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May 2004 Part B Medicare Bulletin

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2004 Jurisdiction List

Provider Types Affected
Durable Medical Equipment (DME) Suppliers.

Provider Action Needed
DME Suppliers should be aware of which Medicare contractor to bill for codes provided on the jurisdiction list of the Healthcare Common Procedure Coding System (HCPCS). This HCPCS list for DME Regional Carrier (DMERC) and local carrier jurisdictions is updated on annual basis to provide accurate billing information to providers.

Ensure that your billing staffs know how to find the list and use the list in their billing processes for Medicare claims.

Background
The HCPCS is updated annually to reflect changes in medical practice and the provision of health care. The Centers for Medicare & Medicaid Services (CMS) provides a file containing updated HCPCS codes to Medicare carriers, DMERCs, and intermediaries and to Medicaid State Agencies 60 to 90 days before the implementation of the annual update. A spreadsheet containing an updated list of the HCPCS for DMERC and Part B local carrier jurisdictions is updated annually to reflect codes that have been added or discontinued (deleted) during each year. CMS publishes a recurring update notification annually to notify the DMERCs and Part B carriers that the list has been updated and is available on the CMS Web site. Both the DMERCs and the local carriers publish this list to educate providers as to which contractor—the DMERC or local Part B carrier—to bill for codes provided on that list.

Additional Information
Updates are available on an Excel spreadsheet on the CMS Web site at:
http://www.cms.hhs.gov/suppliers/dmepos

The actual instruction issued to the DMERCs may be found at: http://www.cms.hhs.gov/manuals/pm_trans/R127CP.pdf

[EM 2004-0229/3139]

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Advate-rAHF-PFM (antihemophilic recombinant Factor VIII)  

Effective 05/01/2004, claims for Advate should be filed using HCPCS code J7192. The name of the drug and the total units administered/delivered must be entered in Block 19 of the CMS - 1500 form or the electronic equivalent. In block 24-F enter your total charge and in 24-G enter the number of units as one (1). The allowed amount will be based on the total units entered in Block 19 or the electronic equivalent. With the first claim filed, you should include the physician’s notes and prescription information (if this information is acquired through a certificate of medical necessity (CMN), the CMN information will be sufficient documentation).

(04-0813)

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Cardiac Output Monitoring By Thoracic Electrical Bioimpedance (TEB)

(Rev. 6, 01-23-04)

Thoracic electrical bioimpedance (TEB) devices, a form of plethysmography, monitor cardiac output by noninvasively measuring hemodynamic parameters, including: stroke volume, systemic vascular resistance, and thoracic fluid status. Under the previous coverage determination, effective July 1, 1999, use of TEB was covered for the “noninvasive diagnosis or monitoring of hemodynamics in patients with suspected or known cardiovascular disease.” In reconsidering this policy, CMS concluded that this use was neither sufficiently defined nor supported by available clinical literature to offer the guidance necessary for practitioners to determine when TEB would be covered for patient management. Therefore, CMS revised its coverage policy language in response to a request for reconsideration to offer more explicit guidance and clarity for coverage of TEB based on a complete and updated literature review.

  1. Covered Indications
    1. TEB is covered for the following uses:
      1. Differentiation of cardiogenic from pulmonary causes of acute dyspnea when medical history, physical examination, and standard assessment tools provide insufficient information, and the treating physician has determined that TEB hemodynamic data are necessary for appropriate management of the patient.
      2. Optimization of atrioventricular (A/V) interval for patients with A/V sequential cardiac pacemakers when medical history, physical examination, and standard assessment tools provide insufficient information, and the treating physician has determined that TEB hemodynamic data are necessary for appropriate management of the patient.
      3. Monitoring of continuous inotropic therapy for patients with terminal congestive heart failure, when those patients have chosen to die with comfort at home, or for patients waiting at home for a heart transplant.
      4. Evaluation for rejection in patients with a heart transplant as a predetermined alternative to a myocardial biopsy. Medical necessity must be documented should a biopsy be performed after TEB.
      5. Optimization of fluid management in patients with congestive heart failure when medical history, physical examination, and standard assessment tools provide insufficient information, and the treating physician has determined that TEB hemodynamic data are necessary for appropriate management of the patient.
    2. Contractors have discretion to determine whether the use of TEB for the management of drug-resistant hypertension is reasonable and necessary. Drug resistant hypertension is defined as failure to achieve goal BP in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic.
  2. Noncovered Indications
    1. TEB is noncovered when used for patients:
      1. With proven or suspected disease involving severe regurgitation of the aorta;
      2. With minute ventilation (MV) sensor function pacemakers, since the device may adversely affect the functioning of that type of pacemaker;
      3. During cardiac bypass surgery; or
      4. In the management of all forms of hypertension (with the exception of drug-resistant hypertension as outlined above).

    2. All other uses of TEB not otherwise specified remain non-covered.

(This NCD last reviewed January 2004.)

[EM 2004-0050/ CR2689]

(04-0736)

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Consolidation of the Claims Crossover Process: Additional Common Working File (CWF) Functionality

Provider Types Affected
All Medicare providers.

Provider Action Needed
Medicare physicians, suppliers, and providers should note that this instruction communicates changes to the existing Medicare claims crossover process. CMS is implementing a new initiative known as the “Coordination of Benefits Agreement (COBA) consolidated crossover process.” This article provides guidance on the new COBA crossover strategy, including a new claim-based Medigap and Medicaid crossover process to be implemented by Medicare carriers and DMERCs on October 4, 2004. It is especially important to understand that the new claim-based COBA IDs being issued by CMS to Medigap insurers and State Medicaid Agencies must be submitted on incoming claims in certain defined instances, as explained later in this article.

Background
The Centers for Medicare & Medicaid Services (CMS) Coordination of Benefits (COB) program identifies the health benefits available to a Medicare beneficiary and coordinates the payment process to ensure appropriate payment of Medicare benefits. The program offers an automatic crossover service to other insurers, or trading partners, that may pay benefits after the Medicare claim has been processed. The trading partner is charged a fee-per-claim that is crossed by Medicare. COB trading partners include:

In order to better service its customers, CMS is streamlining the claims crossover process and is
consolidating the claims crossover function under one contractor, the Medicare Coordination of Benefits Contractor (COBC). As part of this streamlined process, COB trading partners, who are eligible to receive Medicare paid claims directly from CMS for purposes of calculating their secondary liability, will no longer have to sign separate agreements with individual Medicare carriers and intermediaries. Instead, each COB trading partner will:

These changes are the result of input from affected stakeholders in the health insurance industry and will result in a more effective implementation of the COBA process and more effective processes for Medicare providers to receive claim payments that are secondary to Medicare benefits. In addition, the revised COBA process will ensure that CMS fulfills the requirements imposed by the HIPAA ANSI-X12 835 (Electronic Remittance Advice (ERA)) Implementation Guide with respect to communication of crossover information to its Medicare providers and suppliers.

Eligibility-Based Crossover Process
As previously mentioned, national COBAs will now be executed with the COBC by the trading partners and trading partners will send COB eligibility files to the COBC. Trading partners that provide eligibility files will be assigned COBA IDs to facilitate the crossover process.

For an eligibility file-based crossover, the COBA ID of the trading partner, along with all other eligibility file data elements associated to an individual beneficiary, will be stored in Medicare’s Common Working File (CWF) in the recently established Beneficiary Other Insurance (BOI) auxiliary record. CWF will also house the COBA Insurance file that will contain specific information associated to the trading partner that is identified on the BOI auxiliary record. As Medicare claims are processed, CWF will be equipped to apply each COB trading partner’s claims selection criteria against the Medicare claims and provide information to the Medicare carrier or intermediary to enable those entities to place appropriate crossover claims information on the HIPAA ANSI X12N 835 Electronic Remittance Advice sent to providers and suppliers.

Claim-Based Crossover Process
For those Medigap and Medicaid insurers that do not provide COB eligibility files identifying beneficiaries that are insured by their plans, a claim-based crossover process will be implemented by October 4, 2004. Unique five-digit COBA IDs will be assigned by the COBC to Medigap and Medicaid insurers that do not provide eligibility files to the COBC. Medicare providers and suppliers will receive a listing of all Medigap and Medicaid insurers that have been assigned unique claim-based COBA IDs and will be responsible for entering the unique claim-based COBA IDs on each claim submitted to Medicare to initiate the crossing over of claims to the Medigap or Medicaid insurer for supplemental payment to the provider or supplier.

Through this instruction, Medicare claims processing systems will also be modified to house Medigap and Medicaid claim-based COBA IDs and the associated Medigap or Medicaid information necessary for the Medicare carrier or DMERC to prepare an ERA and send the claim to the COBC to cross to the Medigap or Medicaid insurer. The Part B or DME provider or supplier is required to include a claim-based COBA ID on incoming Medicare claims where:

Implementation
July 6, 2004

Because of this instruction’s impact on providers and suppliers, Carriers and DMERCs will not be required to implement the COBA claim-based crossover requirements described in this instruction until October 4, 2004. Effective October 4, 2004, all participating Part B and DME providers and suppliers will cease including the Carrier or DMERC-issued Medigap or Medicaid ID on incoming claims. Instead, they will begin to include the claim-based COBA ID, which will be assigned by Medicare’s Coordination of Benefits Contractor (COBC), on incoming claims. When Part B or DME providers or suppliers check the claim based COBA ID listing and locate the beneficiary’s identified Medigap plan, they shall include the Medigap claim-based COBA ID on the incoming claim if: 1) the provider or supplier participates in the Medicare Program; and 2) the beneficiary assigns (or has assigned) his/her rights to benefits to the provider or supplier. When Part B or DME providers or suppliers that participate in the Medicare Program check the claim-based COBA ID listing and locate the State Medicaid Agency that pays benefits for the beneficiary, they shall include the Medicaid claim-based COBA ID on the incoming claim.

As of October 4, 2004, CMS will require participating Part B and DME providers and suppliers to include the CMS-issued Medigap or Medicaid claim-based COBA ID on their submitted claims to Medicare if they wish to have their patients’ Medicare claims crossed over to the Medigap or Medicaid insurer that does not supply an eligibility file for their insured’s. (Section 70.6 of Chapter 28 of the Medicare Claims Processing Manual (Pub 100-04) has complete details concerning this requirement as well as other coordination of benefits procedures.)

Additional Information
You can find the Centers for Medicare & Medicaid Services (CMS) Program Manuals Index at the following CMS Web site: http://www.cms.hhs.gov/manuals/cmsindex.asp.

Also, the Medicare Claims Processing Manual (Pub 100-04) is located at the following CMS Web site: http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp

Chapter 28 of that manual may be found at: http://www.cms.hhs.gov/manuals/104_claims/clm104c28.pdf.

Additional Coordination of Benefits information can be found at: http://www.cms.hhs.gov/manuals/105_msp/msp105c04.pdf.

[EM 2004-0149]

(04-0755)

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PROVIDER ENROLLMENT - DELAYS IN PROCESSING PROVIDER APPLICATIONS 

QUESTIONS AND ANSWERS:

Over the past few months, questions have been raised by members of the healthcare community regarding the Medicare provider enrollment process and delays encountered with the process.  In order to address those inquiries, the following questions and answers are being provided to clarify the developments associated with provider enrollment.

Q: Why are providers and suppliers experiencing delays associated with processing their provider/supplier applications?
A:

On November 3, 2003, CMS’ Medicare carriers began using a new electronic database for recording and retaining enrollment data for providers/suppliers.  This electronic database is known as the Provider Enrollment, Chain and Ownership System (PECOS).  The PECOS system is the electronic implementation of a policy decision made by CMS in 1995, as a result of a CMS fraud and abuse initiative, “Operation Restore Trust”, to create a national, uniform business process for provider/supplier enrollment. 

The PECOS system was implemented for Medicare carriers on November 3, 2003; fiscal intermediaries began using the system in July 2002.  As of this date carriers were instructed to process any new enrollments and any changes in enrollment applications through PECOS.   While some carriers have backlogs that must be reduced, other carriers have handled the transition to PECOS with less difficulty.

In addition to issues directly related to PECOS implementation, there have been unanticipated CMS data center infrastructure issues that have caused system outages.  These unanticipated outages have made PECOS inaccessible to carrier staffs for certain periods of time.

Another factor is the learning curve staff is experiencing at our carriers.  This is a new, uniform business process, most times different from the way carriers processed provider enrollment applications in the past.  Ongoing training and support has been provided by CMS but, as with any change of this magnitude, it is anticipated that slowdowns in work processing will occur for a time.

Another factor that has caused delays is the budget process.  This fiscal year, CMS’ appropriation was held up in Congress.  As a result, CMS and its Medicare contractors were operating at a prior year continuing resolution levels until earlier this calendar year.
Q: What is CMS doing to resolve the delays associated with processing provider/supplier applications?
A:

CMS recently assembled a senior leadership team with accountability for resolving these delays.  This team is focusing on expeditiously resolving delays in processing provider enrollment applications.  Steps are being taken to address the backlogs and all options are being considered. 

Teams of representatives from CMS headquarters and regional offices and the PECOS system developers have been assembled and began conducting site visits to each Medicare carrier beginning the week of March 1, 2004.  These teams will have direct responsibility to provide on-site focused customer service to individual carriers to expeditiously resolve any issues related to PECOS and the provider enrollment business process so that delays in processing can be reduced or eliminated. 

On the CMS infrastructure front, CMS is working diligently to resolve CMS data system infrastructure issues that are causing outages in access to PECOS.  CMS is also in the process of addressing any current funding constraints so that carriers have the necessary resources to address the delays and reduce their inventories. 

The goal of CMS senior leadership is to have the backlog inventories reduced by the summer of 2004. 

[EM 2004-0186]

(04-0742)

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Follow-up Consultation Codes

Reviews of claims for CPT codes 99261 - 99263, Follow-up In-patient Consultation - established patient, have revealed a high rate of incorrect use of these codes. This suggests that many providers and coders may not have a clear understanding of the services described by these codes.

These codes are for use only in the in-patient hospital setting, or in a nursing facility. Follow-up consultations are visits to complete the initial consultation OR subsequent consultative visits requested by the attending physician. A follow-up consultation might include monitoring progress (but without assuming any portion of on-going care), recommending management modifications (but only recommending, with no direct involvement in patient management), or advising on a new plan of care in response to changes in the patient's status (again, only in an advisory capacity, with no assumption of direct responsibility for any portion of the management of the care).

If the physician consultant has assumed ANY portion of the management of the patient, or has initiated ANY treatment at the initial consultation, AND/OR participates in ANY WAY thereafter in the patient's management, the codes for subsequent hospital care (99231 - 99233) should be used for any visits after the initial consultation. Making daily visits to the patient is considered assuming part of the management of the patient, as it indicates regular, on-going involvement in management.

As an example, if the consultant writes or gives any order at the time of the initial consult, all encounters thereafter should be billed as subsequent hospital care. If the consultant at the time of the initial consultation indicates agreement with the attending physician's diagnosis and treatment plan, but writes no orders, and then returns after three days to monitor the progress and observes that the patient is doing well and should continue on the present course, and writes no orders, then that visit could be considered a follow-up consultation. Of course, all this must be properly documented.

If, in the above scenario, the consultant noted a problem at the second visit three days after the initial consultation, and noted that in the record and wrote an order, then that visit and all subsequent ones become subsequent hospital care (99213 - 99233). In all cases, a follow-up consultation and a subsequent hospital care visit require a face-to-face service by the billing provider. In most cases, a follow-up consultation will require another request from the attending for the consultant to see the patient.

We hope this clarifies the appropriate use of the CPT codes for follow-up consultation codes, 99261 - 99263.

(04-0739)

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Frequency Limitations for Darbepoetin Alfa (trade name Aranesp) for Treatment of Anemia in End Stage Renal Disease (ESRD) Patients on Dialysis

Provider Types Affected
Renal Dialysis Facilities.

Provider Action Needed

STOP – Impact to You
Medicare is instituting new frequency limitations for treatment of ESRD patients on dialysis with Darbepoetin Alfa (trade name Aranesp).

CAUTION – What You Need to Know
Be aware of these frequency limitations to assure correct and timely payment for services supplied to Medicare patients.

GO – What You Need to Do
Make sure you understand the changes effective for services provided on and after April 1, 2004, for the frequency limitations on Darbepoetin Alfa for ESRD.

Background
Section 1881(b) (11) (B) of the Social Security Act states that payment will be provided for erythropoietin when a patient diagnosis is ESRD. Darbepoetin Alfa, a new erythropoietin-like product, differs from Epoetin Alfa by the addition of two carbohydrate chains, which lengthens the biologic half-life. This change affects how often the biological can be administered and results in a decreased dosing schedule for Darbepoetin Alfa by comparison to Epoetin Alfa.

Additional Information
This notice establishes frequency limitations for darbepoetin alfa, and also reiterates the frequency
limitations for Epoetin Alfa (trade name EPO) will remain the same. You can refer back to CR2963 for the payment guidelines on Darbepoetin Alfa (trade name Aranesp).

That CR may be found at http://www.cms.hhs.gov/manuals/pm_trans/R39OTN.pdf

Please note that this notice does not apply to physicians’ payments for Aranesp or EPO; those payments are established in the Drug Payment Limits Pricing File, set by the Medicare Prescription Drug, Modernization, and Improvement Act of 2003.

According to its FDA-approved labeling, Darbepoetin Alfa is to be given once a week, up to a maximum of five times for a calendar month (30/31 days). Coverage rules for Darbepoetin Alfa are the same as Epoetin Alfa for ESRD-related anemia.

To view the actual change request related to this article (CR2984), go to http://www.cms.hhs.gov/manuals/pm_trans/R8BP.pdf

[EM 2004-00189/2984]
(04-0800)


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Helpful Hint to Providers Regarding Appeals and ABNs

When you write in to request a review (or redetermination - new terminology coming into effect in July 2004), on a service that was denied for “medical necessity” and you have, prior to rendering the service, given your patient an Advanced Beneficiary Notice (ABN), we suggest that in order to streamline the review process you include a copy of that ABN with your appeal request.

If the review upholds the original denial, and your claim indicates (e.g., via the GA modifier) you gave your patient an ABN, we will be requesting a copy of that ABN to determine assignment of liability. We will review the ABN to make this determination. If the ABN is valid and properly executed, the patient will be held liable for the service. If you do not provide a copy of the ABN upon request, or if the ABN you provide is not valid or properly executed, then the liability for the service will shift to you, the provider. If you have included a copy of your ABN with your appeal, it will speed up the review process to some extent.

Please understand that we are not saying that you must include an ABN (if you have one) with your appeal request. If it becomes necessary for us to review your ABN as a part of the review process, we will request a copy if you have not included it with your request.

NOTE: If a service was previously denied for medical necessity and is allowed upon review, there is no issue of determining liability. Medicare’s coverage of the service means Medicare has assumed normal liability for the service (i.e., appropriate rate of payment after the patient has satisfied their deductible for the calendar year). In this situation, an ABN will not be reviewed even if it was included with the appeal request.

For information regarding valid ABN forms and their proper execution, please refer to one or more of the following sources:

The CIGNA Government Services Web site at the following URL: www.cignamedicare.com/articles/nov02/ws0392.html

The CIGNA Part B Medicare Bulletin for December 2002 or

The CMS.gov Web site at the following URL:
http://www.cms.gov/manuals/pm_trans/AB02168.pdf

(04-0806)

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MMA - New Part B Annual Deductible

Providers Affected
Physicians, suppliers, and providers.

Provider Action Needed
Physicians, suppliers, and providers should note that, effective January 1, 2005, the Supplementary
Medical Insurance (SMI) or Medicare Part B deductible will be $110. These providers should assure that their billing processes are adjusted to handle this change in the Medicare Part B deductible.

Background
Medicare Part B helps beneficiaries pay for physician’s services, diagnostic tests, ambulance services,
durable medical equipment, and other health services, and the beneficiary is responsible for the first
$100.00 deductible of Medicare Part B approved charges each calendar year, i.e. their annual deductible.

For calendar years 1991 through 2004, the Medicare Part B annual deductible has been $100. Beginning in 2005, the Medicare Part B deductible will be $110 (based on Section 629 of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA)).

Implementation
This change is effective on January 1, 2005, and the implementation date in Medicare claims processing systems will be January 3, 2005.

Related Instructions
The Medicare General Information, Eligibility, and Entitlement Manual Chapter 3 (Deductibles, Coinsurance Amounts, and Payment Limitations, Section 20 (Supplementary Medical Insurance (SMI) (Part B), Subsection 20.2 (Part B Annual Deductible) has been revised and is included below with changes bolded and italicized. 20.2 - Part B Annual Deductible - (Rev.)

In each calendar year, a cash deductible must be satisfied before payment can be made under SMI. (See 20.4 of this chapter for exceptions.)

• For 2005, and until further notice, the deductible is $110.
• From 1991 through 2004, the deductible is $100.
• From 1982 through 1990, the deductible was $75.
• From 1973 through 1981, the deductible was $60.
• From 1966 through 1972, the deductible was $50.

Expenses count toward the deductible on the basis of incurred, rather than paid expenses, and are based on Medicare allowed amounts. Non-covered expenses do not count toward the deductible. Even though an individual is not entitled to Part B benefits for the entire calendar year (i.e., insurance coverage begins after the first month of a year or the individual dies before the last month of the year), he or she is still subject to the full deductible for that year. Medical expenses incurred in the portion of the year preceding entitlement to medical insurance are not credited toward the deductible.

The date of service generally determines when expenses were incurred, but expenses are allocated to the deductible in the order in which the bills are received. Services that are not subject to the deductible cannot be used to satisfy the deductible.

Additional Information
You can find the Centers for Medicare & Medicaid Services (CMS) Program Manuals Index at the following CMS Web site http://www.cms.hhs.gov/manuals/cmsindex.asp

Also, the Medicare General Information, Eligibility, and Entitlement Manual is located at the following CMS Web site http://www.cms.hhs.gov/manuals/101_general/ge101index.asp

[EM 2004-0199/3121]

(04-0761)

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MMA Drug Pricing Update—Drug Exceptions


Provider Types Affected
Physicians and suppliers.

Provider Action Needed
Physicians and suppliers should note that the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), (Section 303(b)(2)), created a process for increasing the 2004 payment limits for some Medicare Part B drugs and biologicals provided from April 1, 2004, through December 31, 2004.This instruction identifies those drugs and biologicals granted increases under this process and their new payment amounts.

Background
MMA. (Section 303(b)(2)), provides an opportunity for the manufacturer of a drug to submit data and information requesting a different percentage than the percentage the Centers for Medicare & Medicaid Services (CMS) published in the Federal Register notice on January 7, 2004, or the 85 percent general rule.

Based on this data and information provided by the drug manufacturer, CMS may adjust the percentage beginning April 1, 2004, as appropriate for such granted exceptions.

These exceptions are described in the following table:

HCPCS Short Description AWP% New 2004 Payment
Limit
J2353 Octreotide acetate injection 92 $77.14
J3240 Thyrotropin injection 90 $585.65
J3395 Verteporfin injection 91 $1,404.26
J7320 Hylan G-F injection 83 $204.03
J7342 Metabolically active tissue 89 $14.42
J9045 Carboplatin injection 88 $137.54
J9201 Gemcitabine HCl 87 $111.33
J9206 Irinotecan injection 85 $130.24
Q3025 IM inj interferon beta 1-a 89 $80.22

Note that the absence or presence of a HCPCS code and its associated payment limit does not indicate
Medicare coverage of the drug.

Implementation
The implementation date for this instruction is April 5, 2004.

Related Instructions
The official instruction issued to your carrier regarding this change may be found by going to the CMS Website http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp
From that Web page, look for CR3161 in the CR NUM column on the right, and click on the file for that CR. If you have any questions, please contact your carrier at their toll-free number, which may be found at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

[EM 2004-0204/3161]

(04-0773)

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MMA-Implementation of Section 414 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)

Providers Affected
Ambulance suppliers

Provider Action Needed

STOP – Impact to You
The new Medicare Prescription Drug, Improvements, and Modernization Act of 2003 (MMA) makes a number of important changes to Medicare payment for ambulance services rendered on or after July 1, 2004.

CAUTION – What You Need to Know
During the five-year period, July 1, 2004 – December 31, 2009, the Fee Schedule will include certain temporary increases in payments.

GO – What You Need to Do
Make sure your billing staff understands the new changes and bill according to those changes to assure receipt of accurate payment.

Background
The MMA provides several changes to the payment for ground ambulance services under Section 414 of the Act. Specifically, this section establishes a floor amount for the fee schedule portion of the payment, provides increased payments for urban and rural services, adds an increased payment for ambulance transports originating in certain low density population areas, and provides a 25 percent bonus on the mileage rate for ground transports of 51 miles or greater. These payment changes apply to ground transports only and the air ambulance base rates and mileage rates remain unchanged.

Regional Ambulance FS Payment Rate Floor for Ground Ambulance Transports
To discuss these changes further, we begin with the provision regarding the regional ambulance fee
Schedule (FS) payment rate floor for ground transport services. For services furnished during the period of July 1, 2004, through December 31, 2009, the base rate portion of the payment under the ambulance FS for ground transports is subject to a minimum amount. This minimum depends upon the area of the country in which the service is furnished. Basically, the country is divided into 9 census divisions and each of those divisions has a regional FS that is constructed using the same methodology as the national FS. Where the regional FS is greater than the national FS, the base rates for ground ambulance transports are determined by a blend of the national FS rate and the regional rate in accordance with the following schedule:

Year National FS Percentage Regional FS Percentage
7/1/04-12/31/04 20% 80%
CY 2005 40% 60%
CY 2006 60% 40%
CY 2007-CY 2009 80% 20%
CY 2010 and thereafter 100% 0%

Where the regional rate is not greater than the national rate, there is no blending and only the national FS amount applies.

Adjustment to the Ground Mileage Payment Amount for Miles Greater than 50
For services furnished during the period July 1, 2004, through December 31, 2008, a 25 percent increase is applied to the appropriate ambulance FS mileage rate for each mile of a transport (both urban and rural points of pickup (POP) that exceeds 50 miles (i.e., 51 miles or greater) when the beneficiary is onboard the ambulance.

Adjustments for FS Payment Rate for Certain Rural Ground Ambulance Transports
For services furnished during the period July 1, 2004, through December 31, 2009, the base rate of the
payment under the FS for ground ambulance transports furnished in certain rural areas is increased by an amount determined by the Centers for Medicare & Medicaid Services (CMS). This increase applies where the POP is in a rural county (or Goldsmith Area) that is comprised by the lowest quartile by population of all such rural areas arrayed by population density.

Adjustments for FS Payment Rates for Ground Ambulance Transports
The payment rates under the FS for ground ambulance transports (both the FS base rates and the mileage amounts) are increased for services furnished during the period of July 1, 2004, through December 31, 2006. For services furnished where the POP is urban, the rates are increased by 1 percent and for services furnished where the POP is rural, the rates are increased by 2 percent.

Important Dates
These changes will sunset on different dates but all apply beginning with services furnished on July 1,
2004.

Additional Information
For further information, you may wish to view the actual instruction issued to your Medicare contractor. That instruction can be seen at http://www.cms.hhs.gov/manuals/pm_trans/R88CP.pdf

[EM 2004-0097/3099]

(04-0751)

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NCD: Current Perception Threshold/Sensory Nerve Conduction Threshold Test (sNCT)

Provider Types Affected
Physicians, suppliers, and providers.

Provider Action Needed
Providers should be aware that the Centers for Medicare & Medicaid Services (CMS) have reviewed its policy on sNCT and reaffirms its original national non-coverage decision on sNCT.

Background
Based on a reconsideration of current Medicare policy for sNCT, CMS reaffirms its original national noncoverage policy regarding Current Perception Threshold/Sensory Nerve Conduction Threshold Test (sNCT). The National Coverage Determination Manual (Pub. 100-03; Chapter 1; Subsection 160.23) has been updated to reflect this most recent non-coverage determination as a result of the reconsideration review.

Please note that the revision to the National Coverage Determination Manual is a National Coverage
Determination (NCD) and NCDs are binding on all Medicare carriers, fiscal intermediaries, quality
improvement organizations, health maintenance organizations, competitive medical plans, and health care prepayment plans.

Also, under 42 Code of Federal Regulations (CFR) 422.256(b), an NCD that expands coverage is also
binding on Medicare+Choice Organizations. In addition, an administrative law judge may not review an NCD. (See §1869(f)(1)(A)(i) of the Social Security Act.)

Implementation
The effective and implementation dates of this instruction are April 1, 2004.

Additional Information
The official instruction issued to your carrier regarding this change may be found by going to:
http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

On that Web page, look for CR2988 in the CR NUM column on the right, and click on the file for that CR. The revised portions of the NCD Manual are included with that CR.

[EM 2004-0220/2988]

(04-0801)

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Online Medicare Participating Physicians and Suppliers Directory (MEDPARD)Provider Types Affected


In an ongoing effort to provide Medicare beneficiaries with information to assist them in making health care choices, the Centers for Medicare & Medicaid Services has a Participating Physician Directory. The directory contains the names, addresses, telephone numbers and specialties of Medicare participating physicians, practitioners and suppliers who have agreed to accept assignment on all Medicare covered services. In addition, the directory contains information about the physician’s medical school attended, year of graduation, any board certification in a medical specialty, gender, and hospitals at which the physician has admitting privileges. The directory is updated monthly and includes any foreign language capabilities of the physician. The directory can be found on the Centers for Medicare & Medicaid Services Web site at www.medicare.gov, and the CIGNA Government Services’s Part B Web site at www.cignamedicare.com/medicare_dynamic/medpard/index.html. The directory is available at no cost to the public.

Any questions regarding the MEDPARD should be addressed to CIGNA Government Services’s Customer Service Units:
· Idaho - 866.502.9051
· North Carolina - 866.238.9651
· Tennessee - 866.502.9056

[EM 2003-0990/2889]

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Ordering and Performing Psychotherapy Services in Nursing Facilities 

Probe reviews identified that numerous psychotherapy services are ordered and delivered on a continuous basis (month after month), for several years. For most patients, there is no documentation of medical necessity by the referring physician for these services. Many patients have been seen for psychotherapy services 6-8 times per month for over two years, and there is no indication that the referring provider has re-assessed them. Consequently, no efforts are being made to modify the therapy, including the frequency of the sessions.

Standing orders for psychotherapy are not acceptable by Medicare. Each order must be specific and address the patient's individual situation at a specific point in time in the course of an episode of illness. The referring provider must document progress and the rationale why the therapy is being continued. In situations when prolonged treatment, in excess of 20 sessions, for example, has no evident benefit, it would be considered not medically necessary and not payable by Medicare.

When prescribing, renewing, or rendering psychotherapy services in nursing facilities and other places of service, providers should be attentive to the following issues (this is not an all inclusive list):

  1. A treatment plan must be formulated and adhered to. The rationale for any departure from the plan or extension of therapy needs to be documented in the medical record.
  2. Activities of daily living (ADLs), sadness about nursing home placement (a recognized common problem not to be belittled), roommate conflicts, and the like, are not covered indications for psychotherapy. Providing mental health support for these and similar situations generally does not require the specialized skills of a therapist and is included in the services usually required from the facility.
  3. The services must exceed the kind of advice a friend, a family member, or a nursing home employee could usually provide. Otherwise stated, the specialized services of a mental health care professional must be required.
  4. Team conferences with the facility staff about the patient are not covered and are not to be billed to Medicare.
  5. It is the standard of practice and Medicare's expectation that the request for services/consultation, whether initial or on-going, is made by the treating physician. It cannot come from the facility staff.
  6. There must be patient/therapist interaction. The therapist cannot only document his/her assessment of the patient's problems. There must be an indication that the patient has voiced these problems during the session.
  7. The therapist must document his/her interventions and the patient's response to them. In other words, if a code descriptor calls for insight oriented, behavior modifying and/or supportive psychotherapy, the provider must document, among other things, as to what the behavior modifying interventions were and how the patient responded to them.
  8. The patient must be amenable to therapy. If a cognitive defect is present, it must not be severe enough to prevent establishment of a relationship with the therapist that would allow insight-oriented therapy to be effective. Somnolent patients are not candidates for psychotherapy.
  9. Many patients are seen at a high frequency, usually eight times per month, for prolonged periods of time, but there is no indication of improvement or changes in their condition. If psychotherapy is not helpful in the long term, discontinuation is appropriate. Similarly, patients who improve may require less frequent sessions.
  10. It must be evident that during the course of an episode of illness there is communication and coordination between the psychiatrist, who directs the drug management, and the psychotherapist. This is to avoid duplication of efforts and to guard against adverse effects of concurrent and potentially competing interventions.
  11. The notes must be legible.

The provider rendering psychotherapy services should be guided by the following general questions and considerations:

These principles also apply to the provider evaluating the patient, establishing the need, and requesting psychotherapy services. From a medical review and billing perspective, the assessment of a patient for whom psychotherapy is ordered/renewed is a reflection of the evaluation and management services rendered to this patient and speaks to the key components of the E/M codes billed by the referring provider, specifically the complexity of the decision making process.

(04-0767)

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Radiofrequency Energy Delivery to the Gastroesophageal Junction (The Stretta Procedure)* 

The Stretta procedure is an endoluminal treatment for Gastroesophageal Reflux Disease (GERD) in which radiofrequency energy is delivered to smooth muscle of the lower esophageal sphincter (LES). A flexible catheter equipped with special needle electrodes for precise energy delivery is placed by mouth into the esophagus and carefully controlled radiofrequency energy is then delivered to the LES and gastric cardia, creating thermal lesions. It is believed that the changes that occur immediately, and over time, result in a "tighter" LES and a less compliant gastric cardia. Additionally, the interruption of nerve pathways in the LES area is believed to reduce the incidence of inappropriate LES relaxations, leading to an improvement in GERD symptoms.

In the absence of a National Coverage Determination (NCD) or Local Medical Review Policy (LMRP), claims will be adjudicated on a case-by-case basis. This carrier will evaluate medical reasonableness and necessity based on the following:

1. Criteria that may support medical necessity for the Stretta Procedure

  1. inadequate symptom improvement while on a properly escalated anti-secretory regimen for at least one year, or
  2. intolerance to anti-secretory therapy, or
  3. an unwillingness/inability to continue a long-term high-dose anti-secretory regimen because of accepted medical reasons, such as potential drug interactions, co-morbidities, etc., and

2. GERD confirmed by

  1. pathologic esophageal acid exposure, or
  2. biopsy proven esophagitis, or
  3. gross evidence of esophagitis, or
  4. Barretts metaplasia, and

3. The patient is not a candidate for a surgical anti-reflux procedure.

According to current literature and expert opinion, the following would be considered as exclusion criteria for the Stretta Procedure:

i. Age less than 14,
ii. pregnancy,
iii. hiatal hernia > 3 cm,
iv. achalasia or incomplete LES relaxation in response to swallow
v. poor surgical candidate, ASA IV Classification,
vi. Barretts metaplasia (> 2 cm),
vii. active esophagitis grades III or IV by Savary criteria,
viii. collagen vascular disease.

The Stretta Procedure should be coded using the appropriate Category III Code, 0057T, which became effective January 1, 2004:

0057T - Upper gastrointestinal endoscopy, including esophagus, stomach, and either the duodenum and/or jejunum as appropriate, with delivery of thermal energy to the muscle of the lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease.

This code is all inclusive of the endoscopy portion of the procedure and the delivery of the radiofrequency energy.

Billing Guidelines:

Providers should not submit any medical record documentation with the initial claim. Upon receipt of the claim, CIGNA Government Services will solicit additional documentation by means of an Additional Documentation Request (ADR) letter. Providers who qualify for the exception to bill on paper and elect to do so, should insert "Stretta Procedure" in Field 19 of Form CMS 1500. Electronic billers should enter "Stretta Procedure" in the NTE segment (notes and comment segment). This is the electronic equivalent for Field 19 of Form CMS 1500 in HIPAA compliant transactions.

This article updates and supersedes an article with the same title published on our Web site on May 28, 2003. The revision consists of the introduction of code 0057T, amended coding and billing instructions, and the addition of the evaluation criterion of medical reasonableness and necessity that the patient is not a candidate for a surgical anti-reflux procedure.

*This article replaces: Radiofrequency Energy Delivery to the Gastroesophageal Junction (The Stretta Procedure) published 06/01/2003, Article database ID# A1841.

(04-0754)

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Updated Policy and Claims Processing Instructions for Ambulatory Blood Pressure Monitoring (ABPM)

Provider Types Affected
Physicians, Hospitals, Critical Access Hospitals (CAHs), Comprehensive Outpatient Rehabilitation Facilities (CORFs), Skilled Nursing Facilities (SNFs), Federally Qualified Health Centers (FQHCs), and Rural Health Clinics (RHCs).

Provider Action Needed

STOP – Impact to You
Medicare has expanded payment for ABPM to include HCPCS code 93788 in addition to the three HCPCS codes already payable. (HCPCS code 93788 is defined as “ABPM utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; scanning analysis with report.”) ABPM is only payable for patients with suspected “white coat hypertension” (WCH). Note: This is designated as an outpatient service; patients admitted to a hospital or residing in institutions (such as SNFs) who receive ABPM are not qualified for coverage. Additionally, if ABPM must be performed more than once for a particular beneficiary, the qualifying criteria (described in the Background section) must be met for each subsequent ABPM test.

CAUTION – What You Need to Know
ABPM involves the use of a non-invasive devise to measure blood pressure in 24-hour segments, the results of which are stored in the device and interpreted later by a physician. To be covered, ABPM must be performed for at least a 24-hour time period; the diagnosis code 796.2 (Elevated blood pressure reading without diagnosis of hypertension) must be used; and the results must be interpreted by a physician.

GO – What You Need to Do
Refer to the Additional Information section for HCPCS code information by provider type specific to ABPM for suspected WCH FI and for carrier billing instructions, which can be found in the Medicare Claims Processing Manual, Chapter 32, and in CR 2726, at: http://www.cms.hhs.gov/manuals/pm_trans/R109CP.pdf

Background

The qualifying criteria for white coat hypertension include:

  1. Clinic/office blood pressure >140/90 mm Hg on at least three separate clinic/office visits with two
    separate measurements made at each visit;

  2. At least two documented separate blood pressure measurements taken outside the clinic/office which are <140/90 mm Hg; and
  3. No evidence of end-organ damage.

Additional Information
When a claim for ABPM is made, the diagnosis code 796.2 (Elevated blood pressure reading without
diagnosis of hypertension) must be used. Additionally, the effective dates for applicable HCPCS codes for ABPM for suspected WCH are as follows:

HCPCS Definition Effective Date
93784 ABPM, utilizing a system
such as magnetic tape and/or
computer disk, for24 hours
or longer, including recording,
scanning analysis, interpretation
and report. 		04/01/2002
93786 ABPM, utilizing a system
such as magnetic tape and/or
computer disk, for24 hours
or longer; recording only. 		04/01/2002
93788 ABPM, utilizing a system
of magnetic tape and/or
computer disk, for 24hours
or longer; scanning analysis
with report. 		01/01/2004
93790 ABPM, utilizing a system
such as magnetic tape and/or
computer disk, for24 hours or
longer; physician review with
interpretation and report. 		04/01/2002

The above HCPCS codes can be billed by the following providers, for outpatients, as specified below:

The official instruction issued to your carrier regarding this change may be found by going to:
http://www.cms.hhs.gov/manuals/pm_trans/R109CP.pdf

You may also refer to Medicare National Coverage Determinations Manual, Chapter 1, Section 20.19,
which may be found at http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp

[EM 2004-0161/2726]

(04-0816)

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Order Influenza Vaccine Now

In order to ensure the availability of influenza vaccine for administration early in the Fall of 2004, physicians and providers should begin to order supplies of influenza vaccine immediately. Last year, large numbers of cases of influenza began to appear in October, and activity was widespread. Anticipation of increased demand for vaccine in the Fall of 2004 makes it imperative that physicians and providers who care for Medicare beneficiaries and others at high risk for complications from influenza begin to prepare for the 2004-2005 influenza season immediately.

While the recently enacted Medicare Prescription Drug, Improvement and Modernization Act of 2003 changed the Medicare payments for many covered drugs and biologicals, the basis for Medicare payment of influenza vaccine will continue to be 95% of the average wholesale price.

[2004-0238]

(04-0787)

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Payment for Services Provided Under a Contractual Agreement

The instructions on reassignment have been revised to expand the locality for which payment may be made for services provided under a contractual agreement.

The revised instructions allow carriers to make payments to an entity (i.e., a person, group, or facility) that is enrolled in the Medicare program and that submits claims for services provided by a physician or other person under a contractual arrangement with that entity, regardless of where the services are rendered. Therefore, services may be rendered on or off the premises of the entity submitting the bill. The contractual arrangement between the entity and the physician or other person should include the following program integrity safeguards:

  1. Joint and several liabilities are shared between the entity submitting the claim and the person actually furnishing the service, for any Medicare overpayment relating to such claim.
  2. The person furnishing the service has unrestricted access to claims submitted by the entity for the services provided by that person.

[EM 2004-0163/3083]

(04-0737)

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Pronouncement of Death 

Medicare allows reimbursement for the services associated with the pronouncement of death. According to established legal principles, an individual is not considered deceased until there has been official pronouncement of death. An individual is therefore considered to have expired as of the time he/she is pronounced dead by a person who is legally authorized to make such a pronouncement, usually a physician. Reasonable and necessary medical services rendered up to and including pronouncement of death by a physician are covered diagnostic or therapeutic services. [CMS Manual System, Pub 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 70.4 (http://www.cms.hhs.gov/manuals)]
There is no specific code for the pronouncement of death. To be reimbursable by Medicare, a service must be billed using the CPT code that most accurately describes the work performed. Accordingly, this carrier will accept the code that best describes the services rendered to an individual patient during the pronouncement of death. This may include the hospital discharge codes (CPT Codes 99238 and 99239), as long as the provisions of the code descriptor are met as documented in the medical record.

This publication supersedes the article “Hospital Discharge with Expired Patient,” published in a previous Medicare Bulletin, General Release 99-3, May/June 1999.

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