Flaws in Medicare coding interpretations

We work with medical oncologists/hematologists across the country in both the private practice and hospital settings. Based on our experience, I'd like to point out a couple of key flaws in the current Medicare code interpretations.

First, several of our oncology physician clients in various states have recently experienced what I consider to be unfair treatment and flat out harassment by local carriers over the topic of “medical necessity”. Local Medicare carriers have taken it upon themselves to “down code” many of these physicians’ visits without foundation (mainly those billed at level V) and send them accompanying letters that are threatening in nature.

We have conducted our own audits on these charges in question and feel that thorough documentation has been provided in every case to warrant appropriate billing. Within a specialty like oncology, we should expect to see high-level coding on a regular basis. The local carriers do not believe these visits met the criteria of “medical necessity”, thus their decision was to “down code”. Their interpretation of the national Medicare regulation is that a level V visit requires a “new medical problem”. We disagree.

We firmly believe these physicians have billed for legitimate services within the published guidelines, and their notes reflect as such. We feel these local carriers are acting wrongly and unfairly. There is no documentation published at either the local or national level stating that a “new medical problem” is required to bill higher level codes.

Over the past few years, we requested numerous ALJ hearings in response to these down-coding situations and have won several of them – one as recent as this month for an oncology practice in Paducah, Kentucky.

That leads me to the second problem needing to be addressed. While we keep winning local ALJ hearings, our physicians continue to get down-coded for the same reasons over and over again. There appears to be no process (or the current process is flawed) for taking these ALJ Hearing victories up the food chain and communicating them to the proper people – so that local carriers can become informed in order to keep these same errors from happening to other physicians. A related issue is that the ALJ victories apply to only the specific charts that the carriers have audited. They then go after more charts for these same physicians, and the process starts all over again. It’s a waste of the physicians’ time and a waste of tax payer’s money.

What should we do to fix this situation?