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January 2004 Part B Medicare Bulletin

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HIPAA Contingency Plan - Additional Guidance from CMS

CMS (Centers for Medicare and Medicaid Services) provided the following instruction for Medicare contractors for operating under Medicare's contingency plan for HIPAA.

You will recall that on September 23, 2003, you were notified that a HIPAA Contingency Plan was enacted as a temporary measure to maintain provider cash flow and minimize operational disruption while trading partners work with Medicare to achieve full compliance.  The HIPAA compliant standard for claim and remittance advice is ANSI X12 837 (claim) and 835 (remittance advice) version 4010A1. 

This contingency plan is only for a limited time. Providers, who must continue to bill and receive non-compliant formats, must test and move into production on the HIPAA required formats as soon as possible, or risk possible cash flow problems.

This contingency plan implies that it is available for those providers who are not HIPAA compliant and are actively working to achieve full compliance.   

Effective Immediately:

CIGNA Government Services has free electronic claims software available that you may want to consider as a contingency measure to become HIPAA compliant.  For more information about this free software, contact the EDI Support Help Desk at 1.866.520.4022 or visit the website at: www.cignamedicare.com.

(04-0383)

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Payment for Ambulance Services Furnished by New Suppliers

Medicare-covered ambulance services are paid based on a fee schedule (FS) published in the February 27, 2002, issue of the Federal Register (Volume 67, Number 39) described originally in Program Memorandum (PM) AB-00-88 and further clarified in a series of subsequent PMs.  This fee schedule is phased in over a transition period during which the Medicare payment allowance is based on a blend of the supplier's reasonable charge and the new fee schedule amount.  This One-Time Notification addresses the amount to be used for a new supplier's reasonable charge for the period January 1, 2000, through March 31, 2002, and also for the reasonable charge portion of the blended rate applicable during the ambulance FS transition period.

For purposes of this One-Time Notification, a new supplier includes:

  1. An entity that established itself as an ambulance supplier after it could no longer establish a customary charge because carriers no longer profile charges;
  2. An established supplier that had never billed Medicare and began furnishing and billing for Medicare ambulance services for the first time after it could no longer establish a customary charge because carriers no longer profile charges;
  3. An established supplier that begins furnishing services in another geographic area; or
  4. An established supplier that begins furnishing a service that it did not previously provide.  For example, an ambulance supplier that formerly furnished only BLS services begins furnishing ALS services as well.

For a new supplier, the reasonable charge to be used for ambulance services furnished on or after January 1, 2000, including the reasonable charge portion of the blended transitional rate; is the lower of the supplier's submitted charge, the 50th percentile prevailing charge, and the prevailing IIC (inflation indexed charge).  The 50th percentile prevailing becomes a supplier's "default" customary charge for the purposes of calculating the supplier's reasonable charge.  Carriers must use the 50th percentile as the default customary charge for new suppliers.

The 50th percentile amounts are subject to the IIC requirements applied to payment allowances for ambulance services.  Per PM AB-00-88 (reissued as AB-01-185), carriers no longer construct customary and prevailing charge profiles from actual claims submitted to them.  Instead, carriers apply the ambulance inflation update factor to the previous year's allowances to determine current reasonable charge amounts.  Following established program claims data requirements, the new supplier's customary charge is updated on January 1 of the year following the calendar year in which the new supplier has established with the Medicare carrier charge experience dating back at least to the month of April.  Because carriers no longer profile charges, the updated customary charge is set at the prevailing IIC as indexed by inflation.  Therefore, if a supplier establishes charge experience with its Medicare carrier that dates back to April, that supplier's customary charge for that service(s) may be updated to the prevailing IIC effective for services furnished on or after the following January 1 (i.e., after approximately 9 months).  If a supplier establishes charge experience with its Medicare carrier that dates back to May, that supplier's customary charge for that service(s) may be updated to the prevailing IIC effective for services furnished on or after January 1 of the year following the subsequent January 1 (i.e., after approximately 20 months).

[EM 2003-1031 / CR 2700]

(04-0344)

 

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Bexxar Payment

This article is to describe the method of payment for tositumomab (cold antibody) and I-131 labeled tositumomab (the radiopharmaceutical) when these agents are covered by the Medicare program. Currently, this regimen is approved only for treatment of patients with CD20+ follicular, non-Hodgkins lymphoma with and without transformation, whose disease is refractory to rituximab, and has relapsed following chemotherapy. The Bexxar therapeutic regimen is administered in two separate steps: the dosimetric and the therapeutic. Each step consists of a sequential infusion of tositumomab followed by I-131 tositumomab.

The dosimetric step involves radionuclide scanning to determine the biodistribution of tositumomab. The procedure encompasses administration of radiolabeled tositumomab and whole body radionuclide scanning following administration of I-131 tositumomab. The purpose of the dosimetric dose is to determine individual pharmacokinetics and amount of radioactivity to be delivered in the therapeutic dose. Determining appropriate biodistribution involves making a qualitative comparison of isotope uptake in several organ systems between three scans taken over the seven days following the dosimetric administration of I-131 tositumomab. The therapeutic step is administered 7-14 days after the dosimetric step.

When Bexxar is administered in the hospital out-patient setting it is paid under the Hospital OPPS. Please see the intermediary instructions for appropriate billing in those situations. Whether given in the hospital setting or ambulatory setting, the 78990, 78999 and 78800 - 78803 codes are NOT to be used. Similarly, codes 79900, 79100, 79400 and 77750 are NOT to be used when billing for Bexxar treatment.

If a physician furnishes Bexxar to a Medicare beneficiary outside the hospital setting, the physician should bill using the following HCPCS codes:

  1. Dosimetric/Diagnostic regimen
    A4641 Supply of radiopharmaceutical diagnostic imaging agent, NOC
    78804 (new code, effective 01/01/2004) Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); whole body, requiring two or more days imaging
  2. Therapeutic regimen
    A9699 Supply of radiopharmaceutical therapeutic imaging agent, NOC
    79403 (new code effective 01/01/2004) Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion
  3. Dosimetric Calculation
    77300 should be used to bill for the dosimetric calculation. Only one 77300 will be paid per complete treatment course.
The radiopharmaceutical and the cold tositumomab will be paid at invoice, and the claim, if filed electronically, should have the actual invoice cost/ invoice on file stated in the narrative field. If filing on paper, the invoice should accompany the claim, with the statement invoice attached in Box 19.

The claims for the Dosimetric/Diagnostic step should be submitted on one claim, the Therapeutic on another. Only one 78804 will be paid per complete treatment course of Bexxar, regardless of the number of scans performed.

Services furnished after 7/1/03 but before 1/1/04 should be billed as above, but with G0273 instead of 78804, and G0274 instead of 79403.

(04-0367)

 

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Quarterly Update to Correct Coding Initiative (CCI) edits, Version 10.0, Effective January 1, 2004

I. GENERAL INFORMATION

The latest package of Correct Coding Initiative (CCI) edits, Version 10.0, effective January 1, 2004, will be available via the CMS Data Center (CDC). A test file will be available on or about October 31, 2003, and the final file will be available on or about November 14, 2003.

Version 10.0 will include all previous versions and updates from January 1, 1996, to the present and will be organized in two tables: Column 1/Column 2 Correct Coding Edits.

Attention: The heading “Comprehensive/Component Edits” has been changed to the heading “Column 1/ Column 2 Correct Coding Edits”. The table containing comprehensive/component edits also includes edits which do not involve a comprehensive/component relationship, but are codes that should simply not be reported together for other reasons, for example “misuse of the code”, etc. The headings have been changed to more accurately reflect the overall category of the edits within the tables and to eliminate the confusion as the result of using the term(s) “comprehensive/component”. For more detailed information, please refer to Chapter 1 – General Correct Coding Policies - Section A, Pages 1 and 2.

A. Background: The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment in Part B claims.

B. Policy: The coding policies developed are based on coding conventions defined in the American Medical Association’s CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practice and review of current coding practice.

[ EM 2003-0973/ CR2938 ]
(04-0296)

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Claims Crossover Process Transition to Consolidated Contractor

CMS has decided to streamline the claims crossover process to better serve our customers.  The claims crossover process provides for complementary insurers to receive claims payment information from Medicare contractors based on eligibility files they provide or on claims information (Medigap) that you submit as part of your claim to Medicare. 

Medicare complementary insurers (i.e., non-Medigap plans), Title XIX State Medicaid Agencies, and Medigap plans—collectively known as coordination of benefit (COB) trading partners—that are eligible to receive Medicare paid claims directly from CMS for purposes of calculating their secondary liability will no longer have to sign separate agreements with individual Medicare contractors.  Each COB trading partner will now enter into one national Coordination of Benefits Agreement (COBA) with CMS’ consolidated claims crossover contractor, the Coordination of Benefits Contractor (COBC).  Likewise, each COB trading partner will no longer need to prepare and send separate eligibility files to Medicare intermediaries or carriers nor receive numerous crossover files.

Medicare contractors will be testing the implementation of the new process over the next several months.  The expected date for the phased-approach transition of this workload to the COB Contractor is between April 2004 and October 2004.  The complementary insurer eligibility file based transfers will be the first workload in the transition. 

CMS will provide generic Medicare Summary Notice (MSN) and Remittance Advice (RA) messages for claims transmitted to the COBC for crossover purposes and we will keep you informed of the changes to the current process.  You will continue to contact the Medicare carrier Customer Service department for your questions about an individual's crossover status.

Please watch for future communication regarding this change.  

(04-0316)

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2004 Healthcare Common Procedure Coding System (HCPCS) Additions and Deletions

Below are the 2004 HCPCS Additions and Deletions. New CPT codes/modifiers are effective for dates of service January 1, 2004 and after. Deleted codes are valid until 3/31/2004.

 ADDITIONS:

UN --TWO PATIENTS SERVED
UP --THREE PATIENTS SERVED
UG --FOUR PATIENTS SERVED
UR --FIVE PATIENTS SERVED
US --SIX OR MORE PATIENTS SERVED

NEW CODES--Please refer to the 2004 HCPCS Level II for the description

A0800 J2353 Q4055 36556 37765 65780 89268
A4216 J2354 Q4075 36557 37766 65781 89272
A4217 J2505 Q4076 36555 43237 65782 89280
A9525 J2783 Q4077 36556 43238 67912 89281
A9526 J3411 0052T 36557 47140 68371 89290
A9528 J3415 0053T 36558 47141 70557 89291
A9529 J3465 0054T 36560 47142 70558 89335
A9530 J3486 0055T 36561 53500 70559 89342
A9531 J7303 0056T 36563 57425 75998 89343
A9532 J7621 0057T 36565 59070 76082 89344
A9533 J9098 0058T 36566 59072 76083 89346
A9534 J9178 0059T 36568 59074 76514 89352
G0297 J9263 0060T 36569 59076 76937 89353
G0298 J9395 0061T 36570 59897 76940 89354
G0299 L8631 01183 36571 61537 78804 89356
G0300 L8659 01958 36575 61540 79403 90655
G0302 P9051 20982 36576 61566 84156 90698
G0303 P9052 21685 36578 61567 84157 90715
G0304 P9053 22532 36580 61863 85055 90734
G0305 P9054 22533 36581 61864 85396 91110
G0306 P9055 22534 36582 61867 87269 95991
G0307 P9056 31632 36583 61868 87329 97755
G3001 P9057 31633 36584 63101 87660 99601
J0152 P9058 34805 36585 63102 88112 99602
J0215 P9059 35510 36589 63103 88361  
J0583 P9060 35512 36590 64449 89220  
J0595 Q0137 35522 36595 64517 89225  
J2001 Q0182 35525 36596 64681 89230  
J2185 Q3031 35697 36597 65780 89235  
J2280 Q4054 36555 36838 65781 89240  

DELETED CODES

A4214 G0112 J7508 Q9928 00544 61862 99554 99569
A4319 G0113 J9180 Q9929 36488 76085 99555  
A4323 G0114 Q0086 Q9930 36489 76490 99556  
A4621 G0115 Q2010 Q9931 36490 89252 99557  
A4622 G0116 Q4052 Q9932 36491 89256 99558  
A4631 G0167 Q4053 Q9933 36493 89350 99559  
A4644 G0236 Q4078 Q9934 36530 89355 99560  
A4645 G0262 Q9920 Q9935 36531 89360 99561  
A4646 G0272 Q9921 Q9936 36532 89365 99562  
A4712 G0273 Q9922 Q9937 36533 89399 99563  
A7020 G0274 Q9923 Q9938 36534 90659 99564  
A9518 J0151 Q9924 Q9939 36535 99025 99565  
G0025 J1910 Q9925 Q9940 36536 99551 99566  
G0110 J2000 Q9926 0002T 36537 99552 99567  
G0111 J2352 Q9927 0025T 47134 99553 99568  

(04-0361)

 

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Claims Processing and Payment of Incomplete Screening Colonoscopies

When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances (refer to Medicare Carriers Manual §15100B), Medicare will pay for the interrupted colonoscopy at a rate consistent with that of a flexible sigmoidoscopy as long as coverage conditions are met for the incomplete procedure.  When a covered colonoscopy is next attempted and completed, Medicare will pay for that colonoscopy according to its payment methodology for this procedure as long as coverage conditions are met.  This policy is applied to both screening and diagnostic colonoscopies.  When submitting a claim for the interrupted colonoscopy, professional providers are to suffix the colonoscopy code with a modifier of -53 to indicate that the procedure was interrupted.  When submitting a claim for the facility fee associated with this procedure, Ambulatory Surgical Centers (ASCs) are to suffix the colonoscopy code with -73 or -74 as appropriate.  Payment for covered screening colonoscopies, including that for the associated ASC facility fee when applicable, shall be consistent with payment for diagnostic colonoscopies, whether the procedure is complete or incomplete.

Medicare  expects the provider to maintain adequate information in the patient's medical record in case it is needed by the contractor to document the incomplete procedure.

[EM 2003-0732 / CR 2822]

(04-0342)

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Lung Volume Reduction Surgery (LVRS)

A. Background:  Lung Volume Reduction Surgery (LVRS) (also known as reduction pneumoplasty, lung shaving, or lung contouring) is an invasive surgical procedure to reduce the volume of a hyperinflated lung in order to allow the underlying compressed lung to expand, and thus, establish improved respiratory function.

On and after January 1, 2004, Medicare will cover LVRS under certain conditions as described in §240 of Pub. 100-03, National Coverage Determinations (NCD).

B.  Policy:  On and after January 1, 2004, Medicare will cover LVRS under the conditions described in §240 of Pub. 100-03, National Coverage Determinations (NCD).  Physicians, when submitting claims for LVRS that meet the coverage conditions noted, are to use CPT code 32491.  Carriers shall follow the procedures they have in place for establishing diagnosis codes as appropriate for covered LVRS.

In addition, Medicare will pay for professional services for CPT Code 32491 according to fee-for-service methodology for beneficiaries in a risk M+C plan, including the application of coinsurance, but excluding the application of the Part B deductible.  (Beneficiaries in a risk M+C plan are liable for the coinsurance for this service, but are considered to have already met their Part B deductible.)

Because Medicare’s fee-for-service claims processing systems automatically exclude claims for services provided for risk M+C beneficiaries, except in certain circumstances for which editing has been created (e.g., claims for services performed in clinical trials), physicians are to add the modifier KZ (new coverage not implemented by managed care) to CPT code 32491 on claims for LVRS performed on Medicare beneficiaries in a risk M+C plan.

Carriers are to pay claims for LVRS CPT Code 32491 furnished to beneficiaries enrolled in risk M+C plans as noted above until the capitation rates to M+C organizations are adjusted to include the cost of this expanded coverage and carriers receive additional instructions.  In addition, because the systems changes needed to create edits for modifier KZ will not be implemented until April 5, 2004, carriers are to hold all claims for CPT code 32491 with modifier KZ from January 1, 2004, through March 31, 2004, or until the systems changes are made.

[EM 2003-0997 / CR 2688]

(04-0297)

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Clarification of Mammography Annual Screening Examination

Medicare provides Part B coverage of screening mammography for women. Screening mammographies are radiologic procedures for early detection of breast cancer. The Balanced Budget Act of 1997 provides for annual screening mammographies for women over age 39 and waives the Part B deductible.

The purpose of this notification is to clarify the “annual” screening time frame. As stated in MCM 4601.2 & MIM 3660.10, crosswalked to IOM Pub 100-04 Section 20, providers must count 11 full months after the month the screening examination was performed. For example, if Mrs. Smith received a screening mammography examination at any time in March 2002, start counting in April 2002 and continue until 11 full months have elapsed, i.e., February 2003. The next annual mammography screening test may be done as early as March 1, 2003.

[EM 2003-1044/CR 2932]

(04-0373)

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Informing Beneficiaries About Which Laboratory Negotiated National Coverage Determination (NCD) is Associated with Their Claim Denial

Contractors, beginning January 1, 2003, were required to give notice to Medicare beneficiaries when denials are based in part or in whole on an LMRP.  Beneficiaries should know why their claims are denied, so they can decide whether to appeal those claim denials, and how to avoid such denials in the future. The above mentioned transmittal created a Medicare Summary Notice (MSN) message to be used in conjunction with existing messages. These messages inform the beneficiary that one or more LMRPs were used when the contractor was making the claim determination.  However, it does not tell the beneficiary which LMRP(s) were used. Intermediaries are  to identify the specific NCD or LMRP ID number that was used as a basis of denial of claims.  However, the negotiated clinical diagnostic laboratory NCDs were exempt from this requirement.  The clinical diagnostic laboratory edit module that implements the negotiated NCDs has been modified to include the identification number for the NCD associated with claim denials for Part B clinical diagnostic laboratory services.

By April 1, 2004, the clinical diagnostic laboratory service edit module will be changed to include the NCD number(s) of each NCD associated with the 23 negotiated clinical diagnostic laboratory service edits.  The NCD number is the manual section number associated with that NCD in the Medicare Coverage Database on the Internet at cms.hhs.gov/coverage.  The edit module will include the identification number in its response.

Effective April 1, 2004 contractors must notify beneficiaries when a lab NCD was the basis for the claim denial.

[EM 2003-0972 / CR 2936]

(04-0294)

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Update to Outpatient Therapy

Notice: This article has been revised by CMS. Click here to read the revised article.

CMS Manual System, Pub 100-4, Chapter 5, Sections 10.2 - The Financial Limitation  and 20.1 - Discipline Specific Outpatient Rehabilitation Modifiers - All Claims - have been revised. The CMS manual can be found at http://www.cms.hhs.gov/manuals/.

I.  SUMMARY OF CHANGES:  The manual is updated to include new information in §10.2 concerning the financial limitation on therapy services, including manualization of the changes in Change Request 2821, and the amount of the therapy limitation for 2004.  It adds codes 97755 and 97010; deletes codes 92601, 92602, 92603, 92604, V5362, V5363, and V5364 from the list of applicable codes.  Section 20.1 is modified to consolidate information concerning therapy modifiers that was in §10.2 and §20.1.

II.   GENERAL INFORMATION

A.  Background: 

Section 4541(a)(2) of the Balanced Budget Act (BBA) (P.L. 105-33) of 1997, which added §1834(k)(5) to the Social Security Act (the Act), 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) of an annual per beneficiary limit of $1500 for all outpatient physical therapy services (including speech-language pathology services), and a separate $1500 limit for all occupational therapy services.  The $1500 limit is based on incurred expenses and includes applicable deductible ($100) and co-insurance (20 percent).  The annual limitation does not apply to services furnished directly or under arrangement by a hospital to an outpatient, or to a hospital inpatient who is not in a covered Part A stay.  The BBA provided that the $1500 limits be indexed by the Medicare Economic Index (MEI) each year beginning in 2002.

B.  Policy: 

For the calendar year 2004, the limit for outpatient physical therapy and speech-language pathology combined is $1640; the limit for occupational therapy is $1640. 

Procedure Code Updates

HCPCS procedure codes 97755 and 97010 shall be added to the list of applicable therapy codes effective January 1, 2004. Procedure code 97010 will be bundled when billed with any therapy code.

HCPCS procedure codes 92601, 92602, 92603, 92604, V5362, V5363, V5364 will be removed from the list of applicable therapy codes effective January 1, 2004.  These are no longer applicable outpatient rehabilitation therapy codes. 

[EM 2003-1021 / CR 2973]

(04-0319)

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PIM Update

CHAPTER REVISION SECTION TITLE
35.1.1 Prepayment Edits - Adding LMRP and NCD ID Numbers to Edits

[EM 2003-0971/ CR2916 ]
(04-0295)

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Quarterly Provider Update

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

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

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

[ EM 2003-0500]
(04-0364)

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Remittance Advice Remark Code and Claim Adjustment Reason Code Update X12N 835 Health Care Remittance Advice Remark Codes

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. The 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. Traditionally, remark code changes that impact Medicare are requested by Medicare staff in conjunction with a policy change.

The complete list of remark codes is available at:

http://www.cms.hhs.gov/providers/edi/hipaadoc.asp

and

http://www.wpc-edi.com/codes/Codes.asp

The list is updated threetimes a year – in the months following X12 trimester meetings. The following list summarizes changes made from March 1, 2003, to June 30, 2003.

Code Current Narrative Medicare Initiated
N202 Additional information/explanation will be sent separately.  
N203 Missing/incomplete/invalid anesthesia time/units.  
N204 Services under review for possible pre-existing condition. Send medical records for prior 12 months.  
N205 Information provided was illegible.  
N206 The supporting documentation does not match the claim.  
N207 Missing/incomplete/invalid birth weight.  
N208 Missing/incomplete/invalid DRG code.  
N209 Missing/invalid/incomplete taxpayer identification number (TIN).  
N210 You may appeal this decision.  
N211 You may not appeal this decision.  

Modified Remark Codes

Code Current Modified Narrative Modification Date
M13 Only one initial visit is covered per specialty per medical group. (Modified 6/30/03)
M18 Certain services may be approved for home use. Neither a hospital nor a skilled nursing facility (SNF) is considered to be a patient's home. (Modified 6/30/03)
M25 Payment has been adjusted because the information furnished does not substantiate the need for this level of service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this level of service, or if you notified the patient in writing in advance that we would not pay for this level of service and he/she agreed in writing to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request a review, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her in excess of any deductible and coinsurance amounts. We will recover the reimbursement from you as an overpayment. (Modified 6/30/03)
26

Payment has been adjusted because the information furnished does not substantiate the need for this level of service. If you have collected any amount from the patient for this level of service /any amount that exceeds the limiting charge for the less extensive service, the law requires you to refund that amount to the patient within 30 days of receiving this notice.

The law permits exceptions to the refund requirement in two cases:

  • If you did not know, and could not have reasonably been expected to know, that we would not pay for this service; or
  • If you notified the patient in writing before providing the service that you believed that we were likely to deny the service, and the patient signed a statement agreeing to pay for the service

If you come within either exception, or if you believe the carrier was wrong in its determination that we do not pay for this service, you should request review of this determination within 30 days of the date of this notice. Your request for review should include any additional information necessary to support your position.

If you request review within 30 days of receiving this notice, you may delay refunding the amount to the patient until you receive the results of the review. If the review decision is favorable to you, you do not need to make any refund. If, however, the review is unfavorable, the law specifies that you must make the refund within 15 days of receiving the unfavorable review decision.

The law also permits you to request review at any time within 120 days of the date of this notice. However, a review request that is received more than 30 days after the date of this notice, does not permit you to delay making the refund. Regardless of when a review is requested, the patient will be notified that you have requested one, and will receive a copy of the determination.

The patient has received a separate notice of this denial decision. The notice advises that he/she may be entitled to a refund of any amounts paid, if you should have known that we would not pay and did not tell him/her. It also instructs the patient to contact your office if he/she does not hear anything about a refund within 30 days.

The requirements for refund are in 1842(l) of the Social Security Act and 42CFR411.408. The section specifies that physicians who knowingly and willfully fail to make appropriate refunds may be subject to civil monetary penalties and/or exclusion from the program.

Contact this office if you have any questions about this notice.

 
M60 Missing/incomplete/invalid Certificate of Medical Necessity. (Modified 6/30/03)
M86 Service denied because payment already made for some/similar procedure within set time frame. (Modified 6/30/03)
M117 Not covered unless submitted via electronic claim. (Modified 6/30/03)
M129 Missing/incomplete/invalid indicator of x-ray availability for review. (Modified 6/30/03)
M134 Performed by a facility/supplier in which the provider has a financial interest. (Modified 6/30/03)
MA01

If you do not agree with what we approved for these services, you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the review. However, in order to be eligible for a review, you must write to us within 120 days of the date of this notice, unless you have a good reason for being late.

An institutional provider, e.g., hospital, skilled nursing facility (SNF), home health agency (HHA) or hospice may appeal only if the claim involves a reasonable and necessary denial, a SNF recertified bed denial, or a home health denial because the patient was not homebound or was not in need of intermittent skilled nursing services, or a hospice care denial because the patient was not terminally ill, and either the patient or the provider is liable under Section 1879 of the Social Security Act, and the patient chooses not to appeal.

If your carrier issues telephone review decisions, a professional provider should phone the carrier’s office for a telephone review if the criteria for a telephone review are met.

 (Modified 6/30/03)
MA02

If you do not agree with this determination, you have the right to appeal. You must file a written request for reconsideration within 120 days of the date of this notice. Decisions made by a Quality Improvement Organization (QIO) must be appealed to that QIO within 60 days.

An institutional provider, e.g., hospital, skilled nursing facility (SNF), home health agency (HHA) or a hospice may appeal only if the claim involves a reasonable and necessary denial, a SNF non-certified bed denial, or a home health denial because the patient was not homebound or was not in need of intermittent skilled nursing services, or a hospice care denial because the patient was not terminally ill, and either the patient or the provider is liable under Section1879 of the Social Security Act, and the patient chooses not to appeal.

(Modified 6/30/03)
MA03

If you do not agree with the approved amounts and $100 or more is in dispute (less deductible and coinsurance), you may ask for a hearing. You must request a hearing within 6 months of the date of this notice. To meet the $100, you may combine amounts on other claims that have been denied. This includes reopened reviews if you received a revised decision. You must appeal each claim on time. At the hearing, you may present any new evidence which could affect our decision.

An institutional provider, e.g., hospital, skilled nursing facility (SNF), home health agency (HHA) or a hospice may appeal only if the claim involves a reasonable and necessary denial, a SNF noncertified bed denial, or a home health denial because the patient was not homebound or was not in need of intermittent skilled nursing services, or a hospice care denial because the patient was not terminally ill, and either the patient or the provider is liable under Section1879 of the Social Security Act, and the patient chooses not to appeal.

 (Modified 6/30/03)
MA20 Skilled nursing facility (SNF) stay not covered when care is primarily related to the use of an urethral catheter for convenience or the control of incontinence. (Modified 6/30/03)
MA24 Christian science sanitarium/skilled nursing facility (SNF) bill in the same benefit period. (Modified 6/30/03)
MA93 Non-PIP (Periodic Interim Payment) Claim. (Modified 6/30/03)
MA101 A skilled nursing facility (SNF) is responsible for payment of outside providers who furnish these services/supplies to residents. (Modified 6/30/03)
MA106 PIP (Periodic Interim Payment) claim. (Modified 6/30/03)
MA121 Missing/incomplete/invalid date the x-ray was performed. (Modified 6/30/03)
N30 Patient ineligible for this service. (Modified 6/30/03)
N32 Claim must be submitted by the provider who rendered the service. (Modified 6/30/03)
N40 Missing/incomplete/invalid x-ray. (Modified 6/30/03)
N69 PPS (Prospective Payment System) code changed by claims processing system. Insufficient visits or therapies. (Modified 6/30/03)
N71 Your unassigned claim for a drug or biological, clinical diagnostic laboratory services or ambulance service was processed as an assigned claim. You are required by law to accept assignment for these types of claims. (Modified 6/30/03)
N72 PPS (Prospective Payment System) code changed by medical reviewers. Not supported by clinical records. (Modified 6/30/03)
N100 PPS (Prospect Payment System) code corrected during adjudication. (Modified 6/30/03)
N103 Social Security records indicate that this patient was a prisoner when the service was rendered. This payer does not cover items and services furnished to an individual while they are in State or local custody under a penal authority, unless under State or local law, the individual is personally liable for the cost of his or her health care while incarcerated and the State or local government pursues such debt in the same way and with the same vigor as any other debt. (Modified 6/30/03)
N106 Payment for services furnished to skilled nursing facility (SNF) inpatients (except for excluded services) can only be made to the SNF. You must request payment from the SNF rather than the patient for this service. (Modified 6/30/03)
N107 Services furnished to skilled nursing facility (SNF) inpatients must be billed on the inpatient claim. They cannot be billed separately as outpatient services. (Modified 6/30/03)
N113 Only one initial visit is covered per physician, group practice or provider. (Modified 6/30/03)
N115 This decision was based on a local medical review policy (LMRP). An LMRP provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LMRP. (Modified 6/30/03)
N117 This service is paid only once in a patient’s lifetime. (Modified 6/30/03)
N119 This service is not paid if billed once every 28 days, and the patient has spent 5 or more consecutive days in any inpatient or skilled nursing facility (SNF) within those 28 days. (Modified 6/30/03)
N120 Payment is subject to home health prospective payment system partial episode payment adjustment. Patient was transferred/discharged/readmitted during payment episode. (Modified 6/30/03)
N121 No coverage for items or services provided by this type of practitioner for patients in a covered skilled nursing facility (SNF) stay. (Modified 6/30/03)
N177 We did not send this claim to patient’s other insurer. They have indicated no additional payment can be made.

(New Code 2/28/03)
(Modified 6/30/03)

Deactivated Remark Codes

Code Current Modified Narrative Deactivation Date
M43 Payment for this service previously issued to you or another provider by another carrier/intermediary. Deactiv. eff. 1/31/04
Refer to Reason Code 23
M48 Payment for services furnished to hospital inpatients (other than professional services of physicians) can only be made to the hospital. You must request payment from the hospital rather than the patient for this service. Deactiv. eff. 1/31/04
Refer to M97
M63 We do not pay for more than one of these on the same day. Deactiv. eff. 1/31/04
Refer to M86
M98 Begin to report the Universal Product Number on claims for items of this type. We will soon begin to deny payment for items of this type if billed without the correct UPN. Deactiv. eff.1/31/04
Refer to M99
M101 Begin to report a G1-G5 modifier with this HCPCS. We will soon begin to deny payment for this service if billed without a G1-G5 modifier. Deactiv. eff. 1/31/04
Refer to M78
M106 Information supplied does not support a break in therapy. A new capped rental period will not begin. This is the maximum approved under the fee schedule for this item or service. Deactiv. eff. 1/31/04
Refer to MA31
M140 Service not covered until after the patient’s 50th birthday, i.e., no coverage prior to the day after the 50th birthday. Deactiv. eff. 1/31/04
Refer to M82
MA11 Payment is being issued on a conditional basis. If no-fault insurance, liability insurance, Workers' Compensation, Department of Veterans Affairs, or a group health plan for employees and dependents also covers this claim, a refund may be due us. Contact us if the patient is covered by any of these sources. Deactiv. eff. 1/31/04
Refer to M32
MA78 The patient overpaid you. You must issue the patient a refund within 30 days for the difference between our allowed amount total and the amount paid by the patient. Deactiv. eff. 1/31/04
Refer to MA59
MA104 Missing/incomplete/invalid date the patient was last seen or the provider identifier of the attending physician. Deactiv. eff. 1/31/04
Refer to M128 or M57
MA124 Processed for IME only. Deactiv. eff. 1/31/04
Refer to reason code 74
MA129 This provider was not certified for this procedure on this date of service. Deactiv. eff. 1/31/04 Refer to MA120.
and reason code B7
N18 Payment based on the Medicare allowed amount. Deactiv. eff. 1/31/04 Refer to N14
N60 A valid NDC is required for payment of drug claims effective October 02. Deactiv. eff. 1/31/04
Refer to M119
N73 A skilled nursing facility is responsible for payment of outside providers who furnish these services/supplies under arrangement to its residents. Deactiv. eff. 1/31/04
Refer to MA101 or N200
N101 Additional information is needed in order to process this claim. Resubmit the claim with the identification
number of the provider where this service took place. The Medicare number of the site of service provider should be preceded with the letters "HSP" and entered into item #32 on the claim form. You may bill only one site of service provider number per claim.		 Deactiv. eff. 1/31/04
Refer to MA105
N164 Transportation to/from this destination is not covered. Deactiv. eff. 1/31/04
Refer to N157
N165 Transportation in a vehicle other than an ambulance is not covered. Deactiv. eff. 1/31/04
Refer to N158
N166 Payment denied/reduced because mileage is not covered when the patient is not in the ambulance. Deactiv. eff. 1/31/04
Refer to N159
N168 The patient must choose an option before a payment can be made for this procedure/equipment/supply/ service. Deactiv. eff. 1/31/04
Refer to N160
N169 This drug/service/supply is covered only when the associated service is covered. Deactiv. eff. 1/31/04
Refer to N161

X12 N 835 Health Care Claim Adjustment Reason Codes

The Health Care Code Maintenance Committee maintains the health care claim adjustment reason codes. The Committee meets at the beginning of each X12 trimester meeting (February, June, and October) and makes decisions about additions, modifications, and retirement of existing reason codes. The updated list is posted 3 times a year after each X12 trimester meeting at http://www.wpc-edi.com/codes/Codes.asp, and select Claim Adjustment Reason Codes from the pull down menu. All reason code changes approved in June 2003 are listed here.

Reason Code Changes (as of 6/30/03)

Code Current Narrative Notes
155 This claim is denied because the patient refused the service/procedure. New as of 6/03
38 Services not provided or authorized by designated (network/primary care) providers. Modified as of 6/03
107 Claim/service denied because the related or qualifying claim/service was not previously paid or identified on this claim. Modified as of 6/03

The following is a comprehensive list of retired reason codes.

Code Current Narrative Notes
28 Coverage not in effect at the time the service was provided. Inactive for 004010, since 6/98. Redundant to codes 26&27.
36 Balance does not exceed co-payment amount. Inactive for 003040
37 Balance does not exceed deductible. Inactive for 003040
41 Discount agreed to in Preferred Provider contract. Inactive for 003040
46 This (these) service(s) is (are) not covered. Inactive for 004010, since 6/00. Use code 96.
48 This (these) procedure(s) is (are) not covered. Inactive for 004010, since 6/00. Use code 96.
57 Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply. Inactive for 004050. Split into codes 150, 151, 152, 153 and 154.
63 Correction to a prior claim. Inactive for 003040
64 Denial reversed per medical review. Inactive for 003040
65 Procedure code was incorrect. This payment reflects the correct code. Inactive for 003040
67 Lifetime reserve days. (Handled in QTY, QTY01=LA) Inactive for 003040
68 DRG weight. (Handled in CLP12) Inactive for 003040
71 Primary payer amount. Deleted as of 6/00. Use code 23.
72 Coinsurance day. (Handled in QTY, QTY01=CD) Inactive for 003040
73 Administrative days. Inactive for 003050
77 Covered days. (Handled in QTY, QTY01=CA) Inactive for 003040
79 Cost Report days. (Handled in MIA15) Inactive for 003050
80 Outlier days. (Handled in QTY, QTY01=OU) Inactive for 003050
81 Discharges. Inactive for 003040
82 PIP days. Inactive for 003040
83 Total visits. Inactive for 003040
84 Capital Adjustment. (Handled in MIA) Inactive for 003050
86 Statutory Adjustment Inactive for 004010, since 6/98. Duplicative of code 45.
88 Adjustment amount represents collection against receivable created in prior overpayment. Inactive for 004050.
92 Claim paid in full. Inactive for 003040
93 No claim level adjustments. Inactive for 004010, since 2/99. In 004010, CAS at the claim level is optional.
98 The hospital must file the Medicare claim for this inpatient non-physician service. Inactive for 003040
99 Medicare Secondary Payer Adjustment Amount. Inactive for 003040
120 Patient is covered by a managed care plan. Inactive for 004030
123 Payer refund due to overpayment. Inactive for 004030, since 6/99. Refer to implementation guide for proper handling of reversals.
124 Payer refund amount - not our patient. Inactive for 004030, since 6/99. Refer to implementation guide for proper handling of reversals.
A3 Medicare Secondary Payer liability met. Inactive for 004010, since 6/98.
B2 Covered visits. Inactive for 003040
B3 Covered charges.
 Inactive for 003040
B19 Claim/service adjusted because of the finding of a Review Organization. Inactive for 003070
B21 The charges were reduced because the service/care was partially furnished by another physician. Inactive for 003040
D1 Claim/service denied. Level of subluxation is missing or inadequate. Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D2 Claim lacks the name, strength, or dosage of the drug furnished. Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D3 Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing. Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D4 Claim/service does not indicate the period of time for which this will be needed. Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D5 Claim/service denied. Claim lacks individual lab codes included in the test. Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D6 Claim/service denied. Claim did not include patient's medical record for the service. Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D7 Claim/service denied. Claim lacks date of patient's most recent physician visit. Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D8 Claim/service denied. Claim lacks indicator that `x-ray is available for review.' Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D9 Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used. Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D10 Claim/service denied. Completed physician financial relationship form not on file. Inactive for 003070, since 8/97. Use code 17.
D11 Claim lacks completed pacemaker registration form. Inactive for 003070, since 8/97. Use code 17.
D12 Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test. Inactive for 003070, since 8/97. Use code 17.
D13 Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest. Inactive for 003070, since 8/97. Use code 17.
D14 Claim lacks indication that plan of treatment is on file. Inactive for 003070, since 8/97. Use code 17.
D15 Claim lacks indication that service was supervised or evaluated by a physician. Inactive for 003070, since 8/97. Use code 17.

[EM 2003-1027/CR 2975]

(04-0348)

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Correct Reporting for Removal of Skin Tags

11200 Removal of skin tags; multiple fibrocutaneous tags, any area; up to and including 15 lesions

11201 each additional ten lesions (List Separately in addition to code for primary procedure)

(Use 11201 in conjunction with code 11200)

CPT 11200 represents the removal of 1-15 lesions. CPT 11200 should only be billed with 1 unit of service regardless of whether you are reporting 1 or 15 lesions. Medicare reimburses a single fee for CPT 11200, which encompasses 1-15 lesions. See example below:

Date of Service     Procedure      Units
11/12/03                11200            1

11201 should be reported on one line item, for each additional ten lesions. For example, if a physician removes 18 lesions, code 11200 should be reported on one line item with 1 unit. This represents the first 15 lesions. CPT 11201 should be billed on the second line item with 1 unit. This represents up to an additional 10 lesions. Both codes should not exceed one unit. See example below:

Date of Service      Procedure      Units
11/12/03                11200            1
11/12/03                11201            1

In situations where you are removing more than 25 skin tags, you would report code 11200 with 1 unit, and the subsequent line items should reflect code 11201 with 1 unit to represent each additional 10 lesions removed. The following claim example represents 26-35 lesion removals:

Date of Service      Procedure      Units
11/12/03                11200            1
11/12/03                11201            1
11/12/03                11201            1

(04-0327)

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Ultrasound Scans of Spine and for Injections

Data cited in the article below is state specific but this information is being published in the general release for the benefit of each states provider community.

Recent data analysis has shown the state of Tennessee exceeds the national average for utilization of CPT codes 76800 (ultrasound of spinal canal and contents), 76880 (nonvascular ultrasound of extremity), and 76942 (ultrasonic guidance for needle placement). Review of medical records found that these codes were billed for the performance of spinal scans and subsequent injections. Some of the charges were submitted incorrectly, and many of the services did not appear to be medically necessary.

CPT code 76800 is for ultrasound of the entire spinal canal, but providers have incorrectly billed this code for each area of the spine examined. Furthermore, diagnoses of sciatica, lumbago, neuritis, radiculitis, etc. fail to support the medical necessity of diagnostic ultrasounds of the spine, since ultrasound waves cannot clearly distinguish between normal and inflamed states of the area being examined.

CPT code 76880 is for non-vascular ultrasound of an extremity, and medical record reviews failed to show the medical necessity of these when performed with spinal scans.

CPT code 76942 is ultrasonic guidance for needle placement. Because of the shadow casting property of bone, ultrasound is not well suited for needle placement in facet joint and epidural injections. The standard of practice is fluoroscopic guidance rather than sonography. Medical record reviews did not find documentation to support how the ultrasonic guidance helped in determining or guiding the injection sites or contributed toward the treatment of the patient.

In conclusion, the state of Tennessee shows aberrant utilization of the above codes in relation to the performance of spinal scans and injections. There should be medical necessity for ultrasonic scans of extremities and spine (which the latter, if medically appropriate, should be billed as one number of service for code 76800). Generally, ultrasound examinations are not indicated for inflammatory conditions of the spine and nerve roots or as guidance for facet joint or epidural injections.

(04-0391)

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PECOS Implementation

On November 3, 2003, the Centers for Medicare & Medicaid Services (CMS) implemented the latest stage of the Provider Enrollment Chain and Ownership System (PECOS), CMS’ new national provider enrollment system. PECOS has been used by Medicare’s fiscal intermediaries since July 2002 and is now being used by all carriers. As a national system, PECOS will standardize the process used by carriers and will allow a one-time enrollment process for providers and suppliers. Once entered into PECOS, information will be available nationally for all carriers and additional enrollment activity will require only an update to the initial enrollment data. Therefore, the need for individuals and entities practicing in multiple states or billing multiple contractors to completely re-enroll will be eliminated. PECOS will also make updating existing information easier and eliminate the need to send duplicate information to both the local carrier and the Railroad Medicare Carrier. PECOS implementation will be completed in 2004, when the National Supplier Clearinghouse is brought online. In the near future, PECOS will enable applicants to validate and submit their enrollment data via the Internet and will facilitate enrollment between the Medicare and Medicaid programs.

PECOS will also assist Medicare as a tool to detect and fight fraud and abuse. It will improve the accuracy of enrollment data and help ensure that only qualified individuals and entities are enrolled with Medicare. When fraud or abuse is detected, PECOS will make it easier to identify other associated providers and suppliers.

In the long run, CMS expects that PECOS will greatly reduce the amount of time needed to process provider enrollment applications. In the short term, however, providers may experience longer than usual enrollment processing times as carriers get accustomed to the new system. CMS is working with carriers to make sure that any delays that occur during the PECOS implementation are minimized. If you have questions about your specific application or record, please call the Provider Enrollment department at 1.866.520.4007.

(04-0363)

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EFT Enrollment

New Authorization Agreement For Electronic Funds Transfer Application

The Authorization Agreement For Electronic Funds Transfer (Form CMS-588 [09/03]) application has been revised to include privacy act information. This will help ensure that the information provided to us will be used to authorize electronic funds transfers from our bank to yours.

When the completed EFT Authorization form is submitted to CIGNA Government Services, electronic payments will begin within 10-15 business days assuming all information is accurate and complete.

Enroll in the EFT program by using the new form available at www.cignamedicare.com/enrollment/package/eft.html and on the CMS Web site at www.cms.hhs.gov/forms/cms588.pdf. The older forms will no be longer be accepted after February 5, 2004.

Stop waiting for your check to arrive in the mail - CIGNA Government Services can deposit your claims' payment for you!

(04-0314)

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An Update on Chiropractic Reviews

The carriers Part B Medical Review departments recently met and compiled the following list as common reasons chiropractic claims are denied upon review:

To address the above areas, we are recommending the following to providers:

On subsequent visits the documentation must reflect:

(The above was excerpted from the provider manual that can be found at the following link, http://www.cignamedicare.com/provman/pm990307.html#chiroserv).

Additionally, we recommend:

Providers are reminded that failure to completely document the medical necessity of the chiropractor manual spinal manipulation(s) may result in the denial of the claim(s). Documentation must be legible and made available to Medicare upon request. Failure to do so may result in denial of claim(s).

As far as utilization of chiropractic manipulation, it is expected that the number of manipulations provided to any beneficiary in a given year would not be excessive. Providers who use this method in a significantly higher frequency than other chiropractors will be subject for review to determine medical necessity for the service frequency employed. Documentation, such as the following, can be submitted with claims in these instances:

These examples are not inclusive of all situations where additional allowance could be considered.

Finally, national policy only allows chiropractors to provide and bill for spinal manipulation, but labs and radiology groups are referencing their services to chiropractors. These are not valid orders and may result in denial of services.

(04-0398)

1st Qtr. 2004 HCPCS Drug Pricing File

Effective January 1, 2004

H = Higher

L= Lower

A= New Code

D = Discontinued Code

N = No Sources Available

Code Description Unit of Measure 95% of AWP Previous
Allowance		 *Price Change **Status ***Obsolete
 Code
90371 HEPATITIS B IG, IM Per dose 649.80 649.80      
90375 RABIES IG, IM/SC Per dose 72.85 72.85      
90376 RABIES IG, HEAT TREATED Per dose 78.11 78.11      
90385 RHO(D) IG (RHLG), MINIDOSE, IM Per dose 34.77 34.77      
90585 BACILLUS CALMETTE-GUERIN VACCINE, PERCUTANEOUS Per dose 160.13 160.13      
90632 HEPATITIS A VACCINE, ADULT IM Per dose 74.54 61.05 H    
90633 HEPATITIS A VACCINE, PED/ADOL, 2 DOSE Per dose 29.80 29.80      
90634 HEPATITUS A VACCINE, PED/ADOL, 3 DOSE Per dose 29.80 29.80      
90645 HEMOPHILUS INFLUENZA B VACCINE, HBOC, IM Per dose 24.32 25.38 L    
90675 RABIES VACCINE, IM Per dose 136.16 136.16      
90691 TYPHOID VACCINE, IM Per dose 42.00 42.00      
90700 DIPTHERIA, TETANUS TOXOIDS VACCINE, IM Per dose 22.41 22.41      
90703 TETANUS VACCINE, IM Per dose 14.37 14.37      
90704 MUMPS VACCINE, SC Per dose 19.43 19.43      
90705 MEASLES VACCINE, SC Per dose 15.03 15.03      
90706 RUBELLA VACCINE, SC Per dose 16.74 16.74      
90707 MEASLES, MUMPS AND RUBELLA VIRUS VACCINE, SC Per dose 39.04 40.71 L    
90713 POLIOVIRUS VACCINE, IPV, SC Per dose 25.71 25.71      
90716 CHICKEN POX VACCINE, SC Per dose 68.83 68.83      
90717 YELLOW FEVER VACCINE, SC Per dose 59.17 59.17      
90718 TETANUS AND DIPETHERIA TOXOIDS VACCINE > 7, IM Per dose 11.52 11.52      
90720 DIPTHERIA, TETANUS TOXOIDS, & WHOLE CELL PERTUSSIS VACCINE  & HEMOPHILUS INFLUENZA B VACCINE, IM Per dose 37.59 37.59     N
90721 DIPTHERIA, TETANUS TOXOIDS, & ACELLULAR PERTUSSIS VACCINE  & HEMOPHILUS INFLUENZA B VACCINE, IM Per dose 48.84 48.84      
90732 PNEUMOCOCCAL VACCINE Per dose 18.62 18.62      
90733 MENINGOCOCCAL VACCINE, SC Per dose 69.45 65.56 H    
90735 ENCEPHALITIS VACCINE, SC Per dose 79.76 79.76      
90740 HEPATITIS B VACCINE, DIALYSIS OR IMMUNOSUPPRESSED PATIENT, 3 DOSE IM Per dose 110.92 110.92      
90743 HEPATITIS B VACCINE, ADOL, 2 DOSE, IM Per dose 27.05 27.05      
90744 HEPATITIS B VACCINE, PED/ADOL 3 DOSE IM Per dose 27.05 27.05      
90746 HEPATITIS B VACCINE, ADULT, IM Per dose 55.46 55.46      
90747 HEPATITIS B VACCINE, DIALYSIS OR IMMUNOSUPPRESSED PATIENT 4 DOSE IM Per dose 110.92 110.92      
J0130 INJECTION ABCIXIMAB, 10 MG 10 mg 513.02 513.02      
J0150 INJECTION, ADENOSINE, 6 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE 6 mg 37.71 38.89 L    
J0151 INJECTION, ADENOSINE, 90 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE) 90 mg 229.26 223.19 H D  
J0152 INJECTION, ADENOSINE, 30 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE) 30 mg 76.42 N/A   A  
J0170 INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE Up to 1 ml 2.34 2.35 L    
J0200 INJECTION, ALATROFLOXACIN MESYLATE, 100 MG 100 mg 19.04 19.04     N
J0205 INJECTION, ALGLUCERASE, PER 10 UNITS Per 10 units 37.53 37.53      
J0207 INJECTION, AMIFOSTINE, 500 MG 500 mg 452.97 452.97      
J0210 INJECTION, METHYLDOPATE  HCL, UP TO 250 MG Up to 250 mg 11.88 11.88      
J0215 INJECTION, ALEFACEPT, 0.5 MG 0.5 MG 31.51 N/A   A  
J0256 INJECTION, ALPHA 1 - PROTEINASE INHIBITOR - HUMAN, 10 MG 10 mg 2.66 2.66   &nb