DMERC downcodes CRI's Lasette Plus

Friday, May 31, 2002

ALBUQUERQUE, N.M. - The joy Cell Robotics International broadcast in January when the company found out that the allowable on its new blood sampling device came in at $870 has turned into a frustrating educational lap around DMERC policy.

Soon after a provider filed a claim for the E0260 in early March, CRI learned a hard lesson about downcoding. While the provider, and CRI, expected the claim to yield $870, the DMERC declined to cover the item and downcoded the claim to a fraction of the Lasette Plus's allowable.

"A punch in the face would have been as big a surprise," said CRI's COO Paul Johnson. "It came in out of the blue."

CRI said it flew an ombudsman from Palmetto GBA out to its offices for clarification on reimbursement for the product.

"We knew the black and white on downcoding," said Terry Hamilton, CRI's director of sales and marketing, "and we asked if he saw a problem with downcoding. He said, 'No, you're good to go at $870.'"

Palmetto GBA said the issuance of a HCPCS code and a published allowable do not guarantee the payment will be covered under Medicare. In the spring revisions to the DMERC manuals, the carriers rolled the Lasette Plus into the existing medical policy for general diabetes supply.

"It could be that this particular product offers no medical benefit above and beyond the least costly alternative," said Elaine Hensley, manager of DMERC professional relations at Palmetto GBA.

CRI is appealing the downcoding decision through the offices of its Congressional representatives. HME