you taught it) and is questioning whether or not the alcohol hand sanitizer I use is OSHA compliant.
A. It is, unless you’re stocking up on the cheap stuff that’s sometimes passed off as a real alcohol gel in discount stores. CDC recently warned discount shoppers that alcohol hand products must contain at least 60% alcohol to be considered effective. A quick trip down the aisles at local MegaMarts will uncover some concentrations as low as 40% but also plenty of effective products.
Q. All of the sudden, Medicare stopped paying for blood draws. Is this a nationwide change?
A. The good news is that Medicare still pays a measly $3.00 for blood draws, but the CPT code was changed from G0001 to 36415, so I suspect you’re using the wrong code or sending the patient elsewhere to get the blood drawn. Medicare only pays the person who actually extracted the specimen from the patient.
Venipuncture is one of the most commonly billed Medicare codes (about 70 million claims per year with a denial rate of less than 5%) and has consistently reimbursed $3.00 for the last 15 years. Although the laboratory community has been petitioning for a reimbursement raise for venipuncture to about $5.50, so far Uncle Sam isn’t budging.
Doctors Screening for Drugs, Alcohol
Q. Did Medicare recently start paying for in-office drug and alcohol screening tests?
A. No. This month, Medicare and Medicaid introduced two new HCPCS codes: one for drug and alcohol screening, and the other for brief intervention and counseling, to encourage physicians to identify and treat people with substance use disorders. Unfortunately, the screening tools the government is paying for are “questionnaires”!
About 22 million Americans have substance abuse problems; of these, only about 10% are in treatment. The vast majority of the rest are closet members of DAMM (Drunks Against Mad Mothers).
This new benefit sounds almost as good as the “Welcome to Medicare” exam, huh? Unfortunately, even though questionnaires are cheap, doctor’s time isn’t and questionnaires don’t give real answers like urine and blood test kits. A typical question session goes like this:
Physician: “Harry, do you take drugs”?
Patient: “Never, doc. Now can you please refill my Ambien? It works so much better than Jack Daniels alone”.
Screening tests for drugs and alcohol – real ones, not questionnaires- should be covered by Medicare at least for emergency and trauma centers, since 40% to 60% of all patients admitted to trauma centers are loaded on some substance or another. Regrettably, in over 30 states, insurers deny payment for patients injured while under the influence, so some facilities won’t test for fear of losing payment from third party payers (non-Medicare/Medicaid).
Monitoring Patients on Accutane
Q. I have several patients on Accutane and need to monitor their liver and lipid functions in addition to performing a pregnancy test. Currently, we do only the pregnancy test in house. Is there a CLIA-waived product to do all these tests?
A. Check out Cholestech Corp’s new dermatology kit for use in monitoring the key health indicators of Accutane patients. The kit features a CLIA-waived lipid and liver screening system, which enables physicians prescribing Accutane to obtain laboratory-accurate blood results during routine office visits in under five minutes with a simple finger stick. Each kit also includes 25 QuickVue Urine hCG pregnancy test kits. For more information, visit www.cholestech.com.
Pulse Oximetry Payments
Q. My managed care plans won’t pay for either pulse oximetry or urine dipstick testing. It’s just considered part of the office visit. Is this right?
A. The biggest plan in the nation, Aetna, recently capitulated to pressure from state medical societies and agreed to reprocess previously denied claims from back to May 1, 2006 and pay up for these services separately. This new policy is available to participating physicians on Aetna’s website: www.aetna.com/provider/medical_claim_payment.html.
RIA Testing
Q. A local medical supply salesperson suggested doing thyroid and other immunoassays in my office using radioimmunoassay (RIA) equipment rather than an immunoassay instrument. The cost per test is much, much lower on an RIA instrument and the radioisotopes are in such small quantities that they’re negligible. What other considerations should I be aware of before making a decision?
A. Not since disco died has using nukes for thyroid and other hormone testing been popular. Nowadays, most labs (except notably those in Teheran) use immunoassay, which unlike RIA, doesn’t require a license from the Nuclear Regulatory Commission!
From a safety standpoint, just picture little Johnnie wandering back to the lab area, checking out that cool scintillator and taking a swig of plutonium or 14C. That scenario isn’t too far fetched. National headlines recently described a lawsuit stemming from a child who drank phenol from a styrofoam cup that was left sitting on the exam room counter. The final nail in RIA’s coffin: it’s high complexity under CLIA, so a real lab tech is required. Immunoassay testing is moderately complex under CLIA so a high school grad with documented training may perform immunoassays.
Billing for PT-INRs
Q. We have a coumadin clinic and do lots of CLIA-waived PT-INRs. We normally bill for both for the test and for a non-physician office visit (CPT 99211). I understand that there are 2 new codes and that we can’t use 99211 anymore. The test really isn’t very profitable without 99211. What do you know about this?
A. I’ll try to explain something that doesn’t make any sense at all, but consider the source. Uncle Sam announced two new CPT codes that went into effect on 1/1/07:
As with virtually any federal program, I bet you’re wondering: “where’s the rump rocket”? Well, here it is: neither of these codes pays anything! What are the Medicare folks at CMS thinking? Oh, let’s just add a bunch of new paperwork for physicians without paying them anything for it…the new CPT codes are not recognized by Medicare as separately billable services! On the other hand, you can bet your bottom dollar that private (non-Medicare) payers are recognizing these codes…whether or not they’re paying for them is questionable. Check out your insurance company communications and let us know here at “Ask the Expert”, if they’re paying and what amount. Then, we’ll share it with our readers.
The good news is that physicians should continue to bill both for the test (CPT85610) and the E&M code, such as 99211 (reimbursement averages $21) when a nurse (or other office personnel) runs the test and performs a short history and physical. If the physician performs the H&P, a higher E&M code can be billed. So, nothing has really changed in terms of PT-INR reimbursement.
Doubting Thomas’ can contact the PT-INR manufacturer to obtain a Fact Sheet, drafted by their high-paid corporate attorneys, to substantiate what I said above.
Autoclave Versus Dishwasher
Q. I wrote to you last month about using kitty litter to clean up biohazardous spills rather than buying spill kits and in your response, you intimated that I’m cheap. Well, I am thrifty and proud of it. Assuming you want some more fodder for your column, here’s another practical suggestion: use your dishwasher to sterilize reusable vaginal speculums. It works just as well as an autoclave!
A. You’re not from around here, are you? Thanks for the suggestion, but I’m picturing some high-powered, Johnny Cochran-type attorney shooting rapid-fire questions at you on the witness stand: Attorney: 'Now, Dr. X., tell the jury how you knew that the instrument you used on my poor client….whose life will never be the same (wipes a few tears from his eyes for effect) was clean?
Dr. X: Duh…..
Attorney: Then, isn’t it true that the AIDS virus could have been crawling all over that speculum?
I would politely decline refreshments from cups that went through that dishwasher, if offered. Finally, check out the actual CDC requirements for disinfecting semi-critical instruments at http://www.cdc.gov/ncidod/hip/enviro/guide.htm. These Infection Control Guidelines say that reusable items that contact patient’s mucous membranes must be sterilized or receive high-level disinfection before reuse. One last thought would be to switch to disposable speculums….they melt in the dishwasher!
Defibrillator Safety
Q. We’re considering getting an automated external defibrillator for our urgent care clinic, but reports of malfunctions have dominated the medical journals lately. How can I access a report of the most reliable models?
A. First, I applaud you for acquiring this technology. Now that some states require defibrillators in public buildings, and Congress has approved money for rural communities to buy them, almost 200,000 AEDs a year are being sold into ambulatory medical facilities.
Over the past decade, one in five AED’s were recalled because of the potential for malfunction, and those that failed were associated with 370 deaths. This may sound alarming, but if taken in context that the devices have saved tens of thousands of lives, the benefits far outweigh the risk of malfunctions.
These recalls are a problem, but one that can be overcome by performing the same type of maintenance on AEDs that we do on, say, fire extinguishers or lab equipment –follow the manufacturer’s instructions for use and maintenance, have occasional drills and pay attention to recall notices.
For more information, check out Recalls and Safety Alerts Affecting Automated External Defibrillators. JAMA.2006; 296: 655-660
Bogus Alcohol Gel Products
Q. One of my office staff attended an OSHA seminar (you taught it) and is questioning whether or not the alcohol hand sanitizer I use is OSHA compliant.
A. It is, unless you’re stocking up on the cheap stuff that’s sometimes passed off as a real alcohol gel in discount stores. CDC recently warned discount shoppers that alcohol hand products must contain at least 60% alcohol to be considered effective. A quick trip down the aisles at local MegaMarts will uncover some concentrations as low as 40% but also plenty of effective products.