February 2003 Part B Medicare Bulletin
Table of Contents
Revisions to Common Working File Edits for Skilled Nursing Facility (SNF) Consolidated Billing (CB) to Permit Payment for Certain Diagnostic Services Furnished to Beneficiaries Receiving Treatment for End Stage Renal Disease (ESRD) at an Independent or Provider-Based Dialysis Facility
I – General Information
Scope:
This instruction implements changes to the Skilled Nursing Facility (SNF) Consolidated Billing (CB) editing for certain diagnostic services furnished to End Stage Renal Disease (ESRD) beneficiaries receiving dialysis at an independent or provider-based dialysis facility. Beginning, April 1, 2003, for dates of service on or after April 1, 2001, Carriers will not apply the SNF CB edits to line items for diagnostic services where a modifier is placed on the line item to indicate that this service was rendered to an ESRD beneficiary in a SNF Part A stay who is receiving chronic dialysis related services at an Independent or Provider-Based Dialysis Facility.
Background:
The SNF CB provision requires a SNF to include on its Part A bill almost all of the services that its residents receive during the course of a Part A covered stay. However, there are several categories of services that the law (§1888(e)(2)(A)(ii) of the Social Security Act) specifically excludes from this provision, and these excluded services remain separately billable under Part B by the outside supplier that furnishes them. One of the excluded categories encompasses those items and services that fall within the scope of the Part B benefit that covers chronic dialysis for beneficiaries with ESRD (§1861(s)(2)(F) of the Act). In addition to covering the ESRD-related dialysis services themselves, the Part B benefit also covers any associated diagnostic tests (see regulations at 42 CFR 410.50(b) - (c) and 410.52(a)(3)).
Policy:
The SNF CB applies to diagnostic tests that are not ESRD-related. As such, SNF CB applies to diagnostic tests for beneficiaries that do not have ESRD. This would include tests related to “acute dialysis” (that is, dialysis for a beneficiary who is not an ESRD beneficiary), because non-ESRD dialysis services and associated diagnostic tests do not fall within the scope of the Part B dialysis benefit. In addition, SNF CB applies to a diagnostic test for an ESRD beneficiary if the test is unrelated to the beneficiary’s ESRD.
The SNF CB does not apply to diagnostic tests that are ESRD dialysis-related. “ESRD-related” means that: (1) the beneficiary must be an ESRD beneficiary; (2) the test must have been ordered by an ESRD facility; and (3) the test must relate directly to the dialysis treatment of the beneficiary’s ESRD.
A supplier or provider may bill the Carrier or intermediary, respectively, for an ESRD dialysis-related diagnostic test, provided the test is outside the ESRD-facility composite rate, notwithstanding that the beneficiary is a SNF Part A resident.
A supplier or provider may not bill Medicare separately for a diagnostic test for a SNF Part A resident if the test is either: (1) within the ESRD facility composite rate or (2) not an ESRD dialysis-related diagnostic test.
Modifier Effective Date and Submission:
The modifier “CB – services ordered by a dialysis facility physician as part of the ESRD beneficiary’s dialysis benefit, is not part of the composite rate, and is separately reimbursable” is effective April 1, 2003, for dates of service on or after April 1, 2001. The Centers for Medicare & Medicaid Services (CMS) is not requiring that a provider or supplier report the modifier for every service rendered to a ESRD beneficiary; however, the provider or supplier should be aware that SNF CB editing will be applied if the line item does not contain the modifier. The provider or supplier may use the modifier only when it has determined that: (a) the beneficiary has ESRD entitlement, (b) the test is related to the dialysis treatment for ESRD, (c) the test is ordered by a dialysis facility, (d) the test is not included in the dialysis facility’s composite rate payment, and (e) the beneficiary is in a Part A stay. The provider or supplier must secure this information from the dialysis facility and use the modifier for only those line items for which all these factors are present.
Specifically, the use of the CB modifier is inappropriate unless the supplier or provider has exercised due diligence to confirm that: (a) the beneficiary is a resident in a SNF Part A stay, (b) the beneficiary has ESRD entitlement, (c) the test has been ordered by a dialysis facility, (d) the test is not included in the dialysis facility’s composite rate payment, and (e) the test is related to the dialysis treatment of the beneficiary’s ESRD.
This notice is also to advise the supplier or provider that unless this information has been received from the dialysis facility, or has been otherwise confirmed through other credible sources, it is improper to submit a claim to Medicare with the CB modifier and doing so without good faith belief in the legitimacy of using the CB modifier may constitute a false claim.
Denied Claims:
Providers that have had claims denied due to SNF CB and provided a diagnostic service to a beneficiary who has ESRD in an Independent or Provider-Based Dialysis Facility for dates of service April 1, 2001, and later should resubmit these claims with the CB modifier for each line item. For claims with dates of service beyond the timely filing deadline, the claim(s) may be reopened by the Carrier or intermediary or appealed for payment. [EM 2002-1266/CR 2475]
TopRequirements for Payment of Medicare Claims for Foot and Nail Care Services
The Office of Inspector General (OIG) recently studied the appropriateness of Medicare nail debridement payments, which is the single largest paid podiatric service. The OIG found that about one in every four claims did not include documentation of medical need for nail debridement in beneficiaries’ medical records and that more than half of these inappropriate payments included other related inappropriate payments. This article explains the requirements for payment of Medicare claims for foot and nail services including information about routine foot care exclusion, exceptions to routine foot care exclusion, Class Findings, billing instructions, required claim information, and documentation on file.
Routine Foot Care Exclusion
Except as noted in "Exceptions to Routine Foot Care Exclusion" section, routine foot care is excluded from coverage. Services that are normally considered routine and not covered by Medicare include:
- The cutting or removal of corns and calluses;
- The trimming, cutting, clipping, or debriding of nails; and
- Other hygienic and preventive maintenance care such as cleaning and soaking the foot, use of skin creams to maintain skin tone of either ambulatory or bedfast patients, and any other service performed in the absence of localized illness, injury, or symptoms involving the foot.
Exceptions to Routine Foot Care Exclusion
- Services performed as a necessary and integral part of otherwise covered services such as diagnosis and treatment of ulcers, wounds, infections, and fractures.
- The presence of a systemic condition such as metabolic, neurologic, or peripheral vascular disease that may require scrupulous foot care by a professional. Certain procedures that are otherwise considered routine may be covered when systemic condition(s), demonstrated through physical and/or clinical findings, result in severe circulatory embarrassment or areas of diminished sensation in the legs or feet and may pose a hazard if performed by a nonprofessional person on patients with such systemic conditions. In the case of patients with systemic conditions such as diabetes mellitus, chronic thrombophlebitis, and peripheral neuropathies involving the feet associated with malnutrition and vitamin deficiency, carcinoma, diabetes mellitus, drugs and toxins, multiple sclerosis, and uremia, they must also be under the active care of a doctor of medicine or doctor of osteopathy and who documents the condition in the patient's medical record.
- Services performed for diabetic patients with a documented diagnosis of peripheral neuropathy and loss of protective sensation (LOPS) and no other physical and/or clinical findings sufficient to allow a presumption of coverage as noted in the Medicare Carriers Manual. This class of patients can receive an evaluation and treatment of the feet no more often than every six months as long as they have not seen a foot care specialist for some other reason in the interim. LOPS shall be diagnosed through sensory testing with the 5.07 monofilament using established guidelines, such as those developed by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) guidelines. Five sites should be tested on the plantar surface of each foot, according to NIDDK guidelines.
- Treatment of warts, including plantar warts, may be covered. Coverage is to the same extent as services provided for in treatment of warts located elsewhere on the body.
- Treatment of mycotic nails for an ambulatory patient is covered only when the physician attending a patient's mycotic condition documents in the medical record that (1) there is clinical evidence of mycosis of the toenail and (2) the patient has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate. Treatment of mycotic nails for a nonambulatory patient is covered only when the physician attending a patient's mycotic condition documents in the medical record that (1) there is clinical evidence of mycosis of the toenail and (2) the patient suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.
NOTE: Active care is defined as treatment and/or evaluation of the complicating disease process during the six-month period prior to rendition of the routine care or had come under such care shortly after the services were furnished, usually as a result of a referral.
Class Findings
A presumption of coverage may be made by Medicare where the claim or other evidence available discloses certain physical and/or clinical findings consistent with the diagnosis and indicative of severe peripheral involvement. For the purposes of applying this presumption, the following findings are pertinent:
- Class A Findings
Nontraumatic amputation of foot or integral skeleton portion thereof
- Class B Findings
Absent posterior tibial pulse
Advanced trophic changes; three of the following are required: hair growth (decrease or absence), nail changes (thickening), pigmentary changes (discoloration), skin texture (thin, shiny), skin color (rubor or redness)
Absent dorsalis pedis pulse
- Class C Findings
Claudication
Temperature changes
Edema
Paresthesia
Burning
Billing Instructions
The following are the main HCPCS/CPT codes for billing of foot and nail care services (additional codes can be found in the HCPCS/CPT code book):
11719 - Trimming of nondystrophic nails, any number
11720 - Debridement of nail(s) by any method(s); one to five
11721 - Debridement of nail(s) by any method(s); six or more
11730 - Avulsion of nail plate, partial or complete, simple; single
11732 - Avulsion of nail plate, partial or complete, simple; each additional nail plate (list separately in addition to code for primary procedure)
Required Claim Information
NOTE: Program Memorandums AB-02-096 dated July 17, 2002, and AB-02-109 dated July 31, 2002, contain claim and billing instructions for peripheral neuropathy. For information on completing the CMS-1500 form, see the CMS-1500 instructions at http://cms.hhs.gov/providers/edi/1500mast.pdf.
You may also contact our Customer Service department at:
| Idaho | 1.866.502.9051 |
| North Carolina | 1.866.238.9651 |
| Tennessee | 1.866.502.9056 |
The following requirements are of particular importance to podiatrists:
Item 17. Enter the name of the referring or ordering physician if the
service or item was ordered or referred by a physician. A referring physician
is a physician who requests an item or service for the patient for which payment
may be made under the Medicare program.
Item 17a. Enter the CMS assigned UPIN of the referring/ordering physician listed
in item 17.
Item 19. Enter the 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) date patient was last seen and the UPIN of his/her attending physician when an independent physical or occupational therapist or physician providing routine foot care submits claims.
Item 21. Enter the patient's diagnosis/condition. All physician specialties must use an ICD-9-CM code number and code to the highest level of specificity. Enter up to 4 codes in priority order (primary, secondary condition). An independent laboratory must enter a diagnosis only for limited coverage procedures.
All narrative diagnoses for non-physician specialties must be submitted on an attachment.
Item 24d. Enter the procedures, services, or supplies using the HCPCS/CPT code. When applicable, show HCPCS modifiers with the HCPCS code. Enter the Q7 - One Class A finding; Q8 - Two Class B findings; or Q9 - One Class B and two Class C findings as appropriate.
Enter the specific procedure code without a narrative description.
Item 24e. Enter the diagnosis code reference number as shown in item 21 to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number per line item. When multiple services are performed, enter the primary reference number for each service; enter either a 1, or a 2, or a 3, or a 4.
If a situation arises where two or more diagnoses are required for a procedure code, you must reference only one of the diagnoses in item 21.
Documentation on File
Podiatrists may submit claims using the Q7, Q8, or Q9 modifiers to indicate to the carriers the findings they have made on the patient's condition. This does not relieve them of the responsibility of maintaining documentation on file. This documentation must be maintained and made available to the carriers at their request. Failure to produce appropriate documentation may result in denial of the claim. Podiatrists should consult their carriers to verify that they are meeting the documentation requirements for Medicare claims.
[EM 2002-1298; EM 2003-0021/B-02-091/CR 2374]
Frequently Asked Questions
The following represent a variety of questions the Medical Review department has received. CIGNA Government Services will address at least quarterly “Frequently Asked Questions” related to coverage and local medical review policy issues. Providers may submit questions to the Web site at www.cignamedicare.com/customer_service/disclaimer.html.
Recoupments
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Q: |
Why was this claim denied/charges recouped? |
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A: |
The message on the Explanation of Benefits (EOB) or summary notice should help providers understand why a claim has been denied. If there is a technical problem with a claim (such as use of an invalid CPT code) then the claim may deny as a “return/reject.” Claims also “hit against” automated edits such as frequency of utilization parameters and/or covered diagnosis sets. These claims may be denied as “lack of medical necessity” or “this service at this frequency is not warranted.” Services may also be billed within the global period of another surgery; and the second service denies as there was no modifier to indicate it was a staged or unrelated procedure or return to surgery for a post-operative complication. Claims may also be selected for manual review and be denied by the reviewer for a variety of reasons. Examples could include the documentation did not support the service was done or how the charges were billed. On claims manually reviewed by the Medical Review department (*) at CIGNA Government Services, providers may call customer service and request additional detail entered by reviewers in our department from the VIPS notepad system. This information specifies why a service was denied and frequently includes references to CMS or LMRP coverage guidelines or other pertinent citations (such as previously published bulletin articles). This information may help providers determine if an appeal is appropriate. *For claims reviewed as part of a probe, providers will receive a letter
detailing the findings from the review of their claims. |
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Q: |
The beneficiary’s surgery was denied as not covered by Medicare. Why were other charges denied/recouped? |
|
A: |
Services that are done in support of noncovered procedures may also not be paid if they would not have been done unless the noncovered service was performed. Examples of this might include angiography preceding stenting of a the vertebral artery which is excluded from coverage by Medicare according to the Coverage Issues Manual (#50-32) as published by the Centers for Medicare & Medicaid Services (http://cms.gov/manuals/pub06pdf/pub06pdf.asp). This was also addressed in the September/October 2002 Medicare Bulletin (see article “Angioplasty and Stenting of Carotid, Vertebral, and Cerebral Arteries”). |
Related LMRP: See TN 2000-11-01
Screening PSA
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Q: |
My patient qualified for a screening PSA, but the claim for this was denied. Why? |
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A: |
If a beneficiary meets all qualifying criteria (See Medicare Bulletin GR 99-4, July-August 1999) then the denial could be because of a coding error. Make sure screening services are billed with the correct procedure code. Frequently, a diagnostic procedure may be billed with a screening ICD-9 code, or a screening procedure is billed with a diagnostic ICD-9 code. Either can result in a denial. Please make sure if your intention is to order a screening PSA (or any other covered screening test) that the correct CPT/HCPCS code is selected along with the correct/corresponding ICD-9 code. |
Related LMRP: See ID 96-001, NC 96-018, TN 97-05-01
Laboratory Services
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Q: |
Where can I find out information on the National Coverage Decisions about Lab Services? |
| A. | These were posted on our Web site in October 2002 and were published in the December 2002 issue of the Medicare Bulletin. |
HCPCS Codes Used for Home Health Consolidated Billing Enforcement – Quarterly Update
I. GENERAL INFORMATION
A. Background:
In April 2001, CMS established via Program Memorandum (PM) the process of periodically updating the lists of Healthcare Common Procedure Coding System (HCPCS) codes that are subject to the consolidated billing provision of the Home Health Prospective Payment System (HH PPS). Services appearing on this list submitted on claims to both Medicare fiscal intermediaries (FIs) and carriers, including durable medical equipment regional carriers (DMERCs), will not be paid on dates when a beneficiary for whom such a service is being billed is in a home health episode (i.e., under a home health plan of care administered by a home health agency). Medicare will only directly reimburse the primary home health agencies that have opened such episodes during the episode periods. Note that items incidental to physician services, as well as supplies used in institutional settings, are not subject to HH consolidated billing.
This PM is the second quarterly HH consolidated billing update for calendar year 2003. This update adds a single non-routine supply code to the list of codes subject to consolidated billing. This code was identified through additional review of the annual HCPCS update that was reflected in the first quarterly update. However, it was identified too late for inclusion in Medicare systems changes for the January quarter.
The new code to be added is: A6440: Zinc Paste >=3" <5" w/roll
The updated complete list of codes subject to HH consolidated billing to the HH consolidated billing master code list is available at www.cms.hhs.gov/medlearn/refhha.asp.
B. Policy:
Section 1895 of the Social Security Act codifies the HH PPS.
[EM 2003-0018/CR 2515]
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). Providers and Vendors may establish a direct sponsorship agreement with IVANS to obtain connectivity to the data center via the AT&T network. 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 have any questions regarding this article, please contact the EDI technical help desk for your state:
ID/TN: 866.520.4023
NC: 866.352.1608
Hepatitis B Vaccine: Deletion of Q codes and Reactivation of CPT Codes
Q codes Q3021, Q3022, and Q3023 will not be established as new codes for Medicare purposes at this time. Therefore, Medicare is reactivating CPT codes 90740, 90743, 90744, 90746, and 90747 effective January 1, 2003.
[EM 2002-1314/CR 2356]
Invoice Information Filing Instructions
Effective January 1, 2003, the XI modifier (filing invoice cost) used when filing claims electronically will no longer be valid. If you submit claims that require an invoice, you will need to enter the invoice information in the HAO/Narrative field (electronic equivalent for Item 19 of the CMS-1500 form) or you will need to file hard copy using the CMS-1500 form and attach a copy of the purchase invoice.
Paper claims received without a copy of the purchase invoice or electronically filed claims without the invoice information entered in the EMC narrative field will be denied for lack of information.
If you are filing electronically, you may enter the invoice information in the EMC narrative field as follows:
1. If you are submitting the actual invoice cost, you may enter the following statement in the narrative field: Actual invoice cost/invoice on file
2. If you are not submitting actual invoice cost enter the invoice information in the narrative field using the following format:
Des = Description/Name of agent (i.e., Des=TL201 Thallium)
QS = Quantity shipped (i.e., QS=280 mci)
TA = Total amount charged for quantity shipped (i.e., TA=$602.58)
UP = Unit Price (i.e., UP=$2.15 per mci)
DG = Dosage given (i.e., DG=4 mci)
PN = Product number (i.e., PN=TL2011)
[EM 2002-1267; 2002-1246/CR 2381]
2003 Laboratory Services Subject to Reasonable Charge Payment Method
The following codes relate to services subject to laboratory reasonable charge payment method. When these services are performed for a hospital outpatient, payment is made under the hospital outpatient bundled prospective payment system. Sections MIM 3628C and MCM 5114.1B provide reasonable charge payment instructions for other outpatient settings. When the reasonable charge payment method applies (for example, a service rendered for a nonpatient of a hospital), the inflation-indexed update is 1.1 percent for year 2003. The inflation-indexed update is calculated in accordance with §1842(b)(3) of the Act and Section 42 CFR 405.509(b)(1).
Transfusion Medicine and Other Procedures
86850 86860 86870 86880 86885 86886 86890 86891 86900 86901 86903 86904 86905 86906 86920 86921 86922 86927 86930 86931 86932 86945 86950 86965 86970 86971 86972 86975 86976 86977 86978 86985 89250 89251 89252 89253 89254 89255 89256 89257 89258 89259 89260 89261 89264 G0267
[EM 2002-1145/CR 2420]
Reasonable Charge Update for 2003 Splints and Casts Codes
The reasonable charge update for 2003 splints and casts codes is 1.1 percent. Gap-fill payment amounts, for 2002, were increased by this amount. Below are the codes that will receive this increase.
A4565 Q4001 Q4002 Q4003 Q4004 Q4005 Q4006 Q4007 Q4008 Q4009 Q4010 Q4011 Q4012 Q4013 Q4014 Q4015 Q4016 Q4017 Q4018 Q4019 Q4020 Q4021 Q4022 Q4023 Q4024 Q4025 Q4026 Q4027 Q4028 Q4029 Q4030 Q4031 Q4032 Q4033 Q4034 Q4035 Q4036 Q4037 Q4038 Q4039 Q4040 Q4041 Q4042 Q4043 Q4044 Q4045 Q4046 Q4047 Q4048 Q4049
[EM 2002-1279/CR 2510]
Remittance Advice Coding Update
X12N 835 Health Care Remittance Advice Remark Codes
CMS is the national maintainer of remittance advice remark codes used by both Medicare and non-Medicare entities. Under the Health Insurance Portability and Accountability Act (HIPAA), all payers have to use reason and remark codes approved by X-12 recognized maintainers of those code sets instead of proprietary codes to explain any adjustment in the payment.
The list of remark codes is available at http://www.cms.hhs.gov/medicare/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 June 30, 2002.
New Remark Codes
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Code |
Current Narrative |
|
N113 |
You or someone in your group practice has already submitted a claim for an initial visit for this beneficiary. Medicare pays only once per beneficiary per physician, group practice, or provider for an initial visit. |
|
N114 |
During the transition to the Ambulance Fee Schedule, payment is based on the lesser of a blended amount calculated using a percentage of the reasonable charge/cost and fee schedule amounts, or the submitted charge for the service. You will be notified yearly what the percentages for the blended payment calculation will be. |
|
N115 |
This decision is based on a local medical review policy (LMRP). An LMRP provides a guide to assist in determining whether a particular item or service is reasonable and necessary. A copy of this policy is available at www.LMRP.net |
|
N116 |
This payment is being made conditionally because the service was provided in the home, and it is possible that the patient is under a home health episode of care. When a patient is treated under a home health episode of care, consolidated billing requires that certain therapy services and supplies, such as this, be included in the home health agency’s (HHA’s) payment. This payment will need to be recouped from you if we establish that the patient is concurrently receiving treatment under an HHA episode of care. |
Modified Remark Codes
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M25 |
Payment has been (denied for the/made only for a less extensive) service because the information furnished does not substantiate the need for the (more extensive) service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this (more extensive) service, or if you notified the patient in writing in advance that we would not pay for this (more extensive) service and he/she agreed in writing to pay, ask us to review your claim either within 6 months of the date of this notice, if this notice is dated September 30, 2002, or earlier, or within 120 days of the date of this notice, if this notice is dated October 1, 2002, or later. If you do not request a review, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her (for the/in excess of any deductible and coinsurance amounts applicable to the less extensive) service. We will recover the reimbursement from you as an overpayment. |
|
M26 |
Payment has been (denied for the/made only for a less extensive) service because the information furnished does not substantiate the need for the (more extensive) service. If you have collected (any amount from the patient/any amount that exceeds the limiting charge for the less extensive service), the law requires you to refund that amount to the patient within 30 days of receiving this notice. The law permits exceptions to the refund requirement in two cases: • If you did not know, and could not have reasonably been expected to know, that we would not pay for this service; or • If you notified the patient in writing before providing the service that you believed that we were likely to deny the service, and the patient signed a statement agreeing to pay for the service. If you come within either exception, or if you believe the Carrier was wrong in its determination that we do not pay for this service, you should request review of this determination within 30 days. Your request for review should include any additional information necessary to support your position. If you request review within 30 days of receiving this notice, you may delay refunding the amount to the patient until you receive the results of the review. If the review decision is favorable to you, you do not need to make any refund. If, however, the review is unfavorable, the law specifies that you must make the refund within 15 days of receiving the unfavorable review decision. The law also permits you to request review at any time within 6 months of the date of this notice, if this notice is dated September 30, 2002, or earlier or within 120 days of the date of this notice, if this notice is dated October 1, 2002, or later. However, a review request that is received more than 30 days after the date of this notice, does not permit you to delay making the refund. Regardless of when a review is requested, the patient will be notified that you have requested one, and will receive a copy of the determination. The patient has received a separate notice of this denial decision. The notice advises that he/she may be entitled to a refund of any amounts paid, if you should have known that we would not pay and did not tell him/her. It also instructs the patient to contact your office if he/she does not hear anything about a refund within 30 days. The requirements for refund are in 1842(l) of the Social Security Act and 42 CFR 411.408. The section specifies that physicians who knowingly and willfully fail to make appropriate refunds may be subject to civil monetary penalties and/or exclusion from the program. Please contact this office if you have any questions about this notice. |
|
M27 |
The patient has been relieved of liability of payment of these items and services under the limitation of liability provision of the law. You, the provider, are ultimately liable for the patient’s waived charges, including any charges for coinsurance, since the items or services were not reasonable and necessary or constituted custodial care, and you knew or could reasonably have been expected to know, that they were not covered. You may appeal this determination provided that the patient does not exercise his/her appeal rights. If the beneficiary appeals the initial determination, you are automatically made a party to the appeals determination. If, however, the patient or his/her representative has stated in writing that he/she does not intend to request a reconsideration, or the patient’s liability was entirely waived in the initial determination, you may initiate an appeal. You may ask for a reconsideration for hospital insurance (or a review for medical insurance) regarding both the coverage determination and the issue of whether you exercised due care. The request for reconsideration must be filed within 60 days of the date of this notice, if this notice is dated September 30, 2002, or earlier or within 120 days of the date of this notice, if this notice is dated October 1, 2002, or later (or, for a medical insurance review, within 6 months of the date of this notice, if this notice is dated September 30, 2002, or earlier or within 120 days of the date of this notice, if this notice is dated October 1, 2002, or later). You may make the request through any Social Security office or through this office. |
|
MA01 |
(Initial Part B determination, Medicare Carrier or intermediary)—If you do not agree with what we approved for these services, you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the review. However, in order to be eligible for a review, you must write to us within six months of the date of this notice, if this notice is dated September 30, 2002, or earlier or within 120 days of the date of this notice, if this notice is dated October 1, 2002, or later, unless you have a good reason for being late. If you meet the criteria for a telephone review, you should phone this office if you wish to request a telephone review (ID/TN providers call 1.866.520.4021; NC providers call 1.866.352.6695). |
| MA02 | (Initial Medicare Part A determination)—If you do not agree with this determination, you have the right to appeal. You must file a written request for a reconsideration within 60 days of the date of this notice, if this notice is dated September 30, 2002, or earlier or within 120 days of the date of this notice, if this notice is dated October 1, 2002, or later. Decisions made by a QIO must be appealed to that QIO within 60 days. (An institutional provider, e.g., hospital, SNF, HHA or a hospice may appeal only if the claim involves a medical necessity denial, a SNF non-certified bed denial, or a home health denial because the patient was not homebound or was not in need of intermittent skilled nursing services, or a hospice care denial because the patient was not terminally ill, and either the patient or the provider is liable under §1879 of the Social Security Act, and the patient chooses not to appeal.) |
|
N103 |
Social Security records indicate that this beneficiary was a prisoner when the service was rendered. Medicare does not cover items and services furnished to beneficiaries while they are in State or local custody under a penal authority, unless under State or local law, the beneficiary is personally liable for the cost of his or her health care while incarcerated and the State or local government pursues such debt in the same way and with the same vigor as any other debt. Additionally, the following codes were modified before February 28, 2002, but were not included in Transmittal AB-02-067 (CR 1959). |
| MA49 | Missing/Incomplete/invalid six-digit provider number of home health agency or hospice for physician(s) performing care plan oversight services. |
| MA50 | Missing/Incomplete/invalid Investigational Device Exemption number for FDA-approved clinical trial services. |
| MA51 | Missing/Incomplete/invalid CLIA certification number for laboratory services billed by physician office laboratory. |
| MA82 | Did not complete or enter the correct physician/physician assistant/nurse practitioner/clinical nurse specialist/supplier’s billing number/NPI and/or billing name, address, city, state, zip code, and phone number. |
| MA112 | Our records indicate that the performing physician/physician assistant/clinical nurse specialist/certified registered nurse anesthetist/anesthesia assistant/supplier/nurse practitioner is a member of a group practice; however, you did not complete or enter accurately the group’s name, address, zip code and their Carrier assigned individual and group PINs. (Substitute “NPI” for “PIN” when effective.) |
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 three times a year after each X12 trimester meeting at http://www.wpc-edi.com/hipaa/. A reason code may be retired if it is no longer applicable or a similar code exists.
The committee approved the following reason code changes in June 2002:
New Reason Codes
| Code | Current Narrative |
|
145 |
Premium payment withholding |
| 146 | Payment denied because the diagnosis was invalid for the date(s) of service reported. |
| 147 | Provide contracted/negotiated rate expired or not in file |
| 148 | Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete. |
Modified Reason Codes
| Code | Current Narrative |
|
6 |
The procedure/revenue code is inconsistent with the patient’s age. |
| 7 | The procedure/revenue code is inconsistent with the patient’s gender. |
| 8 | The procedure/revenue code is inconsistent with the provider type/specialty (taxonomy). |
| 108 | Payment adjusted because rent/purchase guidelines were not met. |
[EM 2002-1047/CR 2395]
Venipuncture – Reminder!
We still have providers that submit procedure code 36415 for routine venipuncture. CIGNA Government Services no longer accepts this code as it became invalid for Medicare purposes effective January 1, 1994. Procedure code G0001 (Routine Venipuncture for collection of specimen(s)) replaced code 36415. Please use procedure code G0001 for Medicare purposes.
We are aware that other insurers still use procedure code 36415 and not the G0001. In this instance where Medicare is secondary, the claim must be corrected with the correct code before submitting to Medicare.
Not Otherwise Classified Drugs: Single Source Drug Pricing
The Exclusion list reflects:
- Exclusion of special sized packaging, e.g. Institutional Use.
- Exclusion of flip top vial, carpu-ject, tubex, cartridge, rapi-ject, lure lock, syringe, blunt point, abuject, rapiject, leurlock, advantage, min-i-jet, etc. unless it is the only source available.
- Exclusion of single dose vials when they exceed the code description.
- Exclusion of drugs marked preservative free, sulfite free, piggyback, or sterile unless the HCPCS/CPT description specifies their use.
|
Name |
95% AWP |
PREVIOUS |
| Alemtuzumab, 30 mg (Effective |
1533.66 |
N/A |
| Bupivacaine Hydrochloride 2 ml |
0.23 |
N/A |
| Butorphanol Tartrate 20mg |
65.65 |
N/A |
| Cimetidine HCL 150mg |
1.42 |
N/A |
| Cimetidine HCL 300mg |
2.96 |
N/A |
| Darbepoetin Alfa (Aranesp), .04 mg (Effective |
189.53 |
N/A |
| Darbepoetin Alfa (Aranesp), .025 mg (Effective |
118.46 |
N/A |
| Darbepoetin Alfa (Aranesp), .06 mg (Effective |
284.29 |
N/A |
| Darbepoetin Alfa (Aranesp), .1 mg (Effective |
473.81 |
N/A |
| Darbepoetin Alfa (Aranesp), .2 mg (Effective |
947.63 |
N/A |
| Denileukin Diftitox (Ontak) 150 mcg (See code J9160 for 300 mcg) |
605.15 |
N/A |
| Dextrose 10% |
11.72 |
N/A |
| Ertapenem Sodium (Invanz) 1 gm |
45.31 |
N/A |
| Fulvestrant (Faslodex) 50mg |
175.16 |
N/A |
| Hetastarch Sod/CL |
35.31 |
N/A |
| Ketorolac Tromethamine, 30 mg (Use code J1885 per 15mg/ pricing based per 15, 30, and 60 mg) |
6.03 |
N/A |
| Ketorolac Tromethamine, 60 mg (Use code J1885 per 15mg/ pricing based per 15, 30, and 60 mg) |
6.34 |
N/A |
| Lidocaine HCL (Xylocaine-MPF) 5 ml |
2.25 |
N/A |
| Metoprolol Tartrate (Lopressor) 1mg |
0.76 |
N/A |
| Oxaliplatin, 50 mg |
944.57 |
N/A |
| Oxaliplatin, 100 mg |
1889.09 |
N/A |
| Pegfilgrastim G-CSF (Neulasta) 6mg |
2802.50 |
N/A |
| Propofol (Diprivan) 10mg |
0.17 |
N/A |
| Sincalide (Kinevac) 5mcg |
33.42 |
N/A |
| Sodium Bicarbonate 8.4% |
0.06 |
N/A |
| Testosterone 37.5 mg |
0.11 |
N/A |
| Vitamin C (Ascorbic Acid) 500 mg |
0.66 |
N/A |
| Zoledronic Acid (Zometa) 4mg (Effective |
869.70 |
N/A |
[EM 2002-1290/CR 2381]
2003 Jurisdiction List
The following is an updated list of the HCPCS codes for DMERC and local Carrier jurisdictions. An indicator of “D” means that the DMERCs have primary jurisdiction over the codes, while an indicator of “L” means that the local Carriers have jurisdiction over the codes. Some codes with a D indicator may also be billed to the local Carriers if they are furnished incident to a physician’s service. An indicator of “J” means that the claims are processed and paid by both DMERCs and local Carriers. Claims for immunosuppressive drugs, inhalation drugs, oral anticancer drugs, oral antiemetic drugs, or drugs administered in the patient’s home through external infusion pumps should be submitted to the DMERCs. All other claims for drugs should be submitted to the local Carriers. Claims for supplies (including dressings), accessories, and replacement parts for implanted DME or implanted prosthetic devices should be submitted to the local Carriers. In addition, claims for repair of implanted DME or implanted prosthetic devices should be submitted to the local Carriers.
| LOCAL CARRIERS | DMERCS | JOINT | |||
|---|---|---|---|---|---|
| A0021-A0999 | L | A4206-A4211 | D | ||
| A4212 | L | A4213-A4215 | D | ||
| A4220 | L | A4221-A4259 | D | ||
| A4260-A4263 | L | A4265 | D | ||
| A4270 | L | A4280 | D | ||
| A4290-A4301 | L | A4305-A4465 | D | ||
| A4470-A4480 | L | A4481-A4510 | D | ||
| A4550 | L | A4554-A4558 | D | ||
| A4561-A4570 | L | A4575 | D | ||
| A4580-A4590 | L | A4595-A4640 | D | ||
| A4641-A4647 | L | A4649-A6010 | D | A6021-A6406* | J |
| A7000-A7509 | D | ||||
| A9150-A9170 | L | A9190-A9270 | J | ||
| A9300 | D | ||||
| A9500-A9700 | L | A9900* | J | ||
| A9901-B9999 | D | ||||
| D0120-D9999 | L | E0100-E0615 | D | ||
| E0616 | L | E0617-E0745 | D | ||
| E0746 | L | E0747-E0748 | D | ||
| E0749-E0754 | L | E0755 | D | ||
| E0756-E0759 | L | E0760-E0780 | D | E0781** | J |
| E0782-E0783 | L | E0784 | D | ||
| E0785-E0786 | L | E0791-E1310 | D | E1340* | J |
| E1353-E1390 | D | E1399* | J | ||
| E1405-E2101 | D | ||||
| G0001-G9016 | L | K0001-L7499 | D | L7500-L7520* | J |
| L7900-L8490 | D | L8499* | J | ||
| L8500-L8510 | D | ||||
| L8600-L8699 | L | L9900* | J | ||
| M0064-Q0115 | L | Q0136 | J | ||
| Q0163-Q0184 | D | ||||
| Q0183-Q4051 | L | Q9920-Q9940*** | J | ||
| R0070-R0076 | L | V2020-V2629 | D | ||
| V2630-V2632 | L | V2700-V2780 | D | ||
| V2790 | L | V2781 | D | ||
| V2785 | L | V2799 | D | ||
| V5008-V5299 | L | V5336 | D | ||
| V5362-V5364 | L | ||||
* Local Carrier has jurisdiction over claim if it is a supply or accessory
for an implanted prosthetic device (e.g., pleural catheter or LVAS) or implanted
DME (e.g., infusion pump) or repair of an implanted prosthetic device or implanted
DME.
** Local Carrier has jurisdiction over the claim if the infusion is performed
in the physician’s office or if the infusion is initiated and completed
in the physician’s office on the same day.
*** DMERC has jurisdiction over the claim when the item is self-administered
or used by Method II ESRD patients. [EM 2002-1280/CR 2378]
Provider 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 | DESCRIPTIONS |
| 11 | Table of Contents | ||
| 3 | Local Provider Education and Training (LPET) Workload Cost and Savings Allocation | ||
| 3.1 | LPET Overview | ||
| 3.2 | Reporting LPET Workload and Cost Information and Documentation in CAFM II | ||
| 3.3 | CARM II Reporting Instructions for LPRT Activities | ||
| 3.3.1 | Analysis of Information to Identify Local Education Needs | ||
| 3.3.2 | LPET Workload Management | ||
| 3.3.3 | Provider - Specific Education | ||
| 3.3.4 | Comparative Billing Reporting (CBR) Education | ||
| 3.3.5 | Education of Identified Service Specific Errors | ||
| 3.3.6 | Comprehensive Education Interventions | ||
| 3.3.7 | Proactive Local Education Meetings | ||
| 3.3.8 | Frequently Asked Questions Regarding Local Educational Issues | ||
| 3.3.9 | Bulletin Articles/Advisories Regarding Local Education Issues | ||
| 3.3.10 | Scripted Response Documents on Local Education Issues |
[EM 2002-1299/CR 2419]
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:
|
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:
|
