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June 2004 Part B Medicare Bulletin

Table of Contents


INSERT TOPICS - June 2004
  Idaho Insert
North Carolina Insert
Tennessee Insert

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  June 2004 - Idaho (2.3MB)
June 2004 - North Carolina (2.3MB)
June 2004 - Tennessee (2.4MB)

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Part B Not Otherwise Classified Drug Fee Schedule

The most current version of this document is available on the Part B Fee Schedule Index. If you need a copy of the document as it was originally published, please refer to the PDF copy of this Medicare Bulletin.

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2004 Jurisdiction List

HCPCS DESCRIPTION JURISDICTION
A0021 - A0999 Ambulance Services Local Carrier
A4206 - A4209 Medical, Surgical, and Self-Administered Injection Supplies Local Carrier if incident to a physician's service (not separately payable).  If other DME REGIONAL Carrier.
A4210 Needle Free Injection Device DME REGIONAL Carrier
A4211  Medical, Surgical, and Self-Administered Injection Supplies Local Carrier if incident to a physician's service (not separately payable).  If other DME REGIONAL Carrier.
A4212 Non Coring Needle or Stylet with or without Catheter Local Carrier
A4213 - A4215 Medical , Surgical, and Self-Administered Injection Supplies Local Carrier if incident to a physician's service (not separately payable). If  other DME REGIONAL Carrier.
A4216 - A4217 Saline Local Carrier if incident to a physician's service (not separately payable). If  other DME REGIONAL Carrier.
A4220 Refill Kit for Implantable Pump Local Carrier
A4221 - A4250 Medical, Surgical, and Self-Administered Injection Supplies Local Carrier if incident to a physician's service (not separately payable).  If other DME REGIONAL Carrier.
A4253 - A4259 Diabetic Supplies DME REGIONAL Carrier
A4260 Levonorgestrel Implant Local Carrier
A4261 Cervical Cap for Contraceptive Use Local Carrier
A4262 - A4263 Lacrimal Duct Implants Local Carrier
A4265 Paraffin Local Carrier if incident to a physician's service (not separately payable).  If other DME REGIONAL Carrier.
A4266 - A4269 Contraceptives Local Carrier
A4270 Endoscope Sheath Local Carrier
A4280 Accessory for Breast Prosthesis DME REGIONAL Carrier
A4281 - A4286 Accessory for Breast Pump DME REGIONAL Carrier
A4290 Sacral Nerve Stimulation Test Lead Local Carrier
A4300 - A4301 Implantable Catheter Local Carrier
A4305 - A4306 Disposable Drug Delivery System Local Carrier if incident to a physician's service (not separately payable).  If other DME REGIONAL Carrier.
A4310 - A4359 Incontinence Supplies/Urinary Supplies If provided in the physician's office for a temporary condition, the item is incident to the physician's service & billed to the Local Carrier. If provided in the physician's office or other place of service for a permanent condition, the item is a prosthetic device & billed to the DME REGIONAL Carrier.
A4361 - A4434 Ostomy Supplies If provided in the physician's office for a temporary condition, the item is incident to the physician's service & billed to the Local Carrier. If provided in the physician's office  or other place of service for a permanent condition, the item is a prosthetic device & billed to the DME REGIONAL Carrier.
A4450 - A4455 Tape;Adhesive Remover Local Carrier if incident to a physician's service (not separately payable).  If other DME REGIONAL Carrier.
A4458 Enema Bag DME REGIONAL Carrier
A4462 Abdominal Dressing Local Carrier if incident to a physician's service (not separately payable). If other DME REGIONAL Carrier.
A4465 Non-elastic Binder for Extremity DME REGIONAL Carrier
A4470 Gravlee Jet Washer Local Carrier
A4480 Vabra Aspirator Local Carrier
A4481 Tracheostomy Supply Local Carrier if incident to a physician's service (not separately payable). If other DME REGIONAL Carrier.
A4483 Moisture Exchanger DME REGIONAL Carrier
A4490 - A4510 Surgical Stockings DME REGIONAL Carrier
A4521 - A4538 Diapers DME REGIONAL Carrier
A4550 Surgical Trays Local Carrier
A4554 Disposable Underpads DME REGIONAL Carrier
A4556 - A4558 Electrodes; Lead Wires; Con-ductive Paste Local Carrier if incident to a physician's service (not separately payable).  If other DME REGIONAL Carrier.
A4561 - A4562 Pessary Local Carrier
A4565 Sling Local Carrier
A4570 Splint Local Carrier
A4575 Topical Hyperbaric Oxygen Chamber, Disposable DME REGIONAL Carrier
A4580 - A4590 Casting Supplies & Material Local Carrier
A4595 TENS Supplies Local Carrier if incident to a physician's service (not separately payable). If other DME REGIONAL Carrier.
A4606 Oxygen Probe for Oximeter DME REGIONAL Carrier
A4608 Transtracheal Oxygen Catheter DME REGIONAL Carrier
A4609 - A4610 Tracheal Suction Catheter DME REGIONAL Carrier
A4611 - A4613 Oxygen Equipment Batteries and Supplies DME REGIONAL Carrier
A4614 Peak Flow Rate Meter Local Carrier if incident to a physician's service (not separately payable). If other DME Regional Carrier.
A4615 - A4629 Oxygen & Tracheostomy Supplies Local Carrier if incident to a physician's service (not separately payable).  If other DME REGIONAL Carrier.
A4630 - A4640 DME Supplies DME REGIONAL Carrier
A4641 - A4646 Imaging Agent; Contrast Material Local Carrier
A4647 Contrast Material Local Carrier
A4649 Miscellaneous Surgical Supplies Local Carrier if incident to a physician's service (not separately payable).  If other DME REGIONAL Carrier.
A4651 - A4932 Supplies for ESRD DME REGIONAL Carrier
A5051 - A5093 Additional Ostomy Supplies If provided in the physician's office for a temporary condition, the item is incident to the physician's service & billed to the Local Carrier. If provided in the physician's office  or other place of service for a permanent condition, the item is a prosthetic device & billed to the DME REGIONAL Carrier.
A5102 - A5200 Additional Incontinence and Ostomy Supplies If provided in the physician's office for a temporary condition, the item is incident to the physician's service & billed to the Local Carrier. If provided in the physician's office  or other place of service for a permanent condition, the item is a prosthetic device & billed to the DME REGIONAL Carrier.
A5500 - A5511 Therapeutic Shoes DME REGIONAL Carrier
A6000 Non-Contact Wound Warming Cover DME REGIONAL Carrier
A6010-A6024 Surgical Dressing Local Carrier if incident to a physician's service (not separately payable) or if supply  for implanted prosthetic device or implanted DME.  If other DME REGIONAL Carrier.
A6025 Silicone Gel Sheet Local Carrier if incident to a physician's service (not separately payable) or if supply  for implanted prosthetic device or implanted DME.  If other DME REGIONAL Carrier.
A6154 - A6411 Surgical Dressing Local Carrier if incident to a physician's service (not separately payable) or if supply  for implanted prosthetic device or implanted DME. If other DME REGIONAL Carrier.
A6412 Eye Patch Local Carrier if incident to a physician's service (not separately payable) or if supply  for implanted prosthetic device or implanted DME.  If other DME REGIONAL Carrier.
A6441 - A6512 Surgical Dressings Local Carrier if incident to a physician's service (not separately payable) or if supply  for implanted prosthetic device or implanted DME.  If other DME REGIONAL Carrier.
A6550 - A6551 Supplies for Negative Pressure Wound Therapy Electrical Pump DME REGIONAL Carrier
A7000 - A7039 Accessories for Nebulizers, Aspirators, and Ventilators DME REGIONAL Carrier
A7042 - A7043 Pleural Catheter Local Carrier
A7044 - A7046 Respiratory Accessories DME REGIONAL Carrier
A7501-A7526 Tracheostomy Supplies DME REGIONAL Carrier
A9150  Non-Prescription Drugs Local Carrier
A9270 Noncovered Items or Services DME REGIONAL Carrier
A9280 Alarm Device DME REGIONAL Carrier
A9300 Exercise Equipment DME REGIONAL Carrier
A9500 - A9700 Supplies for Radiology Procedures Local Carrier
A9900  Miscellaneous DME Supply or Accessory Local Carrier if used with implanted DME. If other, DME REGIONAL Carrier.
A9901 Delivery DME REGIONAL Carrier
A9999 Miscellaneous DME Supply or Accessory Local Carrier if used with implanted DME. If other, DME REGIONAL Carrier.
B4034 - B9999 Enteral and Parenteral Therapy DME REGIONAL Carrier
D0120 - D9999 Dental Procedures Local Carrier
E0100 - E0105 Canes DME REGIONAL Carrier
E0110 - E0118 Crutches DME REGIONAL Carrier
E0130 - E0159 Walkers DME REGIONAL Carrier
E0160 - E0175 Commodes DME REGIONAL Carrier
E0176 - E0199 Decubitus Care Equipment DME REGIONAL Carrier
E0200 - E0239 Heat/Cold Applications DME REGIONAL Carrier
E0240 - E0248 Bath and Toliet Aids DME REGIONAL Carrier
E0249 Pad for Heating Unit DME REGIONAL Carrier
E0250 - E0304 Hospital Beds DME REGIONAL Carrier
E0305 - E0326 Hospital Bed Accessories DME REGIONAL Carrier
E0350 - E0352 Electronic Bowel Irrigation System DME REGIONAL Carrier
E0370 Heel Pad DME REGIONAL Carrier
E0371 - E0373 Decubitus Care Equipment DME REGIONAL Carrier
E0424 - E0484 Oxygen and Related Respiratory Equipment DME REGIONAL Carrier
E0500 IPPB Machine DME REGIONAL Carrier
E0550 - E0585 Compressors/Nebulizers DME REGIONAL Carrier
E0590 Drug Dispensing Fee DME REGIONAL Carrier
E0600  Suction Pump DME REGIONAL Carrier
E0601 CPAP Device DME REGIONAL Carrier
E0602 - E0604 Breast Pump DME REGIONAL Carrier
E0605 Vaporizer DME REGIONAL Carrier
E0606 Drainage Board DME REGIONAL Carrier
E0607  Home Blood Glucose Monitor DME REGIONAL Carrier
E0610 - E0615 Pacemaker Monitor DME REGIONAL Carrier
E0616 Implantable Cardiac Event Recorder Local Carrier
E0617 External Defibrillator DME REGIONAL Carrier
E0618 - E0619  Apnea Monitor DME REGIONAL Carrier
E0620 Skin Piercing Device DME REGIONAL Carrier
E0621 - E0636 Patient Lifts DME REGIONAL Carrier
E0637 - E0638 Standing Devices DME REGIONAL Carrier
E0650 - E0675 Pneumatic Compressor and Appliances DME REGIONAL Carrier
E0691 - E0694 Ultraviolet Light Therapy Systems DME REGIONAL Carrier
E0700 Safety Equipment DME REGIONAL Carrier
E0701 Helmet DME REGIONAL Carrier
E0710 Restraints DME REGIONAL Carrier
E0720 - E0745 Electrical Nerve Stimulators DME REGIONAL Carrier
E0746 EMG Device Local Carrier
E0747 - E0748 Osteogenic Stimulators DME REGIONAL Carrier
E0749 Implantable Osteogenic Stimulators Local Carrier
E0752 Implantable Nerve Stimulator Electrodes Local Carrier
E0754 Patient Programmer for use with IPG Local Carrier
E0755 Reflex Stimulator DME REGIONAL Carrier
E0756 - E0759 Implantable Nerve Stimulator  Local Carrier
E0760 Ultrasonic Osteogenic Stimulator DME REGIONAL Carrier
E0761 Electromagnetic Treatment Device DME REGIONAL Carrier
E0765 Nerve Stimulator DME REGIONAL Carrier
E0776 IV Pole DME REGIONAL Carrier
E0779 - E0780 External Infusion Pumps DME REGIONAL Carrier
E0781  Ambulatory Infusion Pump Billable to both the local carrier and the DME REGIONAL Carrier.  This item may be billed to the DME REGIONAL  Carrier whenever the infusion is initiated in the physician's office but the patient does not return during the same  business day.
E0782 - E0783 Infusion Pumps, Implantable Local Carrier
E0784 Infusion Pumps, Insulin DME REGIONAL Carrier
E0785 - E0786 Implantable Infusion Pump Catheter Local Carrier
E0791 Parenteral Infusion Pump DME REGIONAL Carrier
E0830 Ambulatory Traction Device DME REGIONAL Carrier
E0840 - E0900 Traction Equipment DME REGIONAL Carrier
E0910 - E0930 Trapeze/Fracture Frame DME REGIONAL Carrier
E0935 Passive Motion Exercise Device DME REGIONAL Carrier
E0940 Trapeze Equipment DME REGIONAL Carrier
E0941 Traction Equipment DME REGIONAL Carrier
E0942 - E0945 Orthopedic Devices DME REGIONAL Carrier
E0946 - E0948 Fracture Frame DME REGIONAL Carrier
E0950 - E1298 Wheelchairs DME REGIONAL Carrier
E1300 - E1310 Whirlpool Equipment DME REGIONAL Carrier
E1340 Repair or Non-routine Service Local Carrier if repair of implanted DME. If other, DME REGIONAL Carrier.
E1353 - E1391 Additional Oxygen Related Equipment DME REGIONAL Carrier
E1399 Miscellaneous DME Local Carrier if implanted DME.  If other, DME REGIONAL Carrier.  
E1405 - E1406 Additional Oxygen Equipment DME REGIONAL Carrier
E1500 - E1699 Artificial Kidney Machines and Accessories DME REGIONAL Carrier
E1700 - E1702 TMJ  Device and Supplies DME REGIONAL Carrier
E1800 - E1840 Dynamic Flexion Devices DME REGIONAL Carrier
E1902 Communication Board DME REGIONAL Carrier
E2000 Gastric Suction Pump DME REGIONAL Carrier
E2100 - E2101 Blood Glucose Monitors with Special Features DME REGIONAL Carrier
E2120 Pulse Generator for Tympanic Treatment of Inner Ear DME REGIONAL Carrier
E2201 - E2399 Wheelchair Accessories DME REGIONAL Carrier
E2402 Negative Pressure Wound Therapy Pump DME REGIONAL Carrier
E2500 - E2599 Speech Generating Device DME REGIONAL Carrier
G0001 - G9016 Misc. Professional Services Local Carrier
J0120 - J0850 Injection Local Carrier if incident to a physician's service or used in an implanted infusion pump. If other, DME REGIONAL Carrier.
J0880 Injection Local Carrier
J0895 - J3570 Injection Local Carrier if incident to a physician's service or used in an implanted infusion pump. If other, DME REGIONAL Carrier.
J3590 Unclassified Biologics Local Carrier
J7030 - J7130 Miscellaneous Drugs and Solutions Local Carrier if incident to a physician's service or used in an implanted infusion pump. If other, DME REGIONAL Carrier.
J7190 - J7192  Factor VIII Local Carrier
J7193 - J7195 Factor IX Local Carrier
J7197  Antithrombin III Local Carrier
J7198 Anti-inhibitor;  per I.U.  Local Carrier
J7199 Other Hemophilia Clotting Factors Local Carrier
J7300 - J7303 Intrauterine Copper Contraceptive Local Carrier
J7308 Aminolevulinic Acid HCL Local Carrier
J7310 Ganciclovir Local Carrier if incident to a physician's service or used in an implanted infusion pump. If other, DME REGIONAL Carrier.
J7317 - J7320 Injection Local Carrier
J7330 Autologous Cultured Chondrocytes, Implant Local Carrier
J7340 - J7350 Dermal and Epidermal - Tissue of Human Origin Local Carriers
J7500 - J7599  Immunosuppressive Drugs Local Carrier if incident to a physician's service or used in an implanted infusion pump. If other, DME REGIONAL Carrier.
J7608 - J7699  Inhalation Solutions Local Carrier if incident to a physician's service. If other, DME REGIONAL Carrier.
J7799 NOC, Other than Inhalation Drugs through DME DME REGIONAL Carrier
J8499 Prescription Drug, Oral, Non Chemotherapeutic DME REGIONAL Carrier
J8510 - J8999 Oral Anti-Cancer Drugs DME REGIONAL Carrier
J9000 - J9999 Chemotherapy Drugs Local Carrier if incident to a physician's service or used in an implanted infusion pump. If other, DME REGIONAL Carrier.
K0001 - K0108 Wheelchairs DME REGIONAL Carrier
K0114 - K0116 Spinal Orthotics DME REGIONAL Carrier
K0195 Elevating Leg Rests DME REGIONAL Carrier
K0415 - K0416 Antiemetic Drugs DME REGIONAL Carrier
K0452 Wheelchair Bearings DME REGIONAL Carrier
K0455 Infusion Pump used for Uninterrupted Administration of Epoprostenal  DME REGIONAL Carrier
K0462 Loaner Equipment DME REGIONAL Carrier
K0552 External Infusion Pump Supplies DME REGIONAL Carrier
K0601 - K0605 External Infusion Pump Batteries DME REGIONAL Carrier
K0606 - K0609 Defibrilator Accessories DME REGIONAL Carrier
K0618 - K0619 TLSOs DME REGIONAL Carrier
K0620 Surgical Dressing Local Carrier if incident to a physician's service (not separately payable) or if supply  for implanted prosthetic device or implanted DME.  If other DME REGIONAL Carrier.
L0100 - L2090 Orthotics DME REGIONAL Carrier
L2106 - L2116 Orthotics DME REGIONAL Carrier
L2126 - L4398 Orthotics DME REGIONAL Carrier
L5000 - L5999 Lower Limb Prosthetics DME REGIONAL Carrier
L6000 - L7499 Upper Limb Prosthetics DME REGIONAL Carrier
L7500 - L7520 Repair of Prosthetic Device Local Carrier if repair of implanted prosthetic device.  If other, DME REGIONAL Carrier.
L7900 Vacuum Erection System DME REGIONAL Carrier
L8000 - L8490 Prosthetics DME REGIONAL Carrier
L8499 Unlisted Procedure for Miscellaneous Prosthetic Services Local Carrier if implanted prosthetic device. If other, DME REGIONAL Carrier.
L8500 - L8501  Artificial Larynx; Tracheostomy Speaking Valve DME REGIONAL Carrier
L8505 Artificial Larynx Accessory DME REGIONAL Carrier
L8507 - L8514 Voice Prosthesis DME REGIONAL Carrier
L8600 - L8699 Prosthetic Implants Local Carrier
L9900 Miscellaneous Orthotic or Prosthetic Component or Accessory Local Carrier if used with implanted prosthetic device. If other, DME REGIONAL Carrier.
M0064 - M0301 Medical Services Local Carrier
P2028 - P9615 Laboratory Tests Local Carrier
Q0035 Influenza Vaccine; Cardio-kymography Local Carrier
Q0081 Infusion Therapy Local Carrier if incident to a physicians service or used in an implanted infusion pump. If other, DME REGIONAL Carrier.
Q0083 - Q0085 Chemotherapy Administration Local Carrier if incident to a physicians service or used in an implanted infusion pump. If other, DME REGIONAL Carrier.
Q0091 Smear Preparation Local Carrier
Q0092 Portable X-ray Setup Local Carrier
Q0111 - Q0115 Miscellaneous Lab Services Local Carrier
Q0136 Injection, Epoetin Alpha Local Carrier if incident to a physician's service.  If other, DME REGIONAL Carrier.
Q0137 Injection Darbepoetin Local Carrier if incident to a physician's service.  If other, DME REGIONAL Carrier.
Q0144 azithromycin dihydrate Local Carrier if incident to a physician's service.  If other, DME REGIONAL Carrier.
Q0163 - Q0181 Anti-emetic DME REGIONAL Carrier
Q0182 - Q0183  Artificial Skin Local Carrier
Q0187 Factor VIIA Local Carrier 
Q1001 - Q1005 New Technology IOL Local Carrier
Q2022 Von Willebrand Factor Local Carrier
Q3014 Telehealth Originating Site Facility Fee Local Carrier
Q3019 - Q3020 ALS Transport Local Carrier
Q3025 - Q3026 Vaccines Local Carrier
Q3031 Collagen Skin Test Local Carrier
Q4001 - Q4051 Splints and Casts Local Carrier
Q4054 - Q4055 Injection DME REGIONAL Carrier when for Method II ESRD beneficiaries.  If other, Local Carrier.
Q4075 - Q4077 Injection Local Carrier if incident to a physicians service or used in an implanted infusion pump. If other, DME REGIONAL Carrier.
R0070 - R0076 Diagnostic Radiology Services Local Carrier
V2020 - V2025 Frames DME REGIONAL Carrier
V2100 - V2513 Lenses DME REGIONAL Carrier
V2520 - V2523 Hydrophilic Contact Lenses Local Carrier if incident to a physician's service.  If other, DME REGIONAL Carrier.
V2530 - V2531 Contact Lenses, Scleral DME REGIONAL Carrier
V2599 Contact Lens, Other Type Local Carrier if incident to a physician's service.  If other, DME REGIONAL Carrier.
V2600 - V2615 Low Vision Aids DME REGIONAL Carrier
V2623 - V2629 Prosthetic Eyes DME REGIONAL Carrier
V2630 - V2632 Intraocular Lenses Local Carrier
V2700 - V2780 Miscellaneous Vision Service DME REGIONAL Carrier
V2781 Progressive Lens DME REGIONAL Carrier
V2782 - V2784 Lenses DME REGIONAL Carrier
V2785 Processing--Corneal Tissue Local Carrier
V2786 Lense DME REGIONAL Carrier
V2790 Amniotic Membrane Local Carrier
V2797 Vision Supply DME REGIONAL Carrier
V2799 Miscellaneous Vision Service DME REGIONAL Carrier
V5008 - V5299 Hearing Services Local Carrier
V5336  Repair/Modification of Augmentative Communicative System or Device DME REGIONAL Carrier
V5362 - V5364 Speech Screening Local Carrier
Revised: February 2004

(04-0883)

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Adjudication of Reference Laboratory Service Claims

Provider Types Affected
Independent clinical diagnostic laboratories.

Provider Action Needed
An independent laboratory may bill for services they refer to another laboratory no matter where the
reference laboratory is located, as long as it is within any Medicare claims processing jurisdiction. When billing for reference laboratory services, independent clinical diagnostic laboratories must submit the zip code of the location where the laboratory service was actually performed. The carriers’ standard billing systems will now price the payment of referred laboratory services based on the zip code where the service was performed.

Any independent laboratories that were assigned a Provider Identification Number (PIN) for the purposes of reimbursement of reference laboratory services in a payment jurisdiction other than one they have a physical presence will have those PINs revoked. The Independent Laboratory will not need to take any action. Carriers will revoke the PIN and notify the appropriate Independent Laboratory. The following requirements apply when billing for reference laboratory services for dates of service, July 1, 2004, and later:

Electronic Claim Submission Requirements

ANSI format:

NSF format:

EA0 Field 39 Facility/Lab Name EA1 Field 08 Facility/Lab City
EA1 Field 06 Facility/Lab ADDR1 EA1 Field 09 Facility/Lab State
EA1 Field 07 Facility/Lab ADDR2 EA1 Field 10 Facility/Lab Zip Code

Paper Claim Submission Requirements

Background
Sometimes a clinical diagnostic laboratory will refer a specimen to another laboratory for testing. In most cases the laboratory that furnishes the service will bill for the service. But it’s also possible for one laboratory to bill for a service performed by another laboratory. Medicare uses certain terms of art in describing laboratories in this context. “Referring laboratory” is defined as the laboratory that refers a specimen to another laboratory for testing. “Reference laboratory” is defined as the laboratory that receives a specimen from another laboratory and performs one or more tests on such specimen.

Medicare’s payment policy for laboratory services is generally based on fee schedules specific to each carrier jurisdiction. Previously, some carriers have been unable to process a claim for a laboratory test performed in another jurisdiction because they did not possess the fee schedule of that other jurisdiction. Thus, some carriers paid for referred services performed outside of their jurisdiction and based payment on the fee schedule for that jurisdiction.

Other carriers attempted to overcome the difficulty by enrolling the laboratory outside their jurisdiction as a reference laboratory. These carriers issued a Provider Identification Number (PIN) for the reference laboratory as a “reference-use-only” PIN. However, not every carrier has been willing to issue “reference use- only” PINs.

Implementation
This change resolves the issues by requiring that:

  1. An independent clinical laboratory may bill only the carrier in which it is enrolled by location.
  2. An independent clinical laboratory may not enroll with a carrier as a “reference-use-only” laboratory.
  3. Every carrier must settle a claim for a referred service submitted by a laboratory located in its
    jurisdiction, regardless of where the service was performed.
  4. Every carrier must pay for a referred service on the basis of the fee schedule in effect in the jurisdiction where the test was performed.
  5. Every carrier must cancel all existing “reference- use-only” enrollments and “reference-use-only”
    PINs and refrain from making any further “reference-use-only” enrollments.
  6. The referring laboratory must identify a referred service as such on the claim and identify reference
    laboratory performing that test and correctly entering the zip code of such laboratory.
  7. Both the referring laboratory and the reference laboratory must be enrolled in Medicare.

When a billing laboratory is the referring laboratory it must identify the referred service as such by use of modifier 90 and must identify the reference laboratory by specifying its CLIA number and the address, including the correct zip code, where the service was actually performed. Also, the referring laboratory must meet one of the following conditions:

  1. It must be located in, or be part of, a rural hospital;
  2. It must be wholly-owned by the reference laboratory; or both it and the reference laboratory are wholly owned subsidiaries of the same entity; or
  3. It refers no more than thirty (30) percent of the clinical laboratory tests annually to other laboratories (not including referrals made under the wholly- owned proviso stated above).

Important Dates
These changes will be implemented by Medicare on July 6, 2004, and will apply to services rendered on or after July 1, 2004.

Related Instructions
If you need further clarification, background, details or just want to see the original change request
implementing these changes, you can find it at:
http://www.cms.hhs.gov/manuals/pm_trans/R85CP.pdf

[EM 2004-0081/3090]

(04-0898)

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Arrangements for Physical, Occupational, and Speech-Language Pathology Services

Provider Types Affected
Physicians, therapists, providers, clinics.

Provider Action Needed
Physicians, suppliers, and providers should note that this instruction clarifies information regarding arrangements for Medicare Part B outpatient physical therapy, occupational therapy, and speech-language pathology services furnished under arrangements with providers and clinics. Revisions have been made to Chapter 15, Section 220.1 of the Medicare Benefits Policy Manual (Pub 100-02). Section 220.1 Therapy Services Furnished Under Arrangements with Providers and Clinics is included in this article for informational purposes. Please note that this information is for clarification purposes only and should not represent any change for providers.

Background
The excerpt from the manual itself is as follows:

“A provider or clinic may have others furnish outpatient physical therapy, occupational therapy, or speech language pathology services through arrangements under which receipt of payment by the provider or clinic for the services discharges the liability of the beneficiary or any other person to pay for the service.”

However, it is not intended that the provider or clinic merely serve as a billing mechanism for the other party. The provider’s or clinics professional supervision over the services requires application of many of the same controls as are applied to services furnished by salaried employees. The provider or clinic must:

In addition, when a clinic provides outpatient physical therapy, occupational therapy, or speech-language pathology services under an arrangement with others, such services must be furnished in accordance with the terms of a written contract, which provides for retention by the clinic of responsibility for and control and supervision of such services. The terms of the contract should include at least the following:

Additional Information
To view Chapter 15 of the Medicare Benefits Policy Manual, visit: http://www.cms.hhs.gov/manuals/102_policy/bp102index.asp

Once at that site, scroll down to Chapter 15 and select the file version you wish to receive. 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

From that web page, look for CR3134 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/intermediary at their toll-free number, which may be found at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

(04-0896)

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Electrical Stimulation and Electromagnetic Therapy for the Treatment of Wounds

Provider Types Affected
Physicians, Therapists, Federally Qualified Health Centers, Rural Health Clinics, Hospitals, and Critical Access Hospitals.

Provider Action Needed

STOP – Impact to You
Effective July 1, 2004, under specific conditions Medicare will cover electromagnetic therapy for wound treatment for the same settings and conditions in which electrical stimulation (ES) for wound treatment is currently covered.

CAUTION – What You Need to Know
Be aware of the conditions under which Medicare will cover this procedure.

GO – What You Need to Do
You may file claims with Medicare for electromagnetic therapy for the treatment of certain wounds for services rendered on or after July 1, 2004. Be sure to use the correct HCPCS and revenue codes as specified below to assure timely and correct payment.

Background
Medicare conducted a reconsideration review of electromagnetic therapy used for the treatment of certain wounds. They found that wounds treated using either electrical stimulation (ES) therapy or electromagnetic therapy resulted in similar improvements. Therefore, CMS decided to cover electromagnetic therapy for wound treatment for the same settings and conditions in which electrical stimulation for wound treatment is currently covered.

Effective July 1, 2004, Medicare will cover ES or electromagnetic therapy for chronic stage III or stage IV pressure ulcers (ulcers that have not healed within 30 days of occurrence), arterial ulcers, diabetic ulcers, and venous stasis ulcers. Electromagnetic therapy services will be covered only when performed by a physician, physical therapist, or incident to a physician service. No other wound treatment using electromagnetic therapy will be covered.

ES and electromagnetic therapy for wound treatment will be covered only after appropriate standard wound treatment has been tried for at least 30 days with no measurable signs of healing. Additionally, wounds undergoing treatment by electromagnetic therapy must be evaluated at least monthly by the treating physician.

Medicare will not continue to cover the treatment if the wound shows no measurable signs of improvement within any 30 day period of treatment. Additionally, ES or electromagnetic therapy must be discontinued when the wound demonstrates a 100% epitheliliazed wound bed. Unsupervised therapy for wound treatment will not be covered, nor will ES and electromagnetic therapy be covered as an initial treatment modality.

Additional Information
The applicable Healthcare Common Procedure Coding System (HCPCS) code for Electromagnetic.

Therapy is as follows:
HCPCS G0329 – Electromagnetic Therapy, to one or more areas for chronic stage III and stage IV
pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable
signs of healing after 30 days of conventional care as part of a therapy plan of care. Effective date: July 1, 2004. Note: Medicare will not cover the device (Code E0761) used for electromagnetic treatment of wounds, nor will Medicare cover unsupervised home use of electromagnetic therapy.

The following revenue codes must be used in conjunction with the HCPCS code identified:

Revenue Code Description
420 Physical Therapy
430 Occupational Therapy
520 Federal Qualified Health Center
521 Rural Health Center
977,978
Critical Access Hospital - method II CAH professional services only

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

From that web page, look for CR 3149 in the CR NUM column on the right, and click on the file for that CR. The CR includes the revised portions of the Medicare National Coverage Determinations Manual, which further explain this change.

[EM 2004-0344/3149]

(04-0899)

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E/M Coding: Volume of Documentation versus Medical Necessity 

The Social Security Act, Section 1862 (a)(1)(A) states: “No payment will be made … for items or services … not reasonable and necessary for the diagnosis or treatment of an injury or illness or to improve the functioning of a malformed body member.” This medical reasonableness and necessity standard is the overarching criterion for the payment for all services billed to Medicare.

During repeated reviews, we have observed the tendency to “over document” and consequently to select and bill for a higher level E/M code than medically reasonable and necessary. Word processing software, the electronic medical record, and formatted note systems facilitate the “carry over” and repetitive “fill in” of stored information. Even if a “complete” note is generated, only the medically reasonable and necessary services for the condition of the particular patient at the time of the encounter as documented can be considered when selecting the appropriate level of an E/M service. Information that has no pertinence to the patient’s situation at that specific time cannot be counted.

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Beneficiary Eligibility Options

As many of our providers and software vendors know, the ASC X12 270/271 Health Care Eligibility Benefit Inquiry and Response (Real Time), version 4010A1 is not yet fully operational for Medicare. Pending the production use of that transaction, CMS has instructed the contractors to continue support of all current formats used for eligibility verification.

The formats that CIGNA Government Services Part B supports are the Beneficiary Direct Data Entry (DDE) and the National Standard Format (NSF) batch eligibility. The DDE allows a provider to enter an eligibility request and receive an eligibility response instantaneously through TCP/IP connectivity. The NSF batch eligibility requires the supplier to create a file containing an eligibility request with as many as 99 requests. The file is then uploaded into the Stratus Network, using the same process as uploading a claim file. A response file will be generated after the nightly batch job is completed and the supplier would download a response file just as they would an electronic report. The NSF batch version does require the use of software to create the eligibility request and to read the response file received from Medicare. Medicare does not provide this software.
If you would like to sign up for the Beneficiary Eligibility feature, please contact EDI Support at 1.866.520.4022.

(04-0885)


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Emergency Correction Regarding Correction to Healthcare Common Procedure Coding System (HCPCS) Codes for Low-Osmolar Contrast Material

Provider Types Affected
All Medicare hospitals and physicians.

Provider Action Needed
Affected providers should note that this instruction provides additional information regarding coding under the Healthcare Common Procedure Coding System (HCPCS) for low-osmolar contrast material. It corrects the effective date for the reinstatement of selected HCPCS codes and the change in status of HCPCS code A9525.

Background
On January 23, 2004, Change Request 3053 - Emergency Correction to Healthcare Common Procedure Coding System (HCPCS) Codes for Low-Osmolar Contrast Material was issued, and it provided the following instructions:

The effective date for these changes was given as April 1, 2004.

This April 1, 2004, date was incorrect. These changes are to be made retroactive to January 1, 2004. Thus, codes A4644 through A4646 are reinstated as of January 1, 2004, and code A9525 is invalid for dates of service on or after January 1, 2004.

On February 20, 2004, Change Request 3128 was issued. It updated the Medicare Physician Fee Schedule Database as follows:

The effective date for these changes was given as January 1, 2004.

This is correct.
Codes A4644 thru A4646 have been reinstated in the HCPCS.

Implementation
The implementation date for this instruction is May 24, 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

From that Web page, look for CR3185 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/intermediary at their toll-free number, which may be found at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

Change Request 3053 - Emergency Correction to Healthcare Common Procedure Coding ystem(HCPCS) Codes for Low-Osmolar Contrast Material, Transmittal 45, dated January 23, 2004, can be found at the following Centers for Medicare & Medicaid Services Medlearn Matters Web site:
http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3053.pdf

Also, Change Request 3128 - 1st Update to the 2004 Medicare Physician Fee Schedule Database Transmittal 105, dated February 20, 2004, can be found at the following CMS Web site:
http://www.cms.hhs.gov/manuals/pm_trans/R105CP.pdf

[EM 2004-0331/3187]

(04-0908)

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Incident to Services

Provider Types Affected
Physicians, suppliers, and providers.

Provider Action Needed

STOP - Impact to You
This instruction clarifies and standardizes the method of indicating the ordering and supervising professionals on the Centers for Medicare & Medicaid Services Health Insurance Claim Form (CMS-1500). Note that the CMS-1500 is the paper form, however, and is superceded now by the electronic form.

Caution - What You Need to Know
This instruction and the CMS Claims Processing Manual update clarifies where physician’s Provider Information Numbers and names should be reported when both an ordering provider and a supervising provider are involved in a service.

GO - What You Need to Do
Please refer to the Background and Additional Information sections of this instruction for further details.

Background
The Centers for Medicare & Medicaid Services (CMS) Health Insurance Claim Form (CMS-1500) is the basic form prescribed by CMS for the submission of claims from physicians and suppliers for the Medicare program. It is used by non-institutional providers and suppliers to bill Medicare Part B covered services and it is also used for billing some Medicaid covered services. It answers the needs of many health insurers and is the basic form prescribed by CMS for the submission of claims on behalf of Medicare patients. (However, please note that the CMS-1500 paper form is superceded by HIPAA electronic formats.)

Because of the multiple requests in Open Door Forums and correspondence, CMS is issuing this instruction to clarify and standardize the method of indicating the ordering and supervising professionals on the CMS-1500.

The Preamble of the Proposed Rule for the Medicare Physician Fee Schedule on November 1, 2001 (66 Fed Reg. 55267) stated “the billing number of the ordering physician (or other practitioner) should not be used if that person did not directly supervise the auxiliary personnel.” This instruction incorporates the rule into the CMS Claims Processing Manual.

The update to the Medicare Claims Processing Manual (Pub 100-4) (referred to in the Web link below) further clarifies where physician’s Provider Information Numbers and names should be reported when both an ordering provider and a supervising provider are involved in a service.

Implementation
The implementation date is May 24, 2004.

Additional Information
The CMS Manuals Index can be found at the following CMS Web site: http://www.cms.hhs.gov/manuals/cmsindex.asp

Also, the Medicare Claims Processing Manual (Pub 100-4) which was revised can be found at:
http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp

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

From that Web page, look for CR3138 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/intermediary at their toll-free number, which may be found at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

If you need to contact your Medicaid State Agency for more details, a list of toll-free telephone numbers exists for each Medicaid State Agency at:
http://www.cms.hhs.gov/medicaid/tollfree.pdf

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G Code Error


On January 1, 2004, CMS implemented NCCI edits with column one codes G0308-G0327 each with column two codes of 90935, 90937, 90945, 90947, and 99201-99356.

As a result of the way these edits were set up, claims have been denied by Carriers during the period from January 1, 2004, until now. These edits will be suspended effective July 1, 2004, and the changes will appear in NCCI version 10.2 scheduled for July 1, 2004. For dates of service between January 1, 2004 and June 30, 2004, providers can bypass these edits by appending modifier -59 when appropriate to CPT codes 90935, 90937, 90945, or 90947 or modifier -25 when appropriate to CPT codes 99201-99356. (The suspension of the edits cannot occur earlier because NCCI version 10.1 scheduled for April 1, 2004, is already completed.) Please use this “modifier workaround” until July 1, 2004, when applicable.

Please note: Providers that have received demand letters in error should notify Recovery @ 1.877.286.6801, Option 2. If the overpayment has been satisfied please contact the Appeals Department.

The basis for these edits remains unchanged. In order to report codes in the range, G0308-G0319, the provider must determine the number of face to face physician visits per month. In determining this number, the physician should not include face to face visits reported as 90935, 90937, 90945, 90947, or 99201-99356.

CMS will suspend these edits indefinitely unless evidence of improper billing is subsequently identified.

(04-0845)

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Not Other Wise Classified Drugs/Biologicals Claim Filing Instructions

When billing for a Not Otherwise Classified Drug, the name of the drug and exact dosage administered must be entered in block 19 of the CMS-1500 claim form or as an attachment for paper claims. For claims submitted electronically, this information would be entered in the narrative field (the electronic equivalent of block 19 of the paper form). The allowed amount for the drug will be based on the information entered in these fields.

Once the drug has been issued a specific procedure code, the assigned procedure code should be used and your number of services should be adjusted based on the description and the dosage of the assigned procedure code. If the miscellaneous code continues to be billed after a specific procedure code has been assigned, your claim may be denied as a billing error. This does not apply to the compounded drugs billed under J3490. Compounded drugs shall continue to be billed under J3490 and the purchase information included with the claim.

(04-0912)

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Medicare Providers: Their Vendors, Clearinghouses, or Other Third-Party Billers and the HIPAA/Medicare Contingency Plan

Provider Types Affected
All Medicare physicians, providers, and suppliers who use a vendor, clearinghouse, or other third-party billing agent to submit Medicare claims.

Provider Action Needed
Understand the requirements of HIPAA, the Medicare HIPAA contingency plan, its impact, and the need to verify HIPAA compliance by those who bill Medicare on your behalf.

Background
In a recent Medlearn Matters article (see MM2981, which may be found at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM2981.pdf the Centers for Medicare & Medicaid Services (CMS) announced a modification of the HIPAA contingency plan implemented by Medicare on October 16, 2003. Specifically, CMS announced on February 27, 2004, that Medicare would continue to accept claims electronically in a pre-HIPAA format on or after July 1, 2004, but such claims would not be eligible for Medicare payment until the 27th day after receipt, at the earliest. All electronic claims today are eligible for payment at 14 days after receipt.

This modification of the HIPAA contingency plan was intended to give providers additional time to become HIPAA compliant, but was also a measured step toward ending the contingency plan for all incoming Medicare claims.

CMS understands that many physicians, providers, and suppliers do not submit claims directly to Medicare, but submit their claims through a third party, such as a billing vendor, clearinghouse or other third-party billing agent. CMS recognizes the importance of these third parties to many providers and the extent to which providers rely on those entities to meet HIPAA requirements in a cost-effective manner with minimal impact on the provider’s most important mission, i.e., delivering high quality medical care to those who need such care.

Each provider has made a business decision to use these agents and is therefore best positioned to
assess the value of that decision.

CMS urges Medicare providers to understand the following issues, to assess their impact on the provider’s business and determine what, if any, steps need to be taken.

Issue # 1- Understand where your vendor, clearinghouse, or other third party biller stands in terms of HIPAA compliance.
Providers are required by statute to achieve compliance and to bill Medicare electronically in a HIPAA compliant manner. Thus, it is crucial for providers to assure themselves of their third-party partner’s readiness. It is especially important to remember that, at the time Medicare’s contingency plan is terminated, providers who remain non-compliant will face significant problems.

So, what steps might providers take to assure that they AND their partners are ready?

As stated earlier, CMS’s business relationship is with providers and we look to the provider to meet
requirements for correct submission of claims in HIPAA compliant formats. We also know that every piece of the process, and every entity involved, must be ready. That is why it is important for providers to question their agents, obtain assurances, and keep abreast of HIPAA developments. Ultimately, the benefits of compliance or the consequences of non-compliance will fall on the provider. Remember that continued timely payment of Medicare claims is closely linked to HIPAA readiness.

Issue #2- Make sure your agent builds on the HIPAA compliance you have achieved.
There have been instances where some third-party billers are taking claims submitted to them by Medicare providers that are HIPAA compliant and then converting them to a non-compliant format before sending them to a Medicare claims processing contractor. Such vendors and agents may be doing this because some of their providers are still not HIPAA compliant and the vendor has chosen to submit non-compliant formats for all their provider customers until all customers are compliant.

These decisions may make good business sense to the vendor, clearinghouse or other third party biller, but their decision may adversely affect providers who are compliant. That will certainly be the case for such claims submitted to Medicare on or after July 1, 2004, when Medicare deems such claims do not qualify for the prompt payment afforded to electronic claims that are HIPAA compliant. At the time Medicare ends its contingency plan, the consequences for non-compliant claims could be even more severe, e.g., a complete stoppage of payments for such claims.

What can providers do? The answer is similar to the one presented for the first issue, i.e., talk with your vendor, clearinghouse, or other third party biller. Ask them about their readiness. Ask them if they are altering your HIPAA compliant input to them into a non-compliant format before sending to Medicare. Ask them to assure you that your claims will remain eligible for payment on the 14th day after receipt on and after July 1, 2004.

As mentioned before, it is the provider’s ultimate responsibility to assure they are HIPAA compliant and that means assuring that your claims meet the transaction code set and format standards.

Issue # 3- Understand when your vendor, clearinghouse, or other third party biller will stop accepting non-compliant transactions.
While CMS implemented a contingency plan on October 16, 2003, which allows Medicare providers,
suppliers, and other electronic billers to continue sending pre-HIPAA formats, that plan is not binding on other entities. At any time, vendors, clearinghouses, and other third party billers could decide to limit or discontinue supporting pre-HIPAA formats.

We encourage providers and suppliers using a third party entity for sending their electronic claims to work closely with that entity to understand the HIPAA electronic claims requirements. Verify that you are submitting the data required under HIPAA and that your claims are being transmitted in the standard HIPAA format.

In conclusion, the bottom line is that, in order to protect your interests and ensure uninterrupted cash
flow, begin immediately to work toward meeting the HIPAA standard requirements.

Additional Information
For additional information on HIPAA, visit the CMS Web site at: http://www.cms.hhs.gov/HIPAAGenInfo/default.asp

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Manualization of POS Code Set Program Memorandum; Revision to Group Home Code Description


Provider Types Affected
Physicians, suppliers, and providers who bill Medicare carriers.

Provider Action Needed
Physicians, suppliers, and providers should note that this article addresses only a new definition for the Place of Service (POS) Code for Group Homes. Other POS code set information was issued on May 16, 2003, in CMS Program Memorandum/Transmittal B-03-040 and Change Request 2730, “Update of the Place of Service (POS) Code Set.” That other information remains unchanged.

Background
Effective April 1, 2004, the description of POS code 14 (Group Home) will be as follows:
“A residence, with shared living areas, where clients receive supervision and other services, such as social and/or behavioral services, custodial services, and minimal services (e.g. medical administration).”

Once again, the remainder of the updated POS code set remains as presented in Program Memorandum B-03-040, which may be found at: http://www.cms.hhs.gov/manuals/pm_trans/B03040.pdf.

Additional Information
The official instruction issued to your carrier regarding this change may be found by going to:
http://www.cms.hhs.gov/manuals/pm_trans/R121CP.pdf.

If you have any questions, please contact your carrier/intermediary at their toll-free number, which may be found at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf.

[EM 2004-0211/3087]

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Manualization NCD: Acupuncture for Fibromyalgia /Osteroarthritis

Provider Types Affected
Physicians, suppliers, and providers.

Provider Action Needed

STOP – Impact to You
Physicians, suppliers, and providers should note that this instruction relates to acupuncture for the treatment of fibromyalgia and osteoarthritis.

CAUTION – What You Need to Know
The Centers for Medicare & Medicaid Services (CMS) concludes that acupuncture is not reasonable and necessary for the treatment of fibromyalgia and osteoarthritis within the meaning of Section 1862(a)(1) of the Social Security Act. Therefore, CMS continues its national noncoverage determination for acupuncture.

GO – What You Need to Do
Refer to the Background and Additional Information sections of this instruction for further details regarding these changes.

Background
After reconsideration of the national noncoverage determination for acupuncture, the Centers for Medicare & Medicaid Services (CMS) concludes that acupuncture is not reasonable and necessary for the treatment of fibromyalgia and osteoarthritis within the meaning of Section 1862(a)(1) of the Social Security Act. Therefore, CMS continues its national noncoverage determination for acupuncture.

This revision is a national coverage determination (NCD), and NCDs are binding on all carriers, fiscal intermediaries, quality improvement organizations, health maintenance organizations, competitive medical plans, and health care prepayment plans. 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 implementation date for this instruction is April 16, 2004.

Related Instructions
The following Internet Only Medicare Manual (IOM) has been edited with revised and new sections to reflect changes implemented with this instruction.

The Medicare National Coverage Determinations Manual (Pub. 100-3), Chapter 1 (Coverage
Determinations)

Changes to sections of the Medicare National Coverage Determinations Manual are included in CR3250 referenced below in the Additional Information section. These revised instructions briefly explain the process CMS used in reaching this decision.

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.

From that Web page, look for CR3250 in the CR NUM column on the right, and click on the file for that CR.

[EM 2004-0344/3250]

(04-0900)

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Medical Review Frequently Asked Questions - April 2004

The following represent a variety of questions the Medical Review department has received. CIGNA Government Services will address at least quarterly “Frequently Asked Questions” related to coverage and local medical review policy issues. The previous issue was published in the January 2004 Web site bulletin. Providers may submit questions to the Web site at http://www.cignamedicare.com/customer_service/disclaimer.html.

1. Unna Boots

Q: When are Unna boots separately payable? Can an evaluation and management visit with modifier 25 also be billed?

A: Per the NCCI rebundling table, the code for Unna boots (CPT code 29580) is component to many other comprehensive surgeries (e.g. tendon sheath injections, joint aspiration/injection, etc.) unless a modifier is appended to reflect the Unna boot was used in a distinct, separate service. Unna boots applied as dressings would not be considered a separately reimbursable service apart from surgical procedure as payment for surgical dressings applied by the physician during his/her encounter with the patient is included in the fee schedule payment for the physician’s service. For medically necessary Unna boots not applied as post operative dressings, CPT code 29580 may be billed; but an evaluation and management visit should not be billed unless there is a distinct, separately identifiable reason for the E&M service. It would be inappropriate to bill an E&M service for the assessment related to Unna boot application. The assessment would be considered part of the pre-procedural evaluation that is component to the procedure/service. This is reflected in the following link to CMS Publication 100-4, The Medicare Claims Processing, Chapter 12, and Section 30.6.6. It explains that each procedure includes a pre-procedural evaluation that should not be separately billed as a distinct, separately payable E&M visit http://www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf.

2. ASC

Q: Does Medicare reimburse ASC facilities for a covered procedure rate and implant cost? Many orthopedic cases involve implants that are substantially more in cost than the group rate fee that is paid.

A: According to CMS Publication 100-4, the Medicare Claims Processing Manual, Chapter 14, Section 10.4, prosthetic devices, other than intraocular lenses (IOLs), whether implanted, inserted, or otherwise applied by covered surgical procedures, are covered; but these are not included in the ASC facility payment amount. These items may be filed separately from the surgery using the appropriate HCPCS code; and if there is no specific code for the implant or prosthesis, providers should use an unlisted HCPCS code. In the latter case, these services would be reviewed to determine whether they fall under Part B or DMERC jurisdiction, if they should be separately paid from the surgery, and if separately paid then how much. Our interpretation for separately payable implants are those that can be set apart from items usually needed to perform the surgery (e.g. wires, screws, clips, tapes, etc.), and we use resources such as the AMA’s Relative Value Update Committee notes in making such determinations. http://www.cms.hhs.gov/manuals/104_claims/clm104c14.pdf

3. ASC

Q: How do ambulatory surgical centers get paid for procedures not on the approved list?

A: Generally, for CPT codes not on the ASC reimbursable list and that do have facility and non-facility prices, the physician gets reimbursed at a nonfacility level. There may be an arrangement between the physician and ASC where the physician might forward some of the differential amount to the ASC. For CPT codes that have identical reimbursements in and outside a facility, this may or may not be feasible and depends on the arrangement and ownership relationship that the physician and ASC might have. It may not be feasible to perform this procedure in an ASC, but this is not within our judgment and jurisdiction. The carrier does not determine when there is a facility/non-facility fee for a given procedure or what procedures are on the approved list. We receive these instructions from CMS. This list can be seen on the CMS Web site through the following link under “Ambulatory Surgical Center (ASC) Base Eligibility File”: http://www.cms.hhs.gov/providers/pufdownload/default.asp?#asc

4. 99211

Q: Can this code be billed at the same time an injection is given or a protime or urinalysis is collected? Can it be billed for assessment of vital signs?

A: CPT code 99211 cannot be billed solely for the purpose of administering an injection or collecting a specimen for a diagnostic test. Furthermore, it should not be billed for routine vital signs that would not impac