March 2004 Part B Medicare Bulletin
Table of Contents
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NEW! Contents of the Part B Medicare Bulletin CD-ROM
- 2004 ASC HCPCS Additions, Deletions and Master Listing
- Coding Change for Ventricular Assist Devices (VADs) for Beneficiaries in a Medicare + Choice (M+C) Plan
- Coding, Testing, and Implementation Phases of CR 2631 for Jurisdiction - Revision to CR 2912
- Common Submitter Testing Problems and Guidance
- Correct Coding Initiative (CCI) Edits, Version 10.1, Effective April 1, 2004
- Correction to January 2004 Annual Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
- Criteria for Using the CB Modifier
- Emergency Correction to HCPCS Codes for Low Osmolar Contrast Material
- Emergency Revised 2004 Update of the DMEPOS and Clinical Laboratory Fee Schedules
- Laboratory Services from Independent Labs
- ListServ Messages
- Medlearn Matters Launch
- Medicare Review Frequently Asked Questions
- New Enrollee Rights, New Provider Responsibilities In M+C Program
- Part B Not Otherwise Classified Drug Fee Schedule
- Part B Provider Manual - Important Changes
- Reminder Notice of the Implementation of the Ambulance Transition Schedule
- Renewed Moratorium on Outpatient Rehabilitation Therapy Caps
- Revised American National Standards Institute X12N 837 Professional Health Care Claim Companion Document
- Treatment of Certain Dental Claims as a Result of the Medicare Prescription Drug Improvement, and Modernization Act of 2003
- Overpayment Refunds
Part B Not Otherwise Classified Drug Fee Schedule
The most current version of this document is available on the Part B Fee Schedule Index. If you need a copy of the document as it was originally published, please refer to the PDF copy of this Medicare Bulletin.
Top2004 ASC HCPCS Additions, Deletions and Master Listing
The most current version of this document is available on the Part B Fee Schedule Index. If you need a copy of the document as it was originally published, please refer to the PDF copy of this Medicare Bulletin.
Coding Change for Ventricular Assist Devices (VADs) for Beneficiaries in an Medicare+Choice (M+C) Plan
CMS is correcting the CPT code so M+C providers can be appropriately paid fee for services directly related to the implantation of a ventricular assist device for the expanded indication (destination therapy) as outlined in Pub. 100-03, Medicare National Coverage Determination (NCD) Manual, Section 20.9.
The original CPT codes in CR 2958 (33975 and 33976) should be replaced with CPT 33979. CPT 33979 correctly describes the service as implanting an intracorporeal VAD.
[EM 2004-0024/ CR 3068]
(04-0561)
Common Submitter Testing Problems and Guidance
New - 837 Inbound Claims and 835 Remittance Advice Instructions
New - Required Data Elements to the 837 Professional Health Care Claim Forms
Common Medicare Submitter Claim Testing Problems
Listed below is a list of technical and non-technical issues that Medicare contractors have encountered that are preventing submitters from moving into production on the 837 claim:
- Errors in data element NM109
Submitters are placing the Medicare provider number or UPIN in NM109 instead of the REF (secondary identification number) segment.
CMS Guidance: NM109 must contain the provider SSN or EIN. Medicare provider numbers must be submitted in the REF02 with the appropriate qualifier in REF01 (1C for Medicare provider number or 1G for the Medicare UPIN).
CIGNA Guidance: NM109 (in Provider loops where NM109 is required) must contain the provider SSN or EIN. Medicare provider numbers must be submitted in the REF02 with the appropriate qualifier in REF01 (1C for Medicare provider number or 1G for the Medicare UPIN).
-
Enveloping issues – ISA and GS segments
GS02 and 03 – invalid submitter codes and receiver codes
ISA06 and 08 – contractor codes are being omitted
Invalid lengths in the data elements contained in the envelopes
ISA15 contains the value “P” when testingCMS Guidance: ISA06 and GS02 must contain the submitter code that is agreed to or assigned by the Medicare contractor. ISA08 and GS03 must contain the Medicare contractor receiver number. The ISA and ISE are fixed length segments. The length defined in the implementation guide must be followed. When testing, the ISA15 must have a value of “T”.
CIGNA Guidance: ISA06 must contain the sender’s PB number (Stratus ID) and GS02 must contain the EMC submitter code that is assigned by the CIGNA Government Services. ISA08 and GS03 must contain the Medicare contractor receiver number (05535 for NC, 05440 for TN, and 05130 for ID). The ISA and ISE are fixed length segments. The length defined in the implementation guide must be followed. When testing, the ISA15 must have a value of “T”.
-
Invalid taxonomy codes
CMS Guidance: Although CMS does not require a taxonomy code; it must be a valid code if submitted. A list of the approved codes is posted at the Washington Publishing Company (WPC) Web site www.wpc-edi.com/codes.
-
Invalid characters in the data stream
CMS Guidance: The basic character set as defined in Appendix A of the 837 implementation guide must be used. In addition, certain characters from the extended character set may be used. Contact your Medicare contractor for a copy of their companion document for further guidance.
CIGNA Guidance: The basic character set as defined in Appendix A of the 837 implementation guide must be used. In addition, certain characters from the extended character set may be used. This is available at http://www.cignamedicare.com/HIPAA/partbcompanion4010A1.pdf
-
SBR (subscriber) data elements missing, such as date of birth and gender. SBR09 identifies the incorrect payer.
CMS Guidance: SBR09 must equal “MB” for Medicare Part B or “MA” for Medicare Part A. All required data elements in the SBR segment must be submitted per the implementation guide.
CIGNA Guidance: SBR09 must equal “MB” for Medicare Part B. All required data elements in the SBR segment must be submitted per the implementation guide. For Medigap payers, SBR05 must equal “MI”
-
Missing/out of order N3 and N4 segments
CMS Guidance: When address information is submitted, the N3 (street address information) and N4 (city, state and zip code information) must be submitted. State codes and zip codes must be valid codes based on the code source in the 837 implementation guide.
CIGNA Guidance: When address information is submitted, the N3 (street address information) and N4 (city, state and zip code information) must be submitted. State codes and zip codes must be valid codes based on the code source in the 837 implementation guide. Failure to include this information when required will result in the rejection of the claim. In addition, many of the address segments will not accept certain Punctuation. See item #4 for further guidance.
-
Submitter’s contact phone number missing
CMS Guidance: Loop 1000A is always required. The submitter’s communications number (fax, email, telephone, etc.) must be provided in this loop.
CIGNA Guidance: Loop 1000A is always required. The submitter’s communications number (fax, email, telephone, etc.) must be provided in this loop in the PER segment. The EMC Submitter ID should be included in the 1000A.NM109.
-
Sending both billing provider loop and rendering provider loop when they are the same entity.
CMS Guidance: When the billing provider is the same as the rendering provider, loop 2310B is not submitted. In this case the rendering provider is identified in loop 2000A.
CIGNA Guidance: When the billing provider is the same as the rendering provider, loop 2310B is not required to be submitted. In such cases the rendering provider is identified in loop 2010AA. This should only be true when the entity submitting claims is a solo practice.
When a group is submitting the claims, the group Medicare ID should be submitted in the 2010A.REF02—not the individual rendering provider ID. In such a case, it is necessary to submit both the 2010AA and the 2310B loops as the Group information should be in the 2010AA loop (Billing Provider Loop) and the individual provider information should be in the 2310B (Rendering Provider Loop).
-
Invalid date formats.
CMS Guidance: When dates are submitted, they must be formatted in accordance with the value in DTP02.
CIGNA Guidance: When dates are submitted, they must be formatted in accordance with the value in DTP02 according to the Implementation Guide.
837 Inbound Claims
- New electronic submitters may only test on the HIPAA format
- New electronic submitters may only go into production on the HIPAA format
- Current electronic submitters may not begin testing or submitting inbound claims for any new providers in other than the HIPAA-compliant format. (Note: If a new electronic provider believes there are extenuating circumstances and should be allowed to begin having an existing vendor submit legacy claims, contractors may approve the arrangement for a limited period of time).
Remittance Advice 835 Transaction
- New electronic remittance receivers may only test and go into production on the HIPAA format
- Any entity (e.g., clearinghouse) currently receiving electronic remittance advice may not add a new provider receiving remittance advice in a pre-HIPAA format
Required Data Element Updates to the 837 Professional Health Care Claim Forms
Listed below are the data elements on the HIPAA X12N 837 professional health care claim forms that are required, but were not previously required on the electronic Medicare Part B (National Standard Format):
Part B 837:
- Receiver name and ID
- Submitter Name
- Submitter Phone Number
- Billing Provider Tax Identification Number or Social Security Number
- Pay-To Provider Tax Identification Number or Social Security Number
- Rendering Provider Tax Identification Number or Social Security Number
- Admission Date for inpatient medical visits
[EM 2004-0009]
(04-0523)
Correct Coding Initiative (CCI) Edits, Version 10.1, Effective April 1, 2004
The next version of the Correct Coding Initiative (CCI) edits, Version 10.1, effective April 1, 2004, will be available via the CMS http://www.cms.hhs.gov/physicians/cciedits
Version 10.1 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 and Mutually Exclusive Code (MEC) Edits.
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.
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 2004-0030/ CR 2997]
(04-0560)
Correction to January 2004 Annual Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
I. GENERAL INFORMATION
A. Background:
The CMS periodically updates the lists of Healthcare Common Procedure Coding System (HCPCS) codes that are subject to the consolidated billing provision of the Home Health Prospective Payment System (HH PPS). With the exception of therapies performed by physicians, supplies incidental to physician services and supplies used in institutional settings, services appearing on this list which are submitted on claims to Medicare contractors will not be paid separately on dates when a beneficiary for whom such a service is being billed is in a home health episode (i.e., under a home health plan of care administered by a home health agency). Medicare will only directly reimburse the primary home health agencies that have opened such episodes during the episode periods. Therapies performed by physicians, supplies incidental to physician services and supplies used in institutional settings are not subject to HH consolidated billing. Medicare contractors include fiscal intermediaries (FIs), carriers, and durable medical equipment regional carriers (DMERCs).
The HH consolidated billing code lists are updated annually, to reflect the annual changes to the HCPCS code set itself. Additional updates may occur as frequently as quarterly in order to reflect the creation of temporary HCPCS codes (e.g., 'K' codes) throughout the calendar year. The new coding identified in each update describes the same services that were used to determine the applicable HH PPS payment rates. These updates do not add services or redefine categories of services subject to home health consolidated billing.
This one-time notification provides a correction to the annual HH consolidated billing update for calendar year 2004. The annual update was published on October 17, 2003 as Transmittal 8 to the Medicare Claims Processing Manual. Among other changes, this update added HCPCS codes A7525 and A7526 to the list of supply codes subject to home health consolidated billing. These codes were added in error.
This instruction is to notify providers that the following codes will not be added to home health consolidated billing enforcement:
A7525 Tracheostomy mask, each
A7526 Tracheostomy tube collar/holder, each
This correction is reflected in the HH consolidated billing master code list, which is available at the following Internet address: cms.hhs.gov/providers/hhapps/#billing.
B. Policy:
Section 1842(b)(6) of the Social Security Act requires that payment for home health services provided under a home health plan of care is made to the home health agency. This requirement is found in Medicare regulations at 42 CFR 409.100.
[EM 2004-0029 / CR 3024]
(04-0517)
Criteria for Using the CB Modifier
I.GENERAL INFORMATION
A. Background:
The purpose of this business requirement (BR) is to address two specific areas of concern related to CR 2475 Transmittal AB-02-175.
Issue/Concern #1:
Providers/suppliers often times cannot ascertain from the dialysis facility or the laboratory order that the End Stage Renal Disease (ESRD) Beneficiary is in a Skilled Nursing Facility (SNF) Part A stay. Transmittal AB-092-175 requires that with respect to the “CB” modifier “the provider or supplier may use the modifier only when it has determined that: (a) the beneficiary has ESRD entitlement, (b) the test is related to the dialysis treatment for ESRD, (c) the test is ordered by a dialysis facility, (d) the test is not included in the dialysis facility’s composite rate payment and (e) the beneficiary is in a SNF Part A stay.”
Issue/Concern #2:
Providers/suppliers need a listing of diagnostic test that are considered ESRD-related in submitting claims for services with the “CB” modifier. Transmittal AB-02-175 did not define specific diagnostic test as ESRD-related.
CMS Response to the Concerns:
The guidance issued on submission of the “CB” modifier is being modified to no longer require that the provider/supplier determine that the beneficiary is in a SNF Part A stay.
The diagnostic test considered ESRD-related are identified (see attachment).
B. Policy:
A provider or supplier may use the “CB” modifier only when it has determined that (a) the beneficiary has ESRD entitlement, (b) the test is related to the dialysis treatment for ESRD, (c) the test is ordered by a doctor providing care to patients in the dialysis facility, and (d) the test is not included in the dialysis facility’s composite rate payment.
CMS has identified the diagnostic services (see attachment) as being commonly furnished to ESRD beneficiaries and payable outside the composite rate. When billed using the “CB” modifier, these services will bypass our SNF CB edits.
Attachment 1 was not designed as an all-inclusive list of Medicare covered diagnostic services. Additional diagnostic services related to the beneficiary’s ESRD treatment/care may be considered ESRD-related. Any diagnostic services related to the beneficiary’s ESRD treatment/care must be submitted using the “CB” modifier, however, if these services are not listed in Attachment 1, supporting medical documentation may be required.
In addition, beneficiaries in a SNF Part A stay are eligible for a broad range of diagnostic services as part of the SNF Part A benefit. Physicians ordering medically necessary diagnostic test that are not directly related to the beneficiary’s ESRD dialysis treatment are subject to the SNF consolidated billing requirements. Physicians may bill the carrier for the professional component of these diagnostic tests. In most cases, however, the technical component of diagnostic tests is included in the SNF PPS rate, and is not separately billable to the carrier. Physicians should coordinate with the SNF in ordering such tests since the SNF will be responsible for reimbursing for the technical component.
Attachment to: Criteria for Using the CB Modifier
| 75790 | Visualize A-V shunt |
| 7579026 | Visualize A-V shunt |
| 75790TC | Visualize A-V shunt |
| 75893 | Venous sampling by catheter |
| 7589326 | Venous sampling by catheter |
| 75893TC | Venous sampling by catheter |
| 75894 | X-rays, transcath therapy |
| 7589426 | X-rays, transcath therapy |
| 75894TC | X-rays, transcath therapy |
| 75896 | X-rays, transcath therapy |
| 7589626 | X-rays, transcath therapy |
| 75896TC | X-rays, transcath therapy |
| 75961 | Retrieval, broken catheter |
| 7596126 | Retrieval, broken catheter |
| 75961TC | Retrieval, broken catheter |
| 75962 | Repair arterial blockage |
| 7596226 | Repair arterial blockage |
| 75962TC | Repair arterial blockage |
| 75964 | Repair artery blockage, each |
| 7596426 | Repair artery blockage, each |
| 75964TC | Repair artery blockage, each |
| 76070 | Ct bone density, axial |
| 7607026 | Ct bone density, axial |
| 76070TC | Ct bone density, axial |
| 76075 | Dexa, axial skeleton study |
| 7607526 | Dexa, axial skeleton study |
| 76075TC | Dexa, axial skeleton study |
| 76080 | X-ray exam of fistula |
| 7608026 | X-ray exam of fistula |
| 76080TC | X-ray exam of fistula |
| 78351 | Bone mineral, dual photon |
| 80048 | Basic metabolic panel |
| 80051 | Electrolyte panel |
| 80053 | Comprehen metabolic panel |
| 80069 | Renal function panel |
| 80074 | Acute hepatitis panel |
| 80076 | Hepatic function panel |
| 80410 | Calcitonin stimul panel |
| 82040 | Assay of serum albumin |
| 82108 | Assay of aluminum |
| 82306 | Assay of vitamin D |
| 82307 | Assay of vitamin D |
| 82308 | Assay of calcitonin |
| 82310 | Assay of calcium |
| 82330 | Assay of calcium |
| 82379 | Assay of carnitine |
| 82435 | Assay of blood chloride |
| 82565 | Assay of creatinine |
| 82570 | Assay of urine creatinine |
| 82570 | Assay of urine creatinine |
| 82585 | Assay of cryofibrinogen |
| 82800 | Blood pH |
| 82803 | Blood gases: pH, pO2 & pCO2 |
| 82805 | Blood gases W/02 saturation |
| 82810 | Blood gases, O2 sat only |
| 82945 | Glucose other fluid |
| 82947 | Assay, glucose, blood quant |
| 82947 | Assay, glucose, blood quant |
| 82948 | Reagent strip/blood glucose |
| 83540 | Assay of iron |
| 83550 | Iron binding test |
| 83970 | Assay of parathormone |
| 83986 | Assay of body fluid acidity |
| 83986 | Assay of body fluid acidity |
| 84100 | Assay of phosphorus |
| 84132 | Assay of serum potassium |
| 84134 | Assay of prealbumin |
| 84155 | Assay of protein |
| 84160 | Assay of serum protein |
| 84295 | Assay of serum sodium |
| 84520 | Assay of urea nitrogen |
| 84525 | Urea nitrogen semi-quant |
| 84540 | Assay of urine/urea-n |
| 84545 | Urea-N clearance test |
| 85002 | Bleeding time test |
| 85004 | Automated diff wbc count |
| 85007 | Bl smear w/diff wbc count |
| 85008 | Bl smear w/o diff wbc count |
| 85009 | Manual diff wbc count b-coat |
| 85013 | Spun microhematocrit |
| 85014 | Hematocrit |
| 85014 | Hematocrit |
| 85018 | Hemoglobin |
| 85018 | Hemoglobin |
| 85021 | Automated hemogram |
| 85022 | Automated hemogram |
| 85023 | Automated hemogram |
| 85024 | Automated hemogram |
| 85025 | Complete cbc w/auto diff wbc |
| 85027 | Complete cbc, automated |
| 85031 | Manual hemogram, cbc |
| 85032 | Manual cell count, each |
| 85041 | Automated rbc count |
| 85044 | Manual reticulocyte count |
| 85045 | Automated reticulocyte count |
| 85046 | Reticyte/hgb concentrate |
| 85048 | Automated leukocyte count |
| 85049 | Automated platelet count |
| 85345 | Coagulation time |
| 85347 | Coagulation time |
| 85348 | Coagulation time |
| 85590 | Platelet count, manual |
| 85595 | Platelet count, automated |
| 85610 | Prothrombin time |
| 85610 | Prothrombin time |
| 85611 | Prothrombin test |
| 85730 | Thromboplastin time, partial |
| 85732 | Thromboplastin time, partial |
| 86645 | CMV antibody, IgM |
| 86687 | Htlv-i antibody |
| 86688 | Htlv-ii antibody |
| 86689 | HTLV/HIV confirmatory test |
| 86692 | Hepatitis, delta agent |
| 86701 | HIV-1 |
| 86702 | HIV-2 |
| 86703 | HIV-1/HIV-2, single assay |
| 86704 | Hep b core antibody, total |
| 86705 | Hep b core antibody, igm |
| 86706 | Hep b surface antibody |
| 86707 | Hep be antibody |
| 86803 | Hepatitis c ab test |
| 86804 | Hep c ab test, confirm |
| 86812 | HLA typing, A, B, or C |
| 86813 | HLA typing, A, B, or C |
| 86816 | HLA typing, DR/DQ |
| 86817 | HLA typing, DR/DQ |
| 86900 | Blood typing, ABO |
| 86903 | Blood typing, antigen screen |
| 86904 | Blood typing, patient serum |
| 86905 | Blood typing, RBC antigens |
| 86906 | Blood typing, Rh phenotype |
| 87070 | Culture, bacteria, other |
| 87071 | Culture bacteri aerobic othr |
| 87073 | Culture bacteria anaerobic |
| 87075 | Culture bacteria anaerobic |
| 87076 | Culture anaerobe ident, each |
| 87077 | Culture aerobic identify |
| 87077 | Culture aerobic identify |
| 87081 | Culture screen only |
| 87084 | Culture of specimen by kit |
| 87086 | Urine culture/colony count |
| 87088 | Urine bacteria culture |
| 87181 | Microbe susceptible, diffuse |
| 87184 | Microbe susceptible, disk |
| 87185 | Microbe susceptible, enzyme |
| 87186 | Microbe susceptible, mic |
| 87187 | Microbe susceptible, mlc |
| 87188 | Microbe suscept, macrobroth |
| 87190 | Microbe suscept, mycobacteri |
| 87197 | Bactericidal level, serum |
| 87340 | Hepatitis b surface ag, eia |
| 87341 | Hepatitis b surface, ag, eia |
| 87350 | Hepatitis be ag, eia |
| 87380 | Hepatitis delta ag, eia |
| 87390 | Hiv-1 ag, eia |
| 87391 | Hiv-2 ag, eia |
| 87515 | Hepatitis b, dna, dir probe |
| 87516 | Hepatitis b, dna, amp probe |
| 87517 | Hepatitis b, dna, quant |
| 87520 | Hepatitis c, rna, dir probe |
| 87521 | Hepatitis c, rna, amp probe |
| 87522 | Hepatitis c, rna, quant |
| 87525 | Hepatitis g, dna, dir probe |
| 87526 | Hepatitis g, dna, amp probe |
| 87527 | Hepatitis g, dna, quant |
| 93307 | Echo exam of heart |
| 9330726 | Echo exam of heart |
| 93307TC | Echo exam of heart |
| 93308 | Echo exam of heart |
| 9330826 | Echo exam of heart |
| 93308TC | Echo exam of heart |
| 93922 | Extremity study |
| 9392226 | Extremity study |
| 93922TC | Extremity study |
| 93923 | Extremity study |
| 9392326 | Extremity study |
| 93923TC | Extremity study |
| 93925 | Lower extremity study |
| 9392526 | Lower extremity study |
| 93925TC | Lower extremity study |
| 93926 | Lower extremity study |
| 9392626 | Lower extremity study |
| 93926TC | Lower extremity study |
| 93930 | Upper extremity study |
| 9393026 | Upper extremity study |
| 93930TC | Upper extremity study |
| 93931 | Upper extremity study |
| 9393126 | Upper extremity study |
| 93931TC | Upper extremity study |
| 93965 | Extremity study |
| 9396526 | Extremity study |
| 93965TC | Extremity study |
| G0008 | Admin influenza virus vac |
| G0009 | Admin pneumococcal vaccine |
| G0010 | Admin hepatitis b vaccine |
| G0015 | Post symptom ECG tracing |
| G0202 | Screeningmammographydigital |
| G020226 | Screeningmammographydigital |
| G0202TC | Screeningmammographydigital |
| 71010 | Chest x-ray |
| 7101026 | Chest x-ray |
| 71010TC | Chest x-ray |
| 71015 | Chest x-ray |
| 7101526 | Chest x-ray |
| 71015TC | Chest x-ray |
| 71020 | Chest x-ray |
| 7102026 | Chest x-ray |
| 71020TC | Chest x-ray |
| 71021 | Chest x-ray |
| 7102126 | Chest x-ray |
| 71021TC | Chest x-ray |
| 71022 | Chest x-ray |
| 7102226 | Chest x-ray |
| 71022TC | Chest x-ray |
| 71030 | Chest x-ray |
| 7103026 | Chest x-ray |
| 71030TC | Chest x-ray |
| 71035 | Chest x-ray |
| 7103526 | Chest x-ray |
| 71035TC | Chest x-ray |
| 73120 | X-ray exam of hand |
| 75710 | Artery x-rays, arm/leg |
| 7571026 | Artery x-rays, arm/leg |
| 75710TC | Artery x-rays, arm/leg |
| 75716 | Artery x-rays, arms/legs |
| 7571626 | Artery x-rays, arms/legs |
| 75716TC | Artery x-rays, arms/legs |
| 75774 | Artery x-ray, each vessel |
| 7577426 | Artery x-ray, each vessel |
| 75774TC | Artery x-ray, each vessel |
| 75820 | Vein x-ray, arm/leg |
| 7582026 | Vein x-ray, arm/leg |
| 75820TC | Vein x-ray, arm/leg |
| 75822 | Vein x-ray, arms/legs |
| 7582226 | Vein x-ray, arms/legs |
| 75822TC | Vein x-ray, arms/legs |
| 75898 | Follow-up angiography |
| 7589826 | Follow-up angiography |
| 75898TC | Follow-up angiography |
| 75901 | Remove cva device obstruct |
| 7590126 | Remove cva device obstruct |
| 75901TC | Remove cva device obstruct |
| 75902 | Remove cva lumen obstruct |
| 7590226 | Remove cva lumen obstruct |
| 75902TC | Remove cva lumen obstruct |
| 76092 | Mammogram, screening |
| 7609226 | Mammogram, screening |
| 76092TC | Mammogram, screening |
| 76778 | Us exam kidney transplant |
| 7677826 | Us exam kidney transplant |
| 76778TC | Us exam kidney transplant |
| 78070 | Parathyroid nuclear imaging |
| 7807026 | Parathyroid nuclear imaging |
| 78070TC | Parathyroid nuclear imaging |
| 80061 | Lipid panel |
| 80061 | Lipid panel |
| 80197 | Assay of tacrolimus |
| 81000 | Urinalysis, nonauto w/scope |
| 81001 | Urinalysis, auto w/scope |
| 81002 | Urinalysis nonauto w/o scope |
| 81003 | Urinalysis, auto, w/o scope |
| 81003 | Urinalysis, auto, w/o scope |
| 81005 | Urinalysis |
| 81007 | Urine screen for bacteria |
| 81015 | Microscopic exam of urine |
| 82009 | Test for acetone/ketones |
| 82010 | Acetone assay |
| 82010 | Acetone assay |
| 82017 | Acylcarnitines, quant |
| 82247 | Bilirubin, total |
| 82248 | Bilirubin, direct |
| 82575 | Creatinine clearance test |
| 82728 | Assay of ferritin |
| 83937 | Assay of osteocalcin |
| 84300 | Assay of urine sodium |
| 84315 | Body fluid specific gravity |
| 84450 | Transferase (AST) (SGOT) |
| 84460 | Alanine amino (ALT) (SGPT) |
| 84460 | Alanine amino (ALT) (SGPT) |
| 85520 | Heparin assay |
| 85652 | Rbc sed rate, automated |
| 86590 | Streptokinase, antibody |
| 87198 | Cytomegalovirus antibody dfa |
| 87199 | Enterovirus antibody, dfa |
| 87205 | Smear, gram stain |
| 93000 | Electrocardiogram, complete |
| 93005 | Electrocardiogram, tracing |
| 93010 | Electrocardiogram report |
| 93040 | Rhythm ECG with report |
| 93041 | Rhythm ECG, tracing |
| 93042 | Rhythm ECG, report |
| 93970 | Extremity study |
| 9397026 | Extremity study |
| 93970TC | Extremity study |
| 93971 | Extremity study |
| 9397126 | Extremity study |
| 93971TC | Extremity study |
| ATP02 | Auto.Test Pane Pricing Code, 1-2 Tests |
| ATP03 | Auto.Test Pane Pricing Code, 3 Tests |
| ATP04 | Auto.Test Pane Pricing Code, 4 Tests |
| ATP05 | Auto.Test Pane Pricing Code, 5 Tests |
| ATP06 | Auto.Test Pane Pricing Code, 6 Tests |
| ATP07 | Auto.Test Pane Pricing Code, 7 Tests |
| ATP08 | Auto.Test Pane Pricing Code, 8 Tests |
| ATP09 | Auto.Test Pane Pricing Code, 9 Tests |
| ATP10 | Auto.Test Pane Pricing Code, 10 Tests |
| ATP11 | Auto.Test Pane Pricing Code, 11 Tests |
| ATP12 | Auto.Test Pane Pricing Code, 12 Tests |
| ATP16 | Auto Test Panel Pricing Code 13-16 Test |
| ATP18 | Auto Test Panel Pricing Code, 17-18 Test |
| ATP19 | Auto Test Panel Pricing Code, 19 Tests |
| ATP20 | Auto Test Panel Pricing Code, 20 Tests |
| ATP21 | Auto Test Panel Pricing Code, 21 Tests |
| ATP22 | Auto.Test Panel Pricing Code, 22+ Tests |
| G0001 | Drawing blood for specimen |
| P9615 | Urine specimen collect mult |
[EM 2004-0042 / CR 2906]
(04-0539)
2004 DIMA Drug Payment Limits - Revised 1/30/04
The most current version of this document is available on the Part B Fee Schedule Index. If you need a copy of the document as it was originally published, please refer to the PDF copy of this Medicare Bulletin.
Emergency Correction to HCPCS Codes for Low Osmolar Contrast Material
Codes A4644 thru A4646 in the HCPCS have been used to bill for low osmolar contrast material since 1994. The HCPCS Alpha-Numeric Editorial Panel decided to add a new single code A9525 for low or iso-osmolar contrast material and delete codes A4644 thru A4646 effective January 1, 2004. In accordance with §20.4 of Chapter 23 of the Medicare Claims Processing Manual (Pub 100-4), a three calendar month grace period applies to deleted codes.
It has been decided that the HCPCS coding change described above may result in incorrect coding of low osmolar contrast material and that providers should continue to use codes A4644 thru A4646 rather than new code A9525. Therefore, effective April 1, 2004, contractors should continue to process claims for low osmolar contrast material coded under A4644 thru A4646. Also, effective April 1, 2004, for claims received on or after April 1, 2004, code A9525 should be made invalid for Medicare claims processing purposes (coverage/status indicator = I). Iso-osmolar products should continue to be coded using the appropriate low osmolar code A6444, A4645, or A4646.
[EM 2004-0048 / CR 3053]
(04-0598)
Emergency Revised 2004 Update of the DMEPOS and Clinical Laboratory Fee Schedules
Section 628 of the Medicare Prescription Drug, Improvement, and Modernization Act (DIMA) of 2003 specifies that the fee update for clinical laboratory services for FY 2004 through 2008 is 0 percent. The revised fee update for clinical laboratory services requires revised fees for traveling to perform a specimen collection for either a nursing home or homebound patient. For dates of service January 1, 2004 though December 31, 2004, the payment for code P9603 (per mileage trip basis) is $.825 and for code P9604 (flat rate trip basis) is $8.25.
In accordance with section 302(c) of the DIMA, the fee schedule update factors for 2004 for DME (other than items classified as class III devices by the Food and Drug Administration), prosthetic devices, prosthetics, orthotics and surgical dressings are equal to 0 percent. In addition, the 2004 payment limits for therapeutic shoes will be frozen at the 2003 amounts.
[EM 2003-1081 / CR 3013]
(04-0592)
Medical Review Frequently Asked Questions
Web site posting January 2004
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 in the December 2003 Web site bulletin.
New issues of FAQ’s are, generally, first posted on the Web site “What’s
New” section and ListServ to registered providers. Providers may submit
questions to the Web site at http://www.cignamedicare.com/customer_service/disclaimer.html.
Providers may register for ListServ announcements at the following Web site:
http://www.cignamedicare.com/mailer/subscribe.asp.
1. Credentialed Facilities and Staff for Noninvasive Vascular Tests
Q: Have there been changes in the coverage of noninvasive vascular tests?
A: Each state’s local medical review policy requires
the facility and staff performing noninvasive vascular testing to be credentialed.
This guideline was effective for North Carolina on January 1, 2002, and
January 1, 2004, for Tennessee and Idaho. (See links to the current LMRPs
below).
We have received a variety of questions with the carrier’s responses
summarized as follows:
- “Incident to” guidelines do not apply to technologists.
Therefore, a noncredentialed technologist cannot perform these tests under
the supervision of a credentialed technologist.
- Physician supervision at the appropriate level (as directed by the MFSDB physician supervision indicator—see link below) would still be required for credentialed technologists
Medicare Physician Fee Schedule Database: http://www.cms.hhs.gov/physicians/mpfsapp/step1.asp
NC LMRP: http://www.cignamedicare.com/partb/lmrp/nc/cms_fu/2000-008-08.htm
ID LMRP: http://www.cignamedicare.com/partb/lmrp/id/cms_fu/2003-04.html
TN LMRP: http://www.cignamedicare.com/partb/lmrp/tn/cms_fu/96-07-05.html
2. Lipid Testing
Q: How often can lipid testing be done? What about measuring the direct LDL?
A: Previously, there were local medical review policies for lipid testing, but these were retired in deference to the implementation of a national coverage determination by CMS that can be viewed at the following link:
http://cms.gov/mcd/viewncd.asp?ncd_id=40-12&ncd_version=7&show=all
The above addresses indications for performing and frequency of testing. Deviating from these guidelines would need to be supported by clinical indication(s) as documented in the medical record. Providers have inquired about separately billing for a direct LDL beyond the calculated LDL included in a lipid profile (as the latter can be an inaccurate value if the triglycerides are high). If the patient’s treatment will be impacted by these results (i.e. by additional dietary or pharmacological therapy) then it is acceptable to separately bill a direct LDL with modifier 59 in addition to the lipid panel. There is no set guideline for a triglyceride level that should be followed with a direct LDL measurement. Testing should be driven by medical reasonableness and necessity rather than an institutional protocol level for triglycerides.
3. PA’s and NP’s Performing “Incident To” in SNF/ NF
Q: How does CIGNA audit records for evaluation and management visits in nursing facilities (skilled or otherwise)?
A: CMS stipulates that “incident to” is not
covered in an inpatient setting. Therefore, if claims reviewed find that
nonphysician practitioners (i.e. physician assistants, nurse practitioners,
etc.) perform these visits and not the physician whose provider number the
service is being billed under, the service will be denied. The nonphysician
practitioners should bill their inpatient visits under their own provider
numbers.
4. Separately Billable Arthroscopic Knee Surgeries
Q: What is the status of codes G0289 and 29877 in relation to
other arthroscopic knee procedures?
A: CPT code 29877 is arthroscopic debridement/shaving of articular cartilage (chondroplasty) which is a component of more comprehensive procedures such as 29881 (arthroscopic medial or lateral meniscectomy) and 29883 (arthroscopic repair of medial and lateral meniscus). This code has been through multiple revisions as far as NCCI rebundling edits. Furthermore, there has been the addition of the HCPCS code G0289 (arthroscopy of knee for removal of loose or foreign body, chondroplasty at the time of other surgical knee arthroscopy in a different compartment of the same knee) effective March 02, 2003. Presently, code 29877 may be separately billed if performed in a different compartment of the same knee (as also being treated with, for example 29881 or 29883) or in the contralateral knee for dates of service prior to March 01, 2003. For dates of service after March 01, 2003, providers should use G0289; but providers should not use 29877 or G0289 for chondroplasties done in the same compartments as more comprehensive procedures. For example, Medical Review has seen claims for 29877 after March 01, 2003, denied as component to the also performed 29883 only to be subsequently refiled and paid as G0289. On inquiry, it has been found that the chondroplasty was done in a compartment of the same knee also treated by medial and lateral meniscus repair. The manner in which the charges were resubmitted represents incorrect use of code G0289. In summary, 29877 and G0289 are to be used in addition to comprehensive procedures for arthroscopic procedures performed in either a different compartment of the same knee or for a compartment treated in the contralateral knee.
5. Cryotherapy for Acne (CPT code 17340)
Q: Are there coverage guidelines for this service?
A: Even though this code is an active/payable code according to the Medicare Physician Fee Schedule Data Base, the service might be performed for cosmetic reasons which would exclude it as a Medicare benefit. In other words, unless the acne poses a threat to health or creates a functional impairment, the service to treat the acne would be considered cosmetic and not payable. Claims for this service may be developed for medical review. If the treatment is done for cosmetic purposes, providers could append modifier –GY to facilitate processing.
NC LMRP: http://www.cignamedicare.com/partb/lmrp/nc/cms_fu/96-001-06.html
TN LMRP:
http://www.cignamedicare.com/partb/lmrp/tn/cms_fu/96-10-06.html
ID LMRP: http://www.cignamedicare.com/partb/lmrp/id/cms_fu/96-104.html
6. Face-to-Face time Required in E&M Visits
Q: Can an evaluation and management visit be billed without
the provider seeing the patient?
A: Face-to-face time is an inherent component to evaluation
and management visits. Even though some E&M codes require only two of
three components for the level of service billed, this does not remove the
requirement that patient contact by the billing provider must be made and
documented. For example, CIGNA Government Services has seen instances where the provider
billing an E&M visit (i.e. 99232-subsequent hospital
care) reviewed only the hospital record then summarized a history of present
illness and rendered complex decision-making via new or revised orders without
ever seeing the patient. The components of E&M codes and, subsequently,
the level of service billed require the billing provider’s performance
of these components by way of his or her direct contact with the patient.
Services performed by the staff of a hospital cannot be counted towards
the level of service billed by the physician. This guideline would not be
limited to subsequent hospital visits but would also extend to inpatient
consult visits, nursing facility visits, etc.
7. Hyperbaric Oxygen Used for Treatment Wounds
Q: Is HBO covered for wound care?
A: The national coverage decision for Hyperbaric Oxygen Therapy was expanded effective April 1, 2003, to allow treatment of diabetic wounds of the lower extremities provided the following conditions are met:
· Patient has type I or II diabetes
· Patient has a lower extremity wound due to diabetes
· The wound is classified as Wagner grade III or higher
· Patient has failed an adequate course of standard wound therapy
(i.e. patient does not demonstrate any measurable signs of healing for at
least 30 days with standard wound therapy).
The NCD can be seen at the following link:
http://cms.gov/mcd/viewncd.asp?ncd_id=35-10&ncd_version=8&show=all
The NCD further defines “standard wound care” and stipulates how long HBO therapy could be covered. Specifically, wounds must be evaluated at least every 30 days for measurable signs of healing. If none have been demonstrated within any 30-day period, then ongoing HBO therapy would no longer be covered.
CIGNA Government Services would review and expect to find medical record documentation in accordance with this NCD. Providers using HBO for this indication should include diagnoses for both diabetes and the wound to facilitate claims processing.
8. Initial Hospital Visits
Q: Does the initial hospital visit have to be done the date of admission?
A: The initial hospital visit should be billed the date the service was delivered. We have seen some instances when providers billed initial visits for the date of admission but did not actually see the patient till the next day— for which they also billed a subsequent hospital visit. Providers are cautioned to avoid this error which can result in an overpayment and recoupment.
9. Manuals on the CMS Web Site
Q: How have these changed?
A: Effective October 2003, CMS reduced over 40,000 pages
of hard-copy instructions from multiple manuals to approximately a single
5000 page manual system entitled IOM for “Internet Only Manuals.”
The Internet Only Manual system can be accessed through the following link:
http://www.cms.hhs.gov/manuals/.
The new system is organized according to functional area (i.e. Medicare Claims Processing, Medicare Benefit Policy, etc.) versus per user (such as carrier or intermediary). See the index of functional areas at the attached link:
http://cms.gov/manuals/cmsindex.asp.
Please note these instructions supercede those previously published in the paper-based manuals, but can be revised with new transmittal releases.
10. G0127 vs. 11719-11721
Q: How should a provider determine which code to bill?
A: The attached link connects to an article previously
published foot care:
http://www.cignamedicare.com/partb/bltin/all/01bltin/01_1/tn/b0101tn04b.asp.
The following table includes the same information but formatted differently to facilitate code selection.
| Code | Nail Pathology |
Systemic Condition(s)? (*) |
# of Nails | Symptoms Required? |
| G0127 | Dystrophic | Yes | any # | No |
| 11719 | Non-dystrophic | No | any # | No |
| 11720 | Dystrophic | May or may not be present |
1-5 nails | Yes (**) |
| 11721 | Dystrophic | May or may not be present |
6 or more | Yes (**) |
*requires documentation of class findings if systemic condition(s) present
**symptoms of a “sick foot” as manifested by 1)marked limitation
of ambulation, infected toenail plate (for an ambulatory patient) or 2)
pain or secondary infection pain, or secondary infection resulting from
the thickening and dystrophy of the resulting from the thickening and dystrophy
of the infected toenail plate (in the nonambulatory patient)
(04-0543)
New Enrollee Rights, New Provider Responsibilities In M+C Program
Introduction
Beginning on January 1, 2004, enrollees of Medicare+Choice (M+C) plans will have the right to an expedited review by a Quality Improvement Organization (QIO) when they disagree with their M+C plan’s decision that Medicare coverage of their services from a skilled nursing facility (SNF), home health agency (HHA), or comprehensive outpatient rehabilitation facility (CORF) should end. This new right stems originally from the Grijalva lawsuit and was established in regulations in a final rule published on April 4, 2003 (68 FR 16652). It is similar to the longstanding right of a Medicare beneficiary to request a QIO review of a discharge from an inpatient hospital.
What is "Grijalva"?
"Grijalva" is Grijalva v. Shalala - a class action lawsuit that challenged the adequacy of the Medicare managed care appeals process. The plaintiffs claimed that beneficiaries in Medicare managed care plans were not given adequate notice and appeal rights when coverage of their health care services was denied, reduced or terminated. Following extended legal negotiations -- and significant changes to appeals procedures that resolved many issues -- CMS reached a settlement agreement with plaintiffs and published a proposed rule based on that agreement in January 2001, and the final rule in April 2003.
New Regulations
Based on the provisions of the April 2003 final rule, SNFs, HHAs, and CORFs must provide an advance notice of Medicare coverage termination to M+C enrollees no later than 2 days before coverage of their services will end. If the patient does not agree that covered services should end, the enrollee may request an expedited review of the case by the QIO in that State and the enrollee’s M+C plan must furnish a detailed notice explaining why services are no longer necessary or covered. The review process generally will be completed within less than 48 hours of the enrollee’s request for a review.
The new SNF, HHA, and CORF notification and appeal requirements distribute responsibilities under the new procedures among four parties:
- The M+C organization generally is responsible for determining the discharge date and providing, upon request, a detailed explanation of termination of services. (In some cases, M+C organizations may choose to delegate these responsibilities to their contracting providers.)
- The provider is responsible for delivering the Notice of Medicare Non-Coverage (NOMNC) to all enrollees no later than 2 days before their covered services end.
- The patient/M+C enrollee (or authorized representative) is responsible for acknowledging receipt of the NOMNC and contacting the QIO (within the specified timelines) if they wish to obtain an expedited review.
- The QIO is responsible for immediately contacting the M+C organization and the provider if an enrollee requests an expedited review and making a decision on the case by no later than the day Medicare coverage is predicted to end.
Again, these new notice and appeal procedures go into effect on January 1, 2004. You should be aware that the Medicare law (section 1869(b)(1)(F) of the Social Security Act) establishes a parallel right to an expedited review for “fee-for-service” Medicare beneficiaries, and we expect to implement similar procedures for these beneficiaries later in 2004.
What Do the New SNF, HHA, and CORF Notification Requirements Mean for Providers?
Notice of Medicare Non-Coverage (NOMNC)
The NOMNC (formerly referred to as the Important Medicare Message of Non-Coverage ) is a short, straightforward notice that simply informs the patient of the date that coverage of services is going to end and describes what should be done if the patient wishes to appeal the decision or needs more information. CMS is developing a single, standardized NOMNC that is designed to make notice delivery as simple and burden-free as possible for the provider. The NOMNC essentially includes only two variable fields (i.e., patient name and last day of coverage) that the provider will have to fill in.
When to Deliver the NOMNC
Based on the M+C organization's determination of when services should end, the provider is responsible for delivering the NOMNC no later than two days before the end of coverage. If services are expected to be fewer than two days, the NOMNC should be delivered upon admission. If there is more than a 2-day span between services (e.g., in the home health setting), the NOMNC should be issued on the next to last time services are furnished. We encourage providers to work with M+C organizations so that these notices can be delivered as soon as the service termination date is known. A provider need not agree with the decision that covered services should end, but it still has a responsibility under its Medicare provider agreement to carry out this function.
How to Deliver the NOMNC
The provider must carry out "valid delivery" of the NOMNC. This means that the member (or authorized representative) must sign and date the notice to acknowledge receipt. Authorized representatives may be notified by telephone if personal delivery is not immediately available. In this case, the authorized representative must be informed of the contents of the notice, the call must be documented, and the notice must be mailed to the representative.
Expedited Review Process
If the enrollee decides to appeal the end of coverage, he or she must contact the QIO by no later noon of the day before services are to end (as indicated in the NOMNC) to request a review. The QIO will inform the M+C organization and the provider of the request for a review and the M+C organization is responsible for providing the QIO and enrollee with a detailed explanation of why coverage is ending. The M+C organization may need to present additional information needed for the QIO to make a decision. Providers should cooperate with M+C organization requests for assistance in getting needed information. Based on the expedited timeframes, the QIO decision should take place by close of business of the day coverage is to end.
Importance of Timing/Need for Flexibility
Although the regulations and accompanying CMS instructions do not require action by any of the four responsible parties until 2 days before the planned termination of covered services, we want to emphasize that whenever possible, it’s in everyone’s best interest for an M+C organization and its providers to work together to make sure that the advance termination notice is given to enrollees as early as possible. Delivery of the NOMNC by the provider as soon as it knows when the M+C organization will terminate coverage will allow the patient more time to determine if they wish to appeal. The sooner a patient contacts the QIO to ask for a review, the more time the QIO has to decide the case, meaning that a provider or M+C organization may have more time to provide required information.
We understand the challenges presented by this new process and have tried to develop a process that can accommodate the practical realities associated with these appeals. With respect to weekends, for example, many QIOs are closed on weekends (except for purposes of receiving expedited review requests), as are the administrative offices of M+C organizations and providers. Thus, to the extent possible, providers should try to deliver termination notices early enough in the week to minimize the possibility of extended liability for weekend services for either M+C enrollees or M+C organizations, depending on the QIO’s decision.
Similarly, SNF providers may want to consider how they can assist patients that wish to be discharged in the evening or on weekends in the event they lose their appeal and do not want to accumulate liability. Tasks such as ensuring that arrangements for follow-up care are in place, scheduling equipment to be delivered (if needed), and writing orders or instructions can be done in advance and, thus, facilitate a faster and more simple discharge. We strongly encourage providers to structure their notice delivery and discharge patterns to make the new process work as smoothly as possible.
We recognize that these new requirements will be a challenge--at least at first – and that there may be unforeseen complications that will need to be resolved as the process evolves. We intend to work together with all involved parties to identify problems, publicize best practices, and implement needed changes.
More Information
Further information on this process, including the NOMNC and related instructions can be found on the CMS website at www.cms.hhs.gov/healthplans/appeals. (Also, see regulations are at 42 CFR 422.624, 422.626, and 489.27 and Chapter 13 of the M+C Manual.)
[EM 2004-0018/CR3044]
(04-0488)
Part B Provider Manual – Important Changes
On October 1, 2003, the Centers for Medicare & Medicaid Services (CMS) transitioned their paper-based manual system to a Web-based system. Their new system is called the Online CMS Manual System and is located at http://www.cms.hhs.gov/Manuals.
In turn, CIGNA Government Services has developed a new Web-based Part B Provider Manual that has been updated and includes links to the new Online CMS Manual System.
CIGNA Government Services’s new Part B Provider Manual can be found at http://www.cignamedicare.com/provman/index.html. Both the old and the new versions of the Part B Provider Manual will be available on the Web site until September 30, 2004. The old Part B Provider Manual is no longer being updated. Only the new Part B Provider Manual will have the most up-to-date changes and information.
If there are discrepancies noted in the CIGNA Government Services Part B Provider Manual and the Online CMS Manual System, the Online CMS Manual System takes precedence over the CIGNA Government Services Part B Provider Manual.
Also, CIGNA Government Services will no longer mail out copies of the Part B Provider Manual. It must be obtained by visiting the CIGNA Government Services Web site or by viewing it on the Part B Medicare Bulletin CD-ROM (beginning with the Second Quarter, FY04 edition).
(04-0577)
Reminder Notice of the Implementation of the Ambulance Transition Schedule
The ambulance fee schedule is subject to a 5-year transition period as follows:
| Year | Cost/Charge Percentage | Fee Schedule Percentage |
| Year 1 (4/1/02 - 12/31/02)* | 20% | 80% |
| Year 2 (CY 2003)* | 40% | 60% |
| Year 3 (CY 2004) | 60% | 40% |
| Year 4 (CY 2005) | 80% | 20% |
| Year 5 (CY 2006 and thereafter) | 100% | 0% |
* Previous and current year percentages
The foregoing schedule signifies that, during the transition schedule, the Medicare allowed amount for ambulance services, mileage, and separately billable supplies will comprise a blended rate. The blended rate will include a portion of the fee schedule, and a portion of the provider's reasonable cost or the supplier's reasonable charge. (For providers billing ambulance services to FIs, all supplies and services rendered are considered part of the base rate and are not separately billable under the ambulance fee schedule. For Part B suppliers billing ambulance services, separately billable supplies may be billed, depending on the supplier's billing method.)
During Year 1, the fee schedule amount was comprised of only 20 percent of the blended amount and the remaining 80 percent of the blended amount was based on the provider's reasonable cost or the supplier's reasonable charge. During Year 2, the fee schedule amount was comprised of 40 percent of the blended amount and the provider's reasonable cost or the supplier's reasonable charge was comprised of the remaining 60 percent. During Year 3, the fee schedule amount will comprise 60 percent of the blended amount and the provider's reasonable cost or the supplier's reasonable charge will comprise the remaining 40 percent. During Year 4, the fee schedule amount will comprise 80 percent of the blended amount and the provider's reasonable cost or the supplier's reasonable charge will comprise the remaining 20 percent. Beginning with Year 5, i.e., for services and supplies furnished, and mileage incurred, beginning January 1, 2006, and each year thereafter, the full fee schedule comprises the entire Medicare allowed amount and no portion of the provider's reasonable cost or the supplier's reasonable charge shall be considered.
[EM 2003-0890 / CR 2834]
(04-0499)
Revised American National Standards Institute X12N 837 Professional Health Care Claim Companion Document
MEDICARE PART B
Companion Document/Trading Partner Agreement
The Health Insurance Portability and Accountability Act (HIPAA) requires that Medicare, and all other health insurance payers in the United States, comply with the EDI standards for health care as established by the Secretary of Health and Human Services. The X12N 837 implementation guides have been established as the standards of compliance for claim transactions. The implementation guides for each transaction are available electronically from the following Web site http://www.wpc-edi.com.
A companion document to the HIPAA ANSI X12N Professional 837, version 004010X098A1 Implementation Guide (IG) has been created. The use of this information is solely for the purpose of clarification. The information describes specific requirements to be used for processing the 004010X98A1 in the CIGNA Government Services system of Idaho, North Carolina, and Tennessee. The information in this document is subject to change. Changes will be made on the Companion Document on the Web site at www.cignamedicare.com. This companion document supplements, but does not contradict, any requirements in the HIPAA ANSI X12N 837, version 004010X098A1 IG. Additional companion documents and Trading Partner Agreements will be developed for use with other HIPAA standards, as they become available.
[EM 2003-1076/CRCR2900]
(04-0524)
Coding, Testing, and Implementation Phases of CR 2631 for Jurisdiction - Revision to CR 2912
CR 2912 required carriers and standard systems to make changes to the National Standard Format (NSF) in order to implement jurisdictional pricing for services paid under the Medicare Physician Fee Schedule and anesthesia services. It has been determined that requiring changes to the NSF format would cause too great an impact on providers, carriers, and standard systems to justify making the changes as the format will no longer be valid in the near future.
Providers/suppliers are being notified that no changes in the submission of claims in the NSF format will be required for jurisdictional pricing for services paid under the Medicare Physician Fee Schedule and anesthesia services.
[EM 2004-0031 / CR 3039]
(04-0575)
Treatment of Certain Dental Claims as a Result of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003
Provider Types Affected
Dentists
Provider Action Needed
Providers who submit dental claims for services provided to Medicare beneficiaries
need to be aware of the new law related to claims submissions to supplemental
or other group health insurers of Medicare beneficiaries.
STOP
As of February 8, 2004, for outpatient dental services that are not covered
by Medicare, you do not need to submit a claim to Medicare and receive a
denial if the beneficiary has group secondary or supplemental coverage.
Group health plans are prohibited from requiring such determinations as
of February 8, 2004, for such services.
CAUTION
A group health plan may continue to require such determinations in cases
involving or appearing to involve inpatient dental hospital services, or
other dental services covered by Medicare.
GO
Please amend your procedures regarding dental service claims for Medicare
patients as reflected by the new legislation. See the Additional Information
section for further illumination.
Background
Under present law, the Medicare benefit does not include coverage of most
dental services. Some insurers have required dentists to receive a claim
denial from Medicare before they will process a claim from the dentist for
a Medicare beneficiary holding coverage from that group health insurer.
Under section 950 of the Medicare Prescription Drug, Improvement, and Modernization
Act of 2003, a group health plan providing supplemental or secondary coverage
to Medicare beneficiaries cannot require dentists to obtain a claim denial
from Medicare for dental services that are not covered by Medicare before
paying the claim.
However, a claims determination, i.e., a submission of a claim to Medicare,
may be required for inpatient dental hospital services
or dental services specifically covered by Medicare. (Payment
may be made under part A for these services.)
This section of the new legislation is to be effective 60 days after enactment
of the legislation, which was enacted on December 8, 2003. Thus, this provision
is effective as of February 8, 2004.
Additional Information
For your convenience, the actual text of Section 950 of the Medicare Prescription
Drug, Improvement, and Modernization Act of 2003 reads as follows:
“Sec. 950 Treatment of Certain Dental Claims
(a) In General—Section 1862 (42 U.S.C. 1395y) is amended by adding at the end, after the subsection transferred and redesignated by section 948 (a), the following new subsection:
(k) (1) Subject to paragraph (2), a group health plan (as defined in subsection (a) (1) (A) (v)) providing supplemental or secondary coverage to individuals also entitled to services under this title shall not require a Medicare claims determination under this title for dental benefits specifically excluded under subsection (a) (12) as a condition of making a claims determination for such benefits under the group health plan.
(2) A group health plan may require a claims determination under this title in cases involving or appearing to involve inpatient dental hospital services or dental services expressly covered under this title pursuant to actions taken by the Secretary.
(b) Effective Date —The amendment made by subsection (a) shall take effect on the date that is 60 days after the date of the enactment of this Act.”
(04-0538)
Have You Been Missing Your ListServ Messages?
Have you not been getting ListServ messages from CIGNA Government Services even though you are signed up to have the latest Medicare information e-mailed directly to you?
Last October, CIGNA Government Services updated its ListServ and sent out several notices to all ListServ subscribers informing them of the changes and what they needed to do to ensure they continued to receive these important e-mails.
Since October 1, 2003, ListServ messages are being identified and distributed by specialty area(s). The categories originally defined by CIGNA Government Services for sending ListServ messages have been updated to the new specialty categories required by CMS. There are now fewer categories than before, but these categories will be strictly followed by CIGNA Government Services when sending out messages to our ListServ members. If you are currently receiving messages from us (and we send out approximately 20 each month to both our Part B and DMERC subscribers) then no action is required on your part unless you want to update your profile.
ACTION REQUIRED – If you are not currently receiving ListServ messages even though you are signed up to receive them, please follow these steps to ensure you receive these messages and updates:
1. Visit http://www.cignamedicare.com/medicare_dynamic/mailer/reminder.asp, and enter the e-mail address where you normally receive the ListServ messages. Please note: If your e-mail address has chan