Medicare bonus for practices: Covered services expand, thanks to budget
Medicare bonus for practices: Covered services expand, thanks to budget
Have you changed office procedures to match?
Call it a congressional version of tinkering with this year’s model of Medicare reimbursements. Just as a 1998 car may have a few enhancements over the 1997 model, Congress has beefed up its list of covered Medicare services in a few areas, courtesy of the Balanced Budget Act (BBA).
Known inside the Beltway as "Bubba," BBA brought enhanced reimbursement for several procedures. We’ve included details on the enhancements for mammographies and barium enema colorectal screenings. Other tests now eligible for Medicare payment under the BBA include prostate cancer screening tests, bone mass measurements, blood testing strips, and monitors for Type II diabetics. There also are new requirements for other types of screenings. (See related stories on p. 18 and p. 23 for more details on these requirements.)
The new rules correct a quirk in the law that provided more frequent mammographies for women aged 50 to 64 than for those over 64, even though the risk of breast cancer increases with age. It also makes coverage consistent with the recommendations of most major breast cancer authorities. This breaks down to two major types of changes:
• Equal coverage for all women age 40+. The new law expands coverage to pay for annual screening mammograms for all female Medicare beneficiaries age 40 and older, for services provided on or after Jan. 1, 1998. Previously, Medicare provided coverage of annual screening mammograms for women aged 50 to 64 and for high-risk patients aged 40 to 49. Mammograms for women over 64 and for women 40 to 49 considered at normal risk for breast cancer were previously covered only biennially.
• No more deductibles. Beneficiaries no longer have to meet a deductible before receiving coverage for screening mammographies, although they still have to pay 20% of the bill based on coverage they receive from carriers other than Medicare. However, all mammographies are not created equal. Beneficiaries still must meet deductible and coinsurance requirements for post-screening diagnostic mammographies performed when a potential problem is found. Prior law required beneficiaries to pay any portion of the Part B deductible not already provided for, plus a 20% out-of-pocket cost for both screening and diagnostic mammograms. The new law waives the deductible for screening mammograms for services starting in 1998.
Mammography screenings aren’t the only area where your practice can receive a reimbursement boost. HCFA decided barium enema screening exams are a viable alternative to flexible sigmoidoscopy in certain cases, and declared they are covered by Medicare as of Oct. 31, 1997.
This additional coverage doesn’t come cheap to the government. HCFA estimates it will cost the Medicare program $160 million in fiscal year 1998 and an additional $2.36 billion between fiscal years 1999 and 2002.
Details of the barium screen boost
The action is part of the Medicare cancer screening provisions of the Balanced Budget Act, which was signed into law last August. These provisions required Health Care Financing Administration to decide whether to include barium enema coverage under its approved colorectal cancer screening tests. Other colorectal cancer tests eligible for Medicare payment include fecal-occult blood tests, flexible sigmoidoscopies, and colonoscopies.
Under HCFA’s new barium payment rules:
Physicians must confirm in writing that "the estimated screening potential . . . is equal to or greater than the screening potential that has been estimated for a flexible sigmoidoscopy for that same individual."
Low-risk patients over 50 are only eligible for one Medicare-paid screening every four years.
High-risk individuals are covered "as an alternative to screening colonoscopy," for which Medicare will pay only once every two years.
Double-contrast barium enema becomes the standard type of screening because of its ability to detect small colonic lesions in patients who are "adequately prepared and optimally imaged."
One final piece of good news: Besides barium screens, HCFA also increased payments for positron emission tomography (PET) myocardial perfusion imaging tests. In turn, the agency is raising the work relative value units (RVUs) for the single PET myocardial perfusion image to 1.50 RVUs, and is raising the the multiple PET myocardial perfusion image RVUs to 1.87.
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