April 2003 Part B Medicare Bulletin
Table of Contents
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- 2003 DMEPOS Jurisdiction List
- Additional Emergency Changes to the 2003 Medicare Physician Fee Schedule Database
- Add-on-codes for Anesthesia
- Announcement About Medicare Participation for 2003 – Medicare Physician Fee Schedule Update
- ANSI X12 4010 Transactions and Code Sets, Update
- Changes to the Laboratory National Coverage Determination
(NCD) Edit Software
for April 1, 2003 - Colorectal Cancer Screening Information for Health Care Providers
- Common Paper Claim Filing Errors
- Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease
- EDI and HIPAA – A Winning Combination!
- Hepatitis B Therapy/Vaccination – Non-Covered and Covered
- Instructions to Providers and Suppliers for Submission of MSP Claims with Multiple Primary Payers
- Medical Review Frequently Asked Questions
- Overpayment Refunds
- Revision to July 2002 article on Correct Billing of Laminectomies
- The Multi-Carrier System (MCS) is Coming to Railroad Medicare!
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!
TopAnnouncement About Medicare Participation for 2003 - Medicare Physician Fee Schedule Update
We have great news to share with physicians and other practitioners throughout the country. As you know, CMS was scheduled to implement a negative 4.4 percent update effective March 1, 2003. CMS has worked with Congress for many months in an effort to correct a defect in the formula generated in part by unanticipated changes in economic conditions. We are pleased to announce that Congress has acted - this flaw will be corrected and, instead of a negative 4.4 percent update, we are now preparing to implement a positive 1.6 percent update effective March 1, 2003.
Medicare remains a lifeline to millions of seniors and disabled Americans and your commitment and participation in the Medicare program makes this lifeline possible. We hope that you will keep this in mind as you make your decision regarding your participation in 2003.
All physicians and practitioners now have until April 14, 2003, to make their 2003 Medicare participation decision.
As stated above, the 2003 Participation Enrollment Period is being extended an additional 45 days from March 1, 2003, to April 14, 2003, in order to allow physicians/practitioners an opportunity to make changes to their participation status. The participation period is the period of time in which providers can elect to participate in Medicare or to change their enrollment status. Any change in the participation status made during this period will be effective March 1, 2003. Any change to the participation status made before March 1, is effective back to January 1, 2003.
Reminder: Claims paid under the Medicare Physician Fee Schedule (MPFS) with dates of service January 1 through February 28, 2003, that are processed after March 1 will pay at the new 2003 rate. However, these claims containing 2003 MPFS services will be automatically adjusted in July to be paid correctly at the 2002 rate. Please note that some overpayments may result due to these adjustments and they will be recouped using normal procedures. Calendar year 2003 payment amounts for all services not paid under the MPFS are effective January 1, 2003.
[EM 2003-0203/CR 2601]
Add-on-codes for Anesthesia
Payment for anesthesia services is based on the sum of an anesthesia code-specific base unit value plus anesthesia time units multiplied by the locality-specific anesthesia conversion factor. Under current policy, if the physician is involved in multiple anesthesia services for the same patient during the same operative session, payment is based on the base unit assigned to the anesthesia service having the highest base unit value and anesthesia time that encompasses the multiple services.
The physician reports the anesthesia procedure with the highest base unit value with the multiple procedures modifier, "51," and total time across all surgical procedures.
New Codes
The Current Procedural Terminology includes new add-on-codes for anesthesia involving burn excisions or debridement and obstetrical anesthesia. The add-on code is billed in addition to the primary anesthesia code. In the burn area, code 01953 (1 base unit) is used in conjunction with code 01952 (5 base units). In the obstetrical area, code 01968 (2 base units) is used in conjunction with code 01967 (5 base units); code 01969 (5 base units) is used in conjunction with code 01967 (5 base units). The physician reports the add-on-code with the primary anesthesia code.
Pricing Claims
Anesthesia add-on-codes are priced differently than multiple anesthesia codes.
Generally, for an add-on code, allow only the base unit of the add-on code. All anesthesia time should be reported with the primary anesthesia code. There is an exception for obstetrical anesthesia.
We have learned that third party payers may have different policies for payment of time units for obstetrical anesthesia than for other anesthesia codes. If the time of the add-on obstetrical codes, such as 01968 or 01969, were reported with the primary code, the time units of the add-on code might be undervalued. To prevent this result, we are requiring, for the obstetrical add-on codes, that the anesthesia time be separately reported with each of the primary and the add-on code based on the amount of time appropriately associated with either code. Thus, recognize both the base unit and the time units for the primary and the add-on obstetrical anesthesia codes.
EXAMPLE: Code 01967 is billed with 01968.
Make two separate calculations. Price code 01967 using
5 base units and anesthesia time units and price code 01968 using
two base units and anesthesia time units.
[EM 2003-0186/CR 2539]
Additional Emergency Changes to the 2003 Medicare Physician Fee Schedule Database
In conjunction with emergency changes made in CR 2530, CMS has identified several more changes that have been incoporated into the 2003 Medicare Physician Fee Schedule.
Effective March 1, 2003, the revised 2003 conversion factor is 36.7856.
The revised update factor for March 1, 2003, to December 1, 2003, is 1.0162.
Changes included in this First Update to the 2003 Medicare Physician Fee Schedule Database are as follows:
| CPT/HCPCS | ACTION |
| A0225 | Procedure Status = I |
| A4421 | Procedure Status = I |
| G0025 | Procedure Status = D |
| Note: Effective for dates of service on or after April 1, 2003. | |
| G0125 | Procedure Status = C |
| Work RVU = 0.00 | |
| Non-Facility Practice Expense RVU = 0.00 | |
| Facility Practice Expense RVU = 0.00 | |
| Malpractice RVU = 0.00 | |
| G0125 - TC | Procedure Status = C |
| Work RVU = 0.00 | |
| Non-Facility Practice Expense RVU = 0.00 | |
| Facility Practice Expense RVU = 0.00 | |
| Malpractice RVU = 0.00 | |
| G0279 | |
| Work RVU = 0.00 | |
| Non-Facility Practice Expense RVU = 0.00 | |
| Facility Practice Expense RVU = 0.00 | |
| Malpractice RVU = 0.00 | |
| PC/TC: | 0 |
| SOS: | 1 |
| Global: | XXX |
| Pre-Op: | 0.00 |
| Intra-Op: | 0.00 |
| Post-Op: | 0.00 |
| Mult Surg: | 0 |
| Bilt Surg: | 0 |
| Asst Surg: | 0 |
| Co Surg: | 0 |
| Team Surg: | 0 |
| Diag Supv: | 09 |
| G0280 | Procedure Status = C |
| Work RVU = 0.00 | |
| Non-Facility Practice Expense RVU = 0.00 | |
| Facility Practice Expense RVU = 0.00 | |
| Malpractice RVU = 0.00 | |
| PC/TC: | 0 |
| SOS: | 1 |
| Global: | XXX |
| Pre-Op: | 0.00 |
| Intra-Op: | 0.00 |
| Post-Op: | 0.00 |
| Mult Surg: | 0 |
| Bilt Surg: | 0 |
| Asst Surg: | 0 |
| Co Surg: | 0 |
| Team Surg: | 0 |
| Diag Supv: | 09 |
| G0281 | Non-Facility Practice Expense RVU = 0.16 |
| Facility Practice Expense RVU = 0.16 | |
| G0283 | Non-Facility Practice Expense RVU = 0.16 |
| Facility Practice Expense RVU = 0.16 | |
| J7308 | Procedure Status = I |
| Q3021 | Procedure Status = F |
| Q3022 | Procedure Status = F |
| Q3023 | Procedure Status = F |
| HCPCS Code: | Q3031 |
| Short Desc: | Collagen skin test |
| Proc Stat: | B |
| RVU Work: | 0.00 |
| Non-Fac PE RVU: | 0.00 |
| Fac PE RVU: | 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 |
| Note: Effective for services performed on or after April 1, 2003 | |
| CPT/HCPCS | ACTION |
| V5274 | Procedure Status = E |
| HCPCS Code: | 0019T |
| Proc Stat: | I |
| RVU Work: | 0.00 |
| Non-Fac PE RVU: | 0.00 |
| Fac PE RVU: | 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 |
| HCPCS Code: | 0020T |
| Proc Stat: | C |
| RVU Work: | 0.00 |
| Non-Fac PE RVU: | 0.00 |
| Fac PE RVU: | 0.00 |
| Malpractice RVU: | 0.00 |
| PC/TC: | 0 |
| SOS: | 1 |
| Global: | XXX |
| Pre-Op: | 0.00 |
| Intra-Op: | 0.00 |
| Post-Op: | 0.00 |
| Mult Surg: | 0 |
| Bilt Surg: | 0 |
| Asst Surg: | 0 |
| Co Surg: | 0 |
| Team Surg: | 0 |
| Diag Supv: | 09 |
| CPT/HCPCS | ACTION |
| 17304 | Multiple Procedure Indicator = 1 |
| Bilateral Surgery Indicator = 0 | |
| 28008 | Bilateral Surgery Indicator = 1 |
| 28309 | Bilateral Surgery Indicator = 1 |
| 33224 | Global Period = 000 |
| Pre-Operative Percentage = 0.00 | |
| Intra-Operative Percentage = 0.00 | |
| Post-Operative Percentage = 0.00 | |
| 42820 | Non-Facility Practice Expense RVU = 4.25 |
| Facility Practice Expense RVU = 4.25 | |
| 53853 | Work RVU = 5.24 |
| 56821 | Multiple Procedure Indicator = 2 |
| Remove Endoscopic Base Code | |
| 57420 | Multiple Procedure Indicator = 2 |
| Remove Endoscopic Base Code | |
| 57421 | Multiple Procedure Indicator = 2 |
| Remove Endoscopic Base Code | |
| 58550 | Global Surgery Period = 090 |
| Pre-Operative Percentage = 0.12 | |
| Intra-Operative Percentage = 0.74 | |
| Post-Operative Percentage = 0.14 | |
| 67221 | Procedure Status = R |
| 71275 | Non-Facility Practice Expense RVU = 12.98 |
| 71275 - TC | Non-Facility Practice Expense RVU = 12.33 |
| 71275 | Facility Practice Expense RVU = 12.98 |
| 71275 - TC | Facility Practice Expense RVU = 12.33 |
| 72191 | Non-Facility Practice Expense RVU = 12.59 |
| 72191 - TC | Non-Facility Practice Expense RVU = 11.97 |
| 72191 | Facility Practice Expense RVU = 12.59 |
| 72191 - TC | Facility Practice Expense RVU = 11.97 |
| 73206 | Non-Facility Practice Expense RVU = 11.54 |
| 73206 - TC | Non-Facility Practice Expense RVU = 10.92 |
| 73206 | Facility Practice Expense RVU = 11.54 |
| 73206 - TC | Facility Practice Expense RVU = 10.92 |
| 73706 | Non-Facility Practice Expense RVU = 11.57 |
| 73706 - TC | Non-Facility Practice Expense RVU = 10.92 |
| 73706 | Facility Practice Expense RVU = 11.57 |
| 73706 - TC | Facility Practice Expense RVU = 10.92 |
| 74175 | Non-Facility Practice Expense RVU = 12.62 |
| 74175 - TC | Non-Facility Practice Expense RVU = 11.97 |
| 74175 | Facility Practice Expense RVU = 12.62 |
| 74175 - TC | Facility Practice Expense RVU = 11.97 |
| 77789 | Global Period = 000 |
| 77789 - 26 | Global Period = 000 |
| 77789 - TC | Global Period = 000 |
| 88141 | Non-Facility Practice Expense RVU = 0.19 |
| Facility Practice Expense RVU = 0.19 | |
| 90723 | Procedure Status = I |
| HCPCS Code: | 92597 |
| Short Descriptor: | Oral speech device eval |
| Proc Stat: | A |
| RVU Work: | 0.86 |
| Non-Fac PE RVU: | 1.63 |
| Fac PE RVU: | 0.41 |
| Malpractice RVU: | 0.04 |
| PC/TC: | 0 |
| SOS: | 1 |
| Global: | XXX |
| Pre-Op: | 0.00 |
| Intra-Op: | 0.00 |
| Post-Op: | 0.00 |
| Mult Surg: | 0 |
| Bilt Surg: | 0 |
| Asst Surg: | 0 |
| Co Surg: | 0 |
| Team Surg: | 0 |
| Diag Supv: | 09 |
| CPT/HCPCS | ACTION |
| 93012 | Non-Facility Practice Expense RVU = 5.99 |
| 93315 | Procedure Status = C |
| Work RVU = 0.00 | |
| Non-Facility Practice Expense RVU = 0.00 | |
| Facility Practice Expense RVU = 0.00 | |
| Malpractice RVU = 0.00 | |
| 93315 - TC | Procedure Status = C |
| Work RVU = 0.00 | |
| Non-Facility Practice Expense RVU = 0.00 | |
| Facility Practice Expense RVU = 0.00 | |
| Malpractice RVU = 0.00 | |
| 93317 | Procedure Status = C |
| Work RVU = 0.00 | |
| Non-Facility Practice Expense RVU = 0.00 | |
| Facility Practice Expense RVU = 0.00 | |
| Malpractice RVU = 0.00 | |
| 93317 - TC | Procedure Status = C |
| Work RVU = 0.00 | |
| Non-Facility Practice Expense RVU = 0.00 | |
| Facility Practice Expense RVU = 0.00 | |
| Malpractice RVU = 0.00 | |
| 93660 - TC | Diagnostic Supervision Indicator = 02 |
| 95951 | Procedure Status = C |
| Work RVU = 0.00 | |
| Non-Facility Practice Expense RVU = 0.00 | |
| Facility Practice Expense RVU = 0.00 | |
| Malpractice RVU = 0.00 | |
| 95951 - TC | Procedure Status = C |
| Work RVU = 0.00 | |
| Non-Facility Practice Expense RVU = 0.00 | |
| Facility Practice Expense RVU = 0.00 | |
| Malpractice RVU = 0.00 | |
| HCPCS Code: | 99026 |
| Proc Stat: | N |
| PC/TC: | 9 |
| SOS: | 9 |
| Mult Surg: | 9 |
| Bilt Surg: | 9 |
| Asst Surg: | 9 |
| Co Surg: | 9 |
| Team Surg: | 9 |
| Diag Supv: | 09 |
| HCPCS Code: | 99027 |
| Proc Stat: | N |
| PC/TC: | 9 |
| SOS: | 9 |
| Mult Surg: | 9 |
| Bilt Surg: | 9 |
| Asst Surg: | 9 |
| Co Surg: | 9 |
| Team Surg: | 9 |
| Diag Supv: | 09 |
[EM 2003-0208/CR 2609]
Update to the ANSI X12 4010 Transactions and Code Sets
As the health care industry began implementing the ANSI X12 4010 version, it became apparent that some changes were in order. As a result, the Designated Standards Maintenance Organizations (DSMOs) developed a "fast track" process to address the needed changes to the X12N 4010 implementation guides that were required within the first year for compliance reasons. The DSMOs only considered changes which were necessary for compliance in the strictest sense of the word. It was decided that all other change requests would be handled as part of the regular DSMO process.
As part of the "fast track" process, the DSMOs reviewed all change requests received as of March 1, 2001, and categorized the requests according to the above mentioned criteria. The revised addenda were posted to the Washington Publishing Company's Web site, and the DSMOs presented the consolidated list of approved changes to the National Committee on Vital Health Statistics (NCVHS). The NCVHS approved the DSMO recommendations in June 2001.
A Notice of Proposed Rule Making (NPRM) was published on May 31, 2002. The DSMOs, after reviewing the technical comments received, made recommendations to X12N. X12N, through their due process, reviewed the recommendations and incorporated the changes into a revised addendum to the 4010. X12N posted the revised draft versions of the addenda to the WPC Web site for public comment in August 2002. The public comment phase has since ended, and the final addenda versions are now available at http://hipaa.wpc-edi.com/HIPAAAddenda_40.asp, and are collectively referred to as version 4010A1.
CIGNA Government Services is planning on accepting test files in version 4010A1 beginning April 7, 2003. If you have already successfully tested version 4010 with CIGNA Government Services, you are not required to retest for version 4010A1. However, as of April 7, 2003, CIGNA Government Services will only be testing version 4010A1 and as of October 16, 2003, 4010A1 is the only version CIGNA Government Services will accept. Also, each trading partner that has elected to exchange COB, remittance (835), claim status response (277), and eligibility response (271) electronically with CIGNA Government Services must accept version 4010A1 by October 16, 2003.
We have a large vendor community wishing to test, and a limited amount of time in which to complete testing (by October 16, 2003). Therefore, getting scheduled to test with us as soon as possible is important, and will ensure a thorough testing process which will benefit all concerned parties. When you are ready to test, contact our HIPAA Testing and Reporting Coordinator at 1.866.520.4023, pressing option 1 when prompted.
[EM 2003-0163/CR 2385]
Colorectal Cancer Screening Information for Health Care Providers
Colorectal cancer (CRC) is the second leading cause of cancer-related death in the United States. The American Cancer Society (ACS) estimates that there will be 147,500 new cases and 57,100 deaths from CRC in 2003. However, CRC is one of the most preventable cancers, as well as one of the most curable when detected at an early stage. Screening can help prevent colorectal cancer by detecting polyps so they can be removed before they turn into cancer. According to the ACS, if the cancer is detected early and appropriately treated, the 5-year survival rate is approximately 90 percent. It has been estimated that widespread screening for CRC could save more than 20,000 lives each year.
The Importance of Screening
Despite the proven effectiveness and availability of various CRC screening tests, many Americans are not being screened for the disease. Screening for CRC lags far behind screening for other cancers. Only 21 percent of people aged 50 and older who responded to the Behavioral Risk Factor Surveillance System (BRFSS) in 1999 reported having had a fecal occult blood test (FOBT) within the recommended timeframe of one year. Only 34 percent of respondents had undergone sigmoidoscopy or colonoscopy within the recommended timeframe of five years. These findings underscore the need to increase awareness and promote the use of colorectal cancer screening exams at regular intervals.
As a consequence of the low level of CRC screening, only 37 percent of cases are diagnosed when the disease is still localized. Later diagnosis results in a significantly lower 5-year relative survival rate than would occur if patients were diagnosed when the disease was localized. If the cancer is detected early, the five-year survival rate is approximately 90 percent. When the cancer has spread regionally, the survival rate drops to 65 percent; and when it has metastasized, the rate lowers to only nine percent. These considerable differences in survival rates point to the importance of screening in preventing this disease and in detecting it at its earliest stage, when treatment is most effective.
According to the 2000 U.S. census, there are approximately 76.5 million Americans who are aged 50 and older, with an expected increase of 20 million Americans in this age group through 2005. By 2030, the number of Americans age 65 and older is expected to increase by over 200 percent. If prevention and early detection of colorectal cancer are not significantly improved, the increase in morbidity and mortality from CRC in the aging population will be even more pronounced than it is today.
Incidence and Mortality
CRC usually strikes men and women over the age of 50 (90 percent of cases).
The incidence rate is similar among men and women until age 50. At that age,
it becomes higher in men than in women. CRC incidence and mortality rates vary
substantially by race and ethnicity, with both incidence and death rates being
highest in African Americans and lowest in American Indian/Alaska Natives and
Hispanics. Death rates for colorectal cancer began declining in women in 1950
and in men beginning in 1985. Despite this encouraging trend, the death rates
for CRC are unacceptably high. It has been suggested that the incidence and
mortality of CRC could be reduced by
60 and 80 percent, respectively, if compliance were 60 percent with initial
testing and 80 percent with follow-up.
Screening Tests and Intervals
Several screening regimens have been proven to be effective (in various degrees) in reducing mortality from CRC: the fecal occult blood test (FOBT), flexible sigmoidoscopy, double-contrast barium enema (DCBE), and colonoscopy. These allow detection of adenomatous polyps so they can be removed before they become cancerous and the removal of early-stage colorectal cancer when the disease is still highly curable. Each procedure differs in accuracy, cost and risk.
Regular CRC screening is recommended for all adults aged 50 or older who have no known risk factors. (Seventy-five percent of all new cases of CRC occur in individuals with no risk factors for the disease, and as stated above, more than 90 percent of cases of the disease occur in people over the age of 50.) Screening guidelines have been developed by several scientific agencies and organizations, including the U.S. Preventive Services Task Force; the ACS; and the Interdisciplinary Task Force, which is convened by the Agency for Healthcare Research and Quality (AHRQ) and supported by five major gastroenterology societies. All recommend the following screening procedures:
- Annual FOBT, or
- Flexible sigmoidoscopy every five years, or
- Annual FOBT plus flexible sigmoidoscopy every five years, or
- Total colon examination by colonoscopy every ten years or by double contrast barium enema every five-ten years.
These guidelines emphasize the key health benefit of CRC screening - finding precancerous polyps so they can be removed before they turn into cancer, and finding early stage CRC, so it can be treated. Currently, data are insufficient to determine the best single screening approach. Each option has advantages and disadvantages that may vary for individual patients and practice settings. AHRQ recommends developing a screening strategy based on patient preferences, medical contraindications, patient adherence, and available resources for testing and follow-up. AHRQ advises clinicians to speak with patients about the benefits and potential harms associated with each option before selecting a screening strategy.
Note: For the most up-to-date guidelines, refer to www.guideline.gov, the National Guidelines Clearinghouse.
The Role of the Health Care Professional in Increasing Screening Rates
Health care professionals should offer screening according to currently accepted guidelines to all individuals aged 50 and older who are at average risk for CRC. Those at higher than average risk should be counseled according to the accepted guidelines for those at increased risk. As with other screening tests, a recommendation by a health care professional is an important influence in determining whether or not individuals decide to be screened for CRC. Primary care providers play a very important direct role in facilitating compliance with screening. In general, when primary care providers recommend a screening procedure to patients, patients follow through.
The ACS reports that the low prevalence of CRC screening is due in part to limited communication between physicians and their patients. Patients may be unaware of the benefits of screening unless their health care professionals discuss them. However, physicians may be unlikely to suggest screening unless the patient asks about it. Clinicians should take advantage of every opportunity to recommend preventive care to patients (e.g., during visits for acute care). Reminders should be given at every visit.
Reminder systems have been shown to increase preventive services and screening rates in practices that use them. They are strongly recommended to ensure that cancer screening programs are ongoing rather than a one-time event. Reminder systems are more efficient and effective when they include the participation of office staff. Reminders can be active (e.g., at point of service) or passive (e.g., receiving a postcard in the mail). Follow-up and surveillance should be built into reminder systems. At a minimum, health care professionals can use the Put Prevention Into Practice system (obtainable from AHRQ at 800.358.9295 or ahrqpubs@ahrq.gov).
Numerous educational materials are available on CRC and screening. See the order form for materials that have been developed as a part of the Screen for Life: National CRC Action Campaign. A description of the campaign and the order form follow. Most materials can be obtained from the Centers for Medicare & Medicaid Services at no charge.
Who Should Be Tested
Patients with symptoms require immediate diagnostic testing. Symptoms include:
- Rectal bleeding,
- Frequent abdominal discomfort or pain for no reason,
- Bloating,
- A change in bowel habits, such as having stools that are narrower than usual,
- Iron deficiency anemia, and
- Unexplained weight loss.
For asymptomatic patients, routine screening is recommended for:
- Men and women aged 50 and older. As stated earlier, at least 75 percent of colorectal cancers occur in people with no personal or family history of CRC and no known risk factors.
- Patients at increased risk for developing CRC. These patients may need
to be screened earlier and more frequently than other patients. Those considered
at increased risk have:
- A close relative (sibling, parent, or child) who has had CRC or an adenomatous polyp;
- A personal or family history of familial adenomatous polyposis;
- A personal or family history of hereditary nonpolyposis CRC;
- A personal history of adenomatous polyps;
- A personal history of CRC; or
- Inflammatory bowel disease, including Crohn's disease and ulcerative colitis.
Medicare Coverage and Procedure codes
Medicare covers the following tests/procedures:
| Colorectal Cancer Screening Test/Procedure | CPT Code | Medicare Coverage |
| Screening Fecal-Occult Blood Test | G0107 | Once every 12 months for patients age 50 and older. |
| Screening Flexible Sigmoidoscopy | G0104 | Once every 48 months for patients age 50 and older when performed by a doctor of medicine or osteopathy, or a physician assistant, nurse practitioner, or clinical nurse specialist. |
| Screening Colonoscopy - individual at high risk | G0105 | Once every 24 months for patients at any age who are at high risk for colorectal cancer, when performed by a doctor of medicine or osteopathy. |
| Screening Colonoscopy - individual not meeting criteria for high risk | G0121 | Once every 10 years but not within 48 months of a screening sigmoidoscopy for patients at any age who are not at high risk, when performed by a doctor of medicine or osteopathy. |
| Screening Barium Enema, alternative to G0104 (screening sigmoidoscopy)* | G0106 | Physicians may substitute a barium enema examination for flexible sigmoidoscopy every 4 years for patients age 50 and older. |
| Screening Barium Enema, alternative to G0105 (screening colonoscopy) * | G0120 | Physicians may substitute a barium enema examination for colonoscopy every 2 years for high-risk patients. |
| Screening Barium Enema, not performed as an alternative to G0105 or G0104. | G0122 | This service is denied as noncovered, because it fails to meet the requirements of the benefit. The beneficiary is liable for payment. |
*The screening barium enema must be ordered in writing after determining that the test is the appropriate screening test. The attending physician must determine that the estimated screening potential for the barium enema is equal to or greater than the screening potential estimated for a screening flexible sigmoidoscopy, or for a screening colonoscopy, as appropriate, for the patient.
Note: If during the course of a screening colonoscopy (or screening flexible sigmoidoscopy), a lesion or growth is detected that results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy (or flexible sigmoidoscopy) with biopsy or removal should be billed and paid rather than G0121 (or G0104).
Note: For additional information on covered services, HCPCS Codes, and coverage criteria for colorectal cancer screening services:
- View CMS' Carrier Manual, Part 3, Chapter IV - Claims Review and Adjudication Procedures at: http://cms.hhs.gov/manuals/14_car/3b4010.asp. See Section 4180 for CRC screening.
- Read Medicare Resident & New Physician Training, Screening for Colorectal Cancer, pp. 48-51.
- To obtain a hardcopy of this publication or a CD, send an e-mail note to Medlearn@cms.hhs.gov. Also visit CMS' Medlearn site, which was established for health care professionals, at: http://www.cms.hhs.gov/medlearn/.
Screen for Life National CRC Action Campaign and National CRC Awareness Month Campaign
CMS partners with the Centers for Disease Control and Prevention (CDC) to increase CRC screening within the Medicare population and the general population aged 50 and above. Together CDC and CMS develop and implement the Screen for Life: National Colorectal Cancer Action Campaign (SFL), which informs men and women aged 50 years and older about the importance of CRC screening for early detection and prevention of the disease. (For more information about SFL, visit: www.cdc.gov/cancer/screenforlife.) In addition, in March, CMS joins 50 agencies and organizations to carry out the National CRC Awareness Month Campaign, which generates widespread awareness about CRC and encourages people to learn more about how to reduce their risk of the disease through regular screening and a healthy lifestyle. The Cancer Research and Prevention Foundation (CRPF) leads this national campaign. (For more information on the NCCAM campaign, visit CRPF's Internet site at www.preventcancer.org or call 1.800.227.2732.) Medicare Carriers, Intermediaries, and Quality Improvement Organizations join CMS and its partners in this effort by making people with Medicare aware of the importance of regular CRC screening and by encouraging health care professionals to: (1) educate themselves and their patients about the benefits of screening for prevention and early detection of colorectal cancer; (2) recruit patients for initial colorectal cancer screening; and (3) ensure patient compliance with current screening tests and appropriate follow-up. Both campaigns produce and distribute CRC materials for patients and health care professionals.
Materials, Education and Training
Screen for Life has developed numerous materials (e.g., brochures, fact sheets, posters), which health care professionals can make available to patients and use to inform them about the importance of screening. The publications can be obtained free of charge from CMS or CDC. See the table entitled: "Materials on Colorectal Cancer Screening for Health Care Professionals" for information on available print materials and how they may be ordered or downloaded from the Internet.
In addition to the print materials, CDC has developed a slide presentation, "A Call to Action: Prevention and Early Detection of Colorectal Cancer." This was developed to generate awareness among primary care professionals of the importance of CRC screening in the prevention and early detection of CRC. CDC encourages health care professionals to download and present the slides to their colleagues. CDC also offers Web-based tools that health care professionals can use to help patients select screening options (e.g., suggestions for communicating effectively with patients about CRC). The slide presentation and online tools may be viewed, ordered, or downloaded at: www.cdc.gov/cancer/colorctl/calltoaction/.
Information for this article was taken from:
- The American Cancer Society's Cancer Facts & Figures 2002 (Special Section: Colorectal Cancer and Early Detection) and Cancer Facts & Figures 2003;
- CDC's Cancer Prevention and Control, CRC Prevention and Control Initiatives Web site, including Colorectal Cancer: The Importance of Prevention and Early Detection 2002 Fact Sheet;
- CDC's Cancer Prevention and Control, Screen for Life: National CRC Action Campaign Web site, including materials from the campaign;
- CDC's MMWR Weekly, March 9, 2001/50(09); 162-6, "Trends in Screening for Colorectal Cancer - United States, 1997 and 1999;
- Cancer Research and Prevention Foundation's (formerly the Cancer Research Foundation of America) Confronting Colorectal Cancer: Action Steps for Change, October 2002;
- CMS' Medicare Resident & New Physician Training, Sixth Edition, 2002, Screening for Colorectal Cancer; and
- CMS' Carrier Manual, Part 3, Chapter IV - Claims Review and Adjudication Procedures, Section 4180.
Materials on Colorectal Cancer (CRC) Screening
for Health Care Professionals
| Campaign Material | Version | CMS - CDC Pub No. |
Additional Information |
Health Professionals' Fact Sheet BEING UPDATED |
CRC Health Professionals' Facts on Screening | CDC # 099-6487 ORDER FROM CDC |
To order or download copies: 1) visit www.cdc.gov./cancer/screenforlife;
2) e-mail to cancerinfo@cdc.gov;
or phone 1.888.842.6355. Contains table with info on screening tests including scientific evidence supporting the tests, frequency, purpose, important considerations, insurance/ Medicare coverage; etc. Currently, may only be downloaded. |
| Slide Presentation for Health Professionals | "A Call to Action: Prevention and Early Detection of CRC" | ORDER FROM CDC. See "Additional Information." | Developed by CDC to generate a greater awareness among primary care providers of the importance of prevention and early detection of CRC. Visit: www.cdc.gov/cancer/colorctl/calltoaction/index.htm. Download and present slides to colleagues. |
| Poster (English/Span.) | "Medicare Good News" --Caucasian Audience --African-Amer. Audience --Asian-Amer. Audience --Hispanic Audience (Sp.) |
CMS #10122 CMS #10124 CMS #10125 CMS #10142 |
Posterboard backing. |
| Poster | "No Symptoms" | CMS #10183 CDC #099-6478 |
Order version with posterboard backing from CMS. For version that folds, order from CDC (max 50 copies from CDC). |
| Poster | "True or False" | CMS #02256 (large) CMS #02255 (small) |
Colorful poster with 4 questions about CRC & other info. Folds. Large - 17"x22". Small - ll"x17". |
| Basic Fact Sheet for Patients (low literacy version) | "CRC Basic Facts on Screening" | CMS#11011 | 8 ½ x 11", 2-sided sheet. Low literacy version of the detailed fact sheet (see below). Info provided is similar to brochure, CRC Screening Saves Lives. |
| Detailed Fact Sheet for Patients | "CRC Facts on Screening" | CMS#11012 | 8 ½ x 11", 2-sided sheet. Includes a chart on the back, with information on frequency/cost estimate, purpose, important considerations, etc. |
| Brochure for Patients | "CRC Screening Saves Lives" (Eng.) | CMS#11010 | 8 ½ x 11" trifold. Information on types of tests, how screening saves lives, who is at high risk, symptoms, insurance coverage, etc. |
Brochure for Patients (English/Span.) |
"Let's Break the Silence" | CMS #95173 (Eng.) CMS #10158 (Sp.) |
8 ½ x 11" trifold. Discusses terms related to CRC screening, who is at risk, steps to take, talking with the doctor, insurance, symptoms, preventing cancer, etc. Includes diagram of colon and rectum. |
| Pamphlet on Preventive Services Covered by Medicare (for Patients) |
"Medicare Preventive Services . . . To Help Keep You Healthy" | CMS #10110 (Eng.) | Includes a chart that explains which preventive services are covered by Medicare, for whom they are covered, and what the beneficiary pays. Tear-off cards provide detailed information on some of the preventive benefits. |
To view these materials, visit: http://www.cdc.gov/cancer/screenforlife/preview.htm.
COLORECTAL CANCER (CRC) SCREENING PUBLICATIONS
TO ORDER COPIES FROM CMS -- FAX, E-MAIL, OR TELEPHONE:
Orders from CMS For 1 copy:
- Phone: 1.800.MEDICARE (1.800.633.4227)
Orders from CMS For 1-99 copies:
- Fax: 410.786.4786
- E-Mail: LBeasley@cms.hhs.gov
- Phone: If you have questions, or cannot fax or e-mail requests, call Larry
Beasley
(410.786.7843).
Orders for 100 or more copies:
- Fax: 410.786.1905
- E-Mail: STaylor@cms.hhs.gov
- Phone: If you have questions, or cannot fax or e-mail requests, call Susie
Taylor
(410.786.7849).
NOTE: Please order publications via fax or e-mail when possible.
Because of the large
volume of requests, you may not receive an acknowledgment return call for orders
placed on voice mail.
TO ORDER OR DOWNLOAD PUBLICATIONS FROM CMS' INTERNET SITE:
- Internet: To download copies of "Let's Break the Silence" brochures
(English & Spanish)
from the CMS Internet site, visit: www.medicare.gov.
Click "Health Information." Then click "Colorectal Cancer."
TO ORDER OR DOWNLOAD PUBLICATIONS FROM CDC:
- Internet: http://www.cdc.gov/cancer/screenforlife,
To download slide presentation, visit: www.cdc.gov/cancer/colorctl/calltoaction/index.htm.
- Phone: 1.888.842.6355, or
- E-mail: cancerinfo@cdc.gov.
TO VIEW MATERIALS BEFORE ORDERING:
- Internet: Visit the CDC site at: http://www.cdc.gov./cancer/screenforlife
[EM 2003-0197/AB-03-033/CR 2580]
Common Paper Claim Filing Errors
Eighty-four percent of all Medicare claims submitted in 2002 were sent electronically and that number continues to grow* . For more information on the benefits of Electronic Data Interchange (EDI) contact our EDI department at 1.866.520.4022 for TN/ID providers or 1.866.352.1608 for NC providers.
If your office files claims on paper, there are important guidelines you must follow to ensure your claims will process and pay correctly.
** Failure to follow these guidelines could affect payment accuracy resulting in the delay or denial of the claim. **
- Do not use extra verbiage within the claim form. If you must put extra verbiage on the claim, use Item 19 or an attachment.
- Do not use stamps or stickers. If you must put a stamp or sticker on the claim, put it at the top of the claims within the blank area.
- Do not put a description next to the diagnosis code in Item 21. All that is needed is the ICD-9 alpha/numeric diagnosis code.
- Do not leave off the zip code in Item 33. This item is used as the mailing address when a claim is returned.
- Do not write or stamp information in RED ink. Information in red will not show up on the image and will not be available during processing.
- Do not change the size of EOBs or copy them across to two pages. This may cause your EOB to be illegible and rejected. (Example: Blue Cross Blue Shield of TN should be submitted on a legal size sheet of paper just as they sent it to the provider.)
- Do not submit more than one diagnosis pointer in Item 24e. Only the first one will be accepted.
- Do not place the number of units/days in Item 24g too close to the charges in 24f. This may cause the units/days to be read as a part of the submitted charges and the number of units/days to default to 1. Right justifying the days/units in Item 24g will give more space between the two fields.
- Do not leave Item 11 blank. If this field is not filled out correctly, it will cause the claim to deny. If no primary insurance exist, put NONE in the field.
- Do not put a phone number on the first line of Item 33. Please submit the phone number below the provider's name and address.
- Do not put the statements "No Purchased Services Included on This Claims" or "No Purchases Tests Included", they are no longer accepted. Item 20 must be completed to indicate purchased/non-purchased services.
- Do not put a description or times/units of the procedure codes underneath the line item in Items 24a - 24k is not needed and may cause processing errors. (Example: anesthesia time)
- Do not put negative charges on a claim form. (Example: Primary insurance payments should be reflected on the EOB)
- Do not use too light of print or a Dot Matrix printer which causes broken lines. Check to make sure the ink is dark. Also, laser or inkjet printers are preferred.
- Do not use small font type and size. For best processing results we recommend font type Times New Roman and size 12.
- Do not submit black CMS-1500 forms. This includes submitting copies or carbon copies. Always submit a RED CMS-1500 form.
- Do not highlight items on the CMS-1500 form or attachments. This will cause the claim to be illegible which slows down the processing of the claim.
- Do not submit claims to the incorrect PO Box number. (TN - 1465, NC - 671, ID - 22599)
Deep Brain Stimulation for Essential Tremor and Parkinson's Disease
Deep brain stimulation (DBS) refers to high-frequency electrical stimulation of anatomic regions deep within the brain utilizing neurosurgically implanted electrodes. These DBS electrodes are stereotactically placed within targeted nuclei on one (unilateral) or both (bilateral) sides of the brain. There are currently three targets for DBS - the thalamic ventralis intermedius nucleus (VIM), subthalamic nucleus (STN) and globus pallidus interna (GPi).
Essential tremor (ET) is a progressive, disabling tremor most often affecting the hands. ET may also affect the head, voice and legs. The precise pathogenesis of ET is unknown. While it may start at any age, ET usually peaks within the second and sixth decades. Beta-adrenergic blockers and anticonvulsant medications are usually the first line treatments for reducing the severity of tremor. Many patients, however, do not adequately respond or cannot tolerate these medications. In these medically refractory ET patients, thalamic VIM DBS may be helpful for symptomatic relief of tremor.
Parkinson's disease (PD) is an age-related progressive neurodegenerative disorder involving the loss of dopaminergic cells in the substantia nigra of the midbrain. The disease is characterized by tremor, rigidity, bradykinesia and progressive postural instability. Dopaminergic medication is typically used as a first line treatment for reducing the primary symptoms of PD. However, after prolonged use, medication can become less effective and can produce significant adverse events such as dyskinesias and other motor function complications. For patients who become unresponsive to medical treatments and/or have intolerable side effects from medications, DBS for symptom relief may be considered.
Effective on or after April 1, 2003, Medicare will cover unilateral or bilateral thalamic VIM DBS for the treatment of ET and/or Parkinsonian tremor and unilateral or bilateral STN or GPi DBS for the treatment of PD only under the following conditions:
- Medicare will only consider DBS devices to be reasonable and necessary if they are Food and Drug Administration (FDA) approved devices for DBS or devices used in accordance with FDA approved protocols governing Category B Investigational Device Exemption (IDE) DBS clinical trials.
- For thalamic VIM DBS to be considered reasonable and necessary, patients
must meet all of the following criteria:
- Diagnosis of essential tremor (ET) based on postural or kinetic tremors of hand(s) without other neurologic signs, or diagnosis of idiopathic PD (presence of at least 2 cardinal PD features (tremor, rigidity or bradykinesia)) which is of a tremor- dominant form.
- Marked disabling tremor of at least level 3 or 4 on the Fahn-Tolosa-Marin Clinical Tremor Rating Scale (or equivalent scale) in the extremity intended for treatment, causing significant limitation in daily activities despite optimal medical therapy.
- Willingness and ability to cooperate during conscious operative procedure, as well as during post-surgical evaluations, adjustments of medications and stimulator settings.
- For STN or GPi DBS to be considered reasonable and necessary, patients
must meet all of the following criteria:
- Diagnosis of PD based on the presence of at least 2 cardinal PD features (tremor, rigidity or bradykinesia).
- Advanced idiopathic PD as determined by the use of Hoehn and Yahr stage or Unified Parkinson's Disease Rating Scale (UPDRS) part III motor subscale.
- L-dopa responsive with clearly defined "on" periods.
- Persistent disabling Parkinson's symptoms or drug side effects (e.g., dyskinesias, motor fluctuations, or disabling "off" periods) despite optimal medical therapy.
- Willingness and ability to cooperate during conscious operative procedure, as well as during post-surgical evaluations, adjustments of medications and stimulator settings.
DBS is not reasonable and necessary and is not covered for ET or PD patients with any of the following:
- Non-idiopathic Parkinson's disease or "Parkinson's Plus" syndromes.
- Cognitive impairment, dementia or depression which would be worsened by or would interfere with the patient 's ability to benefit from DBS.
- Current psychosis, alcohol abuse or other drug abuse.
- Structural lesions such as basal ganglionic stroke, tumor or vascular malformation as etiology of the movement disorder.
- Previous movement disorder surgery within the affected basal ganglion.
- Significant medical, surgical, neurologic or orthopedic co-morbidities contraindicating DBS surgery or stimulation.
Patients who undergo DBS implantation should not be exposed to diathermy (deep heat treatment including shortwave diathermy, microwave diathermy and ultrasound diathermy) or any type of MRI which may adversely affect the DBS system or adversely affect the brain around the implanted electrodes.
DBS should be performed with extreme caution in patients with cardiac pacemakers or other electronically controlled implants which may adversely affect or be affected by the DBS system.
For DBS lead implantation to be considered reasonable and necessary, providers and facilities must meet all of the following criteria:
- Neurosurgeons must: (a) be properly trained in the procedure; (b) have experience with the surgical management of movement disorders, including DBS therapy; and (c) have experience performing stereotactic neurosurgical procedures.
- Operative teams must have training and experience with DBS systems, including knowledge of anatomical and neurophysiological characteristics for localizing the targeted nucleus, surgical and/or implantation techniques for the DBS system, and operational and functional characteristics of the device.
- Physicians specializing in movement disorders must be involved in both patient selection and post-procedure care.
- Hospital medical centers must have:
- brain imaging equipment (MRI and/or CT) for pre-operative stereotactic localization and targeting of the surgical site(s);
- operating rooms with all necessary equipment for stereotactic surgery; and
- support services necessary for care of patients undergoing this procedure and any potential complications arising intraoperatively or postoperatively.
Payment and pricing information will be on the Medicare Physician Fee Schedule Database (MPFSDB). Pay for Medicare Part B claims on the basis of the MPFS. Deductible and coinsurance apply. Claims from physicians or other practitioners where assignment was not taken are subject to the Medicare limiting charge (refer to MCM Part 3, chapter VII, §7555 for more information).
HCPCS Coding
The following HCPCS codes are available for use when billing for covered deep brain stimulation:
| E0752 | Implantable Neurostimulator Electrode, Each |
| E0756 | Implantable Neurostimulator Pulse Generator |
| 61862 | Twist drill, burr hole, craniectomy for stereotactic implantation of oneneurostimulator array in subcortical site (e.g., thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray) |
| 61880 | Revision or removal of intracranial neurostimulator electrodes |
| 61885 | Incision and subcutaneous placement of cranial neurostimulator
pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array |
| 61886 | Incision and subcutaneous placement of cranial neurostimulator
pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays |
| 61888 | Revision or removal of cranial neurstimulator pulse generator or receiver |
| 95961 | Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of physician attendance |
| 95962 | Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; each additional hour of physician attendance (List separately in addition to code for primary procedure) (Use 95962 in conjunction with code 95961) |
| 95970 | Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (i.e., cranial nerve, peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming |
| 95971 | Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple brain, spinal cord, or peripheral (i.e., peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming |
| 95972 | Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex brain, spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour |
| 95973 | Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex brain, spinal cord, or peripheral (except cranial nerve); complex brain, spinal cord, or peripheral (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, additional 30 minutes after hour (List separately in addition to code for primary procedure) (Use 95973 in conjunction with code 95972) |
Allowable Covered Diagnosis Codes
Deep Brain Stimulation is covered for the following ICD-9-CM diagnosis codes:
332.0 - Parkinson's disease, with paralysis agitans
333.1 - Essential and other specified forms of tremor
[EM 2003-0140/CR 2553]
Hepatitis B Therapy/Vaccination - Non-Covered and Covered
The Medicare Carrier's Manual as published by the Centers for Medicaid & Medicare Services includes in section 2049.4 a list of indications for which Medicare will make payment for Hepatitis B administration. (See CPT codes 90740, 90743, 90744, 90746, and 90747) Also listed are exclusions from coverage. The purpose of this article is to advise providers on the correct manner of billing for these services so to expedite payment or denial as appropriate.
Administration of Hepatitis B therapy is covered for those beneficiaries at high or intermediate risk for contracting Hepatitis B (*see exception below). The criteria for these risks are as follows:
High-risk groups
• End stage renal disease (ESRD) patients;
• Hemophiliacs who receive Factor VIII or IX concentrates;
• Clients of institutions for the mentally retarded;
• Persons who live in the same household as an Hepatitis B Virus (HBV)carrier;
• Homosexual men; and
• Illicit injectable drug abusers.
Intermediate risk groups
• Staff in institutions for the mentally retarded; and
• Workers in health care professions who have frequent contact with blood
or blood-derived body fluids during routine work.
*EXCEPTION: Persons in the above-listed groups would not be considered at high or intermediate risk of contracting hepatitis B, however, if there is laboratory evidence positive for antibodies to hepatitis B. (ESRD patients are routinely tested for hepatitis B antibodies as part of their continuing monitoring and therapy)
Noncovered Therapy
If a beneficiary receiving Hepatitis B therapy does not meet the above criteria (e.g. beneficiary traveling abroad) then this service should be billed with modifier "GY" appended to the correct CPT code effective with claims received on or after March 17, 2003. In accordance with the above guidelines, this will prompt a denial of this charge for which the beneficiary would be responsible. Noncovered services billed without the appropriate modifier would represent misrepresentation of services actually provided, and the carrier will conduct postpayment reviews of these services as indicated to ensure appropriate payment. [MCM 2049.4]
Instructions to Providers and Suppliers for Submission of MSP Claims With Multiple Primary Payers
There are situations where more than one primary payer pays on a Medicare Part B claim and Medicare may still make a secondary payment on the claim. Physicians and suppliers must comply with Section 1.4.2, titled "Coordination of Benefits," found in the 837 version 4010 Professional Implementation Guide regarding the submission of Medicare beneficiary claims to multiple payers for payment. Providers must follow model 1 in section 1.4.2.1 that discusses the provider to payer to provider methodology of submitting electronic claims. When there are multiple primary payers to Medicare you must follow the instructions cited below when sending the claim to Medicare for secondary payment.
Submission of Electronic MSP Claims With Multiple Primary Payers, but With Only One Insurance Type Code
Where there is more than one primary payer on a MSP claim and the primary payers identify the same insurance type code (e.g., the claims show two employer group health plans made payment on the claim which is identified as insurance type code 12), physicians and suppliers can send these claims electronically using the 837 version 4010 claim submission format. When sending these types of claims, you must do the following:
Primary Payer Paid Amounts: For line level services claims, physicians and suppliers must add all primary payer paid amounts for that service line and put the total amount in loop ID 2430 SVD02 of the 837. If only claim level information is sent to Medicare, providers and suppliers must add all other payer paid amounts for that claim and place the total amount in loop ID 2320 AMT02 AMT01=D of the 837.
Primary Payer Allowed Amount: For line level services, physicians and suppliers must take the higher of the allowed amount for that service line, or the total of the other payer paid amounts, whichever is higher, and put the amount in loop ID 2400 AMT02 segment with AAE as the qualifier in the 2400 AMT01 segment of the 837. If only claim level information is sent to Medicare, take the higher of the claim level allowed amount, or the total of the other payer paid amounts, whichever is higher, and put the amount in Loop ID 2320 AMT02 AMT01 = B6.
Obligated to Accept as Payment in Full Amount (OTAF): For line level services, physicians and suppliers must take the lowest OTAF amount for that service line, which must be greater than zero, and put the amount in loop 2400 CN102 CN 101 = 09. If only claim level information is sent to Medicare, take the lowest claim level OTAF amount, which must be greater than zero, and put this information in loop 2300 CN102 CN101 = 9.
Submission of Hardcopy MSP Claims with Multiple Primary Payers, but With More Than One Insurance Type Involvement
There may be situations where two or more insurer types make payment on a
claim; for example, an auto insurer makes a primary payment on a line of service
and, subsequently, a group health plan also makes a primary payment for the
same line of service. Claims with more than one insurance type involvement
cannot be sent electronically to Medicare. A hardcopy claim must be submitted.
Use the current Form CMS-1500 when submitting Part B hard copy claims. Physicians
and suppliers must attach the other payers EOB, or remittance advice, to the
incoming claim when sending it to Medicare for processing. [EM 2003-0082/
CR 2050]
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for April 1, 2003
The purpose of this Program Memorandum (PM) is to announce the changes that will be included in the April release of the edit module. Program Memorandum (PM) AB-02-110 implemented the NCDs for clinical diagnostic laboratory services that were developed by the laboratory negotiated rulemaking committee and published as a final rule on November 23, 2001. We announced in this PM that nationally uniform software would be developed by Computer Sciences Corporation and incorporated into the shared systems so that laboratory claims subject to one of the 23 NCDs would be processed uniformly throughout the nation effective January 1, 2003. The laboratory edit module for the NCDs will be updated quarterly as necessary to reflect ministerial coding updates and substantive changes to the NCDs developed through the NCD process.
- 1. On January 28, 2003, we posted on the Internet a decision memorandum
announcing our intent to add the following ICD-9-CM codes to the serum iron
studies NCD: 282.60, 282.61, 282.62, 282.63, 282.69, and 285.21. These are
codes for anemia in patients with end-stage renal disease and sickle cell
anemia. We believe these codes flow from the existing narrative in the serum
iron studies relating to abnormal blood count values. (See http://cms.hhs.gov/ncdr/memo.asp?id=74 for
additional information regarding this change.)
Pursuant to §1869(f)(1)(B) of the Social Security Act, the term "national coverage determination" means a determination by the Secretary with respect to whether or not a particular item or service is covered nationally under this title [XVIII], but does not include a determination of what code, if any, is assigned to a particular item or service covered under this title or a determination with respect to the amount of payment made for a particular item or service so covered." Thus, the assignment of the ICD-9-CM codes to given services will not be subject to review under section 1869(f).
- The Updates to the Current Procedure Terminology (CPT) codes for 2003 included the deletion of seven codes that are currently in the blood count NCD. We are eliminating the following CPT codes from the edit software: 85021, 85022, 85023, 85024, 85031, 85590, and 85595. The CPT also added new blood count codes for 2003. Therefore, we have undertaken an NCD review to add new codes to this policy. Readers may follow the progress of this NCD review on the Internet at: http://cms.hhs.gov/ncdr/trackingsheet.asp?id=88.
- In PM AB-02-134, question and answer 4 noted that CPT codes 87184 and 87186,
the susceptibility studies for antimicrobial agents, were not specific to
urine. Editing these codes for the diagnoses in the urine culture NCD could
result in inappropriate denials when the code was being used for other identifications.
We stated that the edit module would not edit for these CPT codes, but that
contractors could develop local edits for them.
We have learned that an error was made in developing the edit module and these codes were not removed as planned. The oversight will be corrected in the April update of the edit module. In the meantime, contractors may use the override indicator on all claims with CPT codes 87184 and 87186 to by pass the edit module. Any inappropriate denials should be adjusted when brought to the contractor's attention.
- In the serum iron studies NCD, there is a mismatch between the ICD-9-CM codes and the description of the codes in the list of ICD-9-CM codes covered by Medicare. The coding manual is being corrected to display the correct description of ICD-9-CM codes 562.02 and 562.03 to reflect that these codes indicate diverticulosis and diverticulitis of the small intestine with hemorrhage. No changes in the software are necessary for this change.
- Several changes were made to the NCDs as produced in PM AB-02-110. These
changes were incorporated in the January 1, 2003, release and in the Laboratory
NCD Manual that is on the Internet at: http://cms.hhs.gov/ncd/manual.pdf. These
changes do not reflect substantive changes to the policies, but rather reflect
correction of typographical errors and/or ministerial coding updates that
have taken place prior to the January 2003 release. The changes to the NCDs
are tracked in the NCD Manual Updates section of the NCD Manual. Below is
a listing of the changes that were made in the January release. We believe
that we have captured most of the typographical errors and ministerial coding
update changes and that future changes of this nature will be limited.
- Expanded truncated code 780.9 to 780.99 in the urine culture and thyroid NCD
- Corrected code 99.8 to 099.8 in the HIV diagnostic NCD
- Corrected code 99.9 to 099.9 in the HIV diagnostic NCD
- Expanded the range of codes for coronary atherosclerosis to include new code 414.06 in the prothrombin time, blood glucose and lipid NCDs
- Added new code 414.12 to the range of codes for aneurysm and dissection of coronary artery in the blood glucose and lipid NCDs
- Expanded truncated code 459.1 to 459.10-459.13 and 459.19 in the prothrombin time NCD
- Expanded truncated code 633.9 to 633.90 and 633.91 in the human chorionic gonadotropin NCD
- Expanded truncated code 521.0 to 521.00 in the blood counts NCD
- Expanded truncated code V59.0 to V59.01, V59.02, and V59.09 in the blood count NCD
- Corrected last code in range 813.30-813.38 to 813.33 in the prothrombin time NCD
- Expanded truncated code 863.9 to 863.90 in the prothrombin time NCD
- Expanded truncated code 790.0 to 790.01 and 790.09 in the serum iron studies NCD
- Expanded truncated code 256.3 to 256.31 and 256.39 in the collagen crosslinks and thyroid NCDs
- Expanded truncated code 564.0 to 564.00-564.02, and 564.09 in the thyroid and fecal occult blood NCDs
- Expanded truncated code 200.0 to 200.00 in the serum iron studies NCD
- Deleted sentence 2 of Limitation #1 in the urine culture NCD as the reference was to a code that had been deleted from the CPT.
- Added new code 277.03 to the alpha-fetoprotein NCD
- Added new code 537.84 to the partial thromboplastin time, serum iron studies, and fecal occult blood NCDs
- Added new code 569.86 to the serum iron studies and fecal occult blood NCDs
- Added new codes 771.81 - 771.83 to the urine culture NCD
- Added codes 634.00-634.02, 642.30-642.34, 642.40-642.74, 642.90-642.94 to the human chorionic gonadotropin NCD that were included in the final rule but inadvertently omitted from the PM AB-02-110
- Added code 216.0-216.9 to the blood counts NCD that were included in but were inadvertently omitted from PM AB-02-110
- Corrected typo in code 401.1 to make it 401.0 in the lipid NCD as originally stated in the final rule
- Corrected typo in code 780.2 to make it 780.02 in the urine culture NCD
- Expanded truncated code 780.9 to 780.99 in the thyroid NCD
- Expanded truncated code 733.1 to 733.10 in the prothombin time NCD
- Modified the codes description for the following codes: 85007, 85008, 85014, 85025, 85027, 85048, 780.99, 414.10, 214.0, 402.01, 402.11, 402.91, 428.0, 627.2, 627.4 in the NCD Manual.
[EM 2003-0190/AB-03-030; CR 2578]
Revision to July 2002 Article on Correct Billing of Laminectomies
CPT code 63044 is for re-do laminectomies performed at each additional level subsequent to the initial level treated and billed by CPT code 63042. This code was a new code published in CPT 2001. From the time this code was introduced until the above article was published, the bilateral indicator on the Medicare Physician's Fee Schedule Data Base was "0" which meant bilateral reimbursement was not allowed for this code. The 50 modifier would not apply nor would it be recognized to pay for treating both sides of an intervertebral space. Providers could have billed two charges of 63044 in the above example with each being paid at 100 percent; but the July 2002 article was advising providers to bill only one charge of 63044 per level treated. This article is being written to correct those instructions.
Since this article was published, the bilateral indicator has changed to "1" which does allow bilateral reimbursement. The "1" indicator means 150% payment adjustment for bilateral procedures applies, and modifier 50 is appropriate if the procedure is performed bilaterally. This updates is retroactive to and effective from January 1, 2002. Therefore, that means from that date forward any additional re-do laminectomies done bilaterally per intervertebral level should be billed using code 63044 with modifier 50 appended; but, it would be incorrect to bill 63044 twice for the two sides of the same level treated for dates of service January 1, 2002, forward. A level treated bilaterally would be paid equal to 150 percent and not 200 percent. Only for dates of service January 1, 2001, through December 31, 2001, if both sides of a intervertebral level were treated could two charges of 63044 be billed - each paid at 100 percent of 63044 's reimbursement.
In summary, effective January 1, 2002, and forward, providers should bill code 63044 for each level of re-do laminectomy done after the initial level (which would be billed with CPT code 63042). Providers should receive bilateral reimbursement if both sides of the same intervertebral space were treated. These should be billed using the 50 modifier and not separate charges of 63042 or 63044. Bilateral reimbursement does yield 150 percent payment rather than 200 percent of the code's allowable. These indicators and subsequent pricing are dictated by the Centers for Medicare & Medicaid Services and not the carrier.
Medical Review 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.
- Digitization of Mammography Images
- Low Osmolar Contrast Material for Intrathecal Procedures
Q. Low osmolar contrast was used in the performance of an intrathecal procedure? Why would it be denied?
A. In accordance with national policy, separate payment is made for Low Osmolar Contrast Material (HCPCS codes A4644, A4645, and A4646) in the case of all medically necessary intrathecal radiologic procedures furnished to nonhospital patients. To expedite payment, providers must bill the intrathecal procedure and low osmolar contrast material on the same claim.Related LMRP: See TN 96-03-02.
- Billing for Pachymetry
Q. We have been advised by a professional association to bill CPT code 92135 for pachymetry, but there is also code 0025T. Which is correct?
A. CPT code 92135 is for optical laser scan for glaucoma which is not the same as pachymetry. Pachymetry measures the thickness of the cornea and should be billed using CPT code 0025T (*).Related bulletin article/LMRP: (*) See March 2003 Medicare Bulletin on Pachymetry.
- Billing GY Modifier on Covered Laboratory Services
Q. A covered lab test was denied by Medicare. Upon appeal by the patient, Medicare upheld the original denial making the patient responsible for payment. Why?
A. This happens when modifier "GY" is used inappropriately - namely in situations when a denial based on medical necessity might occur. Please note that modifier "GY" is reserved for statutorily nonpayable/noncovered services. Its use in other scenarios incorrectly assigns liability to the beneficiary and represents inappropriate billing. Providers are cautioned to use this modifier when appropriate and not in situations where the test is medically necessary. - Diskography Radiology Charges
Q. Charges by the hospital's radiologist for diskography (see CPT code 72295 corresponding to 62290) were denied/recouped. Why?
A: Radiologic supervision and interpretation of diskography is typically done by the surgeon injecting the disk, but could be provided by a radiologist present in the operating room during the procedure. Some facilities have been performing "over-reads" of the images made intraoperatively by the surgeon then submitting charges to Medicare for professional interpretation. Subsequently, Medicare has been billed for two sets of radiologic supervision and interpretation of diskography. Medicare will pay only one provider per date of service for these charges. It is incumbent upon the providers to coordinate who is performing the service and how this will be billed. - Consultations preceding screening services
Q. Can a consultation be done on beneficiaries in need of screening services, for example, a patient undergoing a screening colonoscopy?
A. A referral that does not ask for advice or opinion and only asks for a screening procedure to be done does not meet the requirement for a consult.For example, a provider preparing to perform a screening colonoscopy cannot also bill for a pre-procedure visit to determine the suitability of the patient for the colonoscopy. These E/M services, to include consultations, are not separately payable. While the law specifically provides for a screening colonoscopy, it does not also specifically provide for a separate screening visit prior to the procedure. Although no separate payment can be made for these visits currently, the fee schedule payment for all procedures, including colonoscopy, contains payment for the usual pre-procedure work associated with it. This reflects the principle that each procedure has an evaluative component.
See: AMA CPT 2003, TN LMRP 96-05-1.
- Multiple Level Laminectomies
Q. For a 2001 date of service, the provider performed multiple level re-do laminectomies billed using CPT code 63042 for each level treated. Payment was originally made then, later, some payment was recouped. Why?
A. As of January 1, 2001, additional levels of re-do laminectomies were to be billed using CPT code 63044 instead of 63042. The latter code is intended only for the initial level treated. In the above scenario, the provider was billing 63042 for each level treated which resulted in an overpayment as the reimbursement (as set by the Centers for Medicare & Medicaid Services) for 63042 is much greater than that for 63044.See: a related article this bulletin issue (April 2003) addressing billing for bilateral laminectomies of the same intervertebral space.
- Benign Lesion Removal
Q. I am a North Carolina provider, and I am having trouble getting my claim for benign lesion removal paid. Why?
A. The North Carolina local medical review policy for removal of benign lesions was revised late 2002. Diagnoses for warts and seborrheic keratoses and sebaceous cysts were added, but providers were instructed modifiers would be necessary for payment. Removal of benign lesions including the above types would be considered cosmetic unless there was medical necessity for removal as evidenced by the presence of one or more of the following: - The lesion has one or more of the following characteristics: 1) bleeding; 2) intense itching; 3) pain.
- The lesion has physical evidence of inflammation, e.g., purulence, oozing, edema, erythema, etc.
- The lesion obstructs an orifice or clinically restricts vision.
- There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on lesion appearance.
- The lesion is in an anatomical region subject to recurrent physical trauma and there is documentation that such trauma has in fact occurred.
- Wart removals will be covered under the guidelines above. In addition, wart destructions will be covered when any one of the following clinical circumstances is present: 1) periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesion virus shedding; 2) warts showing evidence of spread from one body area to another, particularly in immunosuppressed patients.
Q. Why did charges for digitization of mammograms deny?
A. Digitization of mammography images is billed using either HCPCS code G0263
or CPT code 76085. G0263 should be billed with diagnostic mammograms (CPT
codes 76090 or 76091) whereas 76085 should be billed for digitization of
screening mammograms (CPT code 76092). Claims for digitization will deny
if the codes do not correspond as to whether a screening or diagnostic
service was performed. In other words 76085, digitization of screening
mammography, will deny if billed with 76090, a diagnostic unilateral mammogram.
Please note 76085 was revised in 2003 from the 2002 descriptor which specifically
included the term "screening." Even though the code was revised,
it is still the appropriate code for digitization of screening mammography.
Related Bulletin Article: See January/February 2002 issue of Medicare Bulletin.
If the qualifying criteria have been met, then providers should bill for these services with the KX modifier. If none of the above criteria were met, then the lesion removal would be considered cosmetic, and the beneficiary would be responsible. No claim would have to be filed unless the beneficiary requested. In that case, providers should bill these services either with modifier "GY" or "GA."
Related bulletin article/LMRP: See December 2002 issue of Medicare Bulletin (NC insert); NC LMRP 96-001-04
The Multi-Carrier System (MCS) is Coming to Railroad Medicare!
Under the direction of the Centers for Medicare & Medicaid Services (CMS), Medicare carriers are standardizing their Part B Medicare claims processing systems. The Multi-Carrier System (MCS), maintained by Electronic Data Systems (EDS), has been selected as the national standard Part B system. A single system will help reduce system maintenance costs and will standardize the way Medicare claims are processed.
Many Medicare contractors have already converted to MCS. Palmetto GBA, the carrier for Railroad Retirement Board Medicare beneficiaries, is currently in the process of converting its claims processing system to MCS. Work will continue over the next five months until the planned cutover date of June 2, 2003.
There will be a new telecommunications gateway for providers to submit Railroad Medicare claims and receive electronic remittance notices (ERNs). In February, electronic submitters will receive a special mailing providing specific information about these gateway changes. This will provide ample time for affected submitters to take the necessary actions to ensure there is no interruption to their electronic processes.
To ensure accurate, informative and timely communication to the provider community,
Railroad Medicare will keep providers informed through a variety of educational
sources.
- Palmetto GBA will post and maintain any new billing or claim filing requirements for Railroad Medicare on their Web site, www.palmettogba.com.
- Palmetto GBA will issue a special mailing to electronic submitters with specific information related to electronic claim submission.
- Providers may join Railroad Medicare's free electronic mail list and receive periodic email notification of messages posted to the Web site, including key program alerts, educational tips, and other critical informational articles. This is an excellent way to stay informed on information related to the MCS conversion.
To ensure a successful move to the Multi-Carrier System, it is imperative that providers and billing agencies stay informed of new claim filing requirements. Palmetto GBA's Web site will be a major source of information to keep providers informed about the Railroad Medicare transition to the MCS. Please visit the Palmetto GBA Web site (www.palmettogba.com) often for updates regarding the Railroad Medicare MCS conversion.
If you have questions that cannot be answered by visiting the Palmetto GBA Medicare Web site, please contact their Customer Service department at 1.877.288.7600.
2003 DMEPOS Jurisdiction List
Below is an updated list of the Durable Medical Equipment Prosthetics Orthotics and Supplies (DMEPOS) HCPCS codes for durable medical equipment regional carriers (DMERCs) and Part B carrier jurisdictions.
| HCPCS | DESCRIPTION | JURISDICTION |
| A0021 - A0999 | Ambulance Services | Local Carrier |
| A4206 - A4209 | Medical, Surgical, and Self-Administered Injection Supplies | Local Carrier if incident to a physician's service (not separately payable). If other DME REGIONAL Carrier |
| A4210 | Needle Free Injection Device | DME REGIONAL Carrier |
| A4211 | Medical, Surgical, and Self-Administered Injection Supplies | Local Carrier if incident to a physician's service (not separately payable). If other DME REGIONAL Carrier |
| A4212 | Non Coring Needle or Stylet with or without Catheter | Local Carrier |
| A4213 - A4215 | Medical , Surgical, and Self-Administered Injection Supplies | Local Carrier if incident to a physician's service (not separately payable). If other DME REGIONAL Carrier |
| A4220 | Refill Kit for Implantable Pump | Local Carrier |
| A4221 - A4250 | Medical, Surgical, and Self-Administered Injection Supplies | Local Carrier if incident to a physician's service (not separately payable). If other DME REGIONAL Carrier |
| A4253 - A4259 | Diabetic Supplies | DME REGIONAL Carrier |
| A4260 | Levonorgestrel Implant | Local Carrier |
| A4261 | Cervical Cap for Contraceptive Use | Local Carrier |
| A4262 - A4263 | Lacrimal Duct Implants | Local Carrier |
| A4265 | Paraffin | Local Carrier if incident to a physician's service (not separately payable). If other DME REGIONAL Carrier |
| A4266 - A4269 | Contraceptives | Local Carrier |
| A4270 | Endoscope Sheath | Local Carrier |
| A4280 | Accessory for Breast Prosthesis | DME REGIONAL Carrier |
| A4281 - A4286 | Accessory for Breast Pump | DME REGIONAL Carrier |
| A4290 | Sacral Nerve Stimulation Test Lead | Local Carrier |
| A4300 - A4301 | Implantable Catheter | Local Carrier |
| A4305 - A4306 | Disposable Drug Delivery System | Local Carrier if incident to a physician's service (not separately payable). If other DME REGIONAL Carrier |
| A4310 - A4359 | Incontinence Supplies/Urinary Supplies | If provided in the physician's office for a temporary condition, the item is incident to the physician's service & billed to the Local Carrier. If provided in the physician's office or other place of service for a permanent condition, the item is a prosthetic device & billed to the DME REGIONAL Carrier |
| A4361 - A4422 | Ostomy Supplies | If provided in the physician's office for a temporary condition, the item is incident to the physician's service & billed to the Local Carrier. If provided in the physician's office or other place of service for a permanent condition, the item is a prosthetic device & billed to the DME REGIONAL Carrier |
| A4450 - A4455 | Tape; Adhesive Remover | Local Carrier if incident to a physician's service (not separately payable). If other DME REGIONAL Carrier |
| A4458 | Enema Bage | DME REGIONAL Carrier |
| A4462 | Abdominal Dressing | Local Carrier if incident to a physician's service (not separately payable). If other DME REGIONAL Carrier |
| A4465 | Non-elastic Binder for Extremity | DME REGIONAL Carrier |
| A4470 | Gravlee Jet Washer | Local Carrier |
| A4480 | Vabra Aspirator | Local Carrier |
| A4481 | Tracheostomy Supply | Local Carrier if incident to a physician's service (not separately payable). If other DME REGIONAL Carrier |
| A4483 | Moisture Exchanger | DME REGIONAL Carrier |
| A4490 - A4510 | Surgical Stockings | DME REGIONAL Carrier |
| A4521 - A4538 | Diapers | DME REGIONAL Carrier |
| A4550 | Surgical Trays | Local Carrier |
| A4554 | Disposable Underpads | DME REGIONAL Carrier |
| A4556 - A4558 | Electrodes; Lead Wires; Conductive Paste | Local Carrier if incident to a physician's service (not separately payable). If other DME REGIONAL Carrier |
| A4561 - A4562 | Pessary | Local Carrier |
| A4565 | Sling | Local Carrier |
| A4570 | Splint | Local Carrier |
| A4575 | Topical Hyperbaric Oxygen Chamber, Disposable | DME REGIONAL Carrier |
| A4580 - A4590 | Casting Supplies & Material | Local Carrier |
| A4595 | TENS Supplies | Local Carrier if incident to a physician's service (not separately payable). If other DME REGIONAL Carrier |
| A4606 | Oxygen Probe for Oximeter | DME REGIONAL Carrier |
| A4608 | Transtracheal Oxygen Catheter | DME REGIONAL Carrier |
| A4609 - A4610 | Tr |