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August 2003 Part B Medicare Bulletin

Hot Topics

Annual Update of ICD-9-CM

Good News - No Adjustment of 2003 Physician Fee Schedule

Testing and Other Help Available for HIPAA Compliance

Table of Contents

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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!

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Addition of Temporary Codes Q4052 and Q4053

Effective July 1, 2003, two new “Q” codes have been established for billing Octreotide and Pegfilgrastim. The code descriptions are as follows:

Q4052 Injection, Octreotide, Depot Form for Intramuscular Injection, 1mg
Q4053 Injection, Pegfilgrastim, 1mg

Note: The HCPCS code J2352 may no longer be used to report the depot form of Octreotide.

[EM 2003-0588/CR 2798]

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Cancellation of the Automatic July 2003 Mass Adjustments – 2003 Medicare Physician Fee Schedule

Over the past several months, the Centers for Medicare & Medicaid Services (CMS) had been educating the physician community about the automatic mass adjustments that were going to occur beginning in July 2003. The Medicare Physician Fee Schedule (MPFS) did not become effective until March 1, 2003 (delayed from January 1, 2003). These adjustments were going to be necessary as a result of a limitation in the Medicare payment system, which delayed the implementation of the MPFS, and which resulted in the incorrect payment of a substantial number of claims.

This news had been announced at several of the Physician Open Door Forums, and via carriers’ Web sites, and bulletins. Because January 2003 and February 2003 physician services submitted between March 1 and June 30, 2003, may have resulted in an incorrect payment, CMS had previously directed Medicare carriers to automatically adjust these claims, beginning in July 2003, and to recover any applicable overpayments.

The Good News ….

We now want to inform you that CMS has determined that it will NOT require Medicare carriers to go forward with the automatic July mass adjustments and resulting collection of overpayments. If an overpayment exists, you will not be receiving any “Demand” letters related to an incorrect payment based on the delay of the 2003 MPFS. This also means that Medicare beneficiaries will not be receiving copies of those “Demand” letters that would have potentially caused unnecessary confusion to them. You should be aware, however, that if you bring to the attention of the Medicare carrier that an incorrect payment for January or February 2003 was received, the carrier will still process such an adjustment.

Issues or questions should be addressed to your local carrier on a case-by-case basis.

If you feel you have been overpaid you can submit your payment as a Voluntary Refund. Refer to instructions in the Medicare Bulletin on how to submit this payment.

Personal provider checks sent to us for any reason should be sent to the following address:

Idaho Providers
CIGNA Federal Insurance Benefits - ID
P.O. Box 10957
Newark, NJ 07193-0957

North Carolina Providers
CIGNA Federal Insurance Benefits - NC
P.O. Box 10820
Newark, NJ 07193-0820

Tennessee Providers
CIGNA Federal Insurance Benefits - TN
P.O. Box 10924
Newark, NJ 07193-0924

[EM 2003-0602/CR 2669]

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Chiropractic Services

Documentation Requirements: Initial Visit.--the following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:

  1. History as stated above.
  2. Description of the present illness including:

    o Mechanism of trauma;

    o Quality and character of symptoms/problem;

    o Onset, duration, intensity, frequency, location, and radiation of symptoms;

    o Aggravating or relieving factors;

    o Prior interventions, treatments, medications, secondary complaints; and

    o Symptoms causing patient to seek treatment.

These symptoms must bear a direct relationship to the level of subluxation. The symptoms should refer to the spine (spondyle or vertebral), muscle (myo),bone (osseo or osteo), rib (costo or costal) and joint (arthro)and be reported as pain (algia), inflammation (itis), or as signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause headaches, arm, shoulder, and hand problems as well as leg and foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but in general other symptoms must relate to the spine as such. The subluxation must be causal, i.e., the symptoms must be related to the level of the subluxation that has been cited. A statement on a claim that there is "pain" is insufficient. The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined.

  1. Evaluation of musculoskeletal/nervous system through physical examination.
  2. Diagnosis: The primary diagnosis must be subluxation, including the level of subluxation, either so stated or identified by a term descriptive of subluxation. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the particular bone named.
  3. Treatment Plan: The treatment plan should include the following:

    o Recommended level of care (duration and frequency of visits);

    o Specific treatment goals; and

    o Objective measures to evaluate treatment effectiveness.

  4. Date of the initial treatment.

Documentation Requirements: Subsequent Visits.--the following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:

  1. History

    o Review of chief complaint;

    o Changes since last visit;

    o System review if relevant.

  2. Physical exam

    o Exam of area of spine involved in diagnosis;

    o Assessment of change in patient condition since last visit;

    o Evaluation of treatment effectiveness.

  3. Documentation of treatment given on day of visit.

Necessity for Treatment

  1. The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient's condition and provide reasonable expectation of recovery or improvement of function. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam, as described above.

    Most spinal joint problems may be categorized as follows:

    o Acute subluxation: A patient’s condition is considered acute when the patient is being treated for a new injury, identified by x-ray or physical exam as specified above. The result of chiropractic manipulation is expected to be an improvement in, arrest or retardation of the patient’s condition.

    o Chronic subluxation: A patient’s condition is considered chronic when it is not expected to completely resolve (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the functional status has remained stable for a given condition, without expectation of additional functional improvement, further manipulative treatment is considered maintenance therapy and is not covered.

  2. Maintenance Therapy.—Chiropractic maintenance therapy is not medically reasonable or necessary and is not payable under the Medicare program. Maintenance therapy include services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition.

  3. Contraindications.--Dynamic thrust is the therapeutic force or maneuver delivered by the physician during manipulation in the anatomic region of involvement. A relative contraindication is a condition that adds significant risk of injury to the patient from dynamic thrust, but does not rule out the use of dynamic thrust. The doctor should discuss this risk with the patient and record this in the chart. The following are relative contraindications to dynamic thrust:

    o Articular hyper mobility and circumstances where the stability of the joint is uncertain;

    o Severe demineralization of bone;

    o Benign bone tumors (spine);

[EM 2003-0613//CR 2717]

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Collection of Fee-for-Service Payments Made During Periods of Managed Care Enrollment

The 1999 Balanced Budget Reconciliation Act (BBRA) requires “current month enrollment,” which means that the effective date of enrollment is based upon the date a beneficiary signs an application for enrollment in a Medicare + Choice Organization (M+CO). The effective date of enrollment, as well as the date the M+CO is responsible for providing Medicare services to the beneficiary, is the first day of the month following receipt of the beneficiary’s completed, signed application for enrollment in the M+CO.

The CMS electronic data systems may experience time lags, during which time Medicare services and items are paid twice: through the FFS Medicare contractor and the Managed Care Payment systems in the monthly capitation rate for the beneficiary. When the electronic data systems recognize that a beneficiary has enrolled in a M+CO, the M+CO receives capitation payments for the beneficiary, retroactive to the effective date of enrollment. During the period of time between the effective date of enrollment and when the CMS electronic data system updates, physicians, providers, and suppliers may not be aware of the beneficiary’s enrollment in the M+CO and bill the Medicare FFS system for services and items provided to that beneficiary.

Effective October 1, 2003, CMS contractors will initiative overpayment recovery procedures to retract original Part A and Part B payments and generate adjustments to update or cancel claims connected to erroneous approvals for payment of FFS claims during periods of Managed Care enrollment.

If you have questions about this article, please contact CIGNA Government Services or your intermediary. [EM 2003-0597]

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Coverage of Compression Garments in the Treatment of Venous Stasis Ulcers

Effective for items furnished on or after October 1, 2003, gradient compression stockings falling under the following codes may be covered when the beneficiary has an open venous stasis ulcer that has been treated by a physician or other healthcare professional requiring medically necessary debridement, and when the gradient stocking can be proven to deliver compression greater than 30 mm Hg. and less than 50 mm Hg.

Applicable HCPCS Codes and Modifier

L8110 Gradient compression stocking, below knee, 30-40 mmhg, each
L8120 Gradient compression stocking, below knee, 40-50 mmhg, each
AW Item furnished in conjunction with a surgical dressing should follow each of the above codes

[EM 2003-0580/CR 2739]

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Hand-Carried Ultrasound Examinations

Article Title

Hand-Carried Ultrasound Examinations 

Article Publication Date

08/01/2003

Article Beginning Effective Date

06/01/2003

Article Text

This article updates and replaces the Hand-Carried Ultrasound article published on our CIGNA Government Services Web site February 13, 2003.

Medicare recognizes that the miniaturization of electronic devices is an on-going trend that may be associated with either improved or diminished test performance. Medical equipment described as "hand-carried ultrasound" (HCU) ranges in complexity and capability from lightweight pocket-sized units completely contained within the examiner's hand, to complex equipment systems where only the probe itself is hand-held. The appropriate assignment of a specific ultrasound CPT code is not solely determined by the weight, size, or portability of the equipment, but rather by the extent, quality, and documentation of the procedure. To be reimbursable by Medicare, a diagnostic ultrasound test must meet at least these minimum criteria (this is not an all inclusive list):

  1. It must be medically reasonable and necessary for the diagnosis or treatment of illness or injury.
  2. It should be done for the same purpose as a reasonable physician would order a standard ultrasound examination.
  3. It must be billed using the CPT code that accurately describes the service performed.
  4. The technical quality of the exam must be in keeping with accepted national standards and not require a follow-up ultrasound examination to confirm the results.
  5. The study must be performed and interpreted by qualified individuals.
  6. The medical necessity, images, findings, interpretation and report must be documented in the medical record.

Studies that do not meet all of these criteria, no matter what equipment is used, should not be billed under diagnostic ultrasound codes (93303-93350, 93875-93990 or 76506-76999) or any other CPT codes. As an example, an emergency room "quick look" ultrasound to assess the chest for the presence of fluid, blood, pus or a foreign body may be quite useful as an extension of the physical examination. However, it does not meet the above standards and should not be coded as: 76604, Ultrasound, chest, B-scan (includes mediastinum) and/or real time with image documentation. Similarly, an echocardiogram performed for the purpose of "not missing a murmur" or to evaluate clinically insignificant murmurs or other cardiac conditions should not be coded with codes 93303-93308 or 93320-93325. Medicare considers these studies to be part of the complexity of the physical examination and not separately reimbursable.

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Quarterly Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement

In April 2001, CMS established via Program Memorandum (PM) the process of periodically updating the lists of Healthcare Common Procedure Coding System (HCPCS) codes that are subject to the consolidated billing provision of the Home Health Prospective Payment System (HH PPS). Services appearing on this list submitted on claims to both Medicare fiscal intermediaries (FIs) and carriers, including Durable Medical Equipment Regional Carriers (DMERCs), will not be paid on dates when a beneficiary for whom such a service is being billed is in a home health episode (i.e., under a home health plan of care administered by a home health agency). Medicare will only directly reimburse the primary home health agencies that have opened such episodes during the episode periods. Note that therapies performed by physicians, supplies incidental to physician services and supplies used in institutional settings are not subject to HH consolidated billing.

This PM is the third quarterly HH consolidated billing update for calendar year 2003. The second update occurred in April 2003. There was no update in July 2003. This update adds three non-routine supply codes to the list of codes subject to consolidated billing. It also removes two codes that are no longer valid for Medicare billing. The next update to the list of codes subject to consolidated billing will be the calendar year 2004 annual update.

The new codes to be added are:

K0614 chem/antiseptic solution, 8oz
K0620 tubular elastic dressing
K0621 gauze, non-impreg pack strip

The codes to be deleted are:

A4421 Ostomy Supply misc
97014 Electric stimulation therapy

Providers and suppliers interested in an updated complete list of codes subject to HH consolidated billing can view the master code list available at cms.hhs.gov/medlearn/refhha.asp.

[EM 2003-0625/CR 2776]

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Important Information on HIPAA from Mr. Thomas Scully, Administrator, Centers for Medicare & Medicaid Services

Testing and Other Help Available Before the October 16, 2003 Compliance Date for Health Insurance Portability and Accountability Act (HIPAA) Transaction and Code Set Standards

Dear Medicare Provider,

Will you be ready to bill Medicare effective October 16?

Should you be concerned about getting your Medicare claims paid starting October 16? If you are not ready to use the HIPAA standard transaction and code sets by October 16, you may not get paid!

HIPAA is more than a privacy law; it touches many aspects of health care, including the bills you submit to all health insurers, not just Medicare. Effective October 16, 2003, all electronic transactions covered by HIPAA must comply with these standards for format and content. For example, the electronic claim that a physician or hospital sends to a health plan must be compliant and health plans are only allowed to process compliant transactions. Any non- compliant claims submitted after the October deadline will be returned to you, unpaid.

You may have thought that you can still submit paper bills to Medicare, but in many cases, this is not true. The Administrative Simplification Compliance Act (ASCA) includes a provision that requires electronic submissions to Medicare effective October 16, 2003, with a few exceptions1.

CMS and its contractors are eager to help you through this transition. Testing with your carrier or fiscal intermediary is required to assure that you and your business partners can send and receive HIPAA compliant transactions. Medicare contractors are ready to test with you now! To schedule testing, contact your Medicare carrier or fiscal intermediary. For more information, please review the helpful HIPAA resources, shown below.

Although we have all been working hard to achieve HIPAA compliance and the benefits it will bring, there is still much to be done. Time is growing short; please be sure to test and start sending and receiving HIPAA compliant transactions as early as possible to avoid any last- minute problems.

Thomas A. Scully
Administrator
Centers for Medicare & Medicaid Services

___________________________

1One of the major exceptions is for claims submitted by “a small provider of services or supplier.” The term “small provider of services or supplier” is defined to mean: a provider of services with fewer than 25 full-time equivalent employees; or a physician, practitioner, facility or supplier (other than provider of services) with fewer than 10 full-time equivalent employees. There will be other limited exceptions.

Helpful HIPAA Resources

Upcoming Satellite Broadcasts

HIPAA 101 - The Basics of Administrative Simplification

July 16, 2003
2:00 - 3:00 p.m. ET

July 30, 2003
2:00 - 3:00 p.m. ET

www.cms.hhs.gov/medlearn

Register to be a Host Site for Satellite Broadcasts

www.cms.hhs.gov/HIPAAGenInfo/

General HIPAA Information
Educational Materials
Frequently Asked Questions
HIPAA Administrative Simplification Information Series for Providers
Links to Additional HIPAA Web Pages

www.eventstreams.com/cms/tm_001

View HIPAA Educational Webcast
Topics:
HIPAA Basics
Provider Steps for Getting Paid Under HIPAA

askHIPAA@cms.hhs.gov

Request Answers to Your HIPAA Administrative Simplification Questions

1.866.282.0659

HIPAA Hotline Staff Will Answer Your HIPAA Administrative Simplification Questions or Direct You to the Appropriate Resources

Local Carriers and Fiscal Intermediaries

HIPAA Scheduling and Testing information is available at www.cignamedicare.com/hipaa.

Part B Contacts:

NC testing assistance: 866.352.1608
TN/ID testing assistance: 866.520.4023, Option #1
Information on HIPAA legislation and EDI Benefits: 866.794.0674

[EM 2003-0646]

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Annual Update of the ICD-9-CM

Effective October 1, 2003, (refer to Transmittal B-03-045, dated June 6, 2003) an ICD-9-CM code is required on all paper and electronic claims billed to Medicare carriers with the exception of ambulance claims - specialty type 59. An ICD-9-CM code is now required for all professional claims, e.g., physicians, non-physician practitioners, independent clinical diagnostic laboratories, occupational and physical therapists, independent diagnostic testing facilities, audiologists, and ambulatory surgical centers (ASCs). However, an ICD-9-CM code is not required for ambulance supplier claims.

Beginning October 1, 2003, providers may begin using the 2004 ICD-9-CM codes. There will be a grace period from October 1, 2003, through December 31, 2003. This grace period will allow providers sufficient time to obtain and integrate the updated ICD-9-CM codes into their billing systems. The diagnosis on the claims should be the diagnosis that is valid at the time the procedure is performed. For claims received on or after January 1, 2004, providers must use the latest version of the ICD-9-CM codes. It is important for providers to use the most recent version of the ICD-9-CM coding book and to code to the highest level of specificity. The most recent version may be obtained through the following sources:

Medicode 800.999.4600
CMS Web site
(Contains new, revised, and deleted ICD-9-CM Codes that are effective October 1, 2003)		 www.cms.hhs.gov/medlearn/icd9code.asp
American Medical Association (AMA) 800.621.8335 or www.ama-assn.org
National Center for Health Statistics (NCHS) www.cdc.gov/nchs/icd9.htm

[EM 2003-0589/CR 2763]

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Implanted Capsule pH Monitoring for GERD

Article Title

Implanted Capsule pH Monitoring for GERD 

Article Publication Date

08/01/2003

Article Beginning Effective Date

09/19/2003

Article Ending Effective Date

 

Article Text

In its Medical Position Statement (http://www3.us.elsevierhealth.com/gastro/policy/v110n6p1981.html), the American Gastroenterological Association lists the following guidelines for the clinical use of esophageal pH recording:

  • Esophageal pH recording is indicated to document abnormal esophageal acid exposure in an endoscopy-negative patient being considered for surgical antireflux repair (pH study done after withholding antisecretory drug regimen for 1 week)
  • Esophageal pH recording is indicated to evaluate patients after antireflux surgery who are suspected to have ongoing abnormal reflux (pH study done after withholding antisecretory drug regimen for 1 week).
  • Esophageal pH recording is indicated to evaluate patients with either normal or equivocal endoscopic findings and reflux symptoms that are refractory to proton pump inhibitor therapy (pH study done after withholding antisecretory drug regimen for 1 week if the study is done to confirm excessive acid exposure or while taking the antisecretory drug regimen if symptom-reflux correlation is to be scored).
  • Esophageal pH recording is possibly indicated to detect refractory reflux in patients with chest pain after cardiac evaluation using a symptom reflux association scheme, preferably the symptom association probability calculation (pH study done after a trial of proton pump inhibitor therapy for at least 4 weeks).
  • Esophageal pH recording is possibly indicated to evaluate a patient with suspected otolaryngologic manifestations (laryngitis, pharyngitis, chronic cough) of gastroesophageal reflux disease after symptoms have failed to respond to at least 4 weeks of proton pump inhibitor therapy (pH study done while the patient continues taking their antisecretory drug regimen to document the adequacy of therapy).
  • Esophageal pH recording is possibly indicated to document concomitant gastroesophageal reflux disease in an adult onset, nonallergic asthmatic suspected of having reflux-induced asthma (pH study done after withholding antisecretory drugs for 1 week). Note: a positive test does not prove causality!
  • Esophageal pH recording is not indicated to detect or verify reflux esophagitis (this is an endoscopic diagnosis).
  • Esophageal pH recording is not indicated to evaluate for "alkaline reflux."

Esophageal ph recordings can be obtained by a variety of techniques, one of which is the continuous measurement by a capsule that is temporarily implanted in the lower esophagus. The capsule transmits information about the ph levels to a receiver worn by the patient for up to 48 hours. Eventually, the capsule sloughs off the esophagus and passes through the GI tract.

In the absence of a National Coverage Decision (NCD) or a Local Medical Review Policy (LMRP), CIGNA Government Services will evaluate these claims on an individual case-by-case basis. The service must be performed by a qualified provider. Documentation in support of medical necessity and as to why this methodology was chosen over other modalities must be recorded in the medical record and available to Medicare for review upon request.

Coding Guidelines:

1. Please use CPT code 43499 (unlisted procedure, esophagus) and place the term "implanted capsule pH meter" in Field 19 of the CMS 1500 Form or the electronic equivalent.

2. This service consists of a technical portion (TC - provision of the capsule, hookup of the recording equipment, and uploading of the data) and a professional component (physician's interpretation with report).

3. The place of service for the technical component of the test should be reported as the location where the upload of the data to the computer is performed.

4. The professional component (modifier 26) may be billed in places of service 11 (office), 21(inpatient hospital), 22(outpatient hospital), and 24 (ASC).

5. The global service or technical component (modifier TC) may be billed in place of service 11 (office).

6. The date of service should be entered as the date the capsule is placed and the hook-up is performed, with a quantity of one (1), regardless of the number of days the device is worn.

7. The UPIN of the physician or qualified non-physician provider ordering the test must be included on the claim.

8. Endoscopy for the implantation of the device is not separately reimbursable.

9. Billing of an E/M service solely to report the placement of the capsule and hook-up of the equipment will be denied as part of another payable service.

Pricing:

Global $477.00
Technical component (modifier -TC) $349.00
Professional component (modifier -26) $128.00

Coverage Topic

Diagnostic Tests, X-rays, and Lab Services
 

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Medicare Secondary Payer (MSP) Claims with Multiple Primary Payers

Program Memorandum (PM) B-03-050 is a revision to instructions previously published in the April 2003 Medicare Bulletin based on PM AB-03-011.  The previous memorandum included instructions for billing MSP claims with multiple primary payers electronically.  After the PM was published, concerns were raised as to whether the 837 was able to support all the MSP data necessary for Medicare carriers to process claims with multiple primary payers.  PM B-03-050 instructs physicians and suppliers that MSP claims with multiple primary payers should be submitted on paper with the appropriate explanation of benefits, or remittance advice, and should not be submitted electronically.

  1. When Medicare is the Secondary Payer Following One Primary Payer

    2. There are situations where one primary payer pays on a Medicare Part B claim and Medicare may 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 (IG) regarding the submission of Medicare beneficiary MSP claims (The IG can be found at http://hipaa.wpc-edi.com/HIPAA_40.asp).  Providers must follow model 1 in section 1.4.2.1 that discusses the provider-to-payer-to-provider methodology of submitting electronic claims.  Providers must use the appropriate loops and segments to identify the other payer paid amount, allowed amount, and the obligated to accept payment in full amount on the 837.

    Primary Payer Paid Amount:

    For line level services, physicians and suppliers must indicate the primary payer paid amount for that service line in loop ID 2430 SVD02 of the 837.

    For claim level information, physicians and suppliers must indicate the other payer paid amount for that claim in loop ID 2320 AMT02 AMT01=D of the 837.

    Primary Payer Allowed Amount: 

    For line level services, physicians and suppliers must indicate the primary payer allowed amount for that service line in the Approved Amount field, loop ID 2400 AMT02 segment with AAE as the qualifier in the 2400 AMT01 segment of the 837.

    For claim level information, physicians and suppliers must indicate the primary payer allowed amount in the Allowed Amount field, Loop ID 2320 AMT02 AMT01 = B6.

    Obligated to Accept as Payment in Full Amount (OTAF): 

    For line level services, physicians and suppliers must indicate the OTAF amount for that service line in loop 2400 CN102 CN 101 = 09.  The OTAF amount must be greater than zero.

    For claim level information, physicians and suppliers must indicate the OTAF amount in loop 2300 CN102 CN101 = 09. The OTAF amount must be greater than zero.

  2. When Medicare is the Secondary Payer Following Two Primary Payers

    Submission of Hardcopy MSP Claims with Multiple Primary Payers

    There may be situations where more than one primary insurer to Medicare makes payment on a claim; for example, an employer group health plan makes a primary payment for a service and, subsequently, another group health plan also makes a primary payment for the same service.  Claims with multiple primary payers cannot be sent electronically to Medicare.  A hardcopy claim must be submitted on Form CMS-1500.  Physicians and suppliers must attach the other payers' EOB, or remittance advice, to the claim when sending it to Medicare for processing.

[EM 2003-0623/CR 2758]

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Not Otherwise Classified Drugs 2003 Part B Pricing File 3rd Quarter Update

Article Publication Date

08/01/2003

Article Beginning Effective Date

07/01/2003

Article Text

For 2003 Part B Not Otherwise Classified Drugs Pricing File, 3rd Quarter Update, effective July 01, 2003, please refer to the attached file.

The presence or absence of a particular drug on the SDP file does not represent a determination that the Medicare program either covers or does not cover that drug. The amounts shown on the SDP file indicate the maximum Medicare payment allowance, if the Medicare contractor determines that the drug meets the program's requirements for coverage. Similarly, the absence of a particular drug from the SDP file means that if the Medicare contractor determines that the drug is covered by Medicare, the local contractor must then determine the program's payment allowance by applying the program's standard drug payment policy rules. Medicare contractors separately determine whether a particular drug meets the program's general requirements for coverage and, if so, whether payment may be made for the drug in the particular circumstance under which it was furnished. Examples of this latter determination include but are not limited to determinations as to whether a particular drug and route of administration are reasonable and necessary to treat the beneficiary's condition, whether a drug may be excluded from payment because it is usually self-administered, and whether a least costly alternative to the drug exists. AB-03-014; CR-2544

Other Comments

Include Name of Drug and Dosage Given in Block 19 (paper) or Narrative Field (EMC)

Article Attachments

Not Otherwise Classified Drugs Pricing File, Part B 2003 3rd Quarter Update (9,718 bytes)

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Implementation of Outpatient Therapy Caps Delayed Until September 1, 2003

Background

Section 4541(a)(2) of the Balanced Budget Act (BBA) (P.L. 105-33) of 1997, required payment under a prospective payment system for outpatient rehabilitation services. Outpatient rehabilitation services include the following services:

Section 4541(c) of the BBA required application of a financial limitation to all outpatient rehabilitation services (with the exception of outpatient departments of a hospital). These limits were in effect in 1999, but were removed by law in 2000-2002. The statutory limits went back into effect in 2003. The Centers for Medicare & Medicaid Services (CMS) initially announced implementation of the caps beginning July 1, 2003.

Delay in Implementation

To address issues arising in litigation in Federal Court, CMS has elected to delay implementation of the outpatient therapy limitations from the previously announced implementation date of July 1, 2003, to a new implementation date of September 1, 2003.

Therapy caps will not affect outpatient therapy services provided between January 1, 2003, and August 31, 2003. Services rendered on or after September 1, 2003, will be subject to outpatient therapy caps as described in prior Program Memoranda including AB-03-018, AB-03-057, AB-03-073, and AB-03-085. Only the date of implementation has been changed.

The full amount of $1590 for each cap may be used for therapy services rendered between September 1, 2003, and December 31, 2003.

Denied Claims

CWF will adjust the implementation date so that claims with dates of service July 1, 2003 through August 31, 2003, are not subject to financial limitations. Although unlikely, if a claim is denied due to amounts exceeding the therapy limitations between July 1, 2003, and August 31, 2003, carriers and intermediaries will treat these claims as claims denied in error. The claims will be adjusted to pay the amount that would be appropriately paid without regard to outpatient therapy financial limitations.

[EM 2003-0631/CR 2837]

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Skilled Nursing Facility (SNF) Consolidated Billing - October 2003 Quarterly Update

I. GENERAL INFORMATION

A. Background: Section 4432(b) of the Balanced Budget Act (BBA) requires consolidated billing for SNFs. Under the consolidated billing requirement, the SNF must submit Medicare claims to the fiscal intermediary (FI) for all the Part A and Part B services that its residents receive during the course of a covered Part A stay except for a small number of excluded services. For beneficiaries in a Part B stay, only physical, occupational and speech therapy services must be consolidated.

B Policy: Effective March 1, 2003, the payment status on the Medicare Physician Fee Schedule for procedure code 92597, Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech, changed from “Not valid for Medicare purposes” to “Active.” This procedure code is to be considered part of the speech therapy services that must be consolidated in either a Part A or Part B stay.

Providers and suppliers interested in an updated complete list of codes subject to SNF consolidated billing can view the master code list available at cms.hhs.gov/medlearn/snfcode.asp.

[EM 2003-0626/CR 2781]

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Program Integrity Manual Update

The Program Integrity Manual (PIM) is available only on the Internet in HTML format. Notifications will be included in the Medicare Bulletin anytime there is an update to the PIM.

The Internet address for the PIM is: www.cms.hhs.gov/manuals/108_pim/pim83toc.asp.

Transmittal Number Release Date Summary of Revision Effective/Implementation Date
43 06/20/2003 Revises Chapter 9. The documentation that supports the Plan of Care must be in the medical record.  Therefore, CMS will no longer mandate the use of the Plan of Treatment for Outpatient Rehabilitation (HCFA Form 700) or the Updated Plan of Progress for Outpatient Rehabilitation (HCFA Form 701) in Exhibit 24.  CMS is deleting the forms, all Program Integrity Manual Chapter 9 references to the forms, and table of contents references to the forms.  Instead, providers may use any written format, including a form resembling the HCFA Forms 700/701, to convey the required information. July 1, 2003
42 6/20/2003 Revises Chapter 6. The instructions included within this chapter contain medical review (MR) guidelines for intermediaries.  Many of these instructions are outdated and are being deleted to allow intermediaries to develop their own MR guidelines.  In addition to being outdated, this chapter also contains lists of coverage criteria for therapy services that are being deleted.  These lists include the number of therapy visits that may be covered for a specific duration for a specific diagnosis.  These instructions represent coverage policies and should not be in the PIM.  For medical review purposes, the PIM provides instructions to the contractors on the medical review process and the evidence each contractor should use in determining whether a service is reasonable and necessary.  This chapter also contains instructions for the completion of CMS form 485 that are being deleted.  This form is not required and for the most part the information can be found on the OASIS or other parts of the medical record.  The form is optional and the regulation requires only that certain elements be included in the medical record.  We anticipate in the near future deleting the remaining instructions found in this chapter. July 1, 2003

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Medicare Travel Allowance Fees for Collection of
Specimens - Reminder

Medicare Part B covers a specimen collection fee and travel allowance fee for a laboratory technician to draw a specimen from either a nursing home patient or homebound patient under section 1833(h)(3) of the Social Security Act.  Payment is based on the clinical laboratory fee schedule and the travel allowance is payable only to independent laboratories.   The codes assigned for the travel allowance are P9603 and P9604.  Please see the September/October 1998 Medicare Bulletin for additional billing information.
 
**Payment may be made for travel if the beneficiary is in a nursing home or if the beneficiary is homebound.  No payment may be made if the beneficiary is not homebound.
 
**The fact that the beneficiary is homebound must be indicated in item 19 of the CMS-1500 (12-90) claim form.  On electronic claim submissions, the Homebound indicator must show that the beneficiary is homebound by entering the information in the appropriate field. .  The NSF (National Standard Format) Homebound indicator is:  EAO record—Field 50—From/To positions start at 283.  The ANSI (American National Standard Institute) Homebound indicator is:  2300 Loop-Segment CRC03.  Claims lacking the information will be denied.
 
**Neither the venipuncture nor the travel may be paid if the service rendered is a finger, heel, or ear stick.
 
**The test generating the venipuncture must be medically necessary and ordered by the physician treating the beneficiary or the physician that will use the test results to treat the beneficiary.
 
**No more than one round-trip per beneficiary can be paid per day. [CO EM98-144]

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Carrier Review of Payment Amounts for Portable X-Ray Transportation Services HCPCS Code R0070

In response to a number of inquiries from Carriers and providers, CMS has developed the following clarifying instructions in order to implement CMS policy for the Carrier pricing of HCPCS Code R0070.

As a Carrier priced service, Carriers initially determine a payment rate for portable X-ray transportation services that is associated with the cost of providing the service. In order to determine an appropriate cost, the Carrier should, at a minimum, cost out the vehicle, vehicle modifications, gasoline, and the staff time involved in only the transportation for a portable X-ray service. A review of the pricing of this service should be done every five years. Direct costs related to the vehicle carrying the X-ray machine are fully allocable to determining the payment rate. This includes the cost of the vehicle using a recognized depreciation method, the salary and fringe benefits associated with the staff who drive the vehicle, the communication equipment used between the vehicle and the home office, the salary and fringe benefits of the staff who determine the vehicles route this could be proportional of office staff, repairs and maintenance of the vehicles, insurance for the vehicles, operating expenses for the vehicles and any other reasonable costs associated with this service as determined by the Carrier. The Carrier will have discretion for allocating indirect costs those costs that cannot be directly attributed to portable X-ray transportation between the transportation service and the technical component of the X-ray tests. Suppliers may send Carriers unsolicited cost information. The Carrier may use this cost data as a comparison to its Carrier priced determination. The data supplied should reflect a years worth either calendar or corporate fiscal of information. The data is subject to verification and will be used to supplement other information that is used to determine Medicare’s payment rate.

[EM 2003-0581/CR 2741]

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Remittance Advice Remark and Reason Code Update

CMS is the national maintainer of the remittance advice remark code list that is one of the code lists mentioned in ASC X12 transaction 835 (Health Care Claim Payment/Advice) version 4010A1 Implementation Guide (IG). Under the Health Insurance Portability and Accountability Act (HIPAA), all payers, including Medicare, have to use reason and remark codes approved by X12 recognized maintainers instead of proprietary codes to explain any adjustment in the payment. CMS receives a significant number of requests for new remark codes and modifications in existing remark codes from non-Medicare entities, and these additions and modifications may not impact Medicare.

The list of remark codes is available at http://www.cms.hhs.gov/providers/edi/hipaadoc.asp and http://www.wpc-edi.com/hipaa/, and the list is updated three times a year – in the months following X12 trimester meetings.

The following list summarizes changes made through February 28, 2003.

New Remark Codes

Code Current Narrative Medicare Initiated
N157 Transportation to and from this destination is not covered. YES
N158 Transportation in a vehicle other than an ambulance is not covered. YES
N159 Payment denied/reduced because mileage is not covered when the patient is not in the ambulance. YES
N160 The beneficiary/patient must choose an option before this procedure/equipment/supply/service can be covered. YES
N161 This drug/service/supply is covered only when the associated service is covered. YES
N162 This is an alert. Although your claim was paid, you have billed for a test/specialty not included in your Laboratory Certification. Your failure to correct the laboratory certification information will result in a denial of payment in the near future. YES
N163 Medical record does not support code billed per the code definition. YES
N164 Transportation to/from this destination is not covered. YES
N165 Transportation in a vehicle other than an ambulance is not covered. YES
N166 Payment denied/reduced because mileage is not covered when the patient is not in the ambulance. YES
N167 Charges exceed the post-transplant coverage limit. YES
N168 The beneficiary must choose an option before a payment can be made for this procedure/equipment/supply/service. YES
N169 This drug/service/supply is covered only when the associated service is covered. YES
N170 A new/revised/renewed certificate of medical necessity is needed. YES
N171 Payment for repair or replacement is not covered or has exceeded the purchase price. YES
N172 The patient is not liable for the denied/adjusted charge(s) for receiving any updated service/item. YES
N173 No qualifying hospital stay dates were provided for this episode of care. YES
N174 This is not a covered service/procedure/ equipment/bed, however patient liability is limited to amounts shown in the adjustments under group "PR". YES
N175 Missing/incomplete/invalid Review Organization Approval. YES
N176 Services provided aboard a ship are covered only when the ship is of United States registry and is in United States waters. In addition, a doctor licensed to practice in the United States must provide the service. YES
N177 We did not send this claim to beneficiary's other insurer. They have indicated no additional payment can be made. YES
N178 Missing/invalid/incomplete pre-operative photos or visual field results. YES
N179 Additional information has been requested from the member. The charges will be reconsidered upon receipt of that information.  
N180 This item or service does not meet the criteria for the category under which it was billed.  
N181 Additional information has been requested from another provider involved in the care of this member. The charges will be reconsidered upon receipt of that information.  
N182 This claim/service must be billed according to the schedule for this plan.  
N183 This is a predetermination advisory message, when this service is submitted for payment additional documentation as specified in plan documents will be required to process benefits.  
N184 Rebill technical and professional components separately.  
N185 Do not resubmit this claim/service.  
N186 Non-Availability Statement (NAS) required for this service. Contact the nearest Military Treatment Facility (MTF) for assistance.  
N187 You may request a review in writing within the required time limits following receipt of this notice by following the instructions included in your contract or plan benefit documents.  
N188 The approved level of care does not match the procedure code submitted.  
N189 This service has been paid as a one-time exception to the plan's benefit restrictions.  
N190 Missing/incomplete/invalid contract indicator.  
N191 The provider must update insurance information directly with payer.  
N192 Patient is a Medicaid/Qualified Medicare Beneficiary.  
N193 Specific federal/state/local program may cover this service through another payer.  
N194 Technical component not paid if provider does not own the equipment used.  
N195 The technical component must be billed separately.  
N196 Patient eligible to apply for other coverage which may be primary.  
N197 The subscriber must update insurance information directly with payer.  
N198 Rendering provider must be affiliated with the pay-to provider.  
N199 Additional payment approved based on payer-initiated review/audit.  
N200 The professional component must be billed separately.  
N201 A mental health facility is responsible for payment of outside providers who furnish these services/supplies to residents.  

Modified Remark Codes

Code Current Modified Narrative Modification Date
M19 Missing/incomplete/invalid oxygen certification/re-certification. (Modified 2/28/03)
M20 Missing/incomplete/invalid HCPCS. (Modified 2/28/03)
M21 Missing/incomplete/invalid place of residence for this service/item provided in a home. (Modified 2/28/03)
M22 Missing/incomplete/invalid number of miles traveled. (Modified 2/28/03)
M23 Invoice needed for the cost of the material or contrast agent.  
M24 Missing/incomplete/invalid number of doses per vial. (Modified 2/28/03)
M29 Missing/incomplete/invalid operative report. (Modified 2/28/03)
M30 Missing/incomplete/invalid pathology report. (Modified 2/28/03)
M31 Missing/incomplete/invalid radiology report. (Modified 2/28/03)
M33 Missing/incomplete/invalid UPIN for the ordering/referring/performing provider. (Modified 2/28/03)
M34 Claim lacks the CLIA certification number.  
M35 Missing/incomplete/invalid pre-operative photos or visual field results. (Modified 2/28/03)
M44 Missing/incomplete/invalid condition code. (Modified 2/28/03)
M45 Missing/incomplete/invalid occurrence codes or dates. (Modified 2/28/03)
M46 Missing/incomplete/invalid occurrence span code or dates. (Modified 2/28/03)
M47 Missing/incomplete/invalid internal or document control number. (Modified 2/28/03)
M49 Missing/incomplete/invalid value code(s) or amount(s). (Modified 2/28/03)
M50 Missing/incomplete/invalid revenue code(s). (Modified 2/28/03)
M51 Missing/incomplete/invalid procedure code(s) and/or rates. (Modified 2/28/03)
M52 Missing/incomplete/invalid "from" date(s) of service. (Modified 2/28/03)
M53 Missing/incomplete/invalid days or units of service. (Modified 2/28/03)
M54 Missing/incomplete/invalid total charges. (Modified 2/28/03)
M56 Missing/incomplete/invalid payer identifier. (Modified 2/28/03)
M57 Missing/incomplete/invalid provider identifier. (Modified 2/28/03)
M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections. (Modified 2/28/03)
M59 Missing/incomplete/invalid "to" date(s) of service. (Modified 2/28/03)