DRG Coding Advisor-HCFA announces reimbursement changes

Pap smears, prostate exams affected

Beginning Jan. 1, the Health Care Financing Administration (HCFA) made several changes to Medicare payment policies. Here's a summary:

1. Pap smears. Codes for a physician's interpretation of an abnormal Papanicolaou (Pap) smear were revised in November 1998 to include three HCPCS level II codes (P3001, G0124, and G0141), in addition to the CPT code 88141.

HCFA now says it is more appropriate to evaluate the work, practice expense, and malpractice relative value units for those codes identically to the values for CPT code 88141. The practice expense RVUs are now identical for HCPCS codes P3001, G0124, and G0141.

2. End-stage renal disease. Reacting to concerns about the application of the site-of-service differential to the monthly capitated payment (MCP) for end-stage renal disease services (CPT codes 90918 through 90921), HCFA agreed that site-of-service designations are not meaningful for a monthly service that may be provided in different settings for the same patient in a given month. The final rule specifies that codes 90918 through 90921 "should always be reported as a non-facility service."

3. Prostate cancer screening tests. Provides for Medicare coverage of an annual prostrate cancer screening digital rectal examination (DRE) and an annual screening prostate-specific antigen (PSA) test for men at least age 50, plus one day. To qualify, the DRE screening must be performed by the patient's attending physician who is either a doctor of medicine or qualified osteopathy — or by the beneficiary's attending physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife.

HCFA also created two new HCPCS codes to go with the new regulation:

— HCPCS G0102, prostate cancer screening DRE, to be used for the screening DRE. Because "a DRE is a relatively quick and simple procedure . . . we have assigned it the same value as CPT code 99211, the lowest level E/M service," according to HCFA.

DREs bundled

Because a DRE is usually furnished as part of an E/M service, the agency feels it would be extremely rare for a DRE to be the only service provided during a patient encounter. As such, it is also bundling the DRE into the payment for an E/M service when a covered E/M service is furnished on the same day as a DRE.

"If the DRE is the only service furnished or is provided as part of an otherwise non-covered service, such as CPT code 99397 (preventive services visit), HCPCS code G0102 would be payable separately if all the aforementioned coverage requirements are met," notes the rule.

— HCPCS G0103, prostate screening, prostate specific antigen (PSA), to be used for the screening PSA test. The screening PSA test is priced at the same payment rate as CPT code 84153 (PSA, total) and will be paid under the clinical diagnostic laboratory fee schedule.

4. Physician pathology services and independent laboratories. Payments are ended to independent laboratories under the physician fee schedule for technical component physician pathology services furnished to hospital inpatients. (This provision does not affect hospitals that provide pathology services through hospital laboratories).

Independent laboratories still can bill and receive payment from their Medicare carrier for the technical component of a physician pathology service furnished to beneficiaries who are not hospital inpatients. For the technical component of physician pathology services provided to a hospital inpatient, the hospital will have to bill, and the independent laboratory will have to make arrangements with the hospital to receive payment.