1. In accordance with the decision memorandum published on the coverage Internet site on July 17, 2003, (see http://cms.hhs.gov/ncdr/memo.asp?id=94), we are adding diagnosis code 401.1, benign essential hypertension, to the list of ICD-9-CM codes covered by Medicare for lipid testing. Hypertension may be viewed as a cause of atherosclerosis that requires tighter management when accompanied by dyslipidemia.
2. ICD-9-CM codes are updated annually. New ICD-9-CM codes can render some of the presently covered codes inappropriate. Most commonly codes are expanded so that additional digits are necessary. For example, a code that presently is displayed as 4 digits may be expanded to require 5 digits. The coding changes below are considered ministerial in that we are merely replacing existing codes within the NCD with the more current code structure or adding new codes that are within an existing covered range. We are making the following specific changes to the NCDs and edit module. However, because we provide a 90-day grace period for new ICD-9-CM codes, we will not actually be removing the codes from the edit module until the January 2004 release.
• In the serum iron studies NCD list of covered diagnoses, we are removing code 282.4 and replacing it with 282.41, 282.42, and 282.49. We are removing code V43.2 and replacing it with V43.21 and V43.22. We are also adding new ICD-9-CM diagnosis codes 282.64, 282.68, and 289.52.
• In the urine culture bacterial NCD list of covered diagnoses, we are removing code 600.0 and replacing it with 600.00 and 600.01; removing code 600.1 and replacing it with 600.10 and 600.11; removing 600.2 and replacing it with 600.20 and 600.21; and removing 600.9 and replacing it with 600.90 and 600.91. We are also adding the following new codes: 780.93, 780.94, 785.52, and 788.63.

CMS-Pub. 60AB

• In the human immunodeficiency virus testing (diagnosis) NCD list of covered diagnoses, we are removing ICD-9-CM diagnosis code 348.3 and replacing it with 348.30 and 348.39; and removing code 530.2 and replacing it with 530.20, 530.21, and 530.85. We are also adding new code 331.19.
• In the blood counts NCD list of ICD-9-CM codes that do not support medical necessity, we are removing code 600.0 and replacing it with 600.00 and 600.01; removing code 600.1 and replacing it with 600.10 and 600.11; removing 600.2 and replacing it with 600.20 and 600.21; and removing 600.9 and replacing it with 600.90 and 600.91. We are also removing code V04.8 and replacing it with V04.81, V04.82, and V04.89; removing V53.9 and replacing it with V53.90, V53.91 and V53.99; removing V54.0 and replacing it with V54.01, V54.02, and V54.09. In addition, we are adding the following new codes: 799.81, V25.03, V45.85, and V65.46.
• In the partial thromboplastin time NCD list of covered diagnoses, we are removing code 767.1 and replacing it with 767.11.
• In the prothrombin time NCD list of covered diagnoses, we are removing code 767.1 and replacing it with 767.11. We are also removing code V43.2 and replacing it with V43.21 and V43.22. In addition, we are adding new code 414.07.
• In the collagen cross-links NCD list of covered diagnoses, we are adding new code V58.65.
• In the blood glucose NCD list of covered diagnoses, we are removing code 790.2 and replacing it with 790.21, 790.22, and 790.29; and removing 348.3 and replacing it with 348.31.We are also adding new codes 414.07, V58.63, V58.64, and V58.65.
• In the glycated hemoglobin NCD list of covered diagnoses, we are removing code 790.2 and replacing it with 790.21, 790.22, and 790.29.
• In the thyroid testing NCD list of covered diagnoses, we are removing code 331.1 and replacing it with 331.11 and 331.19. We are also adding new codes 728.87, 780.93 and 780.94.
• In the lipid testing NCD list of covered diagnoses, we are adding codes 414.07, V58.63, and V58.64.
• In the prostate specific antigen NCD list of covered procedures, we are adding new code 788.63.
• In the gamma glutamyl transferase NCD list of covered diagnoses, we are adding new codes 282.64, 282.68, 289.52, V58.63, and V58.64.
• In the fecal occult blood NCD list of covered diagnoses, we are removing code 530.2 and replacing it with new codes 530.20, 530.21, and 530.85. We are also adding new codes V58.63, V58.64, and V58.65.
• In the list of ICD-9-CM codes denied that are applicable to all 23 NCDs, we are removing code V65.1 and replacing it with V65.11 and V65.19.

[EM 2003-0711/ CR2814]

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Invoice Filing Instructions for Drugs/Biologicals/Radiopharmaceuticals

When invoice information is required for processing a claim, please adhere to the following instructions:

Paper CMS 1500 Form

1. A copy of your purchase invoice (e.g., actual invoice from the manufacturer, distributor, or pharmacy) must be attached to the claim.
2. If you are submitting a miscellaneous code, the name of the drug and the exact dosage given must be in block 19 or as an attachment.
3. If you are submitting a claim for compounded drugs used in an implanted infusion pump, all drugs included in the compound should be filed on one line using miscellaneous code J3490 or J9999 accordingly. The name and dosage of each drug in the mixture must be in block 19 or as an attachment.

Paper claims received without a copy of the purchase invoice will be denied for lack of information.

Electronic Media Claims (EMC)

1. Submitting actual invoice cost: The following statement may be entered in the narrative field “Actual invoice cost”
2. Submitting a charge greater than the actual invoice cost: You may enter the invoice information in the narrative field using the following format:
   
   • Des = Description/Name of agent (i.e., Des=TL201 Thallium)
   • QS = Quantity shipped (i.e., QS=280 mci)
   >
   • TA = Total amount charged for quantity shipped (i.e., TA=$602.58)
   • DG = Dosage given (i.e., DG=4 mci)
3. Claims submitted using miscellaneous codes (e.g., A4641, J3490, J9999, or a code that could be used for more than one drug/biological/radiopharmaceutical: The name of the agent and the exact dosage administered must be in the narrative field along with the invoice information from number 1 or 2 accordingly.
4. Claim submitted for compounded medications: All drugs included in the compound should be filed on one line using miscellaneous code J3490 or J9999 accordingly. The name and dosage of each drug in the mixture must be in the narrative field along with the invoice information from number 1 or 2 accordingly.

Electronic claims received without the proper information in the narrative field will be denied for lack of information.

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Clarification Regarding Coverage of Hyperbaric Oxygen (HBO) Therapy for the Treatment of Diabetic Wounds of the Lower Extremities

There are changes to the guideline for coverage of Hyperbaric Oxygen (HBO) Therapy. The changes are as follows:

• In PM AB-02-183, under Conditions of Coverage, applicable ICD-9-CM diagnosis shall include 707.15.
• Some of the diagnosis codes listed in the original AB-02-183 need more digits to be considered a valid ICD-9-CM. For example, 250.7, 250.8 and 707.1 need a 5th digit. 707 was mistakenly listed in CR 2388, this is a title of a category not a valid code.

This article (CR2388) was originally printed in the May 2003 Medicare Bulletin on page 7.

[EM 2003-0697/2003-0697]

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Compounded Medications (Including Medication Administered via Implantable Pump)

An article with instructions was previously published online at www.cignamedicare.com in the June 2002 “What’s New” section and in the online July/August 2002 Part B Medicare Bulletin. The effective date of August 15, 2002 for filing claims based on the previous article is unchanged. These instructions are being redistributed with a few minor changes in wording. The changes are in bold/italics.

Compounded medications created by a pharmacist in accordance with the Federal Food, Drug, and Cosmetic Act may be covered under Medicare when their use meets all other criteria for services incident to a physician’s service. Since the compounded medications do not have an NDC number or an Average Wholesale Price, the specific HCPCS Level II “J” codes may not be used. Instead, providers should use J3490 (unclassified drug) or J9999 (not otherwise classified anti-neoplastic drugs) as appropriate for reimbursement of the drug(s). The charge for the compounded mixture should be submitted on one line of the CMS 1500 form or its electronic equivalent under the appropriate miscellaneous code.

The use of compounded medications has been especially prevalent in the filling of implantable infusion pumps, CPT code 96530. Whether a single agent or a combination of agents is used, the compounded medication must be billed under miscellaneous HCPCS code J3490 or J9999 even though the compound was similar to a specific HCPCS code (e.g., J2275 for preservative free morphine). The dosage set for specific HCPCS Level II codes are based on smaller doses that would be used for a single injection administered in the office, not for continuous infusion via a pump. Powdered forms of these medications should also be billed under J3490 or J9999 with the NDC# (if applicable), strength, and quantity used for each drug included on the claim, whether mixed/compounded by the pharmacist or the physician.

Providers who document and use the true off-the-shelf product from their office supply may continue to use the specific HCPCS code, but this must be documented and the NDC#, quantity, and strength for each drug must be in block 19 of the CMS 1500 form or its electronic equivalent.

Effective August 15, 2002, compounded medications should be billed under HCPCS code J3490 or J9999 in conjunction with the appropriate administration code. (e.g., 96530, 95990) Claims without the following information will be denied:

EMC claims should include the following information in the electronic notepad or HAO record field:

• the name, quantity, strength, and NDC# (if applicable) of each drug in the mixture
• the name and phone number of the pharmacy/provider, if applicable
• the invoice cost

  Paper claims should include the term “Compound prescription, invoice attached.” in field 19 of the CMS 1500 claim form and attach a copy of the invoice from the pharmacy or supplier. The invoice should include the following information:

• the name, quantity, strength, and NDC# (if applicable) of each drug in the mixture

• the invoice cost

In either case, the invoice cost may include a reasonable compounding fee if applicable. Medicare will reimburse the lower of invoice cost or 95 percent of AWP of all components in the mixture.

This does not in any way change the already established medical guidelines for coverage of implantable infusion pumps or the medications administered via the pump.

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Impact of PECOS on RMC Enrollment and Billing

The Provider Enrollment, Chain and Ownership System (PECOS) is a national database which contains Medicare provider, physician, and supplier enrollment information. Beginning October 6, 2003, this database will be used to collect and maintain data submitted on the Form CMS-855 enrollment application. The Railroad Medicare Carrier (RMC) will obtain enrollment information from this database to pay claims.

As of October 6, 2003, physicians and suppliers requiring RMC enrollment will no longer be required to submit an RMC application for enrollment/changes. All enrollment information will be captured through the Medicare Part B enrollment process. Physicians and suppliers will still be required to submit claims to the RMC. However, they must ensure that prior to submitting claims, the provider/supplier information is the same as that used to submit claims to the Medicare Carrier.

New providers/suppliers should obtain a Medicare Part B PIN. (This will provide assurance that they are enrolled at the Part B Carrier). New RMC providers/suppliers will be issued an RMC PIN once their claim has been submitted. Established and new Railroad Medicare providers/suppliers should use their RMC provider/supplier PIN when submitting claims for RMC beneficiaries.

[EM 2003-0694/CR 2777]

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Incentive Payments to Physicians for Professional Services Furnished in Health Professional Shortage Areas (HPSAs)

In accordance with §1833(m) of the Social Security Act, physicians who provide covered professional services in any rural or urban HPSA are entitled to an incentive payment. Beginning January 1, 1989, physicians providing services in certain classes of rural HPSAs were entitled to a 5-percent incentive payment. Effective January 1, 1991, physicians providing services in either rural or urban HPSAs are eligible for a 10-percent incentive payment. It is not enough for the physician merely to have his/her office or primary service location in a HPSA, nor must the beneficiary reside in a HPSA, although frequently this will be the case. The key to eligibility is where the service is actually provided (place of service). For example, a physician providing a service in his/her office, the patient’s home, or in a hospital qualifies for the incentive payment as long as the specific location of the service is within an area designated as a HPSA. On the other hand, a physician may have an office in a HPSA but go outside the office (and the designated HPSA area) to provide the service. In this case, the physician would not be eligible for the incentive payment.

The Internet address for the MCM Part 3 is: www.cms.hhs.gov/manuals/14_car/3btoc.asp.

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Drugs and Biologicals Excluded as Usually Self-Administered

Article Title Drugs and Biologicals Excluded as Usually Self-Administered  Article Publication Date 01/01/2003 Article Beginning Effective Date 01/01/2003 Article Text The Medicare program covers drugs that are furnished "incident to" a physician's service provided that the drugs are not usually self-administered by the patient. Only injectable drugs are eligible for inclusion under the "incident to" provision. The following is a list of injectable drugs that this carrier has determined to be usually self-administered by the patient and are therefore excluded from coverage by Medicare. Please follow the link listed under "Detailed Article URL" to a description of the criteria used to make these determinations. Contractors must provide notice 45 days prior to the date these drugs will not be covered. During the 45 day time period, contractors will maintain existing medical review and payment procedures. Coverage Topic Prescription Drugs

 

Coding Table Information

CPT/HCPCS Codes - Table Format Code Descriptor Generic Name Descriptor Brand Name Effective Date End Date Comments J0270 INJECTION, ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED) Caverject Impulse Injection MUSE Urethral Suppository 01/01/2003 N/A Apparent on its face/Use as needed/Intracavernosal or Intraurethral J0630 INJECTION, CALCITONIN SALMON, UP TO 400 UNITS Miacalcin Injection 01/01/2003 N/A Frequency/USA/SC as needed J1438 INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED) Enbrel 01/01/2003 N/A Apparent on its face/Provided as Kit for Self Administration/SC twice a week J1820 INJECTION, INSULIN, UP TO 100 UNITS Multiple brands 01/01/2003 N/A Frequency/Apparent on its face/SC Daily J1910 INJECTION, KUTAPRESSIN, UP TO 2 ML Kutapressin 01/01/2003 N/A Frequency/Apparent on its face/SC or IM Daily J2940 INJECTION, SOMATREM, 1 MG Somatrem 01/01/2003 N/A Frequency/Apparent on its face/SC or IM Daily J2941 INJECTION, SOMATROPIN, 1 MG Multiple brands 01/01/2003 N/A Apparent on its face/Frequency/Usually self administered SC/Daily or every other day SC/Once monthly or twice monthly on same day(s) {i.e., 1st & 15th} Frequency/SC or IM/3 times a week J3030 INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED) Imitrex Injection 01/01/2003 N/A Apparent on its face/SC as needed Q2010 INJECTION, GLATIRAMER ACETATE, PER DOSE Copaxone 01/01/2003 N/A Frequency/Apparent on its face/SC Daily Q2020 INJECTION, HISTRELIN ACETATE, 10 MCG Histrelin Acetate 01/01/2003 N/A Frequency/Apparent on its face/SC Daily J3490 UNCLASSIFIED DRUGS Pegvisomant for ingection (Somavert) 07/20/2003 N/A Frequency/Apparent on its face/USA/SC Daily J3490 UNCLASSIFIED DRUGS Teriparatide (Forteo) 07/20/2003 N/A Frequency/Apparent on its face/USA/SC Daily J3490 UNCLASSIFIED DRUGS Adalimumab (Humira) 10/07/2003 N/A Apparent on its face/USA/SC every other week

 

Other Information

Detailed Article URL http://www.cms.gov/goodbye.asp?URL=http://www.cignamedicare.com/articles/Oct02/ws0351.html Other Comments This article represents an update of this carrier's list of drugs and biologicals excluded as usually self-administered. For most recent changes, please refer to the Effective/End Dates listed with the specific CPT/HCPCS codes, as applicable. This version corrects a typing error in the effective dates for pegvisomant (Somavert) and teriparatide (Forteo) from 09/20/2003 to 07/20/2003 The effective dates listed are based on the methodology outlined in the linked publication. Prior to this, other coverage criteria and provisions may have applied.

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Healthcare Provider Taxonomy Codes (HPTC) Crosswalk

The Centers for Medicare & Medicaid Services (CMS) authorized all Medicare carriers to begin using the most recent version (3.01) of the Provider Taxonomy code set as of April 1, 2003. This code set is required under HIPAA for use on all ANSI 837 X12N V.4010 Health Care Claims. This is optional for ANSI 837 X12N V4010A1 but if it is used the code must be a valid code. The Code set can be accessed electronically from the Washington Publishing web site at www.wpc-edi.com/codes.

The attached table reflects Healthcare Provider Taxonomy Codes as of April 1, 2003. It “walks” the existing Medicare specialty codes to the appropriate HPTC. CMS Medicare specialty codes were revised on April 1, 2003 and carriers will see some new additions. Also, many taxonomies changed completely while others just changed the “Y” at the end of the code to “X”.

The CMS codes 71 and 72 were re-used by CMS for two new specialties in 2001. The following are 2003 specialty codes that have been cross-walked: 09 (Interventional Pain Management), 32 (Anesthesiologist Assistant) and 74 (Radiation Therapy Center). Specialty codes 73 (Mass Immunization Roster Billers) and 75 (Slide Preparation Facilities) cannot be cross-walked at this time and will require work with the NUCC. Specialty codes 15, 17, 21, 23, 27, 31, and 95 are presently unassigned and are not reflected in this crosswalk.

The following are 2003 specialty codes that have been cross-walked:

CMS SPECIALTY CODE	CMS SPECIALTY DESCRIPTION	PROVIDER TAXONOMY CODE	PROVIDER TAXONOMY DESCRIPTION TYPE	PROVIDER TAXONOMY DESCRIPTION CLASSIFICATION and SPECIALIZATION
l	General Practice	208D00000X	Allopathic/Osteopath Physicians	General Practice
02	General Surgery	208600000X	Allopathic/Osteopath Physicians	Surgery
03	Allergy Immunology	207K00000X	Allopathic/Osteopath Physicians	Allergy & Immunology
04	Otolaryngology	207Y00000X	Allopathic/Osteopath Physicians	Otolaryngology
05	Anesthesiology	207L00000X	Allopathic/Osteopath Physicians	Anesthesiology
06	Cardiology	207RC0000X	Allopathic/Osteopath Physicians	Internal Medicine, Cardiovascular Disease
07	Dermatology	207N00000X	Allopathic/Osteopath Physicians	Dermatology
08	Family Practice	207Q00000X	Allopathic/Osteopath Physicians	Family Practice
09	Interventional Pain Management	208VP0014X	Allopathic/Osteopath Physicians	Pain Management, Interventional Pain Management
10	Gastroenterology	207RG0100X	Allopathic/Osteopath Physicians	Internal Medicine, Gastroenterology
11	Internal Medicine	207R00000X	Allopathic/Osteopath Physicians	Internal Medicine
12	Osteopathic Manipulative Therapy (OMM)	204D00000X	Allopathic/Osteopath Physicians	Neuromusculoskeletal Medicine & OMM
13	Neurology	2084N0400X	Allopathic/Osteopath Physicians	Psychiatry & Neurology, Neurology
14	Neurosurgery	207T00000X	Allopathic/Osteopath Physicians	Neurological Surgery
16	Obstetrics Gynecology	207V00000X	Allopathic/Osteopath Physicians	Obstetrics & Gynecology
18	Ophthalmology	207W00000X	Allopathic/Osteopath Physicians	Ophthalmology
19	Oral Surgery (dental only)	1223S0112X	Dental Providers	Oral & Maxillofacial Surgery
20	Orthopedic Surgery	207X00000X	Allopathic/Osteopath Physicians	Orthopedic Surgery
22	Pathology	207ZP0102X	Allopathic/Osteopath Physicians	Pathology-Anatomic Pathology & Clinical Pathology
24	Plastic and Reconstructive Surgery	2086S0122X	Allopathic/Osteopath Physicians	Surgery, Plastic & Reconstructive
25	Physical Medicine and Rehabilitation	208100000X	Allopathic/Osteopath Physicians	Physical Medicine &  Rehabilitation
26	Psychiatry	2084P0800X	Allopathic/Osteopath Physicians	Psychiatry & Neurology-Psychiatry
28	Colorectal Surgery (formerly Proctology)	208C00000X	Allopathic/Osteopath Physicians	Colon & Rectal Surgery
29	Pulmonary Disease	207RP1001X	Allopathic/Osteopath Physicians	Internal Medicine, Pulmonary Diseases
30	Diagnostic Radiology	2085R0202X	Allopathic/Osteopath Physicians	Radiology Group, Diagnostic Radiology
32	Anesthesiologist Assistant	367H00000X	PA and Advanced Practice Nursing Providers	Anesthesiologist Assistant
33	Thoracic Surgery	208G00000X	Allopathic/Osteopath Physicians	Thoracic Surgery
34	Urology	208800000X	Allopathic/Osteopath Physicians	Urology
35	Chiropractic	111N00000X	Chiropractors	Chiropractor
36	Nuclear Medicine	207U00000X	Allopathic/Osteopath Physicians	Nuclear Medicine
37	Pediatric Medicine	208000000X	Allopathic/Osteopath Physicians	Pediatrics
38	Geriatric Medicine	207RG0300X	Allopathic/Osteopath Physicians	Internal Medicine, Geriatric Medicine
39	Nephrology	207RN0300X	Allopathic/Osteopath Physicians	Internal Medicine, Nephrology
40	Hand Surgery	2086S0105X	Allopathic/Osteopath Physicians	Surgery of the Hand
41	Optometry	152W00000X	Eye and Vision Service Providers	Optometrist
42	Certified Nurse Midwife	367A00000X	Physician Assistants & Advanced Practice Nursing Providers	Midwife, Certified Nurse
43	Certified Registered Nurse Assistant (CRNA)	367500000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Anesthetist, Certified Registered
44	Infectious Disease	207R10200X	Allopathic/Osteopath Physicians	Internal Medicine, Infectious Disease
45	Mammography Screening Center	261QR0206X	Ambulatory Health Care Facilities-Clinic/Center	Clinic/Center-Radiology, Mammography
46	Endocrinology	207RE0101X	Allopathic/Osteopath Physicians	Internal Medicine-Endocrinology, Diabetes & Metabolism
47	Independent Diagnostic Testing Facility	293D00000X	Laboratories	Physiological Laboratory: (Independent Physiological Lab)
48	Podiatry	213E00000X	Podiatric Medicine & Surgery Providers	Podiatrist
49	Ambulatory Surgical Center	261QA1903X	Ambulatory Health Care Facilities	Clinic/Center, Ambulatory Surgical
50	Nurse Practitioner	363L00000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner
51	Medical Supply Company with Orthotist	335E00000X	Suppliers	Prosthetic/Orthotic Supplier
52	Medical Supply Company with Prosthetist	335E00000X	Suppliers	Prosthetic/Orthotic Supplier
53	Medical Supply Company with Orthotist-Prosthetist	335E00000X	Suppliers	Prosthetic/Orthotic Supplier
54	Other Medical Supply Company	332B00000X	Suppliers	Durable Medical Equipment & Medical Supplies
55	Individual Certified Orthotist	222Z00000X	Respiratory, Rehabilitative, and Restorative Service Providers	Orthotist
56	Individual Certified Prosthetist	224P00000X	Respiratory, Rehabilitative, and Restorative Service Providers	Prosthetist
57	Individual Certified Prosthetist-Orthotist	225000000X	Respiratory, Rehabilitative, and Restorative Service Providers	Orthotics/Prosthetics Fitter
58	Medical Supply Company with Pharmacist	332B00000X	Suppliers	Durable Medical Equipment & Medical Supplies
59	Ambulance Service Provider	3416L0300X	Transportation Services	Ambulance (Land)
60	Public Health or Welfare Agency	251K00000X	Agencies	Public Health or Welfare
61	Voluntary Health or Charitable Agency	251V00000X	Agencies	Voluntary or Charitable
62	Psychologist	103T00000X	Behavioral Health & Social Service Providers	Psychologist
63	Portable X-Ray Supplier	335V00000X	Suppliers	Portable X-ray Supplier
64	Audiologist	231H00000X	Speech, Language and Hearing Providers	Audiologist
65	Physical Therapist	225100000X	Respiratory, Rehabilitative & Restorative Service Providers	Physical Therapist
66	Rheumatology	207RR0500X	Allopathic/Osteopath Physicians	Internal Medicine, Rheumatology
67	Occupational Therapist	225X00000X	Respiratory, Rehabilitative & Restorative Service Providers	Occupational Therapist
68	Clinical Psychologist	103TC0700X	Behavioral Health & Social Service Providers	Psychologist/Clinical
69	Clinical Laboratory	291U00000X	Laboratories	Clinical Medical Laboratory
70	Multi-specialty Clinic or Group Practice	261QM1300X	Ambulatory Health Care Facilities	Clinic/Center: Multi-specialty
71	Registered Dietitian/Nutrition Professional	133V00000X	Dietary & Nutritional Service Providers	Dietitian, Registered
72	Pain Management	208VP0000X	Allopathic/Osteopath Physicians	Pain Medicine, Pain Management
73	Mass Immunization Roster Billers	N/A	N/A	N/A
74	Radiation Therapy Centers	261QX0203X	Ambulatory Health Care Facilities	Clinic/Center: Oncology, Radiation
75	Slide Preparation Facilities	N/A	N/A	N/A
76	Peripheral Vascular Disease	2086S0129X	Allopathic/Osteopath Physicians	Surgery, Vascular Surgery
77	Vascular Surgery	2086S0129X	Allopathic/Osteopath Physicians	Surgery, Vascular Surgery
78	Cardiac Surgery	2086S0129X	Allopathic/Osteopath Physicians	Surgery, Vascular Surgery
79	Addiction Medicine	207RA0401X	Allopathic/Osteopath Physicians	Internal Medicine, Addiction Medicine
80	Licensed Clinical Social Worker	1041C0700X	Behavioral Health & Social Service Providers	Social Worker, Clinical
81	Critical Care (Intensivists)	207RC0200X	Allopathic/Osteopath Physicians	Internal Medicine, Critical Care Medicine
82	Hematology	207RH0000X	Allopathic/Osteopath Physicians	Internal Medicine, Hematology
83	Hematology/Oncology	207RH0003X	Allopathic/Osteopath Physicians	Internal Medicine, Hematology & Oncology
84	Preventive Medicine	2083P0901X	Allopathic/Osteopath Physicians	Preventive & Occupational Medicine-Public Health & General Preventive Medicine
85	Maxillofacial Surgery	2084N0600X	Allopathic/Osteopath Physicians	Oral & Maxillofacial Surgery
86	Neuropsychiatry	2084N0600X	Allopathic/Osteopath Physicians	Psychiatry & Neurology, Clinical Neurophysiology
87	All Other Suppliers	N/A	Suppliers	N/A
88	Unknown Supplier/Provider Specialty	N/A	Suppliers	N/A
89	Certified Clinical Nurse Specialist	364S00000X	Physician Assistants & Advanced Practice Nursing Providers	Clinical Nurse Specialist
90	Medical Oncology	207RX0202X	Allopathic/Osteopath Physicians	Internal Medicine, Medical Oncology
91	Surgical Oncology	2086X0206X	Allopathic/Osteopath Physicians	Surgery, Surgical Oncology
92	Radiation Oncology	2085R0001X	Allopathic/Osteopath Physicians	Radiology Group-Radiation Oncology
93	Emergency Medicine	207P00000X	Allopathic/Osteopath Physicians	Emergency Medicine
94	Interventional Radiology	2085R0204X	Allopathic/Osteopath Physicians	Radiology Group, Vascular &  Interventional Radiology
96	Optician	156FX1800X	Eye and Vision Service Providers	Technician/Technologist-Optician
97	Physician Assistant	363A00000X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant
98	Gynecological/Oncology	207VX0201X	Allopathic/Osteopath Physicians	Obstetrics & Gynecology, Gynecologic Oncology
99	Unknown Physician Specialty	N/A	Allopathic/Osteopath Physicians	N/A
A0	Hospital	282N00000X	Hospitals	General Acute Care Hospital
A1	Skilled Nursing Facility	314000000X	Nursing and Custodial Care Facilities	Skilled Nursing Facility
A2	Intermediate Care Nursing Facility	313M00000X	Nursing and Custodial Care Facilities	Nursing Facility/Intermediate Care Facility
A3	Other Nursing Facility	313M00000X	Nursing and Custodial Care Facilities	Nursing Facility/Intermediate Care Facility
A4	Home Health Agency	251E00000X	Agencies	Home Health
A5	Pharmacy	333600000X	Suppliers	Pharmacy
A6	Medical Supply Company with Respiratory Therapist	332B00000X	Suppliers	Durable Medical Equipment & Medical Suppliers
A7	Department Store	332B00000X	Suppliers	Durable Medical Equipment & Medical Suppliers
A8	Grocery Store	332B00000X	Suppliers	Durable Medical Equipment & Medical Suppliers

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Medicare Carriers Manual: Daily Visit Charges & Non-ESRD Patients Requiring Hemodialysis

NEW/REVISED MATERIAL--EFFECTIVE DATE: October 1, 2003

IMPLEMENTATION DATE: October 1, 2003

Section 15062.1, Payment for Physician Services Furnished to Dialysis Inpatients, is revised to clarify a CPT Editorial change in the description for CPT codes 90935 and 90937.

The change in the code descriptor allows for these codes to be used for outpatient acute dialysis services that is, patients who are expected to regain their renal function as well as for inpatient ESRD and acute dialysis services.

Section 15350, Dialysis Services Codes 90935-90999, adds a new subsection allowing payment for CPT codes 90935 or 90937 for dialysis services furnished to acute dialysis patients requiring hemodialysis on an outpatient or inpatient basis.

[EM 2003-0695 / CR 2622]

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Medical Review - Frequently Asked Questions

Article Publication Date	07/28/2003
Article Beginning Effective Date	07/28/2003
Article Text	Medical Review Frequently Asked Questions The following represent a variety of questions the Medical Review department has received. CIGNA Government Services will address at least quarterly "Frequently Asked Questions" related to coverage and local medical review policy issues. The previous issue was published on April 2003 website bulletin. Providers may submit questions to the Web site at http://www.cignamedicare.com/customer_service/disclaimer.html. 1.Trigger Point and Tendon Sheath Injections Q: Are there any restrictions on these codes?: A: Each of the carrier's three states (ID, NC and TN) have their own respective policies for these CPT codes including diagnosis requirements (see attached links). The most significant issue as far as billing of these services came about with the 2002 change in the CPT codes-especially for trigger point injections. Prior to January 1, 2002, each trigger point injected could be billed using CPT code 20550. After January 1, 2002, billing of trigger points switched from per injection to single or multiple injections per number of muscles (CPT code 20552 for single or multiple injections of one or two muscles vs. CPT code 20553 for single or multiple injections of three or more muscles). Also revised were codes for single or multiple injections tendon sheath or ligament (CPT code 20550) and tendon origin/insertion (CPT code 20551). Since that time, we have noted that some providers who had been billing multiple trigger point injections along the spine have now moved to billing for multiple tendon origin/insertion codes - same locations/same beneficiaries (previously treated with trigger point injections). For these injections of tendon sheaths/origins/insertions to be medically necessary, there must be an inflammatory process in a given tendon (tendonitis) or tendon sheath tenosynovitis). Unless there is a systemic underlying illness (autoimmune or the like), the inflammation of multiple tendons, tendon sheaths, and muscle insertions - especially along the spine - should be extraordinarily rare. TN LMRP: http://www.cignamedicare.com/partb/lmrp/tn/cms_fu/9301-01.htm NC LMRP: http://www.cignamedicare.com/partb/lmrp/nc/cms_fu/97-016-03.htm ID LMRP: http://www.cignamedicare.com/partb/lmrp/id/cms_fu/9900201.htm 2. Nonselective versus Selective Catheterizations Q: Why would charges for aortograms or intro of a catheter into an extremity artery (CPT codes 36200 and 36140 respectively) be denied? A: Per the CPT manual, selective catheterization includes introduction and all lesser order selective catheterization used in the approach to the target vessel. Codes 36200 and 36140 represent nonselective catheterization and, therefore, should not be separately paid from the selective catheterization codes (e.g. CPT codes 36215-36217 and 36245-36247). In other words, nonselective catheterization is component to the more comprehensive selective catheterizations. We have recently discovered that the CCI tables do not reflect all of these bundling pairs. We referred this issue to CCI, and we have learned CMS will add the following column1 code/column 2 code edits: (36215-36217)/36200 and 36245/36140. Therefore, we will be editing for these codes to keep any overpayments from being made. 3. Gastric Bypass Q: Does Medicare cover gastric bypass? A: Medicare may cover gastric bypass procedures provided the guidelines outlined in the following Coverage Issue Manual and National Coverage Determination references are met. These procedures may be considered medically reasonable and necessary if the patient's obesity is aggravating a condition such as hypertension, asthma, diabetes, etc, and the treatment of the obesity is integral to the treatment of the underlying disease. The medical record should include such supporting documentation as well as the patient's weight and body mass index. CPT codes 43846 and 43847 are to be used for open procedures but laparoscopic procedures should be billed with an unlisted code and submitted with the above supporting documentation. Related Coverage Issue Manual topics (35-26, 35-33 and 35-40) and National Coverage Determination: http://www.cms.gov/manuals/06_cim/ci35.asp#_35_26 http://www.cms.gov/manuals/06_cim/ci35.asp#_35_33 http://cms.hhs.gov/manuals/06_cim/ci35.asp#_1_46 http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=35-40&ncd_version=1&show=all 4. Documentation for ER visits Q: Can the physician count notes documented by the triage nurse toward the level of service billed? A: The physician's services are supported by his or her documentation alone. Documentation by hospital staff cannot count towards the level of physician's service billed--be it in the ER or for other visits such as subsequent hospital visits. For example, if a hospital triage nurse documented most of the patient's exam then the physician would only report that level of service equal to the exam he or she performed. Please note ER visits using CPT codes 99281-99285 require the three key components (history, exam and decision-making); and the lower the levels of these components yields a lower level of service to be billed. Related Bulletin article: November/December 1999 issue of Medicare Bulletin, TN insert "Focused Medical Review of Subsequent Hospital Visits" 5. Bone Marrow Aspiration and Biopsy Q: If both a bone marrow aspiration and biopsy are done from the same sites what codes can I bill? A: The following answer is taken from the National Correct Coding Policy Manual for Part B Carriers (version 8.3): When bone marrow aspiration is performed alone, the appropriate code to report is CPT code 38220. When a bone marrow biopsy is performed, the appropriate code is CPT code 38221 (bone marrow biopsy); this code cannot be reported with CPT code 20220 (bone biopsy). CPT codes 38220 and 38221 may only be reported together if the two procedures are performed at separate sites or at separate patient encounters. When both a bone marrow biopsy (CPT code 38221) and bone marrow aspiration (CPT code 38220) are performed at the same site through the same incision, only the bone marrow biopsy ( CPT 38221) should be reported. 6. Monitored Anesthesia Care Q: I am having trouble getting claims for MAC paid. What could be the problem? A: First of all, each state has a LMRP for MAC (Monitored Anesthesia Care). Within these policies there are anesthesia codes for which no other documentation is necessary to support the necessity of MAC (column A codes). Column B codes are those that require a diagnosis or physical status indicator supporting the necessity of MAC. Each LMRP has a list of diagnosis codes which support the necessity of MAC (see exhibit A under "ICD-9 codes that support Medical Necessity"). Therefore, column B anesthesia requires an exhibit A diagnosis or an ASA physical status indicator of P3, P4 or P5 indicating that one of the diagnoses in Exhibit A is present. Sometimes providers do not include a physical status indicator or an appropriate diagnosis (such as code is not a covered diagnosis or is longer valid such as it must be coded to a higher level of specificity). These omissions would result in denials. Modifier QS is used to reflect MAC was done. Modifier G8 is to be used on those anesthesia codes designated by an asterisk in the policy. This modifier indicates that the procedure was deep, complex, complicated or markedly invasive and performed on an area of the body that is very sensitive and includes the face (00100 and 00160), neck (00300), breast (00400), or male genitalia (00920) and for access to the central venous circulation (00532). The MAC modifier G9 is used with a column B procedure code to indicate that the patient has, or has had a severe cardiopulmonary condition or that there is significant risk of an exacerbation in a stable patient during the procedure. It is not necessary to use modifier QS in addition to G8 or G9, nor is it necessary to include a physical status indicator when modifier G8 or G9 is used. See: TN LMRP http://www.cignamedicare.com/partb/lmrp/tn/cms_fu/9706-02.htm NC LMRP http://www.cignamedicare.com/partb/lmrp/tn/cms_fu/9706-02.htm ID LMRP http://www.cignamedicare.com/partb/lmrp/id/id96011.html 7. Electrical stimulation for other than wound care Q: Why are my charges for 97014 being denied? A: 97014 was made an inactive code this year when HCPCS code G0283 (Electrical Stimulation, unattended, to one or more areas, for indication(s) other than wound care, as part of a therapy plan of care) was established by CMS. 8. Drug Eluting Stents Q: What codes should be billed for the insertion of drug eluting stents? A: Providers should use the CPT codes 92980-92981 for stent insertion regardless of whether stents are coated (i.e. "drug-eluting") or not. HCPCS codes G0290/G0291 are new codes for 2003 specifically for drug eluting stents, but these codes were intended for only the HOPPS setting (Hospital Outpatient Prospective Payment System). 9. Facility Payment for Extracorporeal Shock Wave Therapy Q: How is pricing assigned for the facility and technical components for these procedures (HCPCS codes 0020T and G0279)? A: These services are not designated as procedures payable in an ASC. Whenever any of these services are performed in an ambulatory surgical center, only the physician's services can be billed, and this is paid at a nonfacility rate.     10. Injection Procedures during Cardiac Catheterizations Q: Are CPT codes 93539-93556 intended to be used per session or per vessel/structure injected? A: The carrier will interpret and edit for these codes as per session. Should the beneficiary require a return to the catheterization lab the same date of service, then these procedures would be appropriately billed again with modifier 76 appended. A provider may also append the 22 modifier in those cases the provider feels were unusually long or complicated. The latter would require submission of the operative report and modifier 22 explanation form. 11. Evaluation and Management Visit prior to Screening Colonoscopy Q: Can a provider bill an E&M visit if a beneficiary is referred for a screening colonoscopy? A: A provider preparing to perform a screening colonoscopy cannot also bill for a pre-procedure visit to determine the suitability of the patient for the colonoscopy. These E/M services, to include consultations, are not separately payable. While the law specifically provides for a screening colonoscopy, it does not also specifically provide for a separate screening visit prior to the procedure. Although no separate payment can be made for these visits currently, the fee schedule payment for all procedures, including colonoscopy, contains payment for the usual pre-procedure work associated with it. This reflects the principle that each procedure has an evaluative component. 12. Index of Payable Diagnoses per CPT Code Q: I'd like to know where to find a website that will tell me, when I put in a procedure code, what diagnosis codes are approved for payment thru CMS. All I find is a list of procedures, not one I can input into a database and get results from that. A: There are certain diagnosis codes that may support medical necessity for certain procedures. These may be listed in the local medical review policies as applicable. Please note it is not enough to link a procedure code to a correct/payable ICD-9code. The condition must be present for the procedure to be paid. Related Link: http://www.cignamedicare.com/partb/lmrp/index.html

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Nasal Mist Flu Vaccine

Article Title	Nasal Mist Flu Vaccine
Article Publication Date	08/15/2003
Article Beginning Effective Date	08/15/2003
Article Text	On June 17, 2003, the FDA approved FluMist, a nasally administered influenza vaccine. It is the first live virus influenza vaccine approved in the U.S. FluMist (Influenza Virus Vaccine Live, Intranasal) is approved to prevent influenza illness due to influenza A and B viruses in healthy children and adolescents, ages 5-17 years, and healthy adults, ages 18-49. Children 5-8 years old need two doses at least 6 weeks apart in their first year of influenza vaccination with FluMist, and individuals 9-49 years old need one dose. When billing for this service, providers should use CPT code 90660 (influenza virus vaccine, live, for intranasal use). The intranasal administration is not separately payable. Upon receipt of each claim, this Carrier will request documentation outlining the rationale as to why this modality was chosen over the injectable form.
Coverage Topic	Flu Shot

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Payment Denial for Medicare Services furnished to Alien Beneficiaries Who are Not Lawfully Present in the United States

THE FINAL RULE IMPLEMENTING THE CREATION OF A MEDICARE EXEMPTION FROM THE PROHIBITION ON ELIGIBILITY FOR QUALIFIED ALIEN BENEFICIARIES WHO ARE LAWFULLY PRESENT IN THE UNITED STATES HAS NOT YET BEEN FINALIZED. AS A RESULT, THERE MAY BE CHANGES MADE TO THIS INSTRUCTION IF THE FINAL RULE IS REVISED.

I. GENERAL INFORMATION

A. Background:
Section 401 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) prohibited aliens who are not "qualified aliens" from receiving Federal public benefits including Medicare. The term "qualified alien" is defined to include six groups of aliens as follows:

1. aliens who are lawfully admitted for permanent residence under the Immigration and Nationality Act (Act);
2. aliens who are granted asylum under section 208 of the Act;
3. refugees admitted into the United States under section 207 of the Act;
4. aliens who are paroled into the United States under section 212(d)(5) of the Act for a period of at least 1 year;
5. aliens whose deportation is being withheld under section 243(h) of the Act; or
6. aliens who are granted conditional entry pursuant to section 203(a)(7) of the Act as in effect prior to April 1, 1980.

Two groups of qualified aliens were added to the statute after the original enactment of the restriction in the 1996 Welfare Reform statute. These groups are certain Cuban and Haitian entrants to the United States and certain "battered aliens."

Under the terms of the PRWORA, non-qualified aliens could not receive Medicare benefits.

Section 5561 of the Balanced Budget Act of 1997 (BBA) amended section 401 of the PRWORA to create a Medicare exemption to the prohibition on eligibility for non-qualified alien beneficiaries, who are lawfully present in the United States and who meet certain other conditions.

Under the provisions of the final rule (the documentation number will be issued at publication), payment may be made for services furnished to an alien who is lawfully present in the United States (and, provided that with respect to benefits payable under Part A of Title XVIII of the Social Security Act [42 U.S.C. 1395c et seq.], who was authorized to be employed with respect to any wages attributable to employment which are counted for purposes of eligibility for Medicare benefits). The definition for "lawfully present in the United States" is found at 8 CFR 103.12.

B. Policy:

Payment for Medicare Benefits
No payments will be made for Medicare services furnished to an alien beneficiary who is not lawfully present in the United States.

Implementation of Payment Policy

1. Common Working File (CWF)

The CWF must establish an auxiliary file based on information from the Enrollment Data Base from the Social Security Administration in order to appropriately edit the claims specifically associated with alien beneficiaries.

2. Carriers

Carriers will deny claims for items and services, based on dates of service, when rejected by CWF.

Carriers will use reason code 30, "Payment adjusted because the patient has not met the required eligibility, spend down, waiting or residency requirements."

When CWF rejects a claim, carriers will issue an MSN Message 5.7, "Medicare payment may not be made for the item or service because, on the date of service, you were not lawfully present in the United States."

MSN Message 5.7 "Medicare no puede pagar por este articulo o servicio porque, en la fecha en que lo recibió, usted no estaba legalmente en los Estados Unidos."

Appeals

A party to a claim denied in whole or in part under this policy may appeal the initial determination on the basis that the beneficiary was lawfully present in the United States on the date of service.

[EM 2003-0733 / CR 2825]

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Third Clarification of Medicare Policy Regarding the Implementation of the Ambulance Fee Schedule

During the implementation of the Ambulance Fee Schedule, issues concerning the interpretation of Medicare policy have arisen which require clarification.

The following clarifications, organized by category, reflect Medicare's policy regarding the implementation of the Ambulance Fee Schedule

Issues Addressed in this PM:

    a. Ambulance Fee Schedule Appeals

    b. Inherent Reasonable (IR) Adjustments

    c. Supplier Requests to Change Billing Methods During the Transition Period

    d. Advance Beneficiary Notice (ABN) Requirements

    e. Physician Certification Statement (PCS) Requirements

    f. Billing for Air Mileage

    g. Unsuccessful Advanced Life Support (ALS) Interventions

    h. ALS Assessment and Definition of "Emergency"

    i. Mandated ALS Response

    j. Intra-facility Transports

    k. Physician Services Provided During an Ambulance Transport

    l. Billing the Beneficiary for Non-covered Services

a. Ambulance Fee Schedule Appeals

The ambulance final rule published on February 27, 2002, established a fee schedule for the payment of ambulance services under the Medicare program, thereby implementing §1834(l) of the Social Security Act.  The Ambulance Fee Schedule is effective for claims with dates of service on or after April 1, 2002.  The final rule established a 5-year transition period, during which time payment will be based on a blended amount, based in part on the Ambulance Fee Schedule and in part on reasonable cost or reasonable charge, as applicable.

In accordance with §1834(l)(5) of the Social Security Act and 42 CFR §414.625, ambulance providers/suppliers may not appeal the fee schedule amounts.

 b. Inherent Reasonable (IR) Adjustments

The final rule implementing inherent reasonable (IR) adjustments to Medicare payment allowances was published in the Federal Register on December 13, 2002 (67 FR 76684).  The criteria for applying IR, specified in the final rule, includes a threshold of 15 percent that must be met before IR adjustments may be made.  That is, if a payment allowance is determined to be either deficient or excessive by an amount that is less than 15 percent, then no IR adjustment may be made.  Prospective payment systems, including the Ambulance Fee Schedule, are exempt from IR.  Therefore, IR applies only to the reasonable charge portion of the blended payment for ambulance services during the transition period. 

The CMS has not yet developed contractor processes for applying IR.  Until these processes are in place, contractors may not make any IR adjustments.  Therefore, carriers that receive requests for IR adjustments to the reasonable charge portion of the blended payment for ambulance services may not make any such adjustments until CMS issues further guidance on how to implement IR. Carriers that receive requests for IR adjustments to the Ambulance Fee Schedule portion of the blended payment must deny any such requests.   

c. Supplier Requests to Change Billing Methods During the Transition Period

A previous PM instructed Medicare carriers to ensure that all suppliers elect a single billing method by March 31, 2002.  In the absence of any election, carriers were required to convert suppliers using multiple billing methods to billing Method 2.  During the transition period, April 1, 2002 through December 31, 2005, a supplier may not change its billing method.  Carriers must deny any such requests from a supplier.  Effective with the full implementation of the Ambulance Fee Schedule beginning January 1, 2006, all ambulance suppliers will be converted to billing Method 2.

d.   Advance Beneficiary Notice (ABN) Requirements

    i. ABN Requirements for Non-Emergency Transports

The ABN (form CMS-R-131) is a written notice a physician or provider/supplier gives to a Medicare beneficiary before items or services are furnished when the physician or provider/supplier believes that Medicare probably or certainly will not pay for some or all of the items or services on the basis of certain Medicare statutory exclusions.  See PM AB-02-168 and AB-02-114 for more information concerning ABN and beneficiary limitation of liability issues. 

 An ABN is rarely used for ambulance services, and may only be issued for non-emergency transports.  An ABN may not be used when a beneficiary is under great duress.  A beneficiary is considered to be under great duress when his or her medical condition requires emergency care.  Intermediaries and carriers should use the following guidelines to determine when it is appropriate for an ambulance provider/supplier to issue an ABN for ambulance services. 

An ABN may be needed and may be used for non-emergency transports in the following situations:

a. A transport by air ambulance when the transporting entity has a reasonable basis to believe that the transport can be done safely and effectively by ground ambulance transportation.

b. A level of care downgrade, e.g., from ALS-2 to ALS-1, or from ALS to Basic Life Support (BLS), when the transport at the lower level of care is a covered transport.

An ABN is not needed, and should not be used, in the following situations:

a. Any denial where the patient could be transported safely by other means (these are denials under §1861(s)(7) of the Social Security Act (the Act)).

b. Any denial that is based on not meeting an origin or destination requirement (these denials are based on 42 CFR 410.40 and generally also constitute §1861(s)(7) denials).

c. A denial for mileage that is beyond the nearest appropriate facility (for the same reason as "b" above).

d. A denial where the PCS or accepted alternative (e.g., certified mail) is not obtained (for the same reason as "b" above).

e. A convenience discharge, e.g., where the patient is an inpatient at one hospital that can care for their needs, but wants to be transferred to a second hospital to be closer to family (for the same reason as "b" above).

The Notice of Exclusions from Medicare Benefits (NEMB, form CMS-20007) is an optional form that CMS developed to assist suppliers and providers in informing beneficiaries that the services they are receiving are excluded from Medicare benefits.  When an ABN is not appropriate to use because medical necessity is not the basis for the expected denial, an NEMB may be used. Ambulance providers/suppliers may develop their own process to communicate to beneficiaries that they will be billed for excluded services, for which the ABN is not appropriate.

The NEMB form CMS-20007 is available in English and Spanish online and can be accessed at the CMS Beneficiary Notices Initiative Web page at http://www.cms.hhs.gov/medicare/bni/.

In the case of the denials listed above for which an ABN is not appropriate, on the NEMB, check Box #1 and write the relevant reason in the "Medicare will not pay for" space (above check Box #1), for example: "ambulance transports that do not meet an origin or destination requirement" or "ambulance transports where the patient could be transported safely by other means" or "personal convenience transports

The following table summarizes situations when an ABN is applicable regarding ambulance services:

Situation	Statutory Provision	ABN Applicable	Limitation On Liability Applicable	Responsible for Payment
Other means of transportation not contraindicated	1861(s)(7) - Benefit Category	NO. An NEMB may be used.	NO	BENEFICIARY
Air to Ground Downcoding	1862(a)(1)(A) Reasonable & Necessary	YES **	YES	SUPPLIER/PROVIDER or BENEFICIARY if ABN is signed
ALS to BLS Downcoding	1862(a)(1)(A) Reasonable & Necessary	YES**	YES	SUPPLIER/PROVIDER or BENEFICIARY if ABN is signed
Mileage Partial Denial	1861(s)(7) - Benefit Category	NO. An NEMB may be used.	NO	BENEFICIARY

**Indicates that an ABN is applicable.  However, if it is an emergency transport, ABNs cannot be used, since beneficiaries are considered under great duress in such situations. (See PM-AB-02-168, section I.2.B.2.).  

      ii.   ABN Requirements for International Flights

Absent the rare circumstance of coverage of an ambulance service under §1814(f) of the Act, services outside the United States furnished to a Medicare beneficiary are statutorily excluded from Medicare coverage under §1862(a)(4) of the Act.  Thus, when the point of pickup is outside the United States, including a point of pickup outside of the U.S. territories, then the transport from the point of pickup to the nearest U.S. point of entry is statutorily excluded.  The use of an ABN is not indicated but the beneficiary should be informed that Medicare will not pay for the international portion of the flight.  An NEMB may be used, in which case, on the NEMB, check Box #2 and the sixth box in the left column ("Health care received outside of the USA") and write the relevant reason in the "Medicare will not pay for" space (above check Box #1), for example: "ambulance transports outside of the USA."  If the beneficiary (or his/her representative) desires a formal Medicare determination on a claim for a transport originating outside the U.S., then the transporting entity must file a claim to Medicare.

Following the international portion of a flight, if the beneficiary is then transported from the nearest point of entry by ambulance, including the same aircraft used to transport the beneficiary on the international flight, then standard Medicare rules apply.  If the beneficiary is transported from the nearest point of entry to the nearest appropriate facility, then, assuming all other Medicare rules are met, the transport would be covered and payable.  If the transporting entity has a reasonable basis to believe that the domestic portion of a non-emergency flight would not be covered because it is not reasonable and necessary under Medicare rules, then use of an ABN is indicated for non-emergency ambulance transports.

    a. PCS Requirements

        i. PCS Requirements for Emergency Transports

The regulations governing PCS requirements are specified at 42 CFR §410.40(d).  As stated in previously issued instructions, a PCS is not required if the transport is an emergency transport.  This instruction applies to providers submitting ambulance claims to intermediaries as well as suppliers submitting ambulance claims to carriers.  In accordance with PM AB-02-130, an emergency response is defined as a BLS or ALS-1 level of service provided in immediate response to a 911 call or the equivalent.  The patient's diagnosis, and whether the transport is documented as an "emergency" due to the patient's condition, is not relevant to this determination.  See item h. for more information concerning the Medicare definition of "emergency."

        ii. PCS Requirements for Repetitive Ambulance Services

The regulations governing PCS requirements for repetitive, scheduled, non-emergency ambulance services are specified at 42 CFR §410.40(d)(2).  A repetitive ambulance service is defined as medically necessary ambulance transportation that is furnished three or more times during a 10-day period or at least once per week for at least three weeks.  Dialysis and respiratory therapy are types of treatments for which repetitive ambulance services are often necessary.  However, the requirement for submitting the PCS form for repetitive, scheduled, non-emergency ambulance services is based on the quantitative standard (three or more times during a ten-day period or at least once per week for at least three weeks).  Similarly, regularly scheduled ambulance services for follow-up visits, whether routine or unexpected, are not "repetitive" for purposes of this requirement unless one of the quantitative standards is met.  PCS requirements for other types of ambulance transports are specified in PM AB-03-007.

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