Fall Brings More Changes

GAO Recommendations for Competitive Bidding

    In a report¹ released on September 9, 2004, the Government Accountability Office (GAO) made several recommendations to the Centers for Medicare and Medicaid Services (CMS) for the competitive bidding program slated by the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) to begin in 2007.

Two competitive bidding demonstration projects for eight product groups (including surgical dressings and urologicals) were conducted between 1999 and 2002 in Texas and Florida. The GAO recommends that the CMS use the observations and conclusions from the results of these two projects as a blueprint for the nationwide program.

    Specifically, the GAO recommends the CMS include the same DME items that were selected for the demonstration projects as well as non-demonstration items that account for high levels of Medicare spending (eg, power wheelchairs and lancets and test strips used by persons with diabetes). The report also suggests two ways to develop methods of streamlining implementation of such a large program: 1) develop a template program that could be replicated in multiple geographic areas, and 2) use mail-order delivery for some items with uniform fees set through a nationwide competition.

    Bids are to be submitted based on items within a specific HCPCS category. Because a single HCPCS includes a broad range of products used for the same purpose but that are different in characteristics and price, the GAO is concerned that suppliers could substitute lower-priced items to reduce their costs. The GAO recommended that the CMS collect specific information such as manufacturer make and model on competitively bid items.

    The GAO report also expresses concern that the program has the inherent potential to underserve some beneficiary populations (particularly those in rural areas) and that suppliers might not deliver quality items and services. The GAO recommends that the CMS develop a plan to routinely monitor the program to prevent such occurrences and reduce the potential of fraud and abuse.

CMS Appoints DME Competitive Bidding Advisory Panel

    The CMS has selected 21 people from hundreds of nominations to serve on a committee that will advise the Centers on the implementation of competitive bidding, the establishment of financial and quality standards for suppliers who want to participate in the Medicare program, beneficiary access issues, and educational strategies. The committee members represent industry, government, home care, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), physicians, and assistive technology and prosthetics and orthotics. The committee was scheduled to hold its first meeting in early October 2004.

Changes in Non-physician Practitioner Billing in SNF and NF

    Effective October 25, 2004,² the way physicians and non-physician practitioners are paid in a nursing facility has been changed. Payment policy has been revised so non-physician practitioners (NPPs) such as clinical nurse specialists (CNS), nurse practitioners (NP), and physician assistants (PA) may provide other covered, medically necessary visits before and after the initial visit by the physician.

    Only a physician is permitted to conduct an initial comprehensive visit (required no later than 30 days after admission) in a skilled nursing facility (SNF) and nursing facility (NF). This responsibility may not be delegated to a NPP. The physician then develops a plan of care and writes or verifies admitting orders for the resident. Generally, CPT code 99303 is used to bill for this visit.

    Other resident assessments may be performed and billed by a physician or NPP. CPT codes (99301-99302) are used for other comprehensive nursing facility assessments to report the evaluation and management services (E/M) involved with the annual assessment or to report a significant complication or a significant new problem that results in a major permanent change in health status. The physician or NPP may bill for these services using CPT codes 99301 or 99302 after the physician has performed and reported the initial comprehensive assessment.

    Skilled nursing facility. Visits to comply with skilled nursing facility (SNF) regulations after the initial visit by the physician may be delegated to a NPP who is working in collaboration with the physician. NPPs also may provide other medically necessary visits before and after the physician performs and reports the initial assessment visit. CPT codes 99301, 99302, and 99311 through 99313 are used for these visits, depending on the clinical status of the patient and the circumstances of the visit.

    Nursing facility. A NPP who is not an employee of the NF in which he/she provides a Part B Medicare service is covered and paid for medically necessary visits and other federally required visits (other than the initial visit provided by the physician) in a NF (including tasks which the regulations specify must be performed personally by the physician — ie, visits), at the option of state regulations Non-physician practitioners employed by the NF may not perform or be paid for the initial comprehensive visit or any other federally required visits. Non-physician practitioners who are employed by the NF may perform other medically necessary visits. If NPs and CNSs employed by a NF opt to reassign payment for their professional services to the NF, the NF can bill the appropriate Medicare Part B carrier under the NPs’ or CNSs’ UPINs (Unique Physician Identification Number) for their professional services. Alternatively, NPs or CNSs who are employed by a NF may bill the carrier directly for their services to NF residents. The NF must always bill the Part B carrier using the PA’s UPIN for the PA’s professional services to NF residents.

1. US Government Accountability Office. Report to Congressional Committees. Medicare: Past Experience Can Guide Future Competitive Bidding for Medical Equipment and Supplies. September 2004. GAO-04-765. Available at: www.gao.gov. Accessed October 3, 2004.

2. Department of Health and Human Services. Centers for Medicare and Medicaid Services Manual System. Pub. 100-04 Medicare Claims Processing, Transmittal 302, Nursing Facility Visits Codes 99301-99313). September 24, 2004. Available at: www.cms.hhs.gov/manuals/pm_trans/R302CP.pdf. Accessed October 4, 2004.