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Waiver of Coinsurance or Deductible Amounts

Where a physician/supplier makes a reasonable collection effort for the payment of coinsurance/deductibles, failure to collect payment is not considered a reduction in the physician’s/supplier’s charge. To be considered a reasonable collection effort, the effort to collect Medicare coinsurance/deductible amounts must be similar to the effort made to collect comparable amounts from non-Medicare patients. It must also involve the issuance of a bill to the beneficiary or to the party responsible for the patient’s personal financial obligations. In addition, it may include other actions, such as subsequent billings, collection letters and telephone calls or personal contacts which constitute a genuine, rather than token, collection effort.

Please keep in mind, physicians or suppliers who routinely waive the collection of deductible or coinsurance from a beneficiary constitute a violation of the law pertaining to false claims and kickbacks. When Medicare becomes aware that a provider routinely and consistently waives the collection of coinsurance or deductible amounts from or on the behalf of Medicare beneficiaries, we are required to review the circumstances to determine whether this constitutes a reduction of the provider’s actual charges.

Further information regarding this subject can be found in the CMS online internet manuals found at http://www.cms.hhs.gov/Manuals/. Please refer to the Medicare Claims Processing Manual (Chapter 23) and the Medicare Program Integrity Manual (Chapter 4). Also, information on this subject can be found in the June/July 1997 Medicare Part B Bulletin on the CIGNA Government Services Web site at http://www.cignagovernmentservices.com/publications.html.

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Q2.

A2.

The Relative Value Unit (RVU) information, including global days, for CPT codes can be found on the CMS Web site. However, there are two options in which this information may be accessed. One option is to use the fee schedule “look-up” tool. Please refer to the following instructions for the look-up tool:

1. You can access the look-up tool at http://www.cms.hhs.gov/apps/pfslookup/step0.asp. Scroll down to the bottom of the page and click on the “Start” button.
2. On the next page, choose the year for which you are interested in information. You can choose to look up a single procedure code, a list of procedure codes or a range of codes. You can also choose what type of information you are interested in viewing; for your question you should choose “Payment Policy Indicators.” Then click “Next.”
3. On the next screen, choose leave “Default fields” selected and click “Next.”
4. On the next page, enter the procedure code(s) and select “All Modifiers” from the “Modifier” drop down list. Click on the “Submit” button.
5. On the next page it will display payment policy information for all codes selected. The column marked “Global” contains the global surgery period information.

The other option in which you can access this information is to download the physician fee schedule relative value unit (RVU) file. You can access this information at http://www.cms.hhs.gov/FeeScheduleGenInfo/.

1. Click on “Physician Fee Schedule.”
2. Next, click on “PFS Relative Value Files.”
3. Under the “Calendar Year” column, select the year in which you would like to download. You will be taken to another page where you will need to click on the file name that is found in the “Downloads” section of the page.  When the screen pops up asking what you want to do with the file, select “Open.”

The file you will want to select is usually titled “PPRRVU##” (## is the last two digits of the year).  There are three versions of the file available, depending on what programs you may or may not have available to you.  (The last file in the list is a word document that provides an explanation of all the various fields of the RVU fee schedule.)

Once you have the document open, there is a column labeled “GLOB DAYS” that list the global period for every procedure code. Definitions for the global surgery indicators are:

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Q3.

A3.

Procedures codes that are specifically affiliated with the North Carolina Local Coverage Determination (LCD) policies will have a specific listing of covered diagnosis codes that are considered acceptable evidence of medical necessity. The NC LCDs can be found on our Web site at http://www.cignagovernmentservices.com/publications.html. Procedures codes that are specifically affiliated with the National Coverage Determination (NCD) policies established by CMS may also have specific listing of covered diagnoses that are considered acceptable evidence of medical necessity (e.g. Laboratory NCDs). The CMS NCD policies can be found on their Web site at http://www.cms.hhs.gov/center/coverage.asp.

However, there is not a coverage determination, local or national, for every procedure code. In the absence of a local or national coverage determination, Medicare will consider these procedure codes for diagnoses that support medical necessity.

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Q4.

The AMA approved code 90714 for tetanus vaccines. We have billed for this CPT code and received denials for this code as being an invalid procedure. Does Medicare reimburse for this code?

A4.

Due to the limited availability of the Tetanus toxoid, codes 90702 (Diphtheria and toxoids adsorbed), 90714, and 90718 are currently being covered when given for an acute injury to a person who is incompletely immunized. Also, the Physician Regulatory Issues Team (PRIT) is looking into the reported shortages of traditional TD vaccines and ways to make sure doctors are appropriately reimbursed for the vaccines they administer. An update to this issue on February 7, 2006, the PRIT states "Td with Thimerosol is still available. Boston Biological is manufacturing the vaccine and is the CDC supplier. Providers can call Henry Schein at 800.772.4346 to order this vaccine." For more information regarding the PRIT and this issue, you can access the CMS Web site at: http://www.cms.hhs.gov/PRIT/.

Although the American Medical Association (AMA) issued code 90714 in July 2005; the current "Medicare" effective date for 90714 will be January 1, 2006. Code 90714 is listed in the April 2006 CMS ASP Drug Pricing File at: http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/. The CMS MLN Matter article 4140, instructs the provider community that an update to the January 2006 Drug File was implemented on April 3, 2006. This update will allow payment for dates of service January 1, 2006-March 31, 2006, for code 90714. You can view this article in its entirety on our website at http://www.cms.hhs.gov/MLNMattersArticles/.

Guidelines from the online Medicare Benefit Policy Manual (Pub 100-2, chapter 15, section 50.4.4.2) indicate that tetanus toxoid injections are not covered as routine immunizations. Vaccines or inoculations are excluded as immunizations unless they are directly related to the treatment of an injury or direct exposure to a disease or condition. In the absence of injury or direct exposure, "preventive" immunization (vaccination or inoculation) is not covered. Chapter 30 (Financial Liability Protections) of the Medicare Claims Processing Manual (Pub 100-4), gives the guidelines for the patient's financial responsibilities of Medicare denials based on a statutory provision. You may wish to view these guidelines on the CMS at http://www.cms.hhs.gov/Manuals/IOM/list.asp.

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Q5.

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