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Ask The Expert
| Article Date: 5/31/2007 |
Ask the Expert, June 2007
ECG Reimbursement
Q. We're having trouble in our Internal Medicine practice getting Medicare to pay for EKG's that were done with E&M's. We used to be in a scarcity area but our town is no longer on the list of underserved counties. Do you have any suggestions?
A. ECG's are always covered by Medicare under two circumstances:
1. Screening ECG's (patient has no symptoms of heart disease) are covered only as part of the new 'Welcome to Medicare exam, see http://www.aafp.org/fpm/20050200/15newy.html for instructions about how to code for this.
2. Diagnostic ECG's (patient has a condition that medically justifies ordering an ECG) when you put an ICD-9 code that justifies an ECG on the claim form.
The best way to determine why your claims aren't being paid is to look at the EOB. If it says 'not medically necessary', you know your problem is #2 above.
If this doesn't solve your problem, call the technical service department of the ECG manufacturer and ask them if they can help. They'll probably want you to send them a copy of an EOB so they can see why claims are being denied.
Disposing of Patient Sharps
Q. Some of our diabetics come in with old mayonnaise jars and milk cartons overflowing with used sharps. Are we required to accept them?
A. No, and because about 9 million Americans generate three billion used sharps a year at home, the EPA encourages them to use one of the following methods rather than placing sharps in the trash:
Drop box or supervised collection sites. Check with local pharmacies for availability in your area. Sharps mail-back programs.
Syringe exchange programs where self-injectors safely exchange used needles for new needles (www.nasen.org).
At-home needle destruction devices that burn or melt needles.
In California, a new law (SB1305), requires self-injectors to use approved sharps containers and dispose of them at state approved locations beginning September 1, 2008.
CLIA-Waived CBCs?
Q. Is there a CLIA-waived CBC instrument?
A. Not at this writing, but two are being considered for CLIA-waiver (Boule and Chempaq). This may be an uphill battle, though. If youÕre old enough to remember the QBC, a ÒdryÓ CBC, where fingerstick blood in a capillary tube was placed in an instrument that gave results in a couple of minutes, youÕll know that several attempts at a CLIA waiver failed. If these two new CBC products are denied a CLIA-waiver, the manufacturers are required to wait one year before re-applying. If one or both analyzers are approved, they would be ideal for small practices that canÕt maintain the volume (about 5 CBC/day) to justify purchasing a moderately complex CBC. Two caveats: These analyzers may provide fewer tests than traditional hematology analyzers do. Second, new CPT codes are needed for ÒpartialÓ CBCÕs and reimbursement for these new codes is unknown. To be a good value proposition, a CLIA waived CBC analyzer should also be reimbursed fairly. Neither criteria have been met for these products.
Masks for Pandemic Flu
Q. Are N-95 masks or regular surgical masks required in the event of a pandemic flu outbreak?
A. Surgical masks are just fine for protecting staff and patients against regular flu, but if the government announces a pandemic, then healthcare facilities must provide N-95 masks for workers to wear.
The only problem with this is that N-95 masks are backordered across the country and there aren't enough Kimberly Clark or 3M reps to fit test every worker in the event that a pandemic actually occurred this year.
This whole flu pandemic issue is hard to predict. Last year, there was a big scare about human-to-human bird flu transmission in Indonesia. But the WHO (World Health OrganizationÉnot the guys who sang ÒWe WonÕt Be Fooled AgainÓ) said that since the 12 villagers were no longer alive to transmit the bug, the evidence for human to human transmission isn't there.
But I digress. If thereÕs a shortage of either type of mask, Uncle Sam advises not to wash and reuse them, but to place a surgical mask over an N95 mask and change the surgical mask and re-use the N-95 mask. ThatÕs if youÕre not asphyxiated first! Have you ever tried walking around performing normal activities wearing a N-95 mask? Good. Now try putting a surgical mask over it and see how long it takes you to turn blue.
New H5N1 Influenza Vaccine
Q. I understand there is a new flu vaccine that is effective against a possible pandemic flu strain. My supplier said they never heard of it and cannot get it. Do you know when this will be available?
A. The FDA has finally approved a vaccine to prevent the H5N1 influenza virus (avian or bird flu), which will be kept in the government stockpile in the event that the virus begins to spread from human to human. If this occurs, the new vaccine will be used to provide initial protection for those aged 18 to 64 who are at increased risk of exposure, until a vaccine tailored to a specific pandemic strain of the virus is developed and produced. Two intramuscular injections, given about one month apart, are expected to protect about 45 percent of those who receive the vaccine. For more information, check out www.fda.gov/cber/products/h5n1san041707.htm
Pandemic Flu Guidance for the Home Setting
Q. My patients are asking me to suggest precautions for pandemic flu. What is the latest advice from our government?
A. At this writing, the latest recommendations from the Centers for Disease Control and Prevention (CDC) advise relying on social distancing and infection control as primary means of controlling pandemic flu. Advise your patients to focus on:
Hand hygiene.
Distancing people who are infected from others.
Getting treatment with antiviral medications.
Staying home when caring for family members who are ill.
.Avoiding crowded places and large gatherings.
Patients should consider wearing a facemask when:
They're sick with the flu and might have close contact (within six feet) of other people. They plan to be in a crowded place. Advise them to limit the amount of time they spend in crowded places.
Patients should consider wearing a respirator if:
They're well and expect to be in close contact with people who are known or thought to be sick with pandemic flu (such as caring for a sick person at home). Advise patients to limit the amount of time they are in close contact with them.
If your patients have additional questions about masks, respirators and pandemic influenza, advise them to call the CDC information line: 1-800-CDC-INFO.
Also, remember to provide a station in your reception area where patients have access to tissues, masks (adult and child) and hand sanitizers as well as a ÒCover Your CoughÓ poster. One such Infection Protection Station is available at http://www.quality-america.com/store/ip_station.htm
And Speaking of RespiratorsÉ.
The FDA approved two filtering facepieces, 3M Respirator 8612F and 8670F, which will be available to the general public without a prescription. Meanwhile, a study following the Katrina disaster in New Orleans proves that simple-looking N-95 respirators arenÕt goof-proof: Only 24 percent wore the mask correctly; almost 22 percent wore it upside down.
Source: Respirator donning in post-hurricane New Orleans. Emerging Infectious Diseases. May 2007 www.cdc.gov/EID/content/13/5/700.htm
EditorÕs Note: N-95 and other respirators must be fit-tested to be effective, but even Uncle Sam admits that this just won't happen for the general public. If patients are extremely paranoid about this, send them to the Web to fine a personal fit-test kit. One such example is a kit for $135 at http://store.pksafety.net/bitfitteskit.html).
ECG Reimbursement
Q. We're having trouble in our Internal Medicine practice getting Medicare to pay for EKG's that were done with E&M's. We used to be in a scarcity area but our town is no longer on the list of underserved counties. Do you have any suggestions?
A. ECG's are always covered by Medicare under two circumstances:
1. Screening ECG's (patient has no symptoms of heart disease) are covered only as part of the new 'Welcome to Medicare exam, see http://www.aafp.org/fpm/20050200/15newy.html for instructions about how to code for this.
2. Diagnostic ECG's (patient has a condition that medically justifies ordering an ECG) when you put an ICD-9 code that justifies an ECG on the claim form.
The best way to determine why your claims aren't being paid is to look at the EOB. If it says 'not medically necessary', you know your problem is #2 above.
If this doesn't solve your problem, call the technical service department of the ECG manufacturer and ask them if they can help. They'll probably want you to send them a copy of an EOB so they can see why claims are being denied.
Disposing of Patient Sharps
Q. Some of our diabetics come in with old mayonnaise jars and milk cartons overflowing with used sharps. Are we required to accept them?
A. No, and because about 9 million Americans generate three billion used sharps a year at home, the EPA encourages them to use one of the following methods rather than placing sharps in the trash:
Drop box or supervised collection sites. Check with local pharmacies for availability in your area. Sharps mail-back programs.
Syringe exchange programs where self-injectors safely exchange used needles for new needles (www.nasen.org).
At-home needle destruction devices that burn or melt needles.
In California, a new law (SB1305), requires self-injectors to use approved sharps containers and dispose of them at state approved locations beginning September 1, 2008.
CLIA-Waived CBCs?
Q. Is there a CLIA-waived CBC instrument?
A. Not at this writing, but two are being considered for CLIA-waiver (Boule and Chempaq). This may be an uphill battle, though. If youÕre old enough to remember the QBC, a ÒdryÓ CBC, where fingerstick blood in a capillary tube was placed in an instrument that gave results in a couple of minutes, youÕll know that several attempts at a CLIA waiver failed. If these two new CBC products are denied a CLIA-waiver, the manufacturers are required to wait one year before re-applying. If one or both analyzers are approved, they would be ideal for small practices that canÕt maintain the volume (about 5 CBC/day) to justify purchasing a moderately complex CBC. Two caveats: These analyzers may provide fewer tests than traditional hematology analyzers do. Second, new CPT codes are needed for ÒpartialÓ CBCÕs and reimbursement for these new codes is unknown. To be a good value proposition, a CLIA waived CBC analyzer should also be reimbursed fairly. Neither criteria have been met for these products.
Masks for Pandemic Flu
Q. Are N-95 masks or regular surgical masks required in the event of a pandemic flu outbreak?
A. Surgical masks are just fine for protecting staff and patients against regular flu, but if the government announces a pandemic, then healthcare facilities must provide N-95 masks for workers to wear.
The only problem with this is that N-95 masks are backordered across the country and there aren't enough Kimberly Clark or 3M reps to fit test every worker in the event that a pandemic actually occurred this year.
This whole flu pandemic issue is hard to predict. Last year, there was a big scare about human-to-human bird flu transmission in Indonesia. But the WHO (World Health OrganizationÉnot the guys who sang ÒWe WonÕt Be Fooled AgainÓ) said that since the 12 villagers were no longer alive to transmit the bug, the evidence for human to human transmission isn't there.
But I digress. If thereÕs a shortage of either type of mask, Uncle Sam advises not to wash and reuse them, but to place a surgical mask over an N95 mask and change the surgical mask and re-use the N-95 mask. ThatÕs if youÕre not asphyxiated first! Have you ever tried walking around performing normal activities wearing a N-95 mask? Good. Now try putting a surgical mask over it and see how long it takes you to turn blue.
New H5N1 Influenza Vaccine
Q. I understand there is a new flu vaccine that is effective against a possible pandemic flu strain. My supplier said they never heard of it and cannot get it. Do you know when this will be available?
A. The FDA has finally approved a vaccine to prevent the H5N1 influenza virus (avian or bird flu), which will be kept in the government stockpile in the event that the virus begins to spread from human to human. If this occurs, the new vaccine will be used to provide initial protection for those aged 18 to 64 who are at increased risk of exposure, until a vaccine tailored to a specific pandemic strain of the virus is developed and produced. Two intramuscular injections, given about one month apart, are expected to protect about 45 percent of those who receive the vaccine. For more information, check out www.fda.gov/cber/products/h5n1san041707.htm
Pandemic Flu Guidance for the Home Setting
Q. My patients are asking me to suggest precautions for pandemic flu. What is the latest advice from our government?
A. At this writing, the latest recommendations from the Centers for Disease Control and Prevention (CDC) advise relying on social distancing and infection control as primary means of controlling pandemic flu. Advise your patients to focus on:
Hand hygiene.
Distancing people who are infected from others.
Getting treatment with antiviral medications.
Staying home when caring for family members who are ill.
.Avoiding crowded places and large gatherings.
Patients should consider wearing a facemask when:
They're sick with the flu and might have close contact (within six feet) of other people. They plan to be in a crowded place. Advise them to limit the amount of time they spend in crowded places.
Patients should consider wearing a respirator if:
They're well and expect to be in close contact with people who are known or thought to be sick with pandemic flu (such as caring for a sick person at home). Advise patients to limit the amount of time they are in close contact with them.
If your patients have additional questions about masks, respirators and pandemic influenza, advise them to call the CDC information line: 1-800-CDC-INFO.
Also, remember to provide a station in your reception area where patients have access to tissues, masks (adult and child) and hand sanitizers as well as a ÒCover Your CoughÓ poster. One such Infection Protection Station is available at http://www.quality-america.com/store/ip_station.htm
And Speaking of RespiratorsÉ.
The FDA approved two filtering facepieces, 3M Respirator 8612F and 8670F, which will be available to the general public without a prescription. Meanwhile, a study following the Katrina disaster in New Orleans proves that simple-looking N-95 respirators arenÕt goof-proof: Only 24 percent wore the mask correctly; almost 22 percent wore it upside down.
Source: Respirator donning in post-hurricane New Orleans. Emerging Infectious Diseases. May 2007 www.cdc.gov/EID/content/13/5/700.htm
EditorÕs Note: N-95 and other respirators must be fit-tested to be effective, but even Uncle Sam admits that this just won't happen for the general public. If patients are extremely paranoid about this, send them to the Web to fine a personal fit-test kit. One such example is a kit for $135 at http://store.pksafety.net/bitfitteskit.html).