July 2003 Part B Medicare Bulletin

Table of Contents

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• 3rd Quarter 2003 HCPCS Drug Pricing File
• 3rd Quarter 2003 Update to the Part B Not Otherwise Classified Drug Pricing File
• Ambulance Reminder
• Common Working File (CWF) Skilled Nursing Facility (SNF) Consolidated Billing (CB) Bypass to Allow Separate Payment for Drugs
• Contracted/Leased (1099 Suppliers)
• Diabetes Outpatient Self-Management Training (DSMT) and the “Incident to” Provision
• Drugs and Biologicals Excluded as Usually Self-Administered
• EDI and HIPAA – A Winning Combination!
• Evaluation and Management Codes, Incorrect Billing
• Expanded Coverage for PET Scans
• Free CMS HIPAA Training
• Free Fax Back Service
• Guidance on the HIPAA Privacy Rule Business Associate Provisions
• ICD-9-CM Coding – Increased Role for Physicians/Practitioners
• Implementation of the Financial Limitation for Outpatient Rehabilitation Services
• Laboratory National Coverage Determination (NCD) Edit Software for July 1, 2003, Changes
• Medicare Program Integrity Manual Chapter 10 New/Revised Material
• Medigap Crossover Reminder
• MSP Processing Reminders
• National Participating Physician Directory
• Overpayment Refunds
• Payment Floors and Payment Ceilings
• Place of Service (POS) Code Set, Update
• Quarterly Provider Update
• Radiofrequency Energy Delivery to the Gastroesophageal Junction (The Stretta Procedure)
• Select Catheterization of Renal Arteries during Cardiac Catheterization
• Use of Cutting Balloon Coronary Angioplasty is not a Coronary Atherectomy

Free CMS HIPAA Training

The CMS Southern Consortium's Achieving Compliance Together Team has developed a series of HIPAA presentations. They can be accessed via the internet and there is no cost to you.

To access these presentations, simply click on the following link.

http://www.eventstreams.com/cms/tm_001/

You can choose any of the following presentations:

1. HIPAA Message to Providers from the Southern Consortium Administrator

2. HIPAA Basics

3. Provider Steps to Getting Paid under HIPAA

4. HIPAA Security (coming soon)

Free Fax Back Service

The CMS Southern Consortium's Achieving Compliance Together Team has developed a HIPAA resource in an effort to reach those without internet/e-mail access! Have your fax number handy and call this number: 800.874.5894

Select Option 1 for the starter set: HIPAA information, resources, and transactions checklist, then follow the prompts. It's that easy! Other documents are also available (for example, information on Medicare's free billing software and a HIPAA glossary).

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!

Guidance on the HIPAA Privacy Rule Business Associate Provisions

By definition, a business associate is a person or entity that performs or assists in the performance of a function or activity involving the use or disclosure of individually identifiable health information on behalf of a covered entity (45 CFR §164.103).

Medicare contractors that perform health care activities involving the use of protected health information on behalf of the Medicare Fee-for-Service (FFS) health plan are not business associates of providers, physicians, suppliers, or other health plans. Likewise, providers, physicians, suppliers, or other health plans are not business associates of the Medicare contractor, unless the provider, physician, supplier, or other health plan is doing work on behalf of the Medicare contractor. For these reasons, CIGNA Government Services should not sign business associate agreements with any provider, physician, supplier, or other plan unless the provider, physician, supplier, or other health plan is doing work on our behalf.

[EM 2003-0503/CR 2712]

New Requirements for ICD-9-CM Coding – Increased Role for Physicians/Practitioners

From the Medicare Learning Network @ CMS

Effective for dates of service on or after October 1, 2003, ICD-9-CM diagnosis codes must be included on all Medicare electronic and paper claims billed to Part B carriers, with the exception of ambulance claims. Providers and suppliers rely on physicians to provide a diagnosis code or narrative diagnostic statement on orders/referrals. This guidance serves as a reminder that physicians/practitioners must provide a diagnosis on all orders and referrals.

Background

In accordance with the Health Insurance Portability and Accountability Act (HIPAA), a final rule published in the Federal Register on August 17, 2000, established new standards, requirements, and implementation specifications for health plans, health care clearing houses, and health care providers who transmit any health information in an electronic form. The applicable electronic format for transmitting Medicare claims information is the ASC X12N 837. The implementation specifications define the new requirements for these formats. The ASC X12N 837 Professional Implementation Guide (version 4010A.1) requires a diagnosis on “all claims/encounters except claims for which there are no diagnoses (e.g., taxi claims).”

PM B-03-045 (CR2725) clarified that based upon the implementation specifications for HIPAA, an ICD-9-CM code is not required for all ambulance supplier claims but is required for all other professional claims, e.g., Physicians, Non-Physician Practitioners, Independent Clinical Diagnostic Laboratories, Occupational and Physical Therapists, Independent Diagnostic Testing Facilities, Audiologists, and Ambulatory Surgery Centers. Although the HIPAA requirements apply only to electronic claims, in order to maintain consistency in claims processing, CMS has mandated that these ICD-9-CM requirements will be applied to paper claims as well as electronic claims.

New Policy

Effective for dates of service on or after October 1, 2003, all paper and electronic claims submitted to carriers must contain a valid diagnosis code with the exception of claims submitted by ambulance suppliers (specialty type 59). Carriers will return as unprocessable paper and electronic claims that do not contain a valid diagnosis code with the exception of claims submitted by ambulance suppliers (specialty type 59).

Carriers will no longer place invalid or valid diagnosis codes on any claim prior to sending the claim to the Common Working File and their coordination-of-benefits trading partners. Therefore, the diagnosis code must be entered on the claim by the submitter.

Immunization Claims

For claims submitted by mass immunizers and any other entities billing for flu and pneumonia vaccinations, Medicare carriers will no longer be able to enter missing diagnosis codes on claims. The diagnosis code must be entered on the claim by the submitter.

Mammography Screening Claims

For claims submitted for screening mammography services, Medicare carriers will no longer be able to enter missing diagnosis codes on claims. The diagnosis code must be entered on the claim by the submitter. Claims for mammography services with no ICD-9-CM code will be returned as unprocessable by carriers.

HIPAA Requirements Affect Physicians/Practitioners When a Diagnostic Test is Ordered

Section 4317 of the Balanced Budget Act of 1997 provides, with respect to diagnostic laboratory and certain other services, that “if the Secretary (or fiscal agent of the Secretary) requires the entity furnishing the services to provide diagnostic or other medical information to the entity, the physician or practitioner ordering the service shall provide that information to the entity at the time the service is ordered by the physician or practitioner.” A laboratory or other provider must report on a claim for Medicare payment the diagnostic code(s) furnished by the ordering/ referring physician/practitioner. In the absence of such coding information, the laboratory or other provider may determine the appropriate diagnostic code based on the ordering/referring physician/practitioner's narrative diagnostic statement or seek diagnostic information from the ordering/referring physician/practitioner. However, a laboratory or other provider may not report on a claim for Medicare payment a diagnosis code in the absence of physician/practitioner-supplied diagnostic information supporting such code.
When providers/suppliers (except ambulance suppliers) submit a claim to a Medicare Part B carrier, they must assign an ICD-9-CM code to the service as follows:

(1) Coding When Diagnosis is Known

Assign an ICD-9-CM code that provides the highest degree of accuracy and completeness. In the past, there has been some confusion about the meaning of “highest degree of specificity” and in “reporting the correct number of digits.” In the context of ICD-9-CM coding, the “highest degree of specificity” refers to assigning the most precise ICD-9-CM code that most fully explains the narrative description of the symptom or diagnosis. Concerning level of specificity, ICD-9-CM codes contain either 3, 4, or 5 digits. If a 3-digit code has a 4-digit code that further describes it, then the 3-digit code is not acceptable for claim submission. If a 4-digit code has a 5-digit code that further describes it, then the 4-digit code is not acceptable for claim submission.

(2) Coding When Diagnosis is Unknown

Diagnoses documented as “probable,” “suspected,” “questionable,” “rule-out,” or “working diagnosis” should not be coded as though they exist. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit such as signs, symptoms, abnormal test results, exposure to communicable disease, or other reason for the visit. (See ICD-9-CM Official Guidelines for Coding and Reporting, page 49, available at http://www.cdc.gov/nchs/data/icd9/icdguide.pdf.)

Information for Laboratories

Information for Ambulance Suppliers

Timely and Accurate Claims Processing

With the exception of ambulance suppliers, physicians/practitioners submitting claims to Medicare Part B carriers must include a valid ICD-9-CM code in order to have their claims processed and paid as quickly as possible. Therefore, physicians/practitioners must ensure that all necessary information is included on orders/referrals. Failure to do so will result in processing delays and nonpayment of covered services.

[EM 2003-0558/CR 2784]

Common Working File (CWF) Skilled Nursing Facility (SNF) Consolidated Billing (CB) Bypass to Allow Separate Payment for Drugs

Currently, when billing for ambulance transports, suppliers indicate whether the transport was part of a SNF Part A covered stay, using the appropriate origin/destination modifier (e.g., “NH” for a transport from a SNF to a hospital). Suppliers bill with an “NN” origin/destination modifier when a SNF to SNF transport occurs. A transport between two SNFs is not separately payable when a beneficiary is in a Part A covered SNF stay, and will result in a denial of a claim for such a transport. Certain drugs, including HCPCS codes J7030, J7040, J7042, J7050, J7051, and J7130 may be billed separately when provided during an ambulance transport to or from a SNF when a beneficiary is in a Part A stay. These items are only separately billable for those suppliers in carrier jurisdictions that paid separately for drugs prior to the implementation of the fee schedule on April 1, 2002. These items are not separately billable when provided during an inter-SNF transport.

Ambulance claims submitted with HCPCS codes J7030, J7040, J7042, J7050, J7051, J7130, or J7050 with dates of service on or after April 1, 2002, may have been denied in error for beneficiaries in a Part A covered SNF stay (except when billed with the “NN” modifier. Affected suppliers should resubmit claims for ambulance services and HCPCS codes J7030, J7040, J7042, J7050, J7051, J7130, or J7050 processed incorrectly on or after April 1, 2002, for reprocessing.

[EM 2003-0457/CR 2707]

Ambulance Reminder

Correct Billing of Supplies and Services

Ambulance vehicles must be a specially designed and equipped automobile or other vehicle for transporting the sick or injured. It must have customary patient care equipment including a stretcher, clean linens, first aid supplies, oxygen equipment, and it must also have such other safety and life saving equipment as is required by state or local authorities.

Reusable devices and equipment such as backboards, neckboards, and inflatable leg and arm splints are considered part of the general ambulance service and would be included in the charge for the trip. Separate reasonable charge may be recognized for nonreusable items and disposable supplies such as oxygen, gauze, and dressings required in the care of the patient during the trip.

A0382 is the designated procedure code for Basic Life Support routine disposable supplies.

A0384 is the designated procedure code for Basic Life Support specialized service disposable supplies.

A0398 is the designated procedure code for Advanced Life Support routine disposable supplies.

A0392, A0394, and A0396 are the designated procedure codes for Advanced Life Support specialized service disposable supplies.

Oral medications and drugs that can be self-administered are not routine disposable supplies and can not be billed using procedure codes A0382 or A0398.

A0999 is listed as ‘unlisted ambulance service.' When this procedure code is billed, a description of the service must be in item 19 of the CMS-1500 (12/90) claim form or on an attachment. It is not appropriate to include the description of service next to the procedure code in 24D.

For additional information please refer to the Medicare Carriers Manual, Part 3, Chapter II, Coverage and Limitations. http://www.cms.hhs.gov/manuals/.

Diabetes Outpatient Self-Management Training (DSMT) and the “Incident to” Provision

This Program Memorandum (PM) informs providers, suppliers and carriers that “incident to” requirements of §1861(s)(2)(A) of the Social Security Act (the Act) do not apply to DSMT services. Section 1861 (s)(2)(S) of the Act authorizes DSMT in a stand alone provision that is not subject to section §1861(s)(2)(A) requirements. The CMS has published regulations implementing this provision at 42 CFR 410.140-146. A previous PM has gone out under Part B 01-40, dated June 15, 2001. This PM may be found at www.cms.hhs.gov/manuals/. Questions have been raised by Medicare contractors and providers of DSMT services as to whether supervision and other “incident to” requirements at §1861(s)(2)(A) must be met when billing for DSMT services. The “incident to” supervision rules and other “incident to” requirements do not apply to DSMT services.

Brief Overview of the Diabetes Outpatient Self-Management Training Services

[EM 2003-0494/CR 2157]

Contracted/Leased (1099 Suppliers)

A Clinic is eligible for reimbursement of Medicare services of contracted/leased suppliers that render services in space which is leased or owned by the clinic. The leased/contracted supplier enters into a contract with the clinic by completing a Reassignment of Benefits Application CMS 855R (11/2001).

The contract between the clinic and contracted/leased supplier is only valid for services rendered in the clinic's owned or leased quarters (office service only). If the contracted/leased supplier renders services outside of the clinic's owned or leased quarters, the clinic is not eligible to be reimbursed for those services. The contracted/leased supplier has two options to bill for services rendered outside the clinic's owned or leased quarters.

These guidelines do not apply to the following individuals:

Expanded Coverage for PET Scans

On April 16, 2003, The Centers for Medicare & Medicaid Services (CMS) announced its intent to expand coverage of positron emission tomography (PET) for Medicare beneficiaries with thyroid cancer and heart disease. This expanded coverage enhances physicians' current evaluative options, and are examples of CMS' commitment to making new medical technologies available to its beneficiaries when evidence is adequate to conclude that the technology is reasonable and necessary for diagnosis or treatment of an illness.

Thyroid Cancer

Thyroid cancer constitutes less than one percent (1%) of all human malignant tumors. In a small number of these patients, the usually accurate Iodine-131 whole body scan is not helpful in identifying recurrent disease following initial treatment. In these patients, CMS determined that the evidence is adequate to conclude that PET is reasonable and necessary, with certain limitations, for management of patients with recurrent thyroid cancer.

Cardiac Diseases

Cardiovascular disease is a broad term encompassing conditions such as hypertension, coronary artery disease, and congestive heart failure. These conditions cause significant morbidity and mortality in the Medicare population. CMS determined that the evidence is adequate to conclude that cardiac imaging with PET, using the radiopharmacological ammonia N-13, is reasonable and necessary, with certain limitations, for the diagnosis and management of patients with known or suspected coronary artery disease.

PET Coverage Not Expanded

Alzheimer's Disease:

Alzheimer's disease (AD) is an age-related and irreversible brain disorder that occurs gradually and results in memory loss, behavior and personality changes, and a decline in thinking abilities. AD is the most common cause of dementia representing approximately two-thirds of cases.

PET has been proposed as a diagnostic tool in the management of patients with AD. CMS's review of the evidence concluded that PET did not improve patient outcomes in this group of beneficiaries and, therefore, CMS will continue its present noncoverage policy. The clinical benefit of using PET for patients with AD has not been demonstrated.

To provide the best of emerging medical technology for Medicare beneficiaries, CMS will design a demonstration to evaluate the appropriate role of PET for patients with suspected dementia. CMS will work with Health and Human Services' National Institutes of Health to convene a multi-disciplinary expert meeting with geriatricians, neurologists, radiologists, PET experts, and patient advocates to fully explore the value of PET for AD.

Soft Tissue Sarcoma:

CMS has decided against expanding coverage of PET for soft tissue sarcoma, a rare type of cancer for which current imaging techniques have good diagnostic capabilities. CMS determined that the evidence was not adequate to conclude that PET for soft tissue sarcoma was reasonable and necessary and, therefore, CMS will continue its present noncoverage policy.

Other Coverage

Medicare covers PET, with certain limitations, for the diagnosis, staging and restaging of various cancers, including lung, esophageal, colorectal, lymphoma, head and neck, and breast along with myocardial viability and pre-surgery evaluation of refractory seizures.

[EM 2003-0564]

Implementation of the Financial Limitation for Outpatient Rehabilitation Services

This article is to instruct providers/suppliers about the new and revised MSN messages and their use. The implementation date of the new MSN messages is October 1, 2003. Additional information on this subject can be found in the March 2003 and June 2003 Medicare Bulletins.

The form number of the Notice of Exclusions from Medicare Benefits form was incorrect in the June bulletin article. The correct number is NEMB Form No. CMS-20007 & Formulario No. CMS-20007.
Providers/physicians/suppliers are advised that they must retain a written plan of care on file for the beneficiary. The plan must be available to the Medicare Carrier for review.

MSN Messages

Existing MSN messages 17.13, and the new MSN messages 17.18 and 17.19 shall be issued on all claims containing outpatient rehabilitation services as noted in this instruction.
MSN 17.13 has been revised to read:

17.13 - Medicare approves a limited dollar amount each year for physical therapy and speech-language pathology services and a separate limit each year for occupational therapy services when billed by providers, physical and occupational therapists, physicians, and other non-physician practitioners. Medically necessary therapy over these limits is covered when received at a hospital outpatient department.

Spanish Translation
17.13 - Coda año, Medicare aprueba una cantidad límite por servicios de terapia física y patología del lenguaje. Anualmente también aprueba otra cantidad límite por servicios de terapia ocupacional cuando son facturados por proveedores, terapistas físicos y ocupacionales, médicos y otros practicantes no médicos. La terapia que es medicamente necesaria y que sobrepasa estas cantidades límites está cubierta cuando se recibe en una unidad de hospital ambulatorio.

17.18 - ($) has been applied during this calendar year (CCYY) towards the ($) limit on outpatient physical therapy and speech-language pathology benefits.

Spanish Translation
17.18 - En este año (CCYY), ($) han sido deducidos de la cantidad límite de ($) por los beneficios de terapia física ambulatoria y de patología del lenguage hablado.

17.19 - ($) has been applied during this calendar year (CCYY) towards the ($) limit on outpatient occupational therapy benefits.

Spanish Translation
17.19 - En este año (CCYY), ($) han sido deducidos de la cantidad límite de ($) por los beneficios de terapia ocupacional ambulatoria.

Carriers and intermediaries shall use the existing Medicare Summary Notice message 17.6 to inform the beneficiaries that they have reached the financial limitation.

17.6 - Full payment was not made for this service because the yearly limit has been met.

Spanish Translation
17.6 - Debido a que usted alcanzó su límite anual por este servicio, no se hará un pago completo.

Provider Notification of Beneficiary Responsibility

Providers/suppliers may use the Notice of Exclusions from Medicare Benefits (NEMB Form No. CMS-20007 & Formulario No. CMS-20007) or a similar form of their own design to notify beneficiaries of the therapy financial limitations and that these limits are applied in all settings except hospital outpatient departments. ABNs cannot be used because of the statutory nature of the financial limitations. Therefore, providers/suppliers should inform beneficiaries that beneficiaries are responsible for 100% of the costs of therapy services above each respective therapy $1590 limit, unless this outpatient care is furnished directly or under arrangement by a hospital. It is the provider's responsibility to present each beneficiary with accurate information about the therapy limits and that, where necessary, appropriate care above the $1590 limit can be obtained at a hospital outpatient therapy department. Providers/suppliers are advised to use the Notice of Exclusion from Medicare Benefits (NEMB) form to inform beneficiaries of the therapy financial limitation at their first therapy encounter with the beneficiary. When using the NEMB form, the practitioner checks box #1 and writes the reason for denial in the space provided at the top of the form. For CY 2003, provide the following: “Medicare will not pay for: physical therapy and speech-language pathology services over $1590 (including dates of service from July 1, 2003, through December 31, 2003).” This same information is provided for occupational therapy services over the $1590 limit for the same time period, as appropriate.

The NEMB form can be found at: http://www.cms.hhs.gov/medlearn/refabn.asp

[EM 2003-0556/CR 2709]

Incorrect Billing of Evaluation and Management Codes

Per the Centers for Medicare & Medicaid Services (CMS), the primary mission of the Medical Review department is to reduce the claims payment error rate. Medical Review accomplishes this by identifying patterns of inappropriate billing, educating providers concerning Medicare coverage and coding requirements, and performing medical review. The following is a message to selected provider specialties in regards to an issue related to their field(s):

The Medical Review department reports varied instances of incorrect use of E&M codes noted in claim reviews conducted via prepay and probe efforts. Individual providers have been educated, but this article is being written to correct in other cases of misuse of these codes in the provider community.

Please note that diagnostic procedures have an inherent evaluative component which is included in the allowable fee for that procedure. To qualify for separate payment, a significant separately identifiable evaluation and management service must be provided. Furthermore, in cases where the beneficiary's circumstances did support a separately billable E&M visit, we continue to identify reporting of the incorrect level of E&M code.

It is incumbent upon providers to know when evaluation and management visits can be separately billed and when they cannot. If a provider feels an E&M visit should be separately paid, there must be notes in the medical record supporting the level of service billed. Upcoding of evaluation and management visits and/or billing of not separately reportable E&M visits represent a significant cost to Medicare and merit educating providers to correct any incorrect billing patterns.

With the publication of the above, providers are advised to incorporate these guidelines into the billing of their claims so to avoid inappropriate billing and payment.

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 1, 2003

Purpose:

This Program Memorandum (PM) announces the changes that will be included in the July release of the edit module for clinical diagnostic laboratory services. Program Memorandum 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 the PM that nationally uniform software would be developed by Computer Sciences Corporation and incorporated in 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 NCD developed through the NCD process. The April update was discussed in PM AB-03-030.

Policy:

The following changes are made to the edit module effective for services furnished on or after July 1, 2003.

In the NCD coding manual released for the January and April software releases, we inadvertently repeated the ICD-9-CM code number 136.2 in the list of covered diagnoses for HIV testing (diagnosis). The descriptions of the codes and the software implementing the NCD edits remained accurate. Thus, we are changing the NCD coding manual only to show the correct ICD-9-CM code for pneumocystosis is 136.3.

[2003-0542/ AB-03-084; CR 2737]

MSP Processing Reminders

MSP claim processors receive many different types of EOBs and must make individual decisions on each claim submitted. Whether the claim is paid as secondary benefits or denied, depends on the information included on the claim and the explanation of benefits from the primary insurance company.

Medicare will deny the claim with ANSI Reason Code: MA04 16 “Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible.”

Some of the reasons for the denial include, but not limited to:

Important MSP Billing Tips

Claims missing the information above will result in a denial.

National Participating Physician Directory

The National Participating Physician Directory contains valuable information about Medicare participating physicians for the use of beneficiaries, their families, and their caregivers. In order to ensure that the Directory includes the most up-to-date information, practicing physicians should check the accuracy of their listings and use the feedback tool on our web site to notify CMS about any information that is incorrect, has changed, or to advise us if you are not listed in the Directory.

Information Included in the Directory

The following information is available regarding Medicare participating physicians (those who have agreed to always accept assignment):

How to Check Accuracy of Your Information

The accuracy of your listing can be checked by clicking on the “Participating Physician Directory” from the home page of www.medicare.gov. Our feedback tool is available to correct any information that is incorrect, has changed, or to advise us if you are not listed in the Directory. The Directory will be updated on a monthly basis. For additional information about the Directory, click on “Physician Note” at the bottom of the page. You may also link to the Directory from the CMS Web site at www.cms.hhs.gov/physicians (under “Participation”).

NOTE: Only participating physicians who have agreed to accept assignment on all Medicare claims and covered services are included in the Directory. Assignment does not apply to Medicare managed care or private fee-for-service plans.

[EM 2003-0549]

Payment Floors and Payment Ceilings

CMS mandates the number of days for the Payment Floor and Ceiling.

The Payment Floor is the minimum amount of time that Medicare can hold a claim before payment can be made. The Payment Floor for paper claims is 26 days, and for electronic claims it is 13 days, which means that if you have a clean claim (one which does not require external development) on the 27th day and 14th day respectively, you will be eligible to receive payment.

The Payment Ceiling is the maximum amount of time that Medicare can hold a claim before payment can be made. Interest must be paid on clean claims if payment is not made within the applicable number of calendar days after the date of receipt. Interest is not paid on:

The rate of interest is determined by the Treasury Department and is applied on the day of payment.
Electronic claims billed to Medicare are eligible to pay in half the time paper claims will. If you are not currently billing electronic claims and would like more information on how to bill electronically, please contact the CIGNA Government Services EDI department using the appropriate telephone number listed below.

Tennessee and Idaho providers call: 866.520.4022
North Carolina providers call: 866.352.1608

You can also receive your payment faster if you receive your checks through Electronic Funds Transfer (EFT). By receiving EFT, your Medicare payments can be transferred directly into your checking account, on the day your check is generated. You do not have to wait several days for your check to arrive in the mail. If you are interested in EFT, please contact the Medicare Provider Enrollment department at 866.520.4007. This number is applicable for Tennessee, Idaho, and North Carolina.

Medicare Program Integrity Manual Chapter 10 New/Revised Material

Effective May 23, 2003, the Medicare Program Integrity Manual, Chapter 10 has been revised to clarify the enrollment process for new Medicare providers/suppliers. For more detailed information regarding the Chapter 10 revisions, you may access the Medicare Program Integrity Manual via the Internet at http://www.cms.gov/pubforms/83pim/pimtoc.htm.

[EM 2003-0510/CR 2592]

Medigap Crossover Reminder

This electronic transfer process was provided as an incentive for participating physicians and suppliers to speed payment of secondary insurance benefits. Medigap therefore, does not apply to non-participating providers who occasionally accept assignment. There are several conditions that must be met before Medicare will consider a claim for Medigap crossover:

Also, it is necessary to complete the 2320 loop SBR segment as instructed in the ANSI4010 Implementation Guide (IG). This segment is required by the IG to be completed in conjunction with the 2330B loop NM1 information.

Claim data is sent on a monthly basis to insurers who receive a claim data by paper, and it is sent on a weekly basis to insurers who receive claim data electronically. Within a reasonable time, if you have not heard from the Medigap insurer, it will be necessary for you to follow-up with the Medigap insurer. The Medicare Carrier's responsibility ends once we have transferred the Medicare payment data to the Medigap insurer.

Complementary Crossover Reminder

Complementary crossover is the transfer of processed Medicare claims data to supplemental insurers based on eligibility data supplied by a specific insurer. All claims processed by Medicare are eligible to cross over to the supplemental insurer. Claim type and/or participation are not factors with the complementary crossover process. The following types of claims are usually suppressed from the crossover process at the request of the other insurer: 100% paid claims, 100% denied claims, 100% paid adjustment claims, 100% denied adjustment claims, and non-monetary adjustments (adjusted claims with no payment change). If a claim does not cross to a complementary insurer and you believe it should, you should contact the other insurer before calling Medicare. If we have crossed a claim to a complementary insurer, the MOA code MA18 will appear on your payment report/ provider remittance. It states:

“The claim information is also being forwarded to the patient's supplemental insurer. Send any questions regarding supplemental benefits to them.”

If you file your Medicare claims electronically and you do not know where to enter the information required for filing Medigap claims electronically into your billing system, please contact your software provider for assistance. Remember, all electronic claims must be sent in the ANSI 4010A1 format after October 16, 2003. If your software is not yet approved for transmission in this format, contact your software provider and urge them to begin testing with us today! To get set up for HIPAA software testing contact the EDI department in NC at 866.352.1608 (option 1), and for TN and ID call 866.520.4023 (option 1).

Update of the Place of Service (POS) Code Set

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) will become effective October 16, 2003, for all covered entities. Medicare is a covered entity under HIPAA.

The final rule, “Health Insurance Reform: Standards for Electronic Transactions,” published in the Federal Register, August 17, 2000, adopts the standards to be used under HIPAA and names the implementation guides to be used for these standards. The ASC X12N 837 professional is the standard to be used for transmitting health care claims electronically, and its implementation guide requires the use of POS codes from the National POS code set, currently maintained by CMS.

As a covered entity, Medicare must use the POS codes from the National POS code set for processing its electronically submitted claims. Medicare must also recognize as valid POS codes from the POS code set when these codes appear on such a claim.

National POS Code Set

The following is the current National POS code set, with facility and non-facility designations noted for Medicare payment for services on the Physician Fee Schedule:

[EM 2003-0475/CR 2730]

Select Catheterization of Renal Arteries during Cardiac Catheterization

Per the Centers for Medicare & Medicaid Services (CMS), the primary mission of the Medical Review department is to reduce the claims payment error rate. Medical Review accomplishes this by identifying patterns of inappropriate billing, educating providers concerning Medicare coverage and coding requirements, and performing medical review. The following is a message to selected provider specialties in regards to an issue related to their fields.

Effective January 1, 2003, HCPCS code G0275 should be used for renal artery angiography unilateral or bilateral performed at the time of cardiac catheterization. Prior to this code, providers billed CPT code 36245 (select catheterization of an abdominal first order vessel). Please note this HCPCS code also includes catheter placement, dye injection, flush aortogram and radiologic supervision, interpretation and production of images. Continuing to use CPT code 36245 for select renal artery arteriography performed at the same time as cardiac catheterization for dates of service 01/01/2003 and forward would be incorrect and result in an overpayment.

With the publication of the above notice, providers are advised to incorporate these guidelines into the billing of their claims so to avoid inappropriate billing and payment.

Radiofrequency Energy Delivery to the Gastroesophageal Junction (The Stretta Procedure)

The Stretta procedure is an endoluminal treatment for Gastroesophageal Reflux Disease (GERD) in which radiofrequency energy is delivered to smooth muscle of the lower esophageal sphincter (LES). A flexible catheter equipped with special needle electrodes for precise energy delivery is placed by mouth into the esophagus and carefully controlled radiofrequency energy is then delivered to the LES and gastric cardia, creating thermal lesions. It is believed that the changes that occur immediately, and overtime, result in a “tighter” LES and a less compliant gastric cardia. Additionally, the interruption of nerve pathways in the LES area is believed to reduce the incidence of inappropriate LES “relaxations”, leading to an improvement in GERD symptoms.

In the absence of a National Coverage Determination (NCD) or Local Medical Review Policy (LMRP), claims will be adjudicated on a case-by-case basis. Billing for this procedure must be by paper claim with supportive documentation attached. This carrier will evaluate medical reasonableness and necessity based on the following:

1. Criteria that may support medical necessity for the Stretta Procedure

a. inadequate symptom improvement while on a properly escalated anti-secretory regimen for at least one year, or
b. intolerance to anti-secretory therapy, or
c. an unwillingness/inability to continue a long-term high-dose anti-secretory regimen because of accepted medical reasons, such as potential drug interactions, co-morbidities, etc., and

2. GERD confirmed by

a) pathologic esophageal acid exposure, or
b) biopsy proven esophagitis, or
c) gross evidence of esophagitis, or
d) Barrett's metaplasia.

According to current literature and expert opinion, the following would be considered as exclusion criteria for the Stretta Procedure:

The Stretta Procedure should be coded using the appropriate Current Procedural Terminology (CPT) codes:

CPT code 43235 is used in reporting the endoscopy portion of the procedure that is typically performed unless the procedure also includes a biopsy or other additional procedures. If this is the case, the proper code describing the endoscopic procedure should be substituted for 43235. CPT code 43499 must be used for reporting the delivery of the radiofrequency energy.

Use of Cutting Balloon Coronary Angioplasty is not a Coronary Atherectomy

Per the Centers for Medicare & Medicaid Services (CMS), the primary mission of the Medical Review department is to reduce the claims payment error rate. Medical Review accomplishes this by identifying patterns of inappropriate billing, educating providers concerning Medicare coverage and coding requirements, and performing medical review. The following is a message to selected provider specialties in regards to an issue related to their fields.

The Medical Review department has discovered during review of some claims that CPT code 92995 (Percutaneous Transluminal Coronary Atherectomy, by Mechanical or other method, with or without balloon angioplasty; single) is being billed when a cutting balloon is used during coronary angioplasty. In these instances, the latter procedure has also been billed using CPT code 92982 (percutaneous transluminal coronary angioplasty). This notice is being written to inform providers that the Carrier does not consider the use of a cutting balloon to be equivalent to a coronary atherectomy. The cutting balloon is a customized device used to perform angioplasty but does not merit additional reimbursement or another charge separate from coronary angioplasty. Furthermore, the use of this device would also be considered component to the work involved in code 92980 (percutaneous transluminal coronary stenting).

With the publication of the above, providers are advised to incorporate these guidelines into the billing of their claims so to avoid inappropriate billing and payment.

Quarterly Provider Update

The Quarterly Provider Update is a comprehensive resource published by the Centers for Medicare & Medicaid Services (CMS) on the first business day of each quarter. It is a listing of all non-regulatory changes to Medicare including Program Memoranda, manual changes, and any other instructions that could affect providers. Regulations and instructions published in the previous quarter are also included in the Update. The purpose of the Quarterly Provider Update is to:

To receive notification when regulations and program instructions are added throughout the quarter, sign up for the Quarterly Provider Update listserv (electronic mailing list) at http://list.nih.gov/cgi-bin/wa?SUBED1=cms-qpu&A=1.

The Quarterly Provider Update can be accessed at http://www.cms.gov/providerupdate. We encourage you to bookmark this Web site and visit it often for this valuable information.

[EM 2003-0500/CR 2686]

Drugs and Biologicals Excluded as Usually Self-Administered