Large group practices are cutting physicians’ salaries, laying off personnel. Office visits are decreasing 20% while home calls are increasing.  Home healthcare companies are advertising on television, along with pharmaceutical companies.  The number of prescriptions filled in 2008 decreased for the very first time.

Elective and preventative services have declined which will increase treatment for acute care.  Knee replacements have decreased 20% between 2007 and 2008, for example. 

BCN has refused participation to family physicians If they do not practice within the parameters set for the average family practitioner peer group.  If the physician decides to increase his scope of practice to better serve his population he faces de-participation.  I feel that we should, as a group, oppose this practice.

We have yet to receive a reply to our inquiry as to the savings, if any, since the inception of the AIMS program.  It would also be interesting to find out how much BC paid to this company since the contract was implemented.

Higher deductibles and delayed insurance payments have forced physicians to require payments up front and to limit the amount of Medicaid and Medicare patients in their practices.  Investment in technology along with EMR discourages small practices.  The stimulus package for EMR does not even start until 2011 and is staged over five years.  The bonuses given now for participation will disappear by that date. 

We all know that E/M services payments will not, by themselves, economically sustain a family practice.  Yet Blue Cross constantly gives lip service to primary care and the Patient Centered Medical Home and indeed declared itself as the credentialing agency for the PCMH, while limiting the amount of ancillary services that the PCMH can provide.

These last two actions, refusing to pay for advanced technology and credentialing of PCMH are incompatible.  If we are not allowed to provide advanced services to our patients there will be no homes for them to credential.

Premiums for health care insurance increased 120% in the past ten years and averages $12,700 for a family of four.  A large part of this cost is because of fragmentation of care.  We are willing to foster wellness under any heading but we must try to reduce re-duplication and fragmentation of services and supplies.  We can do this, we are the base.

We have available for you two pamphlets, Model for In Patient OMT Service and OMT coding and reporting. Also available for you is an Osteopathic Manipulative Treatment Record.

We must remember Dr. Howard Sobel who recently deceased who single handedly forced us to stop smoking at our conventions.  Kudos is extended to Hillers Markets, a supermarket chain that has stopped selling tobacco products out of civic consciousness.

If you are an employed physician, almost 50% of us are, please let us know of any problems you may have.

Abstracted by Samson Inwald, D.O., FACOFP, dist. 

Carrier Advisory Committee Notes - January 27, 2010.

Carrier Advisory Committee Notes - September 9, 2009.

These guidelines are proposed twice a year and submitted to us for comment.  They are complicated and do not always pertain to family practice.  I have abstracted those I think significant and may help us in coding and reporting accuracy.  We have on file the complete document for each of these services. 

Treatment of Varicose Veins of the Lower Extremities (for those of us who do this)
Endoluminal radiofrequency ablation (ERFA) and endoluminal laser ablation have been developed as alternatives to sclerotherapy and surgical intervention.    Evidence and clinical experience supports the use of ultrasound guidance during the procedure (ERFA and laser ablation only).  Intra-operative ultrasound guidance techniques have not been shown to increase the effectiveness or safety of sclerotherapy. 

The treatment of spider veins/telangiectasis (36468) will be considered medically necessary only if there is associated hemorrhage (IDC-9 459.0).

Vitamin B 12 Injections
The physician should not give B12 just because the patient has one of the causes, but only after a deficiency has been documented by serum assay.  Accordingly, when a patient shows neurophychiatric abnormalities, and the serum B12 is low normal, i.e., below 350/pg/ml, the physician may, in the absence of methylmalonic acid or homocysteine tests, presume a B12 deficiency and treat the patient with B12.

Medicare does not cover therapy to achieve supranormal B12 levels.

CPT/HCPCS Codes
J3420             Injection, Vitamin B12 Cyanocobalamin, up to 1000 mcg

ICD-9 Codes that Support Medical Necessity
266.2              Other B-complex deficiencies
281.0              Pernicious anemia
281.1              Other Vitamin 12 deficiency anemia
281.3              Other specified megaloblastic anemia not elsewhere classified
564.2              Postgastric surgery syndromes
579.3              Other and unspecified postsurgical non absorption

Utilization Guidelines
Typical dosing is once monthly with the adult maintenance dose typically ranging from 100-1,000 micrograms.  Initial injections may be more frequent until a steady level is reached.

Immune Globulins
It may be administered either by intravenous (IV) or intramuscular (IM) injection.

1.  Immune serum globulin intramuscular (IM) (IG, Gamma Globulin, ISG, Gamastan, Gammar, (HCPCS codes J1460-J1560) is indicated for the following conditions:

• Hepatitis A
• Measles
• Rubella
• Varicella
• Immunoglobulin Deficiency – when circulating lgG levels are low.

One of the following complicating conditions must be noted to verify necessity; Personal history of leukemia or lymphoma, HIV infection or current immunosuppressive therapy.

2.  Cytomegalovirus immune

3.  Intravenous immune globulin (IVIG) may be indicated for Immunodeficiency Syndrome, Primary thrombocytopenia, Alloimmune thrombocytopenia, plus 25 others.

CPT/HCPCS Codes – J0850 through J1573
ICD-9 Codes that support medical necessity are available.

Bisphosphonate Drug Therapy
Coverage by Medicare is limited to those drugs administered parenterally (IV):
Etidronate disodium (Didronel) orally and  IV (J1436), Pamidronate disodium (Aredia) IV (J2430), Zoledronic acid (Zoledronate), (Zometa) IV (J3487), Zoledronic acid, (Reclast) IV J3488), and Ibandronate (Boniva) oral and IV (J1740).

CPT/HCPCS Codes
J1436, J1740, J2430, J3487, J3488
ICD-9 Codes that Support Medical Necissity
J1436 – Etidronate
J3487 – Zolendronic acid (Zoledronate)
J3488 – Zolendronic acid (Reclast)
J2430 – Pamidronate
J1740 – Ibandronate (Boniva)

Intra-articular Injections of Hyaluronan
This treatment will only be covered for the treatment of pain in osteoarthritis of the knee joint.  It is covered in patients who have failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics.  There must be radiological evidence to support the diagnosis of osteoarthritis.

CPT/HCPCS Codes
J7321 Hyaluronan or Derivative, Hyalgan or Supartz, for Intra-Articular Injection Per dose
J7322  Hyaluronan or Derivative, Synvisc, For Intra-Articular Injection Per dose
J7323 Hyaluronan or Derivative, Euflexxa, For Intra-Articular Injection Per dose
J7324  Hyaluronan or Derivative, Orthovisc, For Intra-Articular Injection, Per dose
J3490  Hylan G-F 20, Synvisc-One
C9399  Hylan G-F 20 Synvisc One
20610 Arthrocentesis, aspiration or injection (knee)

ICD-9 Codes that support medical necessity
715.16           Osteoarthritis, localized, primary of the lower leg (knee)
715.26           Osteoarthritis, localized, secondary of the lower leg (knee)
715.36           Osteoarthritis, localized, not specified whether primary or secondary of the lower leg (knee)
715.96           Osteoarthiritis, unspecified, whether generalized or localized of the lower leg (knee)

Thrombopoietic Growth Factor – Please call for further information.

Injections – Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton’s Neuroma
Indications – when other conservative therapy has not provided acceptable relief, is contraindicated or not appropriate and when there is reasonable likelihood that the injection will significantly improve the patient’s pain and/or functional disability.

• Morton’s neuroma
• Carpal Tunnel or Tarsal Tunnel

Non-covered services

• Prolotherapy
• Dry needling of ganglion cysts, ligaments neuromas, tendon sheaths and their origins
• Vitamin B12 injections to strengthen tendons

CPT/HCPCS Codes
20526, 20550, 20551, 20612, 64455, 64632, 28899
ICD-9 Codes that Support Medical Necessity – available upon request.

Utilization Guidelines

• should be resolved with one to three injections
• The medical necessity for injections of more than two sites at one session or for frequent or repeated injections would be rare

Please contact our office at (800) 657-1556 to request information on the following additional LCD’s

Trigger Points, Local Injections
Optometrist Services
Cataract Surgery and Complex Cataract Surgery
Flow Cytometry
Helicobacter Pylori Testing
Selective Internal Radiation Therapy (SIRT) for Primary and Secondary Hepatic Malignancy

ICD-10 will take effect soon (see sample router).

• 2009 bonus 2%
• In 2011 they will deduct 2% if not done