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April 2004 Part B Medicare Bulletin

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INSERT TOPICS - April 2004
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1st Update to the 2004 MPFSDB

Code Field State Par Non Par Lmt Chrg
76511 PE RVU-INC TO 1.83 TENNESSEE 98.65 93.72 107.78
NORTH CAROLINA 100.79 95.75 110.11
IDAHO 96.90 92.06 105.87
76511TC PE RVU-INC TO 1.43 TENNESSEE 49.65 47.17 54.25
NORTH CAROLINA 51.32 48.75 56.06
IDAHO 48.29 45.88 52.76
76512 PE RVU-INC TO 1.75 TENNESSEE 85.96 81.66 93.91
NORTH CAROLINA 88.01 83.61 96.15
IDAHO 84.17 79.96 91.95
76512TC PE RVU-INC TO 1.45 TENNESSEE 51.01 48.46 55.73
NORTH CAROLINA 52.71 50.07 57.58
IDAHO 49.48 47.01 54.06
76513 PE RVU-INC TO 1.84 TENNESSEE 88.99 84.54 97.22
NORTH CAROLINA 91.14 86.58 99.57
IDAHO 87.13 82.77 95.19
76513TC PE RVU-INC TO 1.54 TENNESSEE 54.03 51.33 59.03
NORTH CAROLINA 55.84 53.05 61.01
IDAHO 52.44 49.82 57.29
76516 PE RVU-INC TO 1.45 TENNESSEE 70.72 67.18 77.26
NORTH CAROLINA 72.41 68.79 79.11
IDAHO 69.29 65.83 75.70
76516TC PE RVU-INC TO 1.20 TENNESSEE 41.92 39.82 45.79
NORTH CAROLINA 43.33 41.16 47.33
IDAHO 40.72 38.68 44.48
76519 PE RVU-INC TO 1.54 TENNESSEE 73.74 70.05 80.56
NORTH CAROLINA 75.54 71.76 82.52
IDAHO 72.25 68.64 78.94
76519TC PE RVU-INC TO 1.29 TENNESSEE 44.95 42.70 49.11
NORTH CAROLINA 46.46 44.14 50.76
IDAHO 43.68 41.50 47.73
76529 PE RVU-INC TO 1.40 TENNESSEE 70.38 66.86 76.89
NORTH CAROLINA 72.02 68.42 78.68
IDAHO 68.94 65.49 75.31
76529TC PE RVU-INC TO 1.15 TENNESSEE 40.47 38.45 44.22
NORTH CAROLINA 41.82 39.73 45.69
IDAHO 39.26 37.30 42.90
89220 STATUS CODE-A TENNESSEE 13.90 13.21 15.19
NORTH CAROLINA 14.37 13.65 15.70
IDAHO 13.51 12.83 14.75
89230 STATUS CODE-A TENNESSEE 15.24 14.48 16.65
NORTH CAROLINA 15.76 14.97 17.22
IDAHO 14.83 14.09 16.20
94240 PE RVU-INC TO .70 TENNESSEE 34.60 32.87 37.80
NORTH CAROLINA 35.42 33.65 38.70
IDAHO 33.80 32.11 36.93
94240TC PE RVU-INC TO .62 TENNESSEE 21.98 20.88 24.01
NORTH CAROLINA 22.71 21.57 24.81
IDAHO 21.29 20.23 23.26
96412 WORK RVU-INC TO .17 TENNESSEE 43.31 41.14 47.31
NORTH CAROLINA 44.47 42.25 48.59
IDAHO 42.16 40.05

46.06

[EM 2004-0145/CR3128]

(04-0718)

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2004 Medicare Physician Fee Schedule ANNUAL CHANGES 

I.  GENERAL INFORMATION

Background:  Effective January 1, 2004, new payment policies under the Medicare Physician Fee Schedule will be established for billing services.

  1. Policy:
    • The fee schedule update for 2004 is 1.5 percent.  The conversion factor is $37.3374.
    • The 2004 national average anesthesia conversion factor is $17.50.
    • Section 1834(m) of the Social Security Act establishes the payment amount for the Medicare telehealth originating site facility fee for telehealth services provided from October 1, 2001, through December 31, 2002, at $20.  For telehealth services on or after January 1 of each subsequent calendar year, the telehealth originating site facility fee is increased as of the first day of the year by the percentage increased in the Medicare Economic Index (MEI) as defined in section 1842(i)(3) of the Act.  The MEI increase for 2004 is 2.9 percent.  For calendar year 2004, the payment amount for HCPCS code “Q3014, telehealth originating site facility fee” is 80 percent of the lesser of the actual charge or $21.20.
    • In those cases where the teaching anesthesiologist is involved in two concurrent anesthesia cases with residents on or after January 1, 2004, the teaching anesthesiologist may bill the usual base units and anesthesia time for the amount of time he/she is present with resident.  The anesthesiologist can bill base units if he/she is present with the resident throughout pre-and post- anesthesia care.  The anesthesiologist should use the “AA” modifier to report such cases.  The teaching anesthesiologist must document his/her involvement in cases with residents.  The documentation must be sufficient to support the payment of the fee and available for review upon request. 
    • For Independent Laboratory Billing for the Technical Component of Physician Pathology Services to Hospital Patients, section 542 of the Benefits and Improvement Act of 2000  provides that the Medicare carrier can continue to pay for the technical component (TC) of physician pathology services when an independent laboratory furnishes this service to an inpatient or outpatient of a covered hospital.  This provision had applied to TC services furnished during the 2-year period beginning on January 1, 2001.  Carriers shall continue to make payments in accordance with Transmittal B-03-001 issued in January, 2003 for 2004 and 2005.
    • For Skin Lesions, Benign, and Malignant (CPT codes 11400 & 11600 series), we have withdrawn our proposal to make the work RVUs equivalent for removal of benign and malignant skin lesions in a budget neutral manner.  We have decided to maintain the current values and request that the specialty societies resurvey the services.
    • List of physicians who can enter into private contracts is expanded to include dentists, optometrists, and podiatrists.  Previously, only physicians who were MDs and Doctors of Osteopathy could enter into private contracts with beneficiaries.
    • For Intensity Modulated Radiation Therapy (IMRT), we will use the non-physician work pool methodology to establish final practice expense RVUs for 2004 that are approximately equal to the current ones.
    • We will extend the deadline for submission of supplemental survey data for practice expense to March 1, 2004 to allow us to publish our decisions regarding survey data in the proposed rule to provide an opportunity for public comments.  The laboratory community has submitted survey data that will be addressed in next year’s Notice of Proposed Rulemaking (NPRM).
    • There is a new definition of diabetes for diabetes self-management training (DSMT) at CFR 410.141 and medical nutritional therapy.  In addition, the DSMT definition replaces the beneficiary’s eligibility criteria in the old regulation.
    • For dialysis patients seeing the doctor, we have created separate temporary codes that describe procedures or services, known as G codes, for 1 physician visit per month, 2-3 visits per month, and 4 or more visits per month, with payment increasing with the number of visits.  The aggregate payments for these services are approximately equal to current payments for CPT codes 90918 to 90921.

      We also created new G codes for the management of home dialysis patients in each of the age groups.  In addition, four new G codes for home dialysis patients who are hospitalized during the month were also created.  These codes are to be used to report daily management of home dialysis patients for the days the patient was not in the hospital.  We have provided a crosswalk from the current CPT codes to the G codes.

      Patients Other than Home Dialysis

      CPT Code Age of Patient  New G Codes Number of Visits
      90918  < 2  G0308
      G0309
      G0310

      4+
      2 to 3
      One visit
      90919 2 to 11   G0311
      G0312  
      G0313       		4+
      2 to 3
      One visit
      90920 12 to 19 G0314
      G0315  
      G0316       		4+
      2 to 3
      One visit
      90921 20 + G0317
      G0318  
      G0319      		 4+
      2 to 3
      One visit

      Home Dialysis Patients (entire month)   

                  
      No distinct CPT Codes  < 2
      2 – 11 
      12 – 19
      20 +      		 G0320
      G0320
      G0320
      G0320
                 

      Home Dialysis Patients (partial month only—per day)

      90922 < 2 G0324
      90923 2 – 11  G0325
      90924 12-19  G0326
      90925 20 + G0327
    • As in previous final rules, we have updated the list of certain services subject to the physician self-referral prohibition to address new and revised CPT and HCPCS codes. 
    • For chemotherapy administration, Section 303 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (DIMA) revises some of the Medicare physician payment policies for chemotherapy services.
      1. For chemotherapy services furnished prior to January 1, 2004, we allow CPT code 96408 (Chemotherapy administration, intravenous; push technique) to be reported only once per day even if the physician administers multiple drugs.  For services furnished on or after January 1, 2004, we will allow code 96408 to be reported more than once per day for each drug administered.
      2. Section 303 of DIMA requires the Secretary to establish work relative value units for drug administration services equal to the work relative values for a level 1 office medical visit for an established patient (CPT code 99211).  The law defines drug administration services as those services classified as of October 1, 2003, within any of the following groups:  therapeutic or diagnostic infusions (excluding chemotherapy); chemotherapy administration services; and therapeutic, prophylactic, or diagnostic injections; for which there are no work relative values units assigned and for which national relative values are assigned. CPT code 99211 is a level 1 established patient office visit with physician work relative value units of .17.  We are adding physician work relative value units of .17 to the following drug administration services:  CPT codes 90780-90781, 90782-90788, 96400, 96408-96425, 96520 and 96530.
      3. For services furnished on or after January 1, 2004, we will not allow CPT code 99211 to be billed on the same day as a drug administration code that has a work relative value unit.  We will continue to allow other office visits to be billed on the same day as a drug administration service with modifier 25 indicating that a separately identifiable evaluation and management service was provided.
      4. We will revise the Internet Only Manual in 2004 to incorporate these revisions.

[EM 2003-1101 / CR 3028]

(04-0618)

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Application Tips for Clinical Psychologists

The following is a list of application tips that will help ensure applications for clinical psychologists are processed in a timely manner.  The information listed below is needed to determine a psychologist’s eligibility to bill Medicare. 

*If the diploma does not indicate the focus of study was psychology, the carrier must verify that the applicant’s doctorate is in psychology.  The carrier may request a copy of the applicant’s transcript to verify their focus of study.

(04-0623)

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Changes to the Laboratory National Coverage Determination (NCD) Edit Software for April 2004

I.   GENERAL INFORMATION

A. Background: This transmittal announces the changes that will be included in the April 2004 release of the edit module for clinical diagnostic laboratory services.  The NCDs for clinical diagnostic laboratory services were developed by the laboratory negotiated rulemaking committee and published as a final rule on November 23, 2001.  Nationally uniform software has been developed by Computer Science Corporation and incorporated in the shared systems so that laboratory claims subject to one of the 23 NCDs are processed uniformly throughout the nation effective January 1, 2003.  The laboratory edit module for the NCDs will be updated quarterly as necessary to reflect ministerial coding updates and substantive changes to the NCDs developed through the NCD process.  (See Pub. 100-4, Chapter 16, §120.2.)

B. Policy:

 1. In accordance with the decision memorandum published on the coverage Internet site on October 30, 2003 (see http://cms.hhs.gov/mcd/viewdecisionmemo.asp?id=99), we are adding the following diagnosis codes to the list of “ICD-9-CM Codes Covered by Medicare” for the serum iron studies NCD:

These codes will be covered for services furnished on or after April 5, 2004.

[EM 2004-0058/CR 3072]

(04-0653)

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IMPORTANT - Claim Filing Instruction Changes - Updates to the new Online Medicare Claims Processing Online Manual - Effective April 1, 2004  

  1. GENERAL INFORMATION

    This article is a general reminder of the changes that become effective April 1, 2004 that includes:

    • Multiple place of service codes
    • Purchased diagnostic tests

    A. Background: Services paid on the physician fee schedule and anesthesia services are to be reimbursed per payment locality (i.e., jurisdiction) based on where the service was rendered.

    B. Policy: This CR implements the jurisdictional payment policy for physician services payable under the Medicare Physician Fee Schedule and for anesthesia services.

    These changes can be found in the CMS Online Manual System, Pub 100-04, Medicare Claims Processing Manual in

    • Chapter 1, General Billing Requirements, Sections 10, 30 and 80
    • Chapter 26 Completing and Processing Form CMS-1500 Data Set, Sections 10 and 20

You can access these and other manuals at http://www.cms.hhs.gov/manuals.

General Reminder

Jurisdictional payment of services paid under the Medicare Physician Fee Schedule and anesthesia services will be made based on the zip code of where the service is provided.

Effective for claims received on or after April 1, 2004:

Below are some reference sections that will assist you in finding the updated sections.

Chapter 1, Section 10.1.1.1, Claims Processing Instructions for Payment Jurisdiction for Claims Received on or after April 1, 2004 is revised to provide instructions for Form CMS-1500 paper claims when more than one place of service code is included on a claim.

Chapter 1, Section 30.2.9 - Payment to Physician for Purchased Diagnostic Tests - is revised to add additional criteria that will cause the claim to be treated as unprocessable:

Chapter 1, Section 80.3.2.1.1.B - Carrier Data Elements Requirements - Required Data Element Requirements -  has been revised to require that services be treated as unprocessable should the name, address, and zip code of the service location not be entered for all services other than those furnished in place of service home - 12.

Chapter 1, Section 30.2.9, Payment to Physician for Purchased Diagnostic Tests - Claims Submitted to Carriers, is revised to add some additional requirements for the completion of claims.

Chapter 1, Section 10.1.1, Payment Jurisdiction for Services Paid Under the Physician Fee Schedule and Anesthesia Services, is a new section that mandates that jurisdiction will be determined by zip code and will apply to all services except those rendered at place of service home - 12.

Chapter 1, Section 10.1.1.1, Claims Processing Instructions for Payment Jurisdiction for Claims Received on or after April1, 2004, is a new section that mandates that the service facility location must be entered on every claim in a manner that will allow the carrier to be able to determine jurisdiction for every service on that claim. Carriers will no longer be able to use the addresses on their provider files for the service location when the place of service is office.

Chapter 1, Section 10.1.1.2, Payment Jurisdiction for Purchased Services, is a new section that clarifies payment jurisdiction for purchased diagnostic tests and interpretations. It also clarifies that global billings will not be acceptable for purchased services.

Chapter 1, Section 10.1.1.3, Payment Jurisdiction for Reassigned Services, is a new section that clarifies payment jurisdiction for reassigned services.

Chapter 1, Section 10.1.4.7 3100.5, Shipboard Services Billed to Carrier, is the former §3101C.

Chapter 1, Section 10.1.3, Exceptions to Jurisdictional Payment, is the former §3101D.

Chapter 26, Section 20 - Form CMS-1500 - Data Matrix, is revised to change the information for certain data elements for electronic claims to be consistent with the requirements of the Accredited Standards Committee X12N 837 Version 4010 Health Care Claim: Professional implementation guide.

Chapter 26, Section 10.4, Items 14-33 - Physician or Supplier Information, is revised for claims received on or after April 1, 2004:

(2003-0930/CR 2912)

(04-0732)

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Comprehensive Error Rate Testing (CERT)

In order to improve the processing and medical decision making involved with payment of Medicare claims, CMS began a new program effective August 2000.  This program is called CERT and is being implemented in order to achieve goals of the Government Performance and Results Act of 1993, which sets performance measurements for Federal agencies.

Under CERT, an independent contractor (AdvanceMed of Richmond, Virginia) will select a random sample of claims processed by each Medicare contractor.  AdvanceMed's medical review staff (to include nurses, physicians, and other qualified healthcare practitioners) will then verify that the contractor decisions regarding the claims were accurate and based on sound policy.  CMS will use the AdvanceMed findings to determine underlying reasons for errors in claims payments or denials, and to implement appropriate corrective actions aimed toward improvements in the accuracy of claims and systems of claims processing.

Eventually, all Medicare contractors will undergo CERT review by AdvanceMed. On a monthly basis, AdvanceMed will request a small sample of claims, approximately 200 from each contractor, as the claims are entered into their system.  AdvanceMed will follow the claims until they're adjudicated, and then compare the contractor's final claims decision with its own.  Instances of incorrect processing (e.g., questions of medical necessity or inappropriate application of medical review policy, etc.) become targets for correction or improvement.  Consequently, it is CMS's intent that the Medicare Trust Fund benefits from improved claims accuracy and payment processes.

How are providers and suppliers of sampled claims impacted by CERT?

You may be asked during AdvanceMed's review to provide more information such as medical records or certificates of medical necessity so that AdvanceMed can verify that billing was proper and that claims processing procedures were appropriate.  You will be advised what documentation is need and the name of your contact.

General questions regarding the CERT initiative may be directed to the CERT Program, at (804) 264-1778.  Otherwise, providers and suppliers will be contacted ONLY if their claim(s) is selected and AdvanceMed requires additional information.

[EM 2004-0165 / CR2976]

(04-0703)

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Darbepoetin Alfa (Aranesp®)

Article Title

Darbepoetin Alfa (Aranesp®) 

Article Text

Aranesp® is an erythropoiesis stimulating protein, closely related to erythropoietin, that is produced in Chinese hamster ovary (CHO) cells by recombinant DNA technology. Aranesp® is a 165-amino acid protein that differs from recombinant human erythropoietin in containing 5 N-linked oligosaccharide chains, whereas recombinant human erythropoietin contains 3 chains (Egrie 2001). The 2 additional N-glycosylation sites result from amino acid substitutions in the erythropoietin peptide backbone. The additional carbohydrate chains increase the approximate molecular weight of the glycoprotein from 30,000 to 37,000 daltons. Aranesp stimulates erythropoiesis by the same mechanism as endogenous erythropoietin. It has an approximately 3-fold longer half-life than Epoetin Alfa when administered by either the IV or SC route. This allows less frequent dosing than other anemia treatments. Aranesp® is formulated as a sterile, colorless, preservative-free protein solution for intravenous (IV) or subcutaneous (SC) administration.

Aranesp® is FDA approved for the treatment of anemia associated with chronic renal failure, including patients on dialysis and patients not on dialysis, and for the treatment of anemia in patients with non-myeloid malignancies where anemia is due to the effect of concomitantly administered chemotherapy.

Pending a Local or National Coverage Determination (LCD or NCD), CIGNA Government Services will consider the following indications as medically reasonable and necessary:

1. Anemia associated with chronic renal failure, including patients on dialysis and patients not on dialysis.

2. Anemia in patients with non-myeloid malignancies where the anemia is due to the effect of concomitantly administered chemotherapy and in patients who had chemotherapy for non-myeloid malignancy within the past year and present with post-chemotherapy anemia (i.e., permanent damage resulting from chemotherapy).

3. Anemia induced by the drug Zidovudine (AZT)

4. Anemia associated with myelodysplastic syndrome (MDS)

5. Chronic anemia associated with Rheumatoid Arthritis (RA)

6. Reduction of allogeneic blood transfusion in anemic surgery patients (hemoglobin > 10 to < 13 g/dl) scheduled to undergo major, elective orthopedic hip or knee surgery who are expected to require > 2 units of blood and who are not able or willing to participate in an autologous blood donation program.

7. Anemia due to chronic disease in patients who have been appropriately evaluated and treated for other treatable causes of anemia.

Unless there are significant symptoms at higher levels, the following are generally accepted Hct levels for the initiation of therapy:

a. Patients with ESRD on dialysis: Hct < 33
b. Patients with chronic renal failure not on dialysis: Hct < 30
c. Non-renal indications: Hct < 30

The generally accepted target hematocrit is 33-36. The medical literature does not support the routine maintenance of hematocrits greater than 37.

The rationale for the initiation and continuation of therapy must be documented in the medical record.

Coding Guidelines:

I. For anemia associated with chronic renal failure, including patients on dialysis and patients not on dialysis, use ICD-9 code 285.21 (anemia in end-stage renal disease) as line item diagnosis. A secondary diagnosis is not necessary, as this code is specific.

II. For anemia in patients with non-myeloid malignancies where the anemia is due to the effect of concomitantly administered chemotherapy and in patients who had chemotherapy for non-myeloid malignancy within the past year and present with post-chemotherapy anemia (i.e., permanent damage resulting from chemotherapy), use ICD-9 code 285.22 (anemia in neoplastic disease) as line item diagnosis and the ICD-9 code for the underlying non-myeloid neoplasm (series 140.0 - 204.91) as the secondary diagnosis.

III. For anemia induced by the drug Zidovudine (AZT), use ICD-9 code 042 (human immunodeficiency virus [HIV] disease) as line item diagnosis and ICD-9 code 995.2 (unspecified adverse effect of drug, medicinal and biological substance [due] to correct medicinal substance properly administered) as secondary diagnosis.

IV. For anemia associated with myelodysplastic syndrome (MDS), use ICD-9 code 285.9 (anemia, unspecified, normocytic, not due to blood loss, profound, progressive) as line item diagnosis and ICD-9 code 238.7 (myelodysplastic syndrome) as secondary diagnosis.

V. For chronic anemia associated with Rheumatoid Arthritis (RA), use ICD-9 code 285.29 (anemia of other chronic illness) as line item diagnosis and one of the ICD-9 codes for rheumatoid arthritis (series 714.0 - 714.2) as secondary diagnosis.

VI. For the reduction of allogeneic blood transfusion in anemic surgery patients (hemoglobin > 10 to < 13 g/dl) scheduled to undergo major, elective orthopedic hip or knee surgery who are expected to require > 2 units of blood and who are not able or willing to participate in an autologous blood donation program, use ICD-9 code 285.9 (anemia, unspecified) as line item diagnosis and ICD-9 code V72.83 (other specified preoperative examination) as secondary diagnosis.

VII. For anemia due to chronic disease in patients who have been appropriately evaluated and treated for other treatable causes of anemia, use ICD-9 code 285.29 (anemia of other chronic illness) as line item diagnosis and the ICD-9 code for the underlying illness as the secondary diagnosis.

Applicable HCPCS codes are listed below. Do not bill any combination of these codes on the same DOS.

Coverage Topic

Dialysis (Kidney) Inpatient
Doctor Office Visits
Prescription Drugs
Dialysis (Kidney) Outpatient
Dialysis (Kidney) Drugs used with Home Dialysis
Chemotherapy (Inpatient)
Chemotherapy (Outpatient)
 

Coding Information

CPT/HCPCS Codes

The following HCPCS codes apply in the office to patients with anemia unrelated to renal causes and to patients with anemia due to renal failure who are not on dialysis:

J0880

INJECTION, DARBEPOETIN ALFA, 5 MCG

Q0137

INJECTION, DARBEPOETIN ALFA, 1 MCG (NON-ESRD USE)

The following HCPCS code applies in the office to patients with anemia due to end stage renal disease (ESRD) who are on dialysis. The hematocrit value must be included on the claim. When filing paper claims, please insert the hematocrit in Field 19 of Form CMS 1500. For ANSI 837 transactions, the hematocrit (Hct) value is reported in 2400 MEA03 with a qualifier of R2 in MEA02 (Pub. 100-20, Transmittal: 36, Date: December 24, 2003, Change Request 3037).

Q4054

INJECTION, DARBEPOETIN ALFA, 1 MCG (FOR ESRD ON DIALYSIS)

(04-0651)

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Downloading Electronic Receipt Listings (ERLs) and Electronic Remittance Notices (ERNs)

Did you know that if you send claims to us electronically, we produce a confirmation (ERL) that is available the very next day after you send claims? This report will identify, per provider, the number of claims you send to us, the total dollar amount of the claims (broken out by assigned claims and unassigned claims), the number of your claims that we accepted, and the number we rejected (if any). If there are rejected claims, it will also provide you with a brief description of the error(s) that caused us to be unable to accept the claim for processing. You should then correct the erroneous claims and retransmit them.

Unfortunately, it seems that far too many of our submitters are unaware that we provide such a report, or at the very least, they are not aware of how to obtain these reports. In many cases, we have submitters that are not aware that their claims have not made it into the system until they realize they received no payment for their claims. Thus, these reports can be a valuable source of information as you manage your billing and accounts receivable.

For our customers’ benefit, we provide instructions on how to download these files, as well as Electronic Remittance Notices (ERNs), in the Stratus Manual we provide to our customers who use the Stratus Bulletin Board system.

Please refer to your Stratus Manual for detailed instructions on how to download files. If you don't have a manual, you can easily download a copy from our website at http://www.cignamedicare.com/edi/pdf/snhrmug.pdf (697K). *Refer to the Stratus Manual sections - Downloading Electronic Receipt Listings (Section 9), Downloading ANSI 997 Functional Acknowledgements (Section 11), and Downloading ANSI Production Files (Section 12).

Follow the instructions for "Configuring Your Mailbox". To download Electronic Receipt Listings (ERL) the data type will need to be set to "RECEIVE_ERL". To download the 835 Electronic Remit Notices (ERN) paid files, the data type should be set to "RECEIVE_ANSIERN".

If you find that you do not have ERL files to download, verify that you also did not receive a 997 Functional Acknowledgement (refer to section 11).

  1. If you did receive a 997, open it and look for the segments "AK5" and "AK9." If there is an "A" after these two segments, your file was received and accepted. You will need to contact the EDI Technical Helpdesk to determine why you did not receive an ERL. If there is an "R" in these segments, your file was rejected at the translator for syntactical errors. You will need to forward this 997 to your vendor so that they may determine what is causing your errors.
  2. If you did not receive an ERL or a 997, it is likely that your file did not make it into your mailbox. At this point make sure that your mailbox data type is properly set to "SEND_ANSICLAIM" , then choose "Upload: Put a File in Mailbox" and resend the file.

If you do not have ERN files available to download, and you have checks pending an Electronic Remittance Notice, contact the EDI Technical Helpdesk. Our staff will determine whether you have a file available, and work with you to retrieve the file.

Our EDI Technical Helpdesk Staff for TN/ID may be reached at 866.520.4023.
NC Technical Helpdesk Staff may be reached at 866.352.1608.

* Manual referenced and instructions given here apply only to HIPAA-ready Stratus mailboxes

(04-0729)

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EDI Support Services Helpdesk

The CIGNA Government Services EDI department, like all other departments within the Medicare operation, prides itself in providing excellent customer service. We strive to assist our customers in a timely manner. However, some of our calls are lengthy and many times a customer must leave a voice message for a return call.

We are asking our customers to include the following information when leaving a voice message:

Providing this information on the voice mail not only saves our customers valuable time, it allows the EDI Support Consultants a chance to research a solution before returning the call.

TN/ID customers should call:

NC customers should call:

(04-0730)

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Elimination of the 90-day Grace Period for Billing Discontinued ICD-9-CM Codes

Provider Types Affected
All physicians, practitioners, and suppliers who use ICD-9-CM Codes in billing Medicare carriers and Durable Medical Equipment Regional Carriers (DMERCs).

Provider Action Needed

STOP – Impact to You
Medicare systems will begin enforcing HIPAA standards on October 1, 2004, requiring that ICD-9-CM codes submitted on claims must be valid at the time the service is provided.

CAUTION – What You Need to Know
Physicians, practitioners, and suppliers should be aware that CMS is instructing carriers and DMERCs to eliminate the 90-day grace period for billing discontinued ICD-9-CM diagnosis codes effective October 1, 2004.

GO – What You Need to Do
Adopt the new codes in your billing processes effective October 1 of each year and begin using them for services rendered on or after that time to assure prompt and accurate payment of your claim.

Background
Medicare has previously permitted a 90-day grace period after the annual October 1 implementation of an updated version of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. This grace period gave physicians, practitioners and suppliers time to become familiar with the new codes and learn about the discontinued codes.

During this 90-day grace period (October 1 through December 31 of each year), physicians, practitioners, and suppliers could use either the previous or the new ICD-9-CM diagnosis codes. For claims received on or after January 1, the updated ICD-9-CM codes were required to be used, and claims received with discontinued diagnosis codes were rejected as Returned Unprocessable Claims (RUCs).

However, the Health Insurance Portability and Accountability Act (HIPAA) Transaction and Code Set Rule requires the use of national/medical code sets that are valid at the time that the service is provided, and ICD-9-CM is a national/medical code set.

Therefore, the Centers for Medicare & Medicaid Services (CMS) can no longer allow a 90 day grace period for physicians, practitioners and suppliers to learn about the discontinued ICD-9 codes.

Providers can view the new, revised, and discontinued ICD-9-CM diagnosis codes at
http://www.cms.hhs.gov/medlearn/icd9code.asp. CMS updates this site annually after the updated diagnosis codes are published in the Federal Register, which usually occurs by May 1 of each year. Effective for dates of service on and after October 1, 2004, no further 90-day grace periods will apply for the annual ICD-9-CM updates. Physicians, practitioners, and suppliers must bill using the diagnosis code that is valid for that date of service. Carriers and DMERCs will no longer be able to accept discontinued codes for dates of service after the date on which the code is discontinued.

This is a HIPAA compliancy issue.

Implementation
October 1, 2004. This is the date on which Medicare’s claims processing systems will be changed.

Related Instructions

The Medicare Claims Processing Manual, Chapter 23, Section 10, Subsection 10.2 (Relationship of ICD-9- CM Codes and Date of Service) has been revised. The relevant revisions to Subsection 10.2 are the following:
10-2 – Relationship of ICD-9-CM Codes and Date of Service

(Rev. 1, 10-01-03)

PM B-02-027 (CR-2108), B-03-063, B-02-064, B-03-002

The Health Insurance Portability and Accountability Act (HIPAA) requires that medical code sets must be date of service compliant. Since ICD-9-CM is a medical code set, effective for dates of service on and after October 1, 2004, CMS will no longer provide a 90-day grace period for providers to use in billing discontinued ICD-9-CM diagnosis codes on Medicare claims. The updated ICD-9-CM codes are published in the Federal Register in April/May of each year as part of the Proposed Changes to the Hospital Inpatient Prospective Payment Systems in Table 6 and effective each October 1.

Carriers and DMERCs must eliminate the ICD-9-CM diagnosis code grace period from their system effective with the October 1, 2004 update. Carriers and DMERCs will no longer accept discontinued diagnosis codes for dates of service October 1 through December 31 of the current year. Claims containing a discontinued ICD-9-CM diagnosis code will be returned as unprocessable. Physicians, practitioners, and suppliers must use the current and valid diagnosis code that is in effect beginning October 1, 2004. After the ICD-9-CM codes are published in the Federal Register, CMS places the new, revised, and discontinued codes on the following Web site: http://www.cms.hhs.gov/medlearn/icd9code.asp.

For more information about the relationship of ICD-9-CM diagnosis codes and dates of service, go to Chapter 23, available at:

http://www.cms.hhs.gov/manuals/104_claims/clm104c23.pdf


To view the actual instruction issued by CMS to your Medicare carrier, please go to:

http://www.cms.hhs.gov/manuals/pm_trans/R95CP.pdf

For more information on HIPAA’s rules that relate to claims submission, other transactions, and code sets, please visit:

http://www.cms.hhs.gov/HIPAAGenInfo/default.asp


[EM2004-0098/CR3094]

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Elimination of the 90-day Grace Period for HCPCS Codes

Provider Types Affected
All physicians, providers, and suppliers who use Healthcare Common Procedure Coding System (HCPCS) codes in billing Medicare Carriers, Durable Medical Equipment Regional Carriers (DMERCs), and Fiscal Intermediaries (FIs).

Provider Action Needed

STOP – Impact to You
Effective January 1, 2005, Medicare providers will no longer have a 90-day grace period to use discontinued HCPCS codes for services rendered in the first 90 days of the year. Use of such codes to bill services provided after the date on which the codes are discontinued will cause your claims to be returned and not paid. In essence, HCPCS codes must be valid at the time the service is rendered.

CAUTION – What You Need to Know
Providers should be aware that effective January 1, 2005, Carriers, DMERCs, and FIs will no longer accept discontinued HCPCS codes for dates of service January 1 through March 31 of the current year (beginning in 2005) that are submitted prior to
April 1.

GO – What You Need to Do
To ensure prompt and timely payment of claims, use the new HCPCS for 2005 beginning with services rendered on or after January 1, 2005, and stop using
discontinued codes at that time. Each year thereafter, be sure to adopt the new codes.

Background
The Healthcare Common Procedure Coding System (HCPCS) consists of the following two levels of codes:

• Level I codes that are copyrighted by the American Medical Association’s Current Procedural
Terminology, Fourth Edition (CPT-4); and
• Level II codes that are five-position alpha-numeric codes approved and maintained jointly by the Alpha-Numeric Panel (consisting of the Centers for Medicare & Medicaid Services (CMS), the Health
Insurance Association of America, and the Blue Cross and Blue Shield Association). The D code series in Level II HCPCS is copyrighted by the American Dental Association.

Medicare has permitted a 90-day grace period after implementation of an updated HCPCS code set to
familiarize providers with the new codes and to learn about the discontinued codes. For example, the 2004 HCPCS codes became effective for dates of service on or after January 1, 2004, and Medicare contractors are able to apply a three-month grace period for all applicable discontinued HCPCS codes. This means that the 2003 discontinued HCPCS codes and the new 2004 HCPCS codes will be accepted by carriers from physicians, suppliers, and providers during the January 2004-March 2004 grace period. This 90-day grace period applies to claims received by the carrier prior to April 1, 2004, which contain the 2003 discontinued codes for dates of service January 1, 2004, through March 31, 2004.

However, the Health Insurance Portability and Accountability Act (HIPAA) Transaction and Code Set Rule requires providers to use the medical code set that is valid at the time that the service is provided.

Therefore CMS will no longer be able to allow a 90-day grace period for providers to learn about the
discontinued HCPCS codes. Providers should be aware that effective January 1, 2005, Carriers, DMERCs, and Fiscal Intermediaries will no longer accept discontinued HCPCS codes for dates of service January 1 through March 31 of the current year (beginning in 2005) that are submitted prior to April 1. In addition, effective January 1, 2005, CMS will no longer allow a 90-day grace period for discontinued codes resulting from any mid-year HCPCS updates.

In order for providers to know about the new, revised, and discontinued numeric CPT-4 codes for the
upcoming year, they should obtain the American Medical Association’s CPT-4 coding book that is
published each October. CMS posts on its Web site the annual alpha-numeric HCPCS file for the upcoming year. The CMS Web site to view the annual HCPCS update is http://www.cms.hhs.gov/providers/pufdownload/anhcpcdl.asp.

Physicians, providers, and suppliers should be aware that Medicare systems will begin to reject such
discontinued codes, beginning on January 1, 2005, if the codes were not effective on the date of service. Such claims will be returned to the submitter for correction.

This is a HIPAA compliancy issue.

Implementation
July 6, 2004. While this is the date on which Medicare’s claims processing systems will be changed to enforce these new rules, the systems will not apply these rules until January 1, 2005.

Related Instructions
The Medicare Claims Processing Manual, Chapter 23, Section 20 (Reporting Hospital Outpatient Services Using Healthcare Common Procedure Coding System (HCPCS)), Subsection 20.4 (Deleted HCPCS Codes/Modifiers) was revised and is included below (changes bolded and italicized). Also, sentences that referred to the three month HCPCS grace period have been deleted from Subsections 40.1 (Access to Clinical Diagnostic Lab Fee Schedule Files) and 50 (Fee Schedules Used by All Intermediaries and Regional Home Health Intermediaries (RHHIs)).

20.4 – Deleted HCPCS Codes/Modifiers

(Rev.1, 10-01-03)

B3-4509.3, HO-442.2

Claims for services in a prior year are reported and processed using the HCPCS codes/modifiers in effect during that year. For example, a claim for a service furnished in November 2002 but received by a carrier/DMERC/intermediary in 2003 should contain codes/modifiers valid in 2002 and is processed using the prior year’s pricing files.

HCPCS codes (Level I CPT-4 and Level II alpha-numeric) are updated on an annual basis. Each
October, CMS releases the annual HCPCS file to carriers/DMERCs/FIs. The HCPCS file contains the CPT-4 and the alpha-numeric updates. Contractors are notified of the release date via a one-time notification instruction. The file contains new, deleted, and revised HCPCS codes which are
effective on January 1 of each year. With each annual HCPCS update, CMS has permitted a 90-day grace period for billing discontinued HCPCS codes for dates of service January 1 through March 31 that were submitted to Medicare contractors by April 1 of the current year.
The Health Insurance Portability and Accountability Act (HIPAA) requires that medical codes sets
must be date of service compliant. Since HCPCS is a medical code set, effective January 1, 2005, CMS will no longer provide a 90-day grace period for providers to use in billing discontinued HCPCS codes. The elimination of the grace period applies to the annual HCPCS update and to any mid-year coding changes. Any codes discontinued mid-year will no longer have a 90-day grace period.

Contractors must eliminate the 90-day grace period from their system effective with the January 1, 2005, HCPCS update. Contractors will no longer accept discontinued HCPCS codes for dates of service January 1 through March 31. Providers can purchase the American Medical Association’s CPT-4 coding book that is published each October that contains new, revised, and discontinued CPT-4 codes for the upcoming year. In addition, CMS posts on its Web site the annual alphanumeric HCPCS file for the upcoming year at the end of each October. Providers are encouraged to access CMS Web site to see the new, revised, and discontinued alpha-numeric codes for the upcoming year.

The CMS Web site to view the annual HCPCS update is http://www.cms.hhs.gov/providers/pufdownload/anhcpcdl.asp

Carriers and DMERCs must continue to reject services submitted with discontinued HCPCS codes.
FIs must continue to return to the provider (RTP) claims containing deleted codes.

See the Medicare Claims Processing Manual, Chapter 22, “Remittance Notices to Providers.”

For more information on HCPCS, visit the CMS Web site at:

http://cms.hhs.gov/medicare/hcpcs.

For more information on HIPAA and its impact on claims submission, please visit the CMS HIPAA Web site at:

http://www.cms.hhs.gov/HIPAAGenInfo/default.asp.

[EM 2004-0098/CR3093]

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Extended Repayment Plan

A debtor is expected to repay any overpayment as quickly as possible.  If it cannot refund the total overpayment within 30 days after receiving the first demand letter, it should request an extended repayment plan (ERP) immediately.  However, an ERP request may be received and shall be reviewed at any time the overpayment is outstanding.  The provider must explain and document its need for an extended (beyond 30 days) repayment plan. A repayment plan may be established to recover all or part of an overpayment. Any approved ERP will run from the date of the initial demand letter.

A written request must be submitted that refers to the specific overpayment for which an extended repayment is being requested.  This request must detail the number of months requested, indicate the approximate monthly payment amount (principal and interest, if possible), and include the first payment.

Please provide the following when requesting an ERP:

If sole proprietor:

If entity other than a sole proprietor:

If the time period between the two balance sheets is less than 6 months (or the provider cannot submit balance sheets prepared by its accountant), it must submit balance sheets for the last two complete Medicare reporting periods (providers that file a cost report) or last two complete fiscal years.

CMS suggests that both the balance sheets and income statements include the following statements:

MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS BALANCE SHEET OR INCOME STATEMENT MAY BE PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW.

CERTIFICATION BY OFFICER OF ADMINISTRATOROF PROVIDER(S)

(For physicians/suppliers, "CERTIFICATION BY OFFICER/OWNER OF DEBTOR(S))

I HEREBY CERTIFY that I have examined the balance sheet and income statement prepared by __________ and that to the best of my knowledge and belief, it is a true, correct, and complete statement from the books and records of the provider.

Signed
Officer or Administrator of
Provider(s)
Title

Date

(For physicians/suppliers:
Signed
Officer or Owner of
Debtor(s)
Title)

[EM 2004-0006/CR2911]

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Health Insurance Portability and Accountability Act (HIPAA) X12N 837 Professional Health Care Claim Implementation Guide (IG) Editing

Provider Types Affected
Physicians, practitioners, suppliers, and providers who bill Medicare carriers, including Durable Medical Equipment Carriers (DMERCs).

Provider Action Needed

STOP – Impact to You
Affected providers should stop submitting electronic claims with diagnosis codes, zip codes, or telephone numbers that are not HIPAA compliant.

CAUTION – What You Need to Know
Providers should note that Medicare systems are strengthening their system edits to assure receipt of HIPAA compliant claims. Effective July 1, 2004, Medicare will reject electronic claims that have diagnosis codes, zip codes, or telephone numbers that are not HIPAA compliant.

GO – What You Need to Do
Be sure your billing systems are modified to generate electronic claims that will pass Medicare’s HIPAA compliancy edits for diagnosis codes, zip codes, and telephone numbers.

Background
The Health Insurance Portability and Accountability Act (HIPAA) directed the Secretary of the Department of Health and Human Services (HHS) to adopt standards for transactions to enable health information to be exchanged electronically. In addition, one of the HIPAA provisions requires standard formats to be used for electronically submitted health care transactions.

CMS is committed to implementing the 837 COB transaction set per the HIPAA implementation guide (IG), and it recognizes that a change in its systems is needed to:

Related Change Request #: 3050 Medlearn Matters Number: MM3050

1) Comply with the 837 Professional IG; and
2) To allow the creation of compliant coordination of benefits (COB) claim files.

To accomplish this, Medicare systems will be changed to include edits that reject electronic claims that contain:

• Invalid diagnosis codes;
• A dash, a space, or special character in any zip code field; and
• A dash, space, special character, or a parenthesis in telephone numbers.

Implementation
July 6, 2004.

Related Instructions
The ANSI X12N 837 implementation guides are the standards of compliance for claim transactions and are available electronically at:

http://www.wpc-edi.com/hipaa/HIPAA_40.asp.

The Medicare Claims Processing Manual, Chapter 24 has been updated to include the new Section 40.7.2, Professional Implementation Guide (IG) Edits. This new section is included below:

40.7.2 – X12N 837 Professional Implementation Guide (IG) Edits

The Part B Carriers and Durable Medical Equipment Regional Contractors (DMERCs) must
reject inbound electronic claims that contain invalid diagnosis codes whether pointed to or
not.

The Part B Carriers and Durable Medical Equipment Regional Contractors (DMERCs) must
reject inbound electronic claims that contain a dash, space, or special character in any zip
code.

The Part B Carriers and Durable Medical Equipment Regional Contractors (DMERCs) must
reject inbound electronic claims that contain dashes, spaces, special characters or
parentheses in any telephone number.


[EM 2004-0082/CR3050]

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HIPAA Insurance Portability and Accountability Act (HIPAA) X12N 837 Coordination of Benefits (COB) Gap Fill Additional Instructions

Gap Filling for X12N 837 COB (Coordination of Benefits) Claims

When non-HIPAA inbound claims do not contain data necessary to create a HIPAA compliant outbound X12N 837 HIPAA COB transaction, CMS requires that CIGNA Government Services shall gap fill alphanumeric data elements with Xs and numeric data elements with 9s. For example, a 5-character alphanumeric data element would contain “XXXXX” and a 5-character numeric data element would contain “99999.”

When non-HIPAA inbound claims do not contain a required telephone number to create a HIPAA compliant outbound X12N 837 HIPPA COB transaction, CMS requires that CIGNA Government Services shall gap fill the phone number data element with “8009999999.”

[EM 2004-0118/CR3100]

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Implementation of Skilled Nursing Facility Consolidated Billing CWF Edit for Therapy Codes Considered Separately Payable Physician Services

I.   GENERAL INFORMATION

A.  Background:  N/A

B.  Policy: 

Physical, occupational, and speech therapy are considered bundled services paid under the Prospective Payment System, through consolidated billing when provided to beneficiaries in either a Part A covered skilled nursing facility (SNF) stay or during a non-covered stay.  A small number of these services are considered surgery when performed by a physician and may be separately paid by the carrier.  They are considered therapy when performed by a physical and occupational therapists and continue to be subject to consolidated billing. 

Effective for claims with dates of service on or after July 1, 2004, the Common Working File (CWF) shall only allow the following codes to pay separately for beneficiaries in a Part A covered skilled nursing facility (SNF) stay or during a non-covered stay when provided by a provider specialty other than 65 - Physical Therapist in Private Practice, 67 – Occupational Therapist in Private Practice, 88 – Unknown Supplier/Provider:

29065, 29075, 29085, 29086, 29105, 29125, 29126, 29130, 29131, 29200, 29220, 29240, 29260, 29280, 29345, 29365, 29405, 29445, 29505, 29515, 29520, 29540, 29550, 29580, 29590, 64550

Carriers shall use the following remittance advice (RA) and revised Medicare Summary Notice (MSN) for non-covered services.

RA

Report claim adjustment reason code 96 – Non-covered charges; and

Remark Code N121 – No coverage for items or services by this type of practitioner for patients in a covered Skilled Nursing Facility (SNF) stay.

MSN

Revised 13.10 – Medicare Part B does not pay for items or services provided by this type of practitioner since our records show that you were receiving Medicare benefits in a skilled nursing facility on this date.

Revised Spanish 13.10 - La Parte B de Medicare no paga por artículos o servicios provistos por este tipo de médico ya que nuestros expedientes indican que usted estaba recibiendo beneficios de Medicare en una institución de enfermería especializada en esta fecha.

Providers should review the explanation of this policy on the CMS website at www.cms.hhs.gov/medlearn/snfcode.asp.

[EM 2004-0109 / CR 2944]

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Medicare Incentive Payments for Physician Care in Underserved Areas

Providers Affected
Psychiatrists

Provider Action Needed
Physicians, including psychiatrists, should note that if they furnish services in primary medical care Health Professional Shortage Areas (HPSAs), they are eligible to receive 10% bonus payments. Psychiatrists furnishing services in mental health HPSAs are also eligible to receive 10% bonus payments.

STOP – Impact to You
This instruction relates to the amount of payment psychiatrists receive if they provide services in a mental health HPSA.

CAUTION – What You Need to Know
Physicians, including psychiatrists, are eligible to receive 10% bonus payments if they furnish services in primary medical care HPSAs. Psychiatrists
furnishing services in mental health HPSAs are also eligible to receive 10% bonus payments.

GO – What You Need to Do
Psychiatrists who qualify for these bonus payments are eligible to submit claims for services furnished in mental health HPSAs, effective for claims with dates of service on or after July 1, 2004.

Background
Under current law, Medicare pays a bonus to physicians for providing health care services in certain
HPSAs. In light of recent physician inquiries, the Centers for Medicare & Medicaid Services has issued instructions to clarify which types of geographic HPSA (primary medical care, dental and mental health) are applicable to the Medicare Bonus Payment program that provides a 10% bonus payment.

Related Change Request #: 3108 Medlearn Matters Number: MM3108

Currently, the Health Resources and Services Administration (HRSA), part of the Department of Health and Human Services, is responsible for designating several types of HPSAs, including HPSA designations based on:
• Areas with shortages of primary care physicians, dentists or psychiatrists, referred to as geographic based HPSAs; and
• Underserved populations within an area, referred to as population-based HPSAs.

Federal law for Medicare bonus payments recognizes geographic-based, primary medical care, and mental health HPSAs as eligible areas for receiving bonus payments. Consequently, physicians, including psychiatrists, furnishing services in a primary medical care HPSA, are eligible to receive bonus payments. In addition, psychiatrists furnishing services in mental health HPSAs are eligible to receive bonus payments. Dental HPSAs remain ineligible for the bonus payment program due to the fact that Medicare does not cover dental services for its beneficiaries.

This change would only affect psychiatrists furnishing services in mental health HPSAs that do not overlap with primary care HPSAs. In other words, these stand-alone mental health HPSAs are now eligible areas, as of July 1, 2004, for psychiatrists to receive bonus payments.

With respect to psychiatrist services in mental health HPSAs, CMS will furnish quarterly lists of mental health HPSAs to Medicare carriers so they can implement this change which is effective for claims with dates of service on or after July 1, 2004. Should an area be both a mental health HPSA and a nonmental health HPSA, only one 10% bonus payment will apply to a single service.

Also, it is important for physicians and psychiatrists to note that the bonus is paid for services in HPSA areas only if those services are actually provided in the HPSA area. For example, if the physician has an office in a HPSA area, but provides the service in the patient’s home, which is outside the service area, the bonus is not payable.

Implementation
The implementation date is July 6, 2004, for the mental health HPSAs and the change for such services will apply effective for dates of service on or after July 1, 2004. For services provided in primary medical care HPSAs, this instruction is meant for clarification and informational purposes only.

Additional Information
The Medicare Claims Processing Manual, Chapter 12 (Physicians/Nonphysician Practitioners), Section 90 (Physicians Practicing in Special Settings), Subsection 90.4 (Billing and Payment in a Health Professional Shortage Areas (HPSAs)) has been revised, and sections have been deleted. You can find this manual at:

http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp
Once at that site, scroll down to Chapter 12 and select the version of the file you would like to view.
Also, to see the specific instruction issued to your Medicare carrier, visit:

http://www.cms.hhs.gov/manuals/pm_trans/R78CP.pdf.

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Announcing the New Medlearn Matters…Information for Medicare Providers Educational Resource for Medicare Providers

Provider Types Affected
All Medicare providers.

Provider Action Needed

The Centers for Medicare & Medicaid Services (CMS) and your Medicare Learning Network introduces Medlearn Matters…Information for Medicare Providers, a new educational resource for Medicare Providers. Medlearn Matters…Information for Medicare Providers is designed to inform you of important changes to the Medicare system in a user-friendly format that will accommodate your busy schedule.

Please let us know if these articles help you understand these changes more readily. Provide us with suggestions for improvements to articles. If there is a special topic of interest that you believe warrants an article, let us know and we will consider a special edition for that topic. To provide feedback, please go to: http://www.cms.hhs.gov/medlearn/suggestform.asp

Bookmark this page, use it frequently, and let us know how best to continue providing good service to you.

Background
CMS is committed to partnering with the Medicare physician, provider, and supplier communities so services to Medicare beneficiaries can be timely and of the highest quality. One way of providing the best services to Medicare patients is assuring that the providers of care have ready access to Medicare’s latest coverage and reimbursement rules and policies in a brief, accurate, and easy-to-understand format.

CMS recognizes that the Medicare provider communities have been hampered by the number, frequency, and complexity of Medicare changes. CMS also appreciates the feedback from those same providers who indicate that Medicare rules and changes are not always relayed to them in an easy, timely, and consistent manner.

To address those issues, CMS has implemented a new initiative — “Consistency in Medicare Contractor Outreach Material” or CMCOM, designed to provide more timely information on Medicare changes. The product of this effort, Medlearn Matters…Information for Medicare Providers, is a series of articles prepared by actual clinicians and billing experts. Medlearn Matters…Information for Medicare Providers articles are tailored, in content and language, to the specific provider types who are affected by Medicare changes.

Previously, each Medicare carrier and intermediary was responsible for crafting educational articles within days of release of the related Medicare change. With this new effort, the Medicare carrier or fiscal intermediary will still be responsible for local provider education. However, they will benefit from the availability of Medlearn Matters…Information for Medicare Providers articles to support their efforts. These
articles are easily accessible from the Medlearn Web site, which providers already access for other Medicare information.

Enlisting the expertise of medical professionals to develop these articles and providing them from a single location will result in more consistent, accurate, and timely information than in the past. This initiative supplements and should improve the ability of your carrier or intermediary to provide better service to you.

Those of you who have relied on Medicare Program Memorandums or Manual Transmittals on the Web, may be familiar with the Change Request (CR) documents and their accompanying CR numbers. Since you may have used the original CRs to get early information on upcoming changes, we think you will agree that those documents were not always clear as to provider impact and action needed.

One reason is that those CRs were written to provide instructions to Medicare carriers, intermediaries, and Medicare system maintainers. Thus, the focus of the message was quite different and probably contained more information than providers needed to know. The intent of Medlearn Matters…Information for Medicare Providers articles is to help focus the information more toward pr