Regulatory Alert

Over the past week, the ISCD has received multiple calls from members in a number of states regarding the improper denial of Medicare (Part B and some Part A) claims for routine axial DXA studies (CPT code 77080). After several phone calls and conversations with members, carriers, and CMS, it appears that the problem emanated from a CMS memo sent in early July 2007, interpreting the rule that took effect last January. ISCD promptly notified CMS of this problem, and they are working with ISCD and a number of carriers to rectify this situation.

The CMS memo that was the source of the problem, intended to explain two things: (1) axial DXA is now the only technology for measurement of bone mass that will be reimbursed by CMS for patients being monitored for response to FDA–approved drug therapy; and (2) for an individual already on or planning to be treated with glucocorticoids the minimum dosage requirement for prednisone or equivalent had been reduced from 7.5 to 5 mg/day.

Unfortunately, the CMS newsletter issued as part of Medicare Learning Network (MLN) is confusing because it states:

“BMM (bone mass measurement) is covered when dual-energy x-ray absorptiometry is used to monitor osteoporosis drug therapy. Therefore, Medicare will pay procedure code 77080 when billed with the following ICD-9-CM diagnosis codes or any of the other valid ICD-9 diagnoses that are recognized by Medicare contractors appropriate for bone mass measurements (bold is ours and not in the CMS memo to carriers): 733.00, 733.03, 733.02, 733.04, 733.09, 733.90, and 255.0.”

Several carriers including those in California, Florida, Michigan, Wisconsin, and Maryland have ignored the bolded language above, and as a result, are only covering for the ICD-9 codes listed above and denying DXA claims for appropriately qualified individuals such as estrogen deficient women, hyperparathyroidism, patients on glucocorticoids, or screening codes approved by the specific local Medicare carrier.

Additionally, you should know that as recently as December 2006, CMS has refused to provide specific ICD-9 codes for each category of qualified individual.

“…our original intent was that local Medicare contractors were to be responsible for developing those appropriate specific diagnostic coding guidelines for the physicians and other providers in their respective localities and for communicating those guidelines to them and to the general medical community, and they have been doing that successfully since 1998. We expect our contractors will continue to do this as necessary in the future.”

By departing from this policy ISCD believes that the authors of the MLN have created further confusion.

As mentioned, CMS is keenly aware of the problem and is working with their regional offices, the carriers and ISCD to rectify this misinterpretation of the law and regulations as quickly as possible.

State Specific Recommendations from the ISCD

California

California appears to have the largest problem identified to date:

Part B: The Part B carrier, National Heritage Insurance Company (NHIC), recognizes the billing error and is working to automatically adjust the claims that have already been denied. If the carrier has requested medical justification for the denied claims and you have not done so, you do not need to supply this documentation and the claims should be approved. If you have already complied with the request for the medical justification, the claim should be approved through the “auto-adjust” process. In either case, providers should not have to take additional steps to be reimbursed for these claims.

Part A: While the Part A carrier acknowledges the problem, they have not resolved it. They are hoping to address the problem in the next two weeks. In the meantime, the carrier recommends that providers hold claims until they are notified that the problem has been resolved.

North Dakota

Part A: The Part A carrier in North Dakota, Noridian Administrative Services, has identified and resolved the problem of improperly denied DXA claims and has sent a memo to providers. Noridian will adjust all claims that were denied after July 1, 2007 to the present. Providers are not required to file appeals or to take any further action. The mass adjustments will be completed by September 14.

Other States

ISCD is aware of similar improper denials of DXA claims submitted after July 1, 2007 to Medicare carriers in Florida, Maine, Maryland, Ohio, Pennsylvania, Vermont, and Wisconsin. If you are experiencing problems in those states, the ISCD recommends the following:

Contact the carrier by phone or e-mail using the sample provider letter (link below) to explain why the claims have been improperly denied;
If you have been asked to provide medical justification for routine DXA claims, do not spend time and money doing this without contacting the carrier first;
If you continue to have problems, contact the CMS regional office about the issue. They have been made aware of the error and should be able to help you navigate the problem; and
If your patients have already been notified that the DXA you ordered or performed is not a Medicare covered service, you can send a copy of the ISCD suggested patient letter (link below). The letter explains the CMS error in simple straightforward language.

Sample Provider Letter

ISCD Suggested Patient Letter

Let us know if you are having problems in other states not listed, in particular, states which have Noridian, NHIC, First Coast Services Option Trailblazer, or Wisconsin Physician Services as the local Medicare carrier. ISCD will attempt to contact the Medical Director of the particular carrier to help facilitate a quick resolution.

In the coming weeks, ISCD will continue to work with carriers, CMS and our members to try to assist in any way. If you have questions, contact Donna Fiorentino, Manager of Public Policy Affairs at dfiorentino@iscd.org.