January 2003 Part B Medicare Bulletin
Table of Contents
Ambulance Fee Schedule Update for 2003
The Ambulance Inflation Factor (AIF) for calendar year 2003 is 1.1 percent.
During the transition period, the AIF is applied to both the fee schedule portion of the blended payment amount and to the reasonable charge/cost portion of the blended payment amount separately for each ambulance provider/supplier. Then, these two amounts are added together to determine the total payment amount for each provider/supplier. The blending percentages used to combine these two components of the payment amounts for ambulance services for CY 2003 are 60 percent of the reasonable charge/cost and 40 percent of the ambulance fee schedule. [EM 2002-1240/CR 2489]
TopHCPCS 2003 Additions
Below are the 2003 HCPCS Additions. New CPT codes/modifiers are effective for dates of service January 1, 2003, and after. 2003 HCPCS additions for the DMERCs are not listed, but can be found in the HCPCS Level II book.
Modifiers
| AU | item furnished in conjunction with a urological, ostomy, or tracheostomy supply |
| AV | item furnished in conjunction with a prosthetic device, prosthetic or orthotic |
| AW | item furnished in conjunction with a surgical dressing |
| BA | item furnished in conjunction with parenteral enteral nutrition (pen) services |
| BO | orally administered nutrition, not by feeding tube |
| EY | no physician or other licensed health care provider order for this item or service |
| JW | drug amount discarded/not administered to any patient |
| KB | beneficiary requested upgrade for abn, more than 4 modifiers identified on claim |
| KX | specific required documentation on file |
| QJ | services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 CFR 411.4(b) |
New codes for supply of radiopharmaceutical diagnostic imaging agents are A9512-A9699.
CODES — Refer to the 2003 HCPCS Level II for the descriptions
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[EM 2002-0927]
2003 HCPCS Deletion
Effective for 2003 dates of service the codes below are deleted. A ninety day grace period exists for claims received on or before March 31, 2003. 2002 services - use ’02 CPT codes no matter when claim is filed. 2003 services-use ’02 or ’03 CPT codes if claim is filed prior to April 1, 2003; use ’03 CPT codes only if claim is filed on or after April 1, 2003.
Only codes that are Part B services are listed. For DMERC and other services, not procesed by Part B, refer to the HCPCS Level II book.
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[EM 2002-0927]
Hearing Aid Exclusion
15903. HEARING AID EXCLUSION
Section 1862(a)(7) of the Social Security Act states that no payment may be made under part A or part B for any expenses incurred for items or services “where such expenses are for . . . hearing aids or examinations therefore. . . “ This policy is further reiterated at 42 CFR 411.15(d) which specifically states that “hearing aids or examination for the purpose of prescribing, fitting, or changing hearing aids” are excluded from coverage.
At the time of passage of the hearing aid exclusion, all hearing aids utilized functional air and/or bone conduction pathways to facilitate hearing. We are clarifying that any device that does not produce as its output an electrical signal that directly stimulates the auditory nerve is a hearing aid for the purposes of Medicare payment policy. Examples of hearing aids are devices that produce air-conducted sound into the external auditory canal, devices that produce sound by mechanically vibrating bone, or devices that produce sound by vibrating the cochlear fluid through stimulation of the round window. Devices such as cochlear implants, which produce as their output an electrical signal that directly stimulates the auditory nerve, are not considered to be hearing aids for purposes of Medicare payment policy
[EM 2002-1217/CR2256]
Percutaneous Image-Guided Breast Biopsy
Percutaneous image-guided breast biopsy is a method of obtaining a breast biopsy through a percutaneous incision by employing image guidance systems. Image guidance systems may be either ultrasound or stereotactic.
The Breast Imaging Reporting and Data System (or BIRADS system) employed by the American College of Radiology provides a standardized lexicon with which radiologists may report their interpretation of a mammogram. The BIRADS grading of mammograms is as follows: Grade I-Negative, Grade II-Benign finding, Grade III-Probably benign, Grade IV-Suspicious abnormality, and Grade V-Highly suggestive of malignant neoplasm.
A. Nonpalpable Breast Lesions.—
Effective January 1, 2003, Medicare covers percutaneous image-guided breast biopsy using stereotactic or ultrasound imaging for a radiographic abnormality that is nonpalpable and is graded as a BIRADS III, IV, or V.
B. Palpable Breast Lesions.—
Effective January 1, 2003, Medicare covers percutaneous image guided breast biopsy using stereotactic or ultrasound imaging for palpable lesions that are difficult to biopsy using palpation alone. Contractors have the discretion to decide what types of palpable lesions are difficult to biopsy using palpation.
Applicable CPT Codes for Percutaneous Image-Guided Breast Biopsy
19102, percutaneous needle core, using imaging guidance
19103 percutaneous automated vacuum assisted or rotating biopsy device, using imaging guidance
10022, fine needle aspiration; with imaging guidance
NOTE: For imagining guidance performed in conjunction with 19102, 19103 see codes 76095, 76096, 76360, 76393, and 76942.
[EM 2002-0977, 2002-978]
Implementation of the HIPAA Health Care Eligibility Benefit Inquiry/Response (270/271) Transaction
For All CIGNA Government Services Part B Electronic Trading Partners
In order to comply with the Health Insurance Portability and Accountability Act (HIPAA) administrative simplification provisions, the 270/271 transaction set has been named as the Electronic Data Interchange (EDI) standard for the Health Care Eligibility Benefit Inquiry/Response. Medicare will implement the 270/271 in an interactive real-time response mode by April 1, 2003. This means that a provider will be able to send a compliant X12N 270 version 4010 inquiry, one inquiry at a time, and receive a compliant 271 response, one response at a time, within seconds. CMS will not offer a batch process. All other EDI formats for this transaction will become obsolete on October 16, 2003.
The 270/271 is a “paired” transaction set. The Trading Partner sends a 270 transaction (Eligibility Benefit Inquiry) to the Medicare contractor to request information. The Medicare contractor responds to this inquiry with a 271 transaction (Eligibility Benefit Response).
To assist our electronic trading partner community in understanding the reporting operation of the 270/271 transaction set, a brief summary of the reports that can be generated from this transaction set follows below:
Summary of 270/271 Transaction Set Reports
- TA1 and/or a 997 (Functional Acknowledgement Report)
If the 270 cannot be translated, or if a security access error exists, a TA1 (Interchange Acknowledgement Report) and/or a 997 (Functional Acknowledgement Report) will be sent to the submitter. - 271 Response
If errors are detected during the translation process a 271 response with the appropriate error messages will be returned to the submitter. (Note: The 997 will not be used to report standard level rejects). If no errors are detected, and a response is possible based upon the information requested in the 270, a 271 response will be sent to the submitter.
In accordance with Medicare security and privacy standards, CIGNA Government Services Part B must have an EDI Trading Partner Agreement on file in order for providers and their agents to receive eligibility benefit information. An EDI Network Service Agreement must be on file for network service vendors to receive eligibility benefit information on behalf of their clients. These documents can be found on the EDI portion of CIGNA Government Services’s Web site at www.cignamedicare.com/edi.
To comply with requirements set forth by the Centers for Medicare & Medicaid Services (CMS), CIGNA Government Services electronic trading partners should be aware of the following important points regarding the 270/271 transactions:
- The 270/271 will be supported in real-time by Medicare and not in batch;
- The 270/271 implementation guide adopted for national use under HIPAA can be obtained at www.wpc-edi.com/HIPAA;
- A provider who prefers to obtain eligibility data in an EDI format, but does not want to use the 270/271 version 4010, may contract with a clearinghouse to translate the information on its behalf; however, that provider would be liable for those clearinghouse costs;
- Provider, clearinghouse, and vendor testing is not required prior to production use, but will be conducted if requested, and there will not be a charge for such testing;
- The home health benefit period information is expected to be of particular interest to providers affected by home health consolidated billing, but they must use the 270/271 to obtain the HHA data elements;
- ARU eligibility queries will continue to be accepted, any changes to the ARU may be made sometime in the future. Information regarding these changes will be communicated at a later date.
- Electronic formats that you may have used for request and receipt of eligibility data will not be used after October 16, 2003;
- The submitter of a 270 must self-program or obtain software to generate and receive HIPAA-compliant 270/271 transactions, receive a TA1 to report transmission envelope errors, receive a 997 to report translation problems, and be able to accept the supplemental implementation guide error report that will be used to report any implementation guide errors that could not be reported in a 271;
- • Real-time queries must be submitted one at a time. One immediate response at a time will be returned. Providers or their agents can program to enable their system to submit multiple eligibility inquiries in succession during a single session. Multiple inquiries cannot be simultaneously submitted as in a batch submission.
- Pursuant to CMS instructions, CIGNA Government Services Part B will support real-time 270/271 transactions transmitted via the Medicare Data Communication Network using AT&T Global Network Services (AGNS). The submitter of the 270 transaction is responsible for all costs incurred to enable connection with AGNS, and responsible for coordinating with AT & T to connect to the MDCN;
- Eligibility inquiries are supported to enable a provider to establish eligibility prior to claim submission. Eligibility data may not be requested for a provider not involved in provision of health care services to a purported Medicare beneficiary, unless the provider has been approached by the purported Medicare beneficiary or other provider to provide health care services to that individual. Searches of eligibility data of possible beneficiaries who are not currently receiving services, or for whom a provider has not been approached to furnish services, is prohibited;
- The ratio of claims to eligibility inquiries per provider will be monitored. Providers will be contacted if their ratio suggests possible overuse of eligibility queries. Providers that are determined to have abused their query privileges will lose eligibility query access either directly through a clearinghouse, or other vendor for 1 year after the date of determination of abuse;
- Although Medicare will furnish providers with basic information on the HIPAA standard transaction requirements to enable providers to make educated and timely decisions to plan for use of a HIPAA standard, Medicare will not furnish in-depth training on the use and interpretation of the standards implementation guides. Providers who feel they have a need to obtain such in-depth training for their staff are expected to obtain training of that nature from commercial vendors, their clearinghouse, or through standards development organizations.
If you any questions regarding this article, please contact the EDI technical help desk for your state:
ID/TN: 866.520.4023
NC: 866.352.1608
[EM 2002-1223/CR 2452]
Change to the X12N 4010 837 Professional Flat File
There has been an update to the X12N 4010 837 Professional Flat File. The update will be effective April 1, 2003. The file was updated for the following reasons:
- To allow the submission of Transmission Type Code 004010X098D in the REF Transmission Type Identification segment, element REF02.
- To correct the example given in the DTP Date – Service Date segment, element DTP03. The “dash” from the RD8 example has been removed to avoid potential confusion.
The updated 837 4010 Professional flat file is called 4010-2.zip and is posted
to the following Web site
http://cms.hhs.gov/providers/edi/4010-2.zip.
Please understand that until April 1, 2003, your transactions may reject unless you enter the value “004010X098” in REF02. [EM 2002-1057/CR 2265]
Levocarnitine for Use in the Treatment of Carnitine Deficiency in ESRD Patients
The following information is effective January 1, 2003.
Carnitine is a naturally occurring substance that functions in the transport of long-chain fatty acids for energy production by the body. Deficiency can occur due to a congenital defect in synthesis or utilization, or from dialysis. The causes of carnitine deficiency in hemodialysis patients include dialytic loss, reduced renal synthesis and reduced dietary intake.
Intravenous levocarnitine will only be covered for those ESRD patients who have been on dialysis for a minimum of three months for one of the following indications.
Patients must have documented carnitine deficiency, defined as a plasma free carnitine level<40 micromol/L (determined by a professionally accepted method as recognized in current literature), along with signs and symptoms of:
- Erythropoietin-resistant anemia (persistent hematocrit <30 percent with treatment) that has not responded to standard erythropoietin dosage (that which is considered clinically appropriate to treat the particular patient) with iron replacement, and for which other causes have been investigated and adequately treated, or
- Hypotension on hemodialysis that interferes with delivery of the intended dialysis despite application of usual measures deemed appropriate (e.g., fluid management). Such episodes of hypotension must have occurred during at least 2 dialysis treatments in a 30-day period.
Continued use of levocarnitine will not be covered if improvement has not been demonstrated within 6 months of initiation of treatment. All other indications for levocarnitine are non-covered in the ESRD population.
For a patient currently receiving intravenous levocarnitine, Medicare will cover continued treatment if:
- Levocarnitine has been administered to treat erythropoietin-resistent anemia (persistent hematocrit <30 percent with treatment) that has not responded to standard erythropoietin dosage (that which is considered clinically appropriate to treat the particular patient) with iron replacement, and for which other causes have been investigated and adequately treated, or hypotension on hemodialysis that interferes with delivery of the intended dialysis despite application of usual measures deemed appropriate (e.g., fluid management) and such episodes of hypotension occur during at least 2 dialysis treatments in a 30-day period; and
- The patient’s medical record documents a pre-dialysis plasma free carnitine
level <40
micromol/L prior to the initiation of treatment; or - The treating physician certifies (documents in the medical record) that
in his/her judgment, if treatment with levocarnitine is discontinued, the
patient’s pre-dialysis carnitine level would fall below 40 micromol/L
and the patient would have recurrent erythropoietin-resistant-anemia or intradialytic
hypotension.
[EM 2002-1169/CR 2438]
Follow the general instruction for preparing claims in §2010, Purpose of Health Insurance Claim Form CMS-1500, Medicare Carriers Manual Part 4, Chapter 2. Claims for Levocarnitine are to be submitted on health insurance claim Form CMS-1500 or electronic equivalent. Claims should be processed in accordance with §4020, Review of Health Insurance Claim Form CMS-1500, Part 3, Chapter IV of the Medicare Carriers Manual.
Coinsurance and deductible apply.
Medicare Summary Notices (MSN) and Remittance Advice
The following MSN will appear on the beneficiary’s Medicare Summary Notice when appropriate:
6.5 – Medicare cannot pay for this injection because one or more requirements for coverage were not met.
Spanish version – 6.5 – Medicare no puede pagar por esta inyeccion porque uno o mas requisitos para la cubierta no fueron cumplidos.
[EM 2002-1169/CR 2438]
Provider Enrollment Application Appeals
The Centers for Medicare & Medicaid Services (CMS) has issued CMS Transmittal 7 of the Program Integrity Manual that establishes the Appeals process for denials and revocations of Provider Enrollment applications. This transmittal instructs Carriers to provide an administrative appeal process for physicians, non-physician practitioners, and other entities that receive reassigned benefits from physicians and non-physician practitioners.
An application is generally denied for the following reasons:
- The applicant, owner, partner, managing organization/employee, officer, director, ambulance crewmember, Medical Director, and/or delegated or authorized official is excluded from a federal program (as set forth in either §1862(e)(1); 42 U.S.C. §1395y(e)(1), 42 CFR §1001.1001, §1001.1901 or is/are debarred from participating in a Federal procurement or non-procurement program; (as set forth in §2455 of the Federal Acquisition Streamlining Act of 1994, Pub. L.No.103-55 (1994).
- The applicant does not have a license or is not authorized by the federal/state/local government to perform the services which it intends to render.
- The applicant does not have a physical business address where services can be rendered and/or does not have a place where patient records are stored to determine the amounts due such provider or other person.
- The applicant does not meet CMS regulatory requirements for the specialty.
- The applicant does not qualify as a provider of services or supplier of medical and health services. An entity seeking Medicare payment must be able to receive reassigned benefits from physicians in accordance with the Medicare reassignment statute in §1842(b)(6) of the Act (42U.S.C. 1395u(b)).
- The applicant does not provide a valid social security number/employer identification number for the applicant, owner, partner, managing organization/employee, officer, director, ambulance crewmember, Medical Director, and/or delegated or authorized official.
Appeals of denials and revocations must be submitted in writing to the Hearing Officer within 60 days from the date of the receipt of the initial determination letter. The request for appeal must be submitted to the following address:
CIGNA Government Services
Hearings Department
PO Box 23226
Nashville, TN 37202
NOTE: Failure to file a timely request for a Carrier hearing is deemed a waiver of all rights to further administrative review.
Requirements for Hearing Request:
- The request may be signed by the physician, non-physician practitioner, or any responsible official within the entity.
- If a timely request for a Carrier hearing is made, a Carrier hearing officer, not involved in the original determination, must hold a hearing within 60 days of receipt (absent extenuating circumstances) of the appeal request, or later if requested by the physician, non-physician practitioner or entity.
- The physician, non-physician practitioner, entity, or the Carrier may offer new evidence. The burden of persuasion is on the physician, non-physician practitioner or entity to show that its enrollment application was incorrectly disallowed or that the revocation of its billing number was incorrect.
Hearing Process:
The Carrier hearing can be held in person or by telephone at the physician’s, non-physician practitioner’s, or entity’s request. The Carrier hearing officer’s determination is based upon the information presented. The hearing is a thorough, independent review of the Carrier’s initial determination and the entire body of evidence, including any new information submitted.
The hearing officer issues a written decision as soon as practicable after the hearing and forwards the decision by certified mail to CMS, the Carrier, and the physician, non-physician practitioner, or entity. The decision includes: (1) the outcome of the hearing, (2) if the decision is unfavorable, information about the Carrier’s, physician’s, non-physician practitioner’s, or entity’s further right to appeal; (3) the address to which the written appeal must be mailed; and (4) the date by which the appeal must be filed, that is, 60 days after the date of receipt of the decision. The term “after the date of receipt” means five days after the date of the notice, unless it is shown that the notice was received earlier or later.
A physician, non-physician practitioner, entity or Carrier may appeal the Carrier hearing officer’s decision to CMS for a final administrative review within 60 days after the date of receipt of the hearing officer’s decision. The appeal maybe submitted to the following address:
CMS
Office of Hearings
Hearing Officer
7500 Security Boulevard
Room C1-09-13
Baltimore, MD 21244-1850
NOTE: Failure to timely request the final administrative review by CMS is deemed a waiver of all rights to further administrative review.
Deactivation of Inactive Provider Numbers
A provider number will be automatically deactivated if it is inactive for twelve (12) consecutive months. Once a number has been deactivated, a new CMS Form 855 must be completed and approved to reactivate the billing number.
CMS-855B Requirement
Providers should report any change in enrollment data on the appropriate CMS-855 form. This is true for those who have previously completed the CMS-855/HCFA-855 form and for those who have not completed the CMS-855/HCFA-855 form.
For those providers/suppliers who are making the following changes, and have never submitted the CMS-855/HCFA-855 form, they must complete one in its entirety.
- Any provider who is making a change to its pay-to address
- Any provider who is adding a new individual to the group and wants to receive reassignment benefits from that individual.
In situations where the group was enrolled prior to the CMS-855/HCFA-855, certain information is needed to ensure the appropriate payment to that group on the individual’s behalf. For example, an authorized official or delegated official could make a change to that individual’s pay-to address. Since that group’s information was submitted prior to a CMS-855/HCFA-855 enrollment, the provider must submit a CMS-855B for the group in order to allow the individual to reassign benefits to the group.
Once the group’s application is received, the new reassignment will be added. The effective date is listed on the 855R. For any other type of changes, and the group enrolled prior to the CMS-855/HCFA-855 form, only the changed information needs to be reported.
PIM Changes
| CHAPTER | REVISED SECTION | NEW SECTION | DESCRIPTION |
| 3 | 5.1.1 | Prepayment Edits |
[EM 2002-1259/CR 2418]
HCPCS Drug Pricing File
HCPCS Drug Pricing File, Effective January 2003
Medicare Bulletin EDI Reader Service Sheet
Medicare Bulletin EDI
Reader Service Sheet 
(8K)
Overpayment Refunds
Personal provider checks sent to us for any reason should be sent to the following address:
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Checks should never be sent to our Nashville operations, as this will create delays in the process. In situations where you have received a letter of notification regarding a Medicare overpayment, these delays can result in payment offset. If you are responding to a particular person or department, include that information on the envelope or correspondence. CIGNA Government Services checks that need to be returned to us should be sent to the following address:
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