March 2003 Part B Medicare Bulletin
Table of Contents
CMS-1500 (12/90) Claim Form – Reminder!
All Medicare claims must be submitted in an approved format according to CMS's claim filing instructions. Claims may be submitted electronically or on the standard CMS-1500 (12/90) claim form.(*)
The CMS-1500 (12/90) claim form is the basic paper form for billing Medicare Part B claims. Medicare does not accept superbills in lieu of completing existing data fields on the CMS-1500 (12/90) form. Providers should also note that only one procedure per line is allowed. If there are more than six services to submit, a second claim form must be completed.
Please be especially mindful of the miscellaneous procedure codes that require a description of service. The description of service in these instances must be in item 19 of the CMS-1500 (12/90) claim form, or on an attachment.
For example, procedure code J3490 is listed as an 'unclassified drug.' The drug's name and dosage must be listed in item 19 of the CMS-1500 (12/90) claim form or on an attachment. Another example is procedure code A0999, which is listed as 'unlisted ambulance service.' The description of the service must be in item 19 of the CMS-1500 (12/90) claim form or on an attachment.
Item 24d of the CMS-1500 (12/90) claim form is used for the submission of procedure codes and modifiers. It is not acceptable to enter descriptions of services in this field.
Regardless of your speciality, the CMS guidelines for completing the CMS-1500 (12/90) claim form must be followed. Please refer to CMS’s Web site http://cms.hhs.gov/providers/edi/edi5.asp for complete CMS-1500 (12/90) claim form instructions.
(*) Effective October 16, 2003, all Medicare claims must be submitted electronically in accordance with the Administrative Simplification Compliance Act (ASCA) of 2001. The ASCA prohibits HHS from paying Medicare claims that are not submitted electronically after this date unless the Secretary grants a waiver from this requirement. CIGNA Government Services is awaiting further instruction on the waiver process and will share that information with you via the Express Email Notification System as well as the Medicare Bulletin. To subscribe to our free Express Email Notification System, visit www.cignamedicare.com.
Top2003 DMEPOS Codes Payable by Part B
| CODE | ID | NC | TN |
|---|---|---|---|
| A4561 | 18.63 | 19.22 | 19.22 |
| A4562 | 46.39 | 47.78 | 47.78 |
| A6259 | 10.94 | 10.94 | 10.94 |
| A6402 | 12.00 | 12.00 | 12.00 |
| A7042 | 167.36 | 169.52 | 169.52 |
| A7043 | 23.52 | 23.31 | 23.31 |
| E0616 | 2,145.36 | 2,145.36 | 2,145.36 |
| E0749 | 256.13 | 217.71 | 217.71 |
| E0752 | 375.69 | 372.52 | 372.52 |
| E0754 | 865.16 | 916.00 | 916.00 |
| E0756 | 6,824.17 | 6,767.01 | 6,767.01 |
| E0757 | 4,875.73 | 4,834.90 | 4,834.90 |
| E0758 | 4,291.77 | 4,255.80 | 4,255.80 |
| E0759 | 635.20 | 558.88 | 558.88 |
| E0782 | 3,867.08 | 3,867.08 | 3,867.08 |
| E0783 | 7,141.27 | 6,267.85 | 6,267.85 |
| E0785 | 361.74 | 361.74 | 361.74 |
| E0786 | 7,192.83 | 7,192.83 | 7,192.83 |
| L7520 | 24.81 | 22.43 | 22.43 |
| L8600 | 584.87 | 500.79 | 500.79 |
| L8603 | 353.26 | 351.71 | 351.71 |
| L8606 | 179.14 | 184.62 | 184.62 |
| L8610 | 532.01 | 513.68 | 513.68 |
| L8612 | 580.80 | 541.78 | 541.78 |
| L8613 | 241.39 | 242.57 | 242.57 |
| L8614 | 15,065.66 | 15,353.47 | 15,353.47 |
| L8619 | 6,467.57 | 6,586.07 | 6,586.07 |
| L8630 | 270.19 | 270.19 | 270.19 |
| L8641 | 374.30 | 293.24 | 293.24 |
| L8642 | 246.32 | 240.71 | 240.71 |
| L8658 | 326.35 | 251.57 | 251.57 |
| L8670 | 446.41 | 446.41 | 446.41 |
Inclusion or exclusion of a fee schedule amount for an item or service does not imply any health insurance coverage. [EM 2002-1280/CR 2378]
EDI and HIPAA – A Winning Combination!
CIGNA Government Services offers a variety of EDI services for your office! Not only can you send your Medicare claims electronically, you can also check the status of your assigned claims, determine whether a patient is eligible for the Medicare program - even receive your Medicare payments electronically! Plus - you can even receive your Remittance Notice, receipt listings and error reports electronically! Does this sound good to you?
Health care providers who use EDI see improvements in office operations including reduced administrative costs, streamlined cash flow and fewer claim-related errors.
And - EDI makes it easy to submit corrected or rejected claims…electronically. Imagine! No more paper claims!
Combine the power of EDI with the new HIPAA (Health Insurance Portability and Accountability Act) standards and you have a WIN-WIN combination! Why settle for manual preparation and longer payment periods when you can streamline the process and improve your cash flow? Log on to our Web site for details on EDI services, www.cignamedicare.com/edi/Index.html.
While you’re online, don’t forget to register for one of our Medicare workshops. We’ll show you even more benefits of EDI and HIPAA!
Hand-Carried Ultrasound (HCU)
Hand-carried ultrasound (HCU) units are lightweight ultrasound machines with Doppler capability. Suggested uses range from basic vascular office testing to emergency room and ICU applications where a physical examination of the thorax or abdomen may be enhanced by an ultrasound examination, especially during emergency situations when a standard ultrasound exam would require additional time to obtain.
These devices are an extension of the physical examination and are not intended to replace standard ultrasound evaluations. The studies allow only a limited view of structures, and the quality of tests performed by clinicians with minimal training (including non-cardiologists and non-radiologists) is not comparable to that obtained by standard machines and fully trained technicians and interpreting physicians. Although, the use of this modality may augment the physical examination, it does not replace testing in a dedicated laboratory with trained and credentialed personnel utilizing dedicated equipment.
Until CMS and the AMA Relative Values Update Committee have reviewed the payment issues surrounding these services, they should not be billed under traditional diagnostic ultrasound codes (CPT 93307 - 93350, CPT 93875 - 93882, or CPT 76506 - 76999). Medicare considers a hand-carried ultrasound study to be part of the complexity of the physical examination and not separately reimbursable.
Implementation of the Financial Limitation for Outpatient Rehabilitation Services
Background
Section 4541(a)(2) of the Balanced Budget Act (BBA) (P.L. 105-33) of 1997, which added §1834(k)(5) to the Social Security Act (the Act), required payment under a prospective payment system for outpatient rehabilitation services. Outpatient rehabilitation services include the following services:
- Physical therapy (PT) (which includes outpatient speech-language pathology); and
- Occupational therapy (OT).
Section 4541(c) of the BBA required application of a financial limitation to all outpatient rehabilitation services (with the exception of outpatient departments of a hospital) of an annual per beneficiary limit of $1500 for all outpatient PT services (including speech-language pathology services) and a separate $1500 limit for all OT services. The $1500 limit is based on incurred expenses and includes applicable deductible ($100) and coinsurance (20 percent). The annual limitation does not apply to services furnished directly or under arrangement by a hospital to an outpatient, or to a hospital inpatient who is not in a covered Part A stay. The BBA provided that the $1500 limits be indexed by the Medicare Economic Index (MEI) each year beginning in 2002. This indexed amount is $1590 for 2003.
The limitation is based on the services the Medicare beneficiary receives, not the type of practitioner who provides the service. Therefore, physical therapists, speech-language pathologists, occupational therapists as well as physicians and non-physicians practitioners could render a therapy service.
As a transitional measure, effective January 1, 1999, providers were instructed to keep track of the allowed incurred expenses. This process was put in place to assure providers did not bill Medicare for patients who exceeded the annual $1500 limitations for PT and for OT services rendered by individual providers.
Moratorium on Therapy Claims
Section 211 of the Balanced Budget Refinement Act of 1999 placed a 2-year moratorium on the application of the financial limitation for claims for therapy services with dates of service January 1, 2000 through December 31, 2001. Section 421 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, extended the moratorium on application of the financial limitation to claims for outpatient rehabilitation services with dates of service January 1, 2002, through December 31, 2002. Therefore, the moratorium was for a 3-year period and applied to outpatient rehabilitation claims with dates of service January 1, 2000, through December 31, 2002.
Application of Financial Limitation
The moratorium on the application of the financial limitation is no longer in effect. As a result, the following instructions, regarding the financial limitation, supersede current instructions in §3653.Q and 3653.R of the Medicare Part A Intermediary Manual, Part 3. Beginning with claims submitted for dates of service on and after July 1, 2003, apply the financial limitation for OT and PT (including speech-language pathology) services in a prospective manner through December 31, 2003. For CY 2003, the financial limitation could not be implemented prior to July 1, 2003 because of systems limitations. For each subsequent calendar year the financial limitations will be effective for the entire calendar year.
There are two separate $1590 limitations: one for PT (including speech-language pathology) services and the other for OT services. Effective July 1, 2003, for claims with dates of service on or after July 1, 2003, the Common Working File (CWF) will track the $1590 PT (which includes speech language pathology services) and the $1590 OT financial limitation for outpatient rehabilitation services.
This financial limitation is an annual per beneficiary limitation. The $1590 limitation is on the allowed incurred expenses, which are defined as the Medicare Physician Fee Schedule (MPFS) amount prior to any application of deductible ($100) and co-insurance (20 percent). If the beneficiary has already satisfied the Medicare Part B deductible, the maximum amount payable by the Medicare program is $1272; that is 80 percent of the $1590 for PT (including speech language pathology) and 80 percent of the $1590 for OT. The beneficiary is responsible for paying the remaining 20 percent co-insurance.
See the following examples:
EXAMPLE I - Part B Deductible Previously Met:
$1590 (MPFS allowed amount) x 80 percent = $1272 (Medicare reimbursement).
The amount applied to the limitation in this example is $1590. The Medicare program pays $1272 and the beneficiary is responsible for $318 co-insurance.
EXAMPLE II - Part B Deductible Not Met:
$1590 (MPFS allowed amount) - $100 (Part B deductible) = $1490 x 80 percent = $1192 (Medicare reimbursement).
The amount applied to the limitation in this example is $1590. The Medicare program pays $1192 and the beneficiary is responsible for $398, ($100 Part B deductible and $298 co-insurance).
EXAMPLE III - Part B Deductible Previously Met:
$800 (MPFS allowed amount) x 80 percent = $640 (Medicare reimbursement).
The amount applied to the limitation in this example is $800. The Medicare program pays $640 and the beneficiary is responsible for $160 co-insurance.
EXAMPLE IV - Part B Deductible Not Met:
$800 (MPFS allowed amount) - $100 (Part B deductible) = $700 x 80 percent = $560 (Medicare reimbursement).
The amount applied to the limitation in this example is $800. The Medicare program pays $560 and the beneficiary is responsible for $240, ($100 Part B Deductible and $140 co-insurance).
NOTE: In the above examples the MPFS allowed amount is the lower of charges or the MPFS rate
times the unit.
The CWF will be tracking the financial limitation based on presence of therapy modifiers GN, GO, and GP; therefore, providers/physicians/suppliers must continue to report one of these modifiers for any therapy service that is provided. The definitions of the therapy modifiers have been changed effective January 1, 2003; they are as follows:
|
These modifiers do not allow a provider to deliver services that they are not recognized by Medicare to perform.
If an audiology procedure (HCPCS) code is performed by an audiologist (specialty code "64"), the above modifiers should not be reported, as these procedures are not subject to the financial limitation.
Providers/physicians/suppliers must retain a written plan of care on file for the beneficiary. The plans must be available to the Medicare Carrier for review.
Carriers will use the existing Medicare Summary Notice message 17.6 to inform the beneficiaries that they have reached the financial limitation. In addition, note that MSN 17.13 should be issued on all therapy claims containing outpatient rehabilitation services as noted in this Program Memorandum ( PM). MSN 17.13 has been revised to read, "Medicare approves up to ( $ ) a year for physical therapy and speech-language pathology services and a separate ( $ ) a year for occupational therapy services when billed by providers, physical and occupational therapists, physicians, and other non-physician practitioners. Medically necessary therapy over these limits is covered when received at a hospital outpatient department."
Spanish translation
17.13 - Medicare aprueba hasta ($) al año por servicios de terapia física y patología del lenguaje hablado y la cantidad separada de ($) al año por servicios de terapia ocupacional cuando son facturados por proveedores, terapistas físicos y ocupacionales, médicos y otros practicantes no médicos. La terapia que es medicamente necesaria y que sobrepasa estas cantidades límites está cubierta cuando se recibe en una unidad de hospital ambulatorio.
Processing Requirements
All claims containing any of the following list of "Applicable Outpatient Rehabilitation HCPCS Codes" should contain one of the therapy modifiers (GN, GO, GP), except as follows: Claims from physicians (all specialty codes) and non-physician practitioners, including specialty codes "50", "89", and "97" do not have to contain modifiers for the HCPCS codes for casts and splints as noted with a "+" sign below.
All other claims submitted by physicians or non-physician practitioners (as previously noted above) containing these applicable HCPCS codes without therapy modifiers, will be returned to the provider. If specialty codes "65", "67", "73", or "74" are present on the claim and an applicable HCPCS code is without one of the therapy modifiers (GN, GO, or GP), the claim will be returned to the provider.
The CWF will capture the amount and apply it to the limitation whenever a service is billed using the GN, GO or GP modifier.
Once the financial limitation has been reached, beneficiaries may receive outpatient rehabilitation services furnished directly by or under arrangement with a hospital.
Applicable Outpatient Rehabilitation HCPCS Codes
The following codes apply to each financial limitation except as noted below. These codes supersede the codes listed in section 3653.D of the Medicare Part A Intermediary Manual: (NOTE: Listing of the following codes does not imply that services are covered.)
|
| * | The physician fee schedule abstract file described below does not contain a price for codes 97799, V5362, V5363, and V5364 since they are priced by the carrier. Therefore, contact the carrier to obtain the appropriate fee schedule amount in order to make proper payment for these codes. |
| ** | Code 97504 should not be reported with code 97116. However, if code 97504 was performed on an upper extremity and code 97116 (gait training) was also performed, both codes may be billed with modifier 59 to denote a separate anatomic site. |
| *** | These codes for casts and splints will not apply to the financial limitations when billed by physicians and non-physician practitioners, as appropriate. When these codes are billed by other providers (bill types 22X, 23X, 34X, 74X, and 75X) or physical therapists or occupational therapists in private practice, specialty codes "65", "67", "73", or "74" they must be billed with a GO, or GP modifier. |
| + | These codes for casts and splints will not apply to the financial limitations when billed by physicians and non-physician practitioners, as appropriate. When these codes are billed by other providers (bill types 22X, 23X, 34X, 74X, and 75X) or physical therapists or occupational therapists in private practice, specialty codes "65", "67", "73", or "74" they must be billed with a GO, or GP modifier. |
| ++ | If an audiology procedure (HCPCS) code is performed by an audiologist, the above modifiers should not be reported as these procedures are not subject to the financial limitation. When these HCPCS codes are billed under a speech language pathology plan of care, they should be accompanied with a GN modifier and applied to the financial limitation. |
Additional Information
Once the limitation is reached, the outpatient rehabilitation therapy services will be denied with no appeal rights for the provider/physician/supplier. Group code PR and claim adjustment reason code 119, benefit maximum for this time period has been reached, will be used in the provider remittance advice to establish the reason for denial. The provider/physician/supplier should advise the beneficiary that a claim for services that exceeds the $1590 limitation is being denied pursuant to §1833(g) of the Social Security Act (42 U.S.C. §1395(g)). As with other denial of benefit determinations, the beneficiary could appeal Medicare's denial of benefits. The beneficiary is to be advised of his or her appeal rights set forth in 42 CFR Part 405, subpart G. The provider/physician/supplier should inform the beneficiary that any additional outpatient rehabilitation services would result in the beneficiary exceeding the financial limitation. Such notification will allow the beneficiary to make an informed choice about continuing to receive services from the provider/physician/supplier or to change to a hospital outpatient department. This is necessary because the beneficiary is responsible for payment of all outpatient rehabilitation services that exceeded the financial limitation on an annual basis.
In situations where a beneficiary is close to reaching the financial limitation and a particular claim might exceed the limitation, the provider should bill their usual and customary charge for the service furnished even though such charge might exceed the $1590 limit. For example, a beneficiary to date received services for which the total amount of payment and the beneficiary coinsurance total $1575. The beneficiary then received 3 services - 1 at $50; 1 at $25; and 1 at $30.
Providers should notify beneficiaries of the therapy financial limitations and that these limits are applied in all settings except hospital outpatient departments. ABNs cannot be used because of the statutory nature of the financial limitations. Therefore, providers should inform beneficiaries that beneficiaries are responsible for 100 percent of the costs of therapy services above each respective therapy $1590 limit, unless this outpatient care is furnished directly or under arrangement by a hospital. It is the provider's responsibility to present each beneficiary with accurate information about the therapy limits and that, where necessary, appropriate care above the $1590 limit can be obtained at a hospital outpatient therapy department. Providers should use the Notice of Exclusion from Medicare Benefits (NEMB) form to inform beneficiaries of the therapy financial limitation at their first therapy encounter with the beneficiary. When using the NEMB form, the practitioner checks box #1 and writes the reason for denial in the space provided at the top of the form. For CY 2003, provide the following: "Medicare will not pay for: PT and speech-language pathology services over $1590 (including dates of service from July 1, 2003 through December 31, 2003)." This same information is provided for OT services over the $1590 limit for the same time period, as appropriate.
The NEMB form can be found at: http://www.cms.hhs.gov/medlearn/refABN.asp.
[EM 2003-0117/CR 2183]
Important Billing Tips for Submitting Primary EOB Information to Medicare
Before filing with Medicare, be sure to file with the appropriate primary insurer(s). When submitting a paper claim, attach a copy of the primary insurer’s EOB or other documentation from the primary insurer which shows how the claim was processed.
Medicare will deny claims with primary EOBs attached that do not include complete payment information from the primary insurer(s). The denial message that appears on the Medicare Summary Notice states: “Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible.”
Medicare receives many different types of primary EOBs that require us to make individual decisions on each claim submitted. However, following the tips below should eliminate most Medicare denials when you submit claims for Medicare secondary payment:
- Submit a complete copy of the EOB, including any remark code explanations.
- When the primary insurer has denied all or part of the claim, the reason for the denial must be included in the information sent to Medicare.
- The name on the primary insurer EOB must match the name on the claim submitted to Medicare.
- When the primary insurance has been cancelled or terminated, be sure to include the termination/cancellation date.
- The date(s) of service on the EOB must match the date(s) of service submitted on the claim form.
- When submitting a photocopy of the EOB, the EOB must be legible.
- When submitting a photocopy of the EOB, include a copy of the front and back, including additional pages.
- When submitting EOB (copy or original), be sure no information has been cut-off.
- Do not submit a claim/EOB with a denial of “duplicate” or “previously paid” unless the EOB indicates the original payment information. To process as secondary an EOB with the payment information is required.
- Do not submit a claim/EOB until the primary insurer has actually made a payment and/or denial. EOBs pending information from primary payer will result in a denial from Medicare.
- EOBs from the other Medicare Carriers and Medicaid Contractors are not considered valid primary insurers and are not considered valid Medicare Secondary EOBs.
- Do not write on the EOB. It is not considered documentation and is not used to make a determination on payment or denial.
- Do not mark through any patient and/or payment information related to the submitted claim.
- EOB must contain all information; Patient name, Date of service and all money amount column headings.
Correct Payment of January and February 2003 Physician Services
Since the 2003 Medicare Physician Fee Schedule rates are effective March 1,
2003, any January 1 through February 28, 2003, dates of service containing
2002 HCPCS processed after March 1, will be paid at the 2003 rates. These claims
will be automatically adjusted after July 1, 2003, to pay at the 2002 rates.
Physicians/practitioners will not need to take any further action to receive
the adjustment payments.
[EM 2003-0086/CR 2549]
2003 Clinical Laboratory Fee Schedule – Addendum
Following are the fees for the CPT codes that were not included on the 2003 Clinical Laboratory Fee Schedule.
| Code | TN | NC | ID |
| 80061 | 18.71
|
18.71
|
15.84
|
| 80061QW | 18.71
|
18.71
|
15.84
|
| 80072 | 36.06
|
36.06
|
36.06
|
| 80074 | 64.34
|
65.12
|
66.54
|
| 80090 | 80.44
|
80.31
|
54.88
|
| 80400 |
45.56
|
45.56
|
40.54
|
| 80402 |
121.46
|
121.46
|
116.45
|
| 80406 | 109.33
|
109.33
|
104.31
|
| 80408 | 112.19
|
175.35
|
175.35
|
| 80410 | 72.94
|
112.25
|
112.25
|
| 80412 | 460.47
|
460.47
|
445.43
|
| 80414 | 72.14
|
72.14
|
65.63
|
| 80415 | 78.09
|
66.56
|
78.09
|
| 80416 | 184.41
|
184.41
|
184.41
|
| 80417 |
61.47
|
61.47
|
61.47
|
| 80418 | 809.73
|
806.94
|
766.66
|
| 80420 | 92.39
|
100.63
|
95.62
|
| 80422 | 64.40
|
64.40
|
64.40
|
| 80424 | 70.57
|
70.57
|
70.57
|
| 80426 | 207.42
|
207.42
|
180.32
|
| 80428 | 96.28
|
93.17
|
93.17
|
| 80430 | 109.61
|
109.61
|
109.61
|
| 80432 |
188.71
|
154.39
|
188.71
|
| 80434 | 141.29
|
141.29
|
128.76
|
| 80435 | 143.87
|
143.87
|
143.87
|
| 80436 | 126.66
|
127.37
|
122.35
|
| 80438 | 70.40
|
68.31
|
65.94
|
| 80439 | 93.86
|
91.08
|
87.92
|
| 80440 |
81.22
|
81.22
|
81.22
|
| 82274 | 5.56
|
5.56
|
5.56
|
Multiple Electroconvulsive Therapy (MECT) Not Covered by Medicare
Multiple Electroconvulsive Therapy (MECT) services performed on or after April 1, 2003, will be non-covered by Medicare.
Background
Per § 35-103 of the Medicare Coverage Issuances Manual, the clinical effectiveness of multiple-seizure electroconvulsive therapy has not been verified by scientifically controlled studies. In addition, studies have demonstrated an increased risk of adverse effect with multiple seizures. Accordingly, MECT cannot be considered reasonable and necessary and is non-covered.
Effective for dates of service on or after April 1, 2003, contractors are
advised not to pay for this therapy in any setting or under any code. The following
HCPCS code will be non-covered effective April 1, 2003.
90871 - Electroconvulsive therapy (includes necessary monitoring);
multiple seisures, per day.
[EM 2003-0019/AB-03-003; CR 2499]
Medicare Carriers Manual Updates
Section 15021, Ordering Diagnostic Tests and Section 15022, Payment Conditions for Radiology Services
The following sections of the Medicare Carriers Manual (MCM) have been updated with an implementation date of February 24, 2003.
Section 15021, Ordering Diagnostic Tests, is revised to broaden the instructions to include additional physicians as interpreting physicians.
Section 15022, Payment Conditions for Radiology Services, is revised to remove weekly radiation therapy management codes 77419-77430 that were deleted and replaced by code 77427.
The following section of the MCM has been updated with information from Transmittal AB-02-030, dated March 5, 2002.
Section 15021, Ordering Diagnostic Tests - In accordance with negotiated rulemaking for outpatient clinical diagnostic laboratory services, no signature is required for the ordering of such services or for physician pathology services.
The Internet address for the MCM is: www.cms.hhs.gov/manuals. [EM 2003-0055/CR 2410]
Pachymetry
Pachymetry is the measurement of corneal thickness. It is useful in determining which patients with elevated intraocular pressure are truly at increased risk for developing glaucoma, and which may have spuriously high (or low) values. Effective March 1, 2003, CIGNA Government Services, the Part B Carrier for Idaho, North Carolina, and Tennessee, will allow separate payment for medically necessary pachymetry (CPT code 0025T). Prior to March 1, 2003, this was considered investigational, and claims for services prior to that date will not be paid. This procedure will be allowed as a bilateral procedure (i.e., performed once for both eyes at same time). It must be billed on one line with “Number of Services” equal one (1). It will be reimbursed only once per lifetime, unless medical necessity for repeat measurements can be documented (i.e., a patient who has undergone LASIK, or has a degenerative disease of the cornea). This test can be reimbursed on the same day as visual fields and general Ophthalmological examinations. Documentation supporting medical necessity must be kept on file but does not need to be submitted with the claim at this time.
Single Drug Pricer (SDP) Files for 01/01/2003 – Additional Corrections
On December 3, 2002, the Centers for Medicare & Medicaid Services (CMS) issued Program Memorandum (PM) AB-02-174 that established the Single Drug Pricer (SDP). Subsequently, on December 6, 2002, CMS released two SDP pricing files. CMS also issued a joint signature memorandum dated December 20, 2002, to correct prices for the following codes: 90371, J0636, J1835, and J7308.
This joint signature memorandum advises of additional corrections to the SDP pricing files. Below are the additional changes that are effective January 1, 2003.
Changes to the SDP Pricing Files
- The correct allowance for Code J2352 is $88.69 (J2352 may be used only to report the LAR depot form of this drug).
- The correct allowance for Code J1563 is $55.20.
- The correct allowance for Code J7340 is $29.30. (Use this code for Apligraf per square centimeter).
- The correct allowance for Code J7342 is $14.92. (Use this code for Dermagraft per square centimeter).
[EM 2002-022/CR 2381]
Single Drug Pricing Informational Statement
The presence or absence of a particular drug on the SDP file does not represent a determination that the Medicare program either covers or does not cover that drug. The amounts shown on the SDP file indicate the maximum Medicare payment allowance, if the Medicare contractor determines that the drug meets the program’s requirements for coverage. Similarly, the absence of a particular drug from the SDP file means that if the Medicare contractor determines that the drug is covered by Medicare, the local contractor must then determine the program’s payment allowance by applying the program’s standard drug payment policy rules. Medicare contractors separately determine whether a particular drug meets the program’s general requirements for coverage and, if so, whether payment may be made for the drug in the particular circumstance under which it was furnished. Examples of this latter determination include but are not limited to determinations as to whether a particular drug and route of administration are reasonable and necessary to treat the beneficiary's condition, whether a drug may be excluded from payment because it is usually self-administered, and whether a least costly alternative to the drug exists.
Program Integrity Manual Updates
The Program Integrity Manual (PIM) is available only on the Internet in HTML format. Notifications will be included in the Medicare Bulletin anytime there is an update to the PIM.
The Internet address for the PIM is: www.cms.hhs.gov/manuals/108_pim/pim83toc.asp.
| CHAPTER | REVISED SECTIONS | NEW SECTIONS | DELETED SECTIONS | DESCRIPTION |
| 3 | 3.2 | Articles – clarifies when contractors may publish coverage/coding articles in their bulletins and Web sites. | ||
| 5 | 1.1.2 | Written Orders | ||
| 5 | 1.1.2.1 | Written orders prior to delivery | ||
| 13 | 2 | Articles - is deleted |
[EM 2003-0033/CR 2471; EM 2003-0083/CR 2120]
Drugs and Biologicals Excluded as Usually Self-Administered
| HCPCS | Descriptor | Comments |
| J0270 | Alprostadil (Caverject, Prostaglandins, Muse) | Apparent on its face/Use as needed/Intracavernosal or Intraurethral |
| J0630 | Calcitonin Salmon | Frequency/USA/SC as needed |
| J1438 | Etanercept (Enbrel) | Apparent on its face/Provided as Kit for Self Administration/SC twice a week |
| J1820 | Insulin | Frequency/Apparent on its face/SC Daily |
| J1910 | Kutapressin | Frequency/Apparent on its face/SC or IM Daily |
| J2940 | Somatrem | Frequency/Apparent on its face/SC or IM Daily |
| J2941 | Somatropin, Inj. (Genotropin, Humatrope, Norditropin, Nutropin AQ, Serostim) (Nutropin Depot) (Saizen) |
Apparent on its face/Frequency/Usually self administered SC/Daily or every other day SC/Once monthly or twice monthly on same day(s) {i.e., 1st & 15th} Frequency/SC or IM/3 times a week |
| J3030 | Sumatriptan Succinate | Apparent on its face/SC as needed |
| Q2010 | Glatiramer Acetate (Copaxone) | Frequency/Apparent on its face/SC Daily |
| Q2020 | Histrelin Acetate | Frequency/Apparent on its face/SC Daily |
Contractors must provide notice 45 days prior to the date these drugs will not be covered. During the 45 day time period, contractors will maintain existing medical review and payment procedures. See our Web site's October 2002 What's New Section for an article detailing the determination process.
**Update 01-01-03
Travel Fees Payable to Independent Laboratories
Following are the 2003 fees for codes P9603 and P9604. These codes are payable to Independent Laboratories only.
| Code | TN | NC | ID |
| P9603 | 0.81 | 0.81 | 0.81 |
| P9604 | 8.02 | 8.02 | 8.02 |
Remittance Advice Remark and Reason Code Update
This Program Memorandum (PM) updates remark and reason codes for intermediaries, carriers and Durable Medical Equipment Regional Contractors (DMERCs).
X12N 835 Health Care Remittance Advice Remark Codes
CMS is the national maintainer of the remittance advice remark code list that is one of the code lists mentioned in ASC X12 transaction 835 (Health Care Claim Payment/Advice) version 4010 Implementation Guide (IG). Under the Insurance Portability and Accountability Act (HIPAA), all payers have to use reason and remark codes approved by X-12 recognized maintainers instead of proprietary codes to explain any adjustment in the payment. As a result, CMS received a significant number of requests for new remark codes and modifications in existing remark codes from non-Medicare entities. These additions and modifications may not impact Medicare. Traditionally, remark code changes that impact Medicare are requested by Medicare staff in conjunction with a policy change. The code changes initiated by Medicare have been identified in this PM to single out codes that must be implemented by the contractors and the Shared System maintainers.
The list of remark codes is available at http://www.cms.hhs.gov/providers/edi/hipaadoc.asp
and http://www.wpc-edi.com/hipaa/, and the list is updated each March, July, and November.
The following list summarizes changes made through October 31, 2002.
New Remark Codes
X12 N 835 Health Care Claim Adjustment Reason Codes
|
The Health Care Code Maintenance Committee maintains the health care claim adjustment reason codes. The Committee meets at the beginning of each X12 trimester meeting (February, June and October) and makes decisions about additions, modifications, and retirement of existing reason codes. The updated list is posted 3 times a year after each X12 trimester meeting at http://www.wpc-edi.com/hipaa/. All reason code changes from July 2002 to October 2002, are listed here.
A reason code may be retired if it is no longer applicable or a similar code exists. Retirements are effective for a specified future and succeeding versions, but contractors also can discontinue use of retired codes in prior versions.
The committee approved the following reason code changes in October 2002:
New Reason Codes
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Modified Reason Codes
|
Retired Reason Codes
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[EM 2003-0097/CR 2546]
Medicare Carriers Manual Part 3 - Claims Process Update
New/Revised Material -- Effective Date/Implementation Date: April 1, 2003
The following is a summation of the additions and revisions to the Medicare Carriers Manual, Part 3 - Claims Process.
Section 2207, Coding Physician Specialty. The title of this section has been revised to read “Specialty Codes.” Revisions to this section provide more information regarding receiving requests to expand the specialty code list. The Osteopathic Crosswalk has been deleted as it has been phased out since 1992. It has been replaced with Primary/Secondary Codes to include language on how to handle a request for a primary or secondary specialty code. The following codes have been added and redefine osteopathic and Group Practice Prepayment Plan (GPPP) codes.
09 - Interventional Pain Management (IPM) - Allows for differences in treatment approaches, training, utilization patterns and costs between pain management specialists and IPM specialists.
72 - Pain Management - Added per Change Request #1872, dated September 21, 2001.
Section 2207.1, Coding Type of Supplier and Non-Physician Practitioners - Changed and/or added the following codes.
32 - Anesthesiologist Assistants (AAs) - Simplifies a planned study by the Agency for Healthcare Research and Quality. AAs previously were grouped with Certified Registered Nurse Anesthetists (43).
43 - Certified Registered Nurse Anesthetist - Removed AAs to code “32.”
65 - Physical Therapist in Private Practice - Removed “independently practicing” and added "Private Practice".
67 - Occupational Therapist in Private Practice - Removed “independently practicing” and added “Private Practice.”
71 - Registered Dietician/Nutrition Professional - Added per Change Request 2142, a PM with a discard date after October 1, 2003.
73 - Mass Immunization Roster Biller - Added to make them more identifiable.
74 - Radiation Therapy Centers - Added to differentiate them from Independent Diagnostic Testing Facilities (IDTFs).
75 - Slide Preparation Facilities - Added to differentiate them from IDTFs.
Section 2207.2, Coding Types of Service for Group Practice Prepayment Plan (GPPP) - Is being deleted because they were phased out in 1992.
Section 2208, Description of Entry Code - Is being deleted. This section is no longer needed.
Medicare contractors will migrate AAs, Radiation Therapy Centers, Slide Preparation Facilities, and Mass Immunization Roster Billers from their current codes to the newly designated codes.
Physicians wishing to choose Interventional Pain Management must submit Form CMS 855I as a change of information to their Medicare Contractor.
The CMS is redefining the osteopathic and GPPP specialty codes with this manual instruction. The codes have been obsolete since 1992. Providers/Suppliers with utilization reported for these codes will be transferred to a more appropriate code by their respective Medicare contractor.
The publication of Transmittal No. B-98-52, dated December 1998, Change Request 761 established the creation of IDTFs and instructed that all IPLs needed to obtain IDTF status to continue billing for diagnostic tests. This new status made the specialty code “95” obsolete and replaced it with specialty code “47.” Providers desiring to become an IDTF must complete a CMS 855B General Enrollment Application and attachment 2 of the CMS 855B application.
The above specialty codes will be updated into the UPIN registry process.
[EM 2002-1126/CR 2337]
Medicare Carriers Manual (MCM) Part 3 - Claims Process Revision to Sections 3103-3110: Railroad Retirement Beneficiary Carrier, United Mine Workers of America (UMWA), Title XIX Beneficiaries Residing in California
Effective July 1, 2003, the following updates will be made to Part 3 of the Medicare
Carriers Manual:
Section 3103, Railroad Retirement Beneficiary Carrier, is revised to
reflect the name of the carrier that currently processes those claims.
Section 3105, United Mine Workers of America (UMWA), is deleted. Information for disposition of UMWA claims is now included in §3110. There are also new Remittance Advice (RA) and Medicare Summary Notice (MSN) denial messages with this update:
RA
Claim adjustment reason code 109 - Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
New remark code N127 - This is a misdirected claim/service for a United Mine Workers of America beneficiary. Submit paper claims to: UMWA Health and Retirement Funds, PO Box 389, Ephraim, UT 84627-0361. Call Envoy at 1.800.215.4730 for information on electronic claims submission.
MSN
11.11 - This claim/service is not payable under our claims jurisdiction. We have notified your provider to send your claim for these services to the United Mine Workers of America for processing.
11.11 - Esta reclamación/servicio no se paga bajo nuestra jurisdicción de reclamaciones. Le hemos notificado a su proveedor que debe enviar la reclamación por estos servicios a la Unión de Trabajadores Mineros de América.
Section 3106, Title XIX Beneficiaries Residing in California, is no longer valid and is deleted.
Section 3110, Disposition of Misdirected Claims, is revised to include information on UMWA claims. As for other misdirected claims, carriers will now return UMWA claims to the provider to resubmit to the UMWA for processing. The RA message N104 is also revised to reflect the correct Web address of www.cms.hhs.gov.
Any references to HCFA have been replaced with CMS.
NOTE: Information concerning Indian Health Service claims can be found in Change Request 2055, Transmittal AB-02-150, issued October 25, 2002. [EM 2003-0099/CR 2502]
A Different View of HIPAA
Cathy Benoit, MBA
HIPAA Coordinator
The Centers for Medicare & Medicaid Services - Atlanta Regional Office
Today, a health care provider may do business with a number of health plans,
each with its own version of forms, code sets, or identifiers required for
payment. The Health Insurance Portability and Accountability Act (HIPAA) sets
out to change that. Under HIPAA, all health plans are required to use the standards
set forth in this regulation.
The standards established by HIPAA will enable administrative efficiency all
across the healthcare industry. Physicians’ offices will have more time
for patients and spend less time on paperwork. We will have standard data,
which will yield better data; and better data will yield better information.
This, in turn, will yield better health outcomes for all of us.
All covered entities must comply with the HIPAA privacy regulations. It is
true that if you are a 100% paper office, you are not a ‘covered entity’ and,
thus, do not have to comply with the HIPAA rules. But, is that a good business
decision? We live in a competitive market. The organizations that embrace HIPAA
as a business opportunity and prepare their organization for the future of
health care will be able to realize the benefits.
Other industries have gone through their own standardization processes. For
example, the banking and grocery industries have embraced technology and standardization
to streamline their costs. There was a time when we had to wait in line for
a bank teller to process all of our transactions, but now we can use the telephone,
computer, or ATM for access to our accounts 24 hours a day, 7 days a week.
We are also capable of processing transactions from any banking institution,
not just the one where we first opened our account .
Do you recall when the stock clerks worked all night to fill the grocery shelves with priced items, and the cashier had to type in the price of each item into a cash register? Then, when we checked-out, we received a generic receipt. Now, every item is identified by a bar code and is scanned for an itemized receipt. In fact, the grocery stores have streamlined the process to the point that we can checkout ourselves via the U-SCAN-it stations. These changes have proved to provide customers greater benefits while saving the industry's service providers money in the long run.
In both of these industries and many more, the use of electronic standards have revolutionized the way business is conducted. Implementing HIPAA will require the health care industry to change many long used and familiar business processes. Change is difficult for most people, and HIPAA is about change. A change of this magnitude will not happen overnight. It will take time, hard work, communication, and possibly investment capital.
HIPAA is the first step in an e-commerce platform for the health care industry. Once the standards are in place, more and more products will be developed that will provide greater benefits to providers and to patients.
Over the past few decades, we have seen healthcare costs continue to rise. HIPAA will result in more efficient business processes which should make more money available for healthcare delivery. We are at a turning point in the healthcare industry.
It is important for all health care providers to realize that HIPAA is about the future of healthcare. HIPAA is a long-term benefit rather than a short-term cost or inconvenience. The providers that embrace HIPAA as an opportunity will be in a better position to adjust to changes and take advantage of the EDI [Electronic Data Interchange] benefits. I urge you to consider the following questions.
- Where are the banks that have not embraced ATMs?
- Where are the companies that have not embraced personal computers (or cell phones)?
- Where are the grocery stores that have not embraced check-out scanners?
- If given the choice between Dr. A and Dr. B where the services are equal, and if Dr. A is obligated by Federal law to protect your health records and Dr. B is not, who would you choose?
It is a fact that we live in a competitive market, so I encourage you to
consider HIPAA as the first step in preparing your organization for the future
of healthcare.
Can you afford not to?
Emergency Update to the 2003 Medicare Physician Fee Schedule Database
The Centers for Medicare & Medicaid Services (CMS) has identified various inconsistencies in the 2003 Medicare Physician Fee Schedule Database (MPFSDB).
Unless otherwise stated in this transmittal, changes will be effective for claims processed on or after March 1, 2003.
Changes included in this Emergency Update to the 2003 Medicare Physician Fee Schedule Database are as follows:
| CPT/HCPCS | ACTION |
| 0040T | Delete Lab Certification Code on HCPCS Tape |
| 0041T | Lab Certification Code = 110 |
| 00540 | Base Units = 12.0 units |
| 01829 | Base Units = 3.0 units |
| 01963 | Base Units = 8.0 units |
| 01991 | Base Units = 3.0 units |
| 01992 | Base Units = 5.0 units |
| G0008 | Procedure Status = X |
| G0008 | PC/TC Indicator = 9 |
| G0008 | Currently, carriers link the payment for HCPCS code G0008 to the payment
associated with CPT code 90782. Effective |
| G0009 | Procedure Status = X |
| G0009 PC/TC | Indicator = 9 |
| G0009 | Currently, carriers link the payment for HCPCS code G0009 to the payment
associated with CPT code 90782. Effective |
| G0010 | Procedure Status = X |
| G0010 | PC/TC Indicator = 9 |
| G0010 | Currently, carriers link the payment for HCPCS code G0010 to the payment
associated with CPT code 90782. Effective |
| G0275 | Facility PE RVU = 0.10 |
| G0278 | Facility PE RVU = 0.10 |
| G0279 | Facility PE RVU = 0.02 |
| G0280 | Facility PE RVU = 0.02 |
| G0281 | Effective Date: |
| G0282 | Effective Date: |
| G0295 | Effective Date: |
| NOTE: | The aforementioned services were inappropriately identified
as effective |
| G0289 | Facility PE RVU = 0.58 |
| Multiple Procedure Indicator = 0 | |
| Pre-Operative Percentage = 0.00 | |
| Intra-Operative Percentage = 0.00 | |
| Post-Operative Percentage = 0.00 | |
| HCPCS Code: J2675 | |
| Short Desc: Inj progesterone per 50 MG | |
| Proc Stat: E | |
| RVU Work: 0.00 | |
| |
|
| |
|
| Malpractice RVU: 0.00 | |
| PC/TC: 9 | |
| SOS: 9 | |
| Global: XXX | |
| Pre-Op: 0.00 | |
| Intra-Op: 0.00 | |
| Post-Op: 0.00 | |
| Mult Surg: 9 | |
| Bilt Surg: 9 | |
| Asst Surg: 9 | |
| Co Surg: 9 | |
| Team Surg: 9 | |
| Diag Supv: 09 | |
| J7308 | Procedure Status = P |
| Q3017 | Procedure Status = F |
| Q3021 | Procedure Status = I |
| Q3022 | Procedure Status = I |
| Q3023 | Procedure Status = I |
| Q3030 | Procedure Status = F |
| 0040T | FYI - The HCPCS Tape incorrectly identifies the lab certification code for CPT code 0040T as 110. There should be no lab certification code associated with this service. |
| 0041T | FYI - The HCPCS Tape inadvertently failed to identify lab certification code 110 for this service. The HCPCS Tape should identify lab certification code 110 for CPT code 0041T. |
| 10021 | Facility PE RVU = 0.53 |
| 10022 | Facility PE RVU = 0.44 |
| 17304 | Bilateral Surgery Indicator = 1 |
| 26587 </ |