by Christopher Richards, RHIA, CCS
This series of posts will highlight potential provider vulnerabilities with respect to the OIG 2015 work plan. Our sister company, Barry Libman Inc., is available to assist you with any areas where you feel you might have potential exposure. Certainly, everyone is in full agreement that a good compliance plan strives to identify concerns before the OIG does.
FROM THE WORK PLAN:
Hospitals—Billing and Payments – Bone marrow or stem cell transplants
“We will review Medicare payments to hospitals for bone marrow or stem cell transplants to determine whether the payments were made in accordance with Federal rules and regulations. Bone marrow or peripheral blood stem cell transplantation includes mobilization, harvesting, and transplant of bone marrow or peripheral blood stem cells and the administration of high-dose chemotherapy or radiotherapy before the actual transplant. When bone marrow or peripheral blood stem cell transplantation is covered, all necessary steps are included in coverage.
“Bone marrow or stem cell transplants are covered under Medicare only for specific diagnoses. Procedure codes must be accompanied by the diagnosis codes that meet specified coverage criteria. Prior OIG reviews have identified hospitals that have incorrectly billed for bone marrow or stem cell transplants.”
HOW DO I NEED TO INTERPRET THIS?
If your facility provides bone marrow or stem cell transplant services, it becomes important to determine which procedures are covered for which diagnoses. This is a rapidly evolving area of medicine; policies exist for clinicians to submit comments to CMS related to the National Coverage Determination Manual. Frequently emerging evidence can lead to Medicare coverage under clinical trials.
The best guidelines are currently published as part of CMS Publication 100-03, The National Coverage Determination Manual, Chapter 1, Part 2, Section 110.8.1 – Stem Cell Transplantation.
This lists the specific conditions covered based on either allogenic transplantations versus autologous transplantation.