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July 2004 Part B Medicare Bulletin

Table of Contents

• 2004 DMEPOS Codes Payable by Part B Updated
• Change to the Skilled Nursing Facility Consolidatd Billing Edits for Ambulance Transport
• CIGNA Government Services Launches Part B Online Educational Training - Netcourses
• Coding of Subsequent Hospital Care
• Collecting, Submitting, and Updating Beneficiary Insurance information to Medicare for Physician and Provider Billing Staff
• Collecting, Submitting, and Updating Beneficiary Insurance Information to Medicare for Clinical Laboratories
• Complying with Medicare Secondary Payer Requirements
• Consolidation of the Claims Crossover Process: Smaller - Scale Initial Implementation
• Diabetes Self-Management Training Services
• Fact Sheet for Provider Billing Staff
• Healthcare Common Procedure Coding System Corrections Involving 0040T and A9603
• Medical Necessity of Routine Pathology Evaluations
• MMA-2nd Update to the 2004 Medicare Physician Fee Schedule Database
• MMA-National 1.800.Medicare Implementation
• MMA-New Medicare Approved Drug Discount Cards and Transitional Assistance Program
• MMA-Payment for Chemotherapy Administration Services, Nonchemotherapy Drug Infusion Services, and Drug Injection Services
• National Council for Prescription Drug Program (NCPDP) Coordination of Benefits (COB) Companion Document
• New Requirements for Chirporactic Billing of Active/Corrective Maintenance Therapy
• Plenaxis (Abarelix/Sodium Choloride)
• Professional Coordination of Benefits (COB) Companion Document
• Quarterly Provider Update
• Remittance Advice Remark Code and Claim Adjustment Reason Code Udpate
• Reporting Medicare Secondary Payer Information on Health Insurance Portability and Accountability Act of 1996 X12N 837, Created Via the Free Billing Software
• Revised American National Standards Institute X12N 837 Professional Health Care Claim Companion Document
• Skilled Nursing Facility Consolidated Billing: Services Furnished Under an "Arrangement" with an Outside Entity
• Tips for Submitting Paper Claims
• Use of Group Health Plan Payment System for Demonstration Serving Medicare Fee-For-Service
• Writing Prescriptions for Covered Injectables

Fact Sheet for Provider Billing Staff

When Medicare is the Primary Payer

Background
As the Medicare program matures and the “baby boomer” generation moves towards retirement, it becomes critical to maintain the viability and integrity of the Medicare Trust Fund. Providers can contribute to the appropriate use of Medicare by complying with all Medicare requirements, including those applicable to Medicare Secondary Payer (MSP). The purpose of this Fact Sheet is to provide a general overview for provider billing staff when Medicare is responsible for paying first or is commonly referred to as the primary payer.

What Is Medicare Secondary Payer (MSP)?
“Medicare Secondary Payer” is the term used by Medicare when it is not responsible for paying a claim first. When Medicare began on July 1, 1966 , it was the primary payer for all beneficiaries, except for those who received benefits from the Federal Black Lung Program, Workers’ Compensation (WC), and those that receive all covered health care services through the Veterans Health Administration (VHA) programs. Beginning in 1980, changes to Medicare laws increased the number of coverage and benefit programs that are primary to Medicare. These changes help to preserve the Medicare Trust Fund and limit the beneficiary’s out-of-pocket costs. However, these changes also made the billing process more complex, especially when trying to determine if Medicare is the first or second payer.

When Does Medicare Pay First?
Medicare remains the primary payer for beneficiaries who are not covered by other types of insurance. Medicare is also the primary payer in other instances, provided several conditions are met. Table 1 lists some common situation when Medicare may be the primary or secondary payer for a patient's claims:

Table 1. List of Common Situations When Medicare May Pay First or Second

If the patient …	And the condition exists….	Then this program pays first…	And this program pays second….
Is age 65 or older, and is covered by a Group Health Plan through a current em-ployer or spouse's current employer…	The employer has less than 20 employees…	Medicare	Group Health Plan
	The employer has 20 or more employees, or at least one employer is a multi-employer group that employs 20 or more individuals…	Group Health Plan	Medicare
Has an employer retirement plan and is age 65 or older or is disabled and age 65 or older…	The patient is entitled to Medicare…	Medicare	Retiree coverage
Is disabled and covered by a Large Group Health Plan from work, or is covered by a family member who is working…	The employer has less than 100 employees…	Medicare	Large Group Health Plan
	The employer has 100 or more employees, or at least one employer is a multi-employer group that employs 100 or more individuals…	Large Group Health Plan	Medicare
Has end-stage renal disease and Group Health Plan Coverage…	Is in the first 30 months of eligibility or entitlement to Medicare….	Group Health Plan	Medicare
	After 30 months…	Medicare	Group Health Plan
Has end-stage renal disease and COBRA coverage…	Is in the first 30 months of eligibility or entitlement to Medicare…	COBRA	Medicare
	After 30 months…	Medicare	COBRA
Is covered under Workers' Compensation because of job-related illness or injury…	The patient is entitled to Medicare….	Workers' Compensation (for health care items or services related to job-related illness or injury)	Medicare
Has black lung disease and is covered under the Federal Black Lung Program…	The patient is eligible for the Federal Black Lung Program…	Federal Black Lung Program (for health care services related to black lung disease)	Medicare
Has been in an accident where no-fault or liabiligy insurance is involved…	The patient is entitled to Medicare…	No-fault or liability insurance (for accident-related health care services)	Medicare
Is age 65 or older OR is disabled and covered by Medicare and COBRA…	The patient is entitled to Medicare…	Medicare	COBRA
Has Veterans Health Administration (VHA) benefits	Receives VHA authorized health care services at a non-VHA facility…	VHA	Medicare may pay when the services provided are Medicare-covered services and are not covered by the VHA

How Do Providers Know When to Bill Medicare First?
To determine if Medicare is the primary payer, providers must ask the beneficiary about any additional coverage that he or she may have. To obtain the most updated information, providers should ask about any other insur-ance coverage at each patient visit. Some of the suggest-ed questions that providers should ask are:

• Is the patient covered by any Group Health Plan (GHP) through his or her current or former employment? If so, how many employees work for the employer providing coverage?
• Is the patient covered by any GHP through a family member’s current or former employment? If so, how many employees work for the employer providing the GHP?
• Is the patient receiving Federal Black Lung Pro-gram benefits?
• Is the illness or injury due to a work-related accident or condition, and is it being covered by WC?
• Is the illness or injury covered under automobile insurance, no-fault insurance, medical payments coverage, personal injury insurance, liability insurance, or a medical “set aside” account from a legal settlement?
• Is the patient being treated for an injury or illness for which another party could be held liable?

Answers to these questions will help providers complete the claim form and submit it to the correct primary payer. If providers do not submit the correct information to Medicare, Medicare retains the right to recover any mis-taken payments made to the provider.

Are There Any Exceptions to MSP Requirements?
In most cases, Federal law takes precedence over state laws and private contracts. Even if a state law or insurance policy states that they are a secondary payer to Medicare, the MSP regulations should be followed when billing for services.

What Happens if the Primary Payer Denies a Claim?
In the following situations, Medicare may make payment assuming the services are covered and a proper claim has been filed.

• The GHP denies payment for services because the beneficiary is not covered by the health plan;
• The no-fault or liability insurer does not pay, or denies the medical bill;
• The WC program denies payment, as in situations where WC is not required to pay for a given medical condition; or
• The Federal Black Lung Program will not pay the bill.

In these situations, providers should include documentation from the primary payer stating that the claim has been denied and/or benefits have been exhausted when submitting the claim to Medicare.

When Will Medicare Make a Conditional Payment?
A conditional payment is a payment made by Medicare, for Medicare covered services, where another payer is responsible for payment and the claim is not expected to be paid promptly (i.e., within 120 days from receipt of the claim). Medicare makes conditional payments to prevent the beneficiary from using his or her own money to pay the claim. However, Medicare has the right to recover any payments. This includes payments that should have been paid under WC, liability, no-fault insurance, or a GHP.

What Is Medicare Coordination of Benefits (COB)?
Coordination of Benefits (COB) is a CMS effort to identify additional health benefits that a Medicare beneficiary may have, and coordinate the payment process to prevent and minimize mistaken Medicare payments. The COB Contractor collects, manages, and maintains information on Medicare's Common Working File (CWF) regarding other health insurance coverage for Medicare beneficiaries. The COB Contractor also initiates all MSP claims investigations. The COB Contractor does not process claims and cannot provide information regarding specific claims. Questions about claims should be directed to the local Medicare claims processing contractor.

How Do Providers Contact the COB Contractor?
Providers may contact the COB Contractor at 1.800.999.1118 (TTY/TDD: 1.800.318.8782), Monday -Friday, 8 a.m. to 8 p.m. Eastern Time (excluding holidays). Providers may contact the COB Contractor to:

• Report potential MSP situations;
• Report incorrect insurance information; or • Address general MSP questions/concerns. Specific claim-based issues (including claim processing) should still be addressed to the provider’s Intermediaries and/ or Carriers.

Where Can I Find More Information on MSP and COB?
CMS offers several online references for information about MSP, COB, and the Medicare program:

The Medicare Learning Network Home Page

www.cms.hhs.gov/medlearn

The Medlearn Home Page features CMS provider education materials for COB and MSP issues, includes, including a link to the Physicians Information Resource for Mediare Home Page.

  The Medicare Secondary Payer and You Home Page

www.cms.hhs.gov/medicare/cob/msp/msp_home.asp

The Medicare Secondary Payer and You Home Page contains many useful resources for the MSP Program, including information on data gathering for providers, claims investigation, and contact information for the COB Contractor.

• The Medicare coordination of Benefits Home Page

 www.cms.hhs.gov/medicare/cob

The Medicare Coordination of Benefits Home page features MSP Program materials for providers such as the COB Contractor Claims Investigation Fact Sheet for Providers and quarterly newsletters.

Written inquiries or request for hardcopy COB newsletters can be sent to:

Medicare - COB
P.O. Box 125
New York , NY 10274-0125

(04-0924)

Top

Change to the Skilled Nursing Facility Consolidated Billing Edits for Ambulance Transports to and from an Diagnostic or Therapeutic Site other than a Physician’s Office or Hospital

Provider Types Affected
Skilled Nursing Facilities (SNF) and suppliers of ambulance services

Provider Action Needed

STOP – Impact to You
If you submit a Part B claim to your carrier for the ambulance transportation of a Medicare beneficiary in a Part A SNF stay, to or from a site other than a physician’s office or a hospital, your claim will be denied.

CAUTION – What You Need to Know
Ambulance transports of beneficiaries in Part A SNF stays, to sites other than a physician’s office or hospital, are considered to be paid as part of the SNF prospective payment system (PPS) rate, and may not be billed as Part B services to the carrier. Effective October 1, 2004, your carrier has been instructed to deny your Part B claims for ambulance transports of your Medicare Part A residents to or from a site other than a physician’s office or hospital (e.g., an independent diagnostic testing facility (IDTF), cancer treatment center, radiation therapy center, wound care center).

GO – What You Need to Do
Make sure that your billing staffs are aware that, for beneficiaries in a Part A stay, a separate Part B claim for the ambulance transport of Medicare Part A residents to or from a site other than a physician’s office or hospital will be denied.

Background
Section 4432 (b) of the Balanced Budget Act (BBA) requires consolidated billing (CB) for SNFs. Under the CB requirement, the SNF must submit (except for certain excluded services) all Medicare claims for all the services that its residents receive under Part A, and, in addition, for all physical, occupational, and speech language pathology services its residents receive under Part B.

All Medicare-covered Part A services that are deemed to be within a SNF’s scope or capability are
considered paid in the SNF prospective payment system (PPS) rate. As mentioned above, ambulance transports to or from an independent diagnostic testing facility (IDTF), or sites other than a physician’s office or hospital, are considered paid in the SNF PPS rate and may not be billed as Part B services to the carrier.

Please note that, in addition to the transport of beneficiaries in Part A stays to or from a site other than a physician’s office or hospital, a beneficiary’s transfer from one SNF to another before midnight of the same day is also included in the SNF PPS rate, and may not be billed separately as a Part B service. In this instance, the first SNF is responsible for billing the services to the intermediary.

Additional Information
You can find additional material related to this CR on the CMS Web site at:
http://www.cms.hhs.gov/manuals/transmittals/cr_num_dsc.asp. From that Web page, look for CR 3196 in the CR NUM column on the right, and click on the file for that CR. Attached to that CR, you can find revised Medicare manual pages for the Medicare Claims Processing Manual (Publication 100-4), Chapter 6, Section 20.3.1 – Ambulance Services, and Chapter 15, Section 30.2.3 – SNF Billing. These pages will provide further detail on this issue.

(04-0943)

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CIGNA Government Services Launches Part B Online Educational Training - NetCourses

In our commitment to providing the Medicare provider community with the most up-to-date educational training, CIGNA Government Services is pleased to announce the introduction of NetCourses. NetCourses are online training modules that can be accessed via the CIGNA Government Services Web site and offer the user a pre-test, a self-paced training session, a post-test, and an evaluation form to get your feedback on this exciting educational tool.

NetCourses are perfect for those new to your office or for those wanting to improve their knowledge of a particular subject. “Getting Started with EDI,” “The Benefits of EDI,” and “EDI Products and Services” are the first three Part B NetCourses offered, and many more will be added throughout the year. To access NetCourses, go to www.cignamedicare.com/webtraining and sign-up as a new user!

(04-0953)

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Coding of Subsequent Hospital Care

A nationwide problem of billing levels of subsequent hospital care codes that can not be supported by the patient’s condition has been identified. The documentation of the History, Physical Exam, and Medical Decision Making will support the code billed. However, the extent of the History documented, the extent of the Physical Examination documented and the level of Medical Decision Making are greater than the levels required by the patient’s condition. All billed services must be based only on activities that are reasonable and necessary for the diagnosis or treatment of illness or injury (SSA 1862(a)(1)(A)).

CPT codes 99231-99233 are used to describe subsequent hospital care. These codes require documentation of the interval history at either problem focused, expanded problem focused, or detailed levels. The examination requires the same levels of documentation. The Medical Decision Making documentation must support straightforward, low, moderate, or high complexity. The nature of the presenting problem usually DETERMINES the levels of history and physical exam REQUIRED.

1. CPT code 99231 usually requires documentation to support that the patient is stable, recovering, or improving.
2. CPT code 99232 usually requires documentation to support that the patient is responding inadequately to therapy or has developed a minor complication. Such minor complications might include careful monitoring of co-morbid conditions requiring continuous active management.
3. CPT code 99233 usually requires documentation to support that the patient is unstable or has a significant new problem or complication.

Clinical examples of subsequent Hospital care codes can be found in Appendix C of CPT 2004.

It is reasonable to expect higher levels of History and Physical exam to be needed in the days immediately following a hospital admission, following transfer from intensive care, or following an acute exacerbation, complication or de-compensation of the patient’s condition(s). It is not expected that these higher levels would be medically necessary when the patient is stable and improving particularly in the visits on days preceding discharge from the hospital. Documentation of History, Physical Examinations and Medical Decision Making should not be performed or billed at levels greater than needed for the patient’s condition, as medical necessity is the overarching criterion for the payment for all services billed to Medicare.

Clinical Example: Coding of the visits during a six-day hospitalization of an 80 year old patient with a presumptive diagnosis of pneumococcal pneumonia and low oxygen saturation.

First day after the day of admission: The patient continues tachypnic with low oxygen saturation, and febrile. The patient is receiving oxygen and broad-spectrum antibiotics awaiting cultures results. At present there is an inadequate response and condition would appear to support the levels of history and Physical exam required for CPT code 99232.

Second day after the day of admission: Less tachypnea, still febrile, still receiving oxygen and broad spectrum antibiotics. Culture results isolate no specific pathogen and current antibiotics are continued. A continued inadequate response would appear to support the levels of history and Physical exam required for CPT code 99232.

Third day after day of admission: Patient is afebrile, room air oxygen saturation is good. Patient is obviously improved. Current antibiotics continued intravenously for one more day. The patient is recovering and improving. Condition would appear to support the levels of History and Physical Exam required for CPT code 99231.

Fourth day after the day of admission: Afebrile with good room air oxygen saturation. IV antibiotics are discontinued and patient started on oral antibiotics. The patient is recovering and improving. Condition would appear to support the levels of history and Physical exam required for CPT code 99231.

Fifth day after day of admission: Patient is discharged and the appropriate discharge code is billed.

(04-0950)

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Collecting, Submitting, and Updating Beneficiary Insurance Information to Medicare for Physician and Provider Billing Staff

Background
As the Medicare program matures and the “baby boomer” generation moves towards retirement, it becomes critical to maintain the viability and integrity of the Medicare Trust Fund. Providers can contribute to the appropriate use of Medicare by complying with all Medicare requirements, including those applicable to Medicare Secondary Payer (MSP). The purpose of this Fact Sheet is to provide a general overview of the MSP Program for individuals involved in the admission and billing procedures at physician’s offices and other provider settings.

What Is Medicare Secondary Payer (MSP)?
Since 1980, the Medicare Secondary Payer (MSP) Program has protected Medicare funds by ensuring that Medicare does not pay for services that private health insurance plans or Government plans have primary responsibilities for paying. The MSP Program applies to claim situations when Medicare is not the beneficiary’s primary insurance. It provides the following benefits for both the Medicare program and the provider:

• National program savings – Medicare saves over $4.5 billion annually on claims processed by insurers that are primary to Medicare.
• Increased provider revenue – Providers that bill a liability insurer before billing Medicare may receive more favorable payment rates. Providers can also reduce administrative costs when health insurance is properly coordinated.

To realize these benefits, providers must have access to accurate, up-to-date information about all health plan insurance coverage that Medicare beneficiaries may have. Current law requires all entities seeking payment for any item or service furnished under Medicare Part B to complete the portion of the claim form relat-ing to the availability of other health insurance, based on infor-mation obtained from the individual to whom the item or service is furnished.

How Is Beneficiary Insurance Information Collected and Coordinated?
The Centers for Medicare & Medicaid Services (CMS) established the Coordination of Benefits (COB) Contract to collect, manage, and maintain information on Medicare’s Common Working File (CWF) regarding other health insurance coverage for Medicare beneficiaries. Providers must collect accu-rate MSP beneficiary information for the COB Contractor to coordinate the information.
To support the goals of the MSP Program, the COB Con-tractor manages several data gathering programs. These programs were implemented in phases, beginning in 2000.

What Are Some of the Activities Managed by the COB Contractor?
The COB Contractor implemented the first two phases of the contract in April 2000:

• Initial Enrollment Questionnaire (IEQ) –
  The COB Contractor sends out the IEQ approximately three months before an individual is eligible for Medicare. This questionnaire asks the beneficiary if he or she has other health care coverage that may be primary to Medicare.
• Internal Revenue Service/Social Security Administration/CMS (IRS/SSA/CMS) Data Match Project Coordination –
  The Omnibus Budget Reconciliation Act of 1989 requires each agency to share information it has regarding employment of Medicare beneficiaries or their spouses. This information helps determine whether a beneficiary may be covered by a group health insurance plan that pays primary to Medicare. This information is sent to the COB Contractor, which coordinates the Data Match Project.

As part of the Data Match project, the Voluntary Data Sharing Agreement (VDSA) program allows for the electronic data exchange of Group Health Plan (GHP) eligibility and Medicare information between CMS, employers, and various insurers. Employers, to meet the mandatory reporting requirements, can sign a VDSA in lieu of completing and submitting the IRS/SSA/CMS Data Match questionnaire.

In January 2001, an additional phase of the MSP Program was implemented:

• MSP Claims Investigation Process –
  The COB Contractor assumed responsibility for all initial MSP development activities previously performed by Intermediaries and Carriers. The COB Contractor provides a one-stop customer service approach for all MSP-related inquiries. However, providers should continue to call the Intermediary and/or Carrier that processes their claims regarding specific claim-based issues.

What Is the Provider’s Role in the MSP Program?
Providers must aid in the collection and coordination of beneficiary insurance information by:

• Requesting updated insurance profiles from the patient at each visit. A suggested method is to incorporate an MSP questionnaire into all patient health records.
• Billing the primary payer before billing Medicare, as required in the Social Security Act.
  How Do Providers Gather Accurate Data from the Beneficiary?
  Providers can save time and money by collecting patient insurance information at each patient visit. Some suggested questions that providers should ask are:
• Is the patient covered by any GHP through his or her current or former employment? If so, how many employees work for the employer providing coverage?
• Is the patient covered by any GHP through his or her spouse or other family member’s current or former employment? If so, how many employees work for the employer providing the GHP?
• Is the patient receiving Federal Black Lung Pro- gram benefits?
• Is the patient receiving Workers’ Compensation (WC) benefits?
• Is the patient covered under automobile insur-ance, no-fault insurance, medical payments coverage, personal injury insurance, liability insurance, or a medical “set aside” account from a legal settlement?
• Is the patient being treated for an injury or illness for which another party could be held liable?

If the provider does not furnish Medicare with a record of other insurance that may be primary to Medicare on any claim and there is an indication of possible MSP, the COB Contractor may request that the provider complete a Development Questionnaire.

Why Gather Additional Beneficiary Insurance Information?
The goal of MSP information-gathering activities is to quickly identify possible MSP situations, thus ensuring cor-rect primary and secondary payments by the responsible parties. This effort may require that providers complete Development Questionnaires to collect accurate benefi-ciary insurance information. Many of the questions on the Development Questionnaires are similar to the coverage questions that providers might ask a beneficiary during a routine visit. This similarity provides another good reason to routinely ask patients about their insurance coverage. If a provider gathers information about a beneficiary’s other insurance and uses that information to complete the claim properly, Development Questionnaires may not be necessary. Accurate submittal of claims may accelerate the processing of the provider’s claim.

The types of questionnaires the COB Contractor may submit to providers include:

• Secondary Claim Development (SCD) Questionnaire; and
• Trauma Development (TD) Questionnaire.

Each questionnaire addresses different potential MSP situations.

What Is a Secondary Claim Development (SCD) Questionnaire?
An SCD Questionnaire may be sent to the provider, when a claim is submitted with an Explanation of Benefits (EOB) attached from an insurer other than Medicare, and perti-nent information was not submitted to properly adjudi-cate the submitted claim. The COB Contractor provides the name and Health Insurance Claim Number (HICN) of each beneficiary for which the provider is requested to complete an SCD Questionnaire. The provider should complete and return the SCD Questionnaire to the COB Contractor.

What Is a Trauma Development (TD) Questionnaire?
A TD Questionnaire may be sent when information re-garding an accident, illness, or injury is received and/or a diagnosis appears on a claim that indicates an accident, illness, or injury has occurred. This incident may be related to a WC, automobile accident, or other liability situation. The TD Questionnaire may be sent to the beneficiary, the provider, the attorney, or the insurer to collect information regarding the existence of other insurance that may be primary to Medicare. If an MSP liability situation is identified after Medicare pays the claim, Medicare has the right to recover any conditional payments made on behalf of the beneficiary.

What Happens if a Provider Bills Another Insurance First and It Does Not Pay in a Timely Manner?
Sometimes claims properly submitted to primary payers (such as automobile, no-fault, liability, or WC insurers) are not paid in a timely manner (within 120 days). This situation may occur when there are delays in settlements. To offset this problem, Medicare may be billed for any Medicare covered service and it will make a conditional payment on the claim. Medicare has the right to recover any conditional payments made on behalf of the beneficiary.

What Happens if the Provider Submits a Claim to Medicare Without Providing the Other Insurer’s Information?
The claim will be paid if it meets Medicare coverage and medical necessity guidelines. However, if the beneficiary’s Medicare record indicates that another insurer should have paid primary to Medicare, the provider will be sent an MSP Development Questionnaire to complete. Medicare will review the information on the questionnaire and determine whether to recover the conditional payments made to the provider, beneficiary, or another party of obligation.

What Happens if the Provider Fails to File Correct and Accurate Claims with Medicare?
Federal law permits Medicare to recover its conditional payments. Providers can be fined up to $2,000 for knowingly, willfully, and repeatedly providing inaccurate information relating to the existence of other benefit plans.

How Does the Provider Contact the COB Contractor?
Providers may contact the COB Contractor at 1.800.999.1118 (TTY/TDD: 1.800.318.8782), Monday - Friday, 8 a.m. to 8 p.m. Eastern Time (excluding holidays). Providers may contact the COB Contractor to:

• Report potential MSP situations;
• Report incorrect insurance information; or
• Address general MSP questions/concerns.
  Specific claim-based issues (including claim processing) should still be addressed to Intermediaries and/or Carriers.

Where Can I Find More Information on the Provider’s Role in MSP and COB?
CMS offers several online references for information about MSP, COB, and the Medicare program:

The Medicare Learning Network Home Page
www.cms.hhs.gov/medlearn/
The Medlearn Home Page features CMS provider education materials for COB and MSP issues, including a link to the Physicians Information Resource for Medicare Home Page.

The Medicare Secondary Payer and You Home Page
www.cms.hhs.gov/medicare/cob/msp/msp_home.asp
The Medicare Secondary Payer and You Home Page contains many useful resources for the MSP Program, including information on data gathering for providers, claims investigations, and contact information for the COB Contractor.

The Medicare Coordination of Benefits Home Page
www.cms.hhs.gov/medicare/cob
The Medicare Coordination of Benefits Home Page features MSP Program materials for providers such as the COB Contractor MSP Claims Investigation Fact Sheet for Providers and quarterly newsletters.
Written inquiries or requests for hardcopy COB newsletters can be sent to:

Medicare – COB
P.O. Box 125
New York, NY 10274-0125

(04-0921)

Top

Collecting, Submitting, and Updating Beneficiary Insurance Information to Medicare For Clinical Laboratories

Background
As the Medicare program matures and the “baby boomer” generation moves toward retirement, it becomes critical to maintain the viability and integrity of the Medicare Trust Fund. Clinical laboratories can contribute towards the appropriate use of Medicare by complying with all Medicare requirements, including those applicable to Medicare Secondary Payer (MSP).

Clinical laboratories operate in a distinctly different environment from other Medicare providers. Unlike physicians and hospitals, a clinical laboratory often furnishes covered services without actually seeing the patient. This lack of patient interaction may create a special challenge when obtaining and maintaining accurate insurance information needed for claim submission. Without accurate insurance information, clinical laboratories may receive unnecessary payment denials or delays in Medicare payments. The purpose of this Fact Sheet is to introduce the MSP Program to clinical laboratory service providers, with particular emphasis on how to maintain and submit updated beneficiary insurance information.

What Is Medicare Secondary Payer (MSP)?
Since 1980, the Medicare Secondary Payer (MSP) Program has protected Medicare funds by ensuring that Medicare does not pay for services that private health insurance plans or Government plans have primary responsibilities for paying. The MSP Program applies to claim situations when Medicare is not the beneficiary’s primary insurance. It provides the following benefits for both the Medicare program and the provider:

• National program savings – Medicare saves over $4.5 billion annually from claims processed by insurers that are primary to Medicare.
• Increased provider revenue – Providers that bill a liability insurer before billing Medicare may receive more favorable payment rates. Providers can also reduce administrative costs when health insurance is properly coordinated.

To realize these benefits, providers must have access to accurate, up-to-date information about all health insurance coverage that Medicare beneficiaries may have. Current law requires all entities seeking payment for any item or service furnished under Medicare Part B to complete the portion of the claim form relating to the availability of other health insurance, based on information obtained from the individual to whom the item or service is furnished.

What Constitutes a Clinical Laboratory?
A clinical laboratory is any facility that tests specimens derived from humans for the purpose of diagnosis prevention, treatment of disease, or impairment and assessment of health. This includes laboratories that provide onsite simple testing such as physician office laboratories, skilled nursing facilities, rural health clinics, and pharmacies.

How Does the Centers for Medicare & Medicaid Services (CMS) Support the MSP Program?
The Centers for Medicare & Medicaid Services (CMS) established the Coordination of Benefits (COB) Contractor to collect, manage, and maintain information on Medicare’s Common Working File (CWF) regarding other health insurance coverage for Medicare beneficiaries.

What is the Clinical Laboratory’s Role in the MSP Program?
All providers must submit accurate beneficiary health insurance information to assist CMS in maintaining accurate beneficiary records. Specifically, clinical laboratories have two primary responsibilities for the collection and coordination of beneficiary insurance information:

• Updating insurance profiles prior to submitting laboratory claims. For laboratories that do not see the beneficiaries, the clinical laboratory should contact the beneficiary to obtain his or her health insurance information. The Health Insurance Portability and Accountability Act (HIPAA) permits communication of beneficiary insurance information between a referring/ ordering provider and a clinical laboratory for the purpose of submitting claims for individual beneficiaries. However, CMS does not authorize nor does it approve of requesting or obtaining insurance information from anyone other than the beneficiary.
• Billing the primary payer before billing Medicare for laboratory services. Clinical laboratories that submit Electronic Media Claims (EMCs) may acquire access to beneficiary eligibility files through their software vendor. EMCs permit billers to instantly determine if a beneficiary is eligible for Medicare benefits, has met his or her deductible, or is enrolled in a Medicare managed care (Medicare Advantage) plan. In addition, clinical laboratories can verify if the beneficiary has other health insurance coverage registered in the MSP database [referred to as the Common working File (CWF)] that should be billed before Medicare. If a beneficiary has other insurance identified in the CWF, the laboratory should confirm with the beneficiary if the information is current and correct. Section 1862 (b) (6)) of the Social Security Act (42 USC 1395y (b) (6)) requires all entities seeking payment for any item or services furnished under Medicare Part B to complete the portion of the claim form relating to the availability of other health insurance, based on information obtained from the individual to whom the item or service is furnished. If a clinical laboratory has updated information, but is not sure if Medicare is the primary or secondary payer, the clinical laboratory may also contact the Medicare COB contractor. When contacting the COB Contractor the clinical laboratory must have its provider number readily available.

What Questions Should a Clinical Laboratory Ask to Gather Accurate Data from the Beneficiary?
Laboratories can save time and money by collecting patient insurance information prior to billing for services. When gathering insurance information, the following questions should be addressed:

• Is the patient covered by any GHP through his or her current or former employment? How many employees work for the employer providing coverage?
• Is the patient covered by any GHP through is or her spouse or other family member’s current or former employment? How many employees work for the employer providing coverage?
• Is the patient receiving Federal Black Lung Program benefits?
• Is the patient receiving Workers’ Compensation (WC) benefits?
• Is the illness or injury covered under automobile insurance, no-fault insurance, medical payments coverage, personal injury insurance, liability insurance, or a medical “set aside” account from a legal settlement?
• Is the patient being treated for an injury or illness for which another party could be held liable?

If the clinical laboratory does not provide Medicare with a record of other health insurance that may be secondary to Medicare on any claim and there is an indication of possible MSP, the COB contractor may request that the provider complete a Development Questionnaire.

Why Gather Additional Beneficiary Insurance Information?
The goal of MSP information-gathering activities is to quickly identify possible MSP situations, thus ensuring correct primary and secondary payments by the responsible parties. This effort may require providers to complete Development questionnaires to collect accurate beneficiary insurance information. Many of the questions on the Development questionnaires are similar to the coverage questions that providers might ask a beneficiary during a routine visit. This similarity provides another good reason to routinely ask patients about their insurance coverage. If a provider gathers information about a beneficiary’s other insurance and uses that information to complete the claim properly, a Development Questionnaire may not be necessary. Accurate submittal of claims may accelerate the processing of the provider’s claim.

The types of questionnaires the COB Contractor may send to providers include:

• Secondary Claim Development (SCD) Questionnaire; and
• Trauma Development (TD) Questionnaire.

Each questionnaire addresses different potential MSP situations.

What is an SCD Questionnaire?
An SCD Questionnaire may be sent to the provider when a claim is submitted with an Explanation of Benefits (EOB) attached from an insurer other than Medicare, and pertinent information was not submitted to properly adjudicate the submitted claim. The COB Contractor provides the name and Health Insurance Claim Number (HICN) of each beneficiary for which the provider is requested to complete and return the SCD Questionnaire to the COB Contractor.

What is a TD Questionnaire?
A TD Questionnaire may be sent when information
regarding an accident, illness, or injury is received and/or a diagnosis appears on a claim that indicates an accident, illness, or injury has occurred. This incident may be related to a Workers’ Compensation (WC), automobile accident, or other liability situation. The TD Questionnaire may be sent to the beneficiary, the provider, the attorney, or the insurer to collect information on the existence of other insurance that may be primary to Medicare. If an MSP situation is identified after Medicare pays the claim, Medicare has the right to recover any conditional payments made on behalf of the beneficiary.

What Happens if Laboratory Bills Another Insurance First and It Does Not Pay in a Timely Manner?
Sometimes claims properly submitted to automobile, no fault, liability, or WC insurers as primary payers, are not paid in a timely manner (within 120 days). This situation may occur when there are delays in settlements. To offset this problem, Medicare may make conditional payments in situations when the primary claims are not expected to be paid in a timely manner. If a provider has not received payment within 120 days, Medicare may be billed for any Medicare covered services provided and Medicare may make a conditional payment on the claim. However, once a settlement has been reached, the primary payer is still responsible for its portion of the claim. Medicare has the right to recover any conditional payments made on behalf of the beneficiary.

What Happens If the Laboratory Submits a Claim to Medicare Without Providing the Other Insurer’s Information?
The claim will be paid if it meets Medicare coverage and medical necessity guidelines. However, if the beneficiary’s Medicare recorded indicates that another insurer should have paid primary to Medicare, the claim will be denied. If the provider has information that contradicts Medicare’s files, this information should be reported to the COB contractor. If necessary and MSP Development Questionnaire will be sent to the beneficiary or other entity. The COB Contractor will review the information on the returned questionnaire and determine whether there is MSP. If necessary, Medicare’s records will be updated and the affected claims will be reprocessed.

What Happens if the Laboratory Fails to File Correct and Accurate Claims with Medicare?
Federal law permits Medicare to recover its conditional payments. Providers can be fined up to $2,000 for knowingly, willfully, and repeatedly providing inaccurate information relating to the existence of other benefit plans.

How Does a Clinical Laboratory Contact the COB Contractor?
Clinical laboratories can contact the COB Contractor at 1.800.999.1118(TTY/TDD: 1.800.318.8782), Monday - Friday, 8 a.m. to 8 p.m. Eastern Time (excluding holidays). Laboratories may contact the COB Contractor to:

• Report potential MSP situations;
• Report incorrect insurance information; or
• Address general MSP questions/concerns.

Specific claim-based issues (including claim processing) should still be addressed to the clinical laboratory’s Carriers.

Where Can I Find More Information on the Clinical Laboratory’s Role in MSP and COB?
CMS offers several online references for information about MSP, COB, and the Medicare program:

The Medicare Learning Network Home Page
www.cms.hhs.gov/medlearn/
The Medlearn home page features CMS provider education materials for COB and MSP issues, including a link to the Physician Information Resource for Medicare home page.

The Medicare Coordination of Benefits Home Page
www.cms.hhs.gov/medicare/cob
The Medicare Coordination of Benefits home page features provider materials for the MSP Program, such as the COB Contractor MSP Claims Investigation Fact Sheet for Providers and quarterly newsletters.

The Medicare Secondary Payer and You Home Page
http://www.cms.hhs.gov/medicare/cob/msp/msp_home.asp
The Medicare Secondary Payer and You home page contains many useful resources for the MSP Program, including information on data gathering for providers, claims investigations, and contact information for the COB Contractors.

The Quarterly Provider Update Page for Clinical Diagnostic Laboratories

www.cms.hhs.gov/providerupdate/clia.asp
The Quarterly Provider Update Page includes regulation, manuals, and Program Memoranda for clinical diagnostic laboratories.

Written inquiries or requests for hardcopy COB newsletters can be sent to:

Medicare - COB
P.O. Box 125
New York, NY 10274-0125

(04-0923)

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Complying with Medicare Secondary Payer Requirements

Background
As the Medicare program matures and the “baby boomer” generation moves towa rd retirement, it becomes critical to maintain the viability and integrity of the Medicare Trust Fund. Providers can contribute to the appropriate use of Medicare by complying with all Medicare requirements, including those applicable to Medicare Secondary Payer (MSP). The purpose of this Fact Sheet is to provide a general overview of the MSP Program for physicians and provider administrators.

What Is Medicare Secondary Payer (MSP)?
“Medicare Secondary Payer” is the term used by Medicare when Medicare is not responsible for paying a claim first. When Medicare began on July 1, 1966, it was the primary payer for all beneficiaries, except for those who received benefits from the Federal Black Lung Program and Workers’ Compensation (WC) and for those who receive all covered health care services through the Veterans Health Administration (VHA) programs. Beginning in 1980, changes to Medicare laws increased the number of coverage and benefit programs that are primary to Medicare. The additions to the MSP requirements included:

• Automobile, liability, and no-fault insurance that may provide benefits for an accident or injury;
• Group Health Plans (GHPs) made available to working Medicare beneficiaries age 65 or older, or Medicare beneficiaries of any age with a spouse who is working and covered by a GHP;
• Large Group Health Plans (LGHPs) made available to disabled Medicare beneficiaries under the age of 65 through their current employment, or the current employment of a family member; and
• GHPs made available to persons with end-stage renal disease (ESRD)/permanent kidney failure (including beneficiaries directly covered, or covered as a dependent.)

With the increase in additional insurance plans and payment programs that are primary to Medicare, the provider’s responsibility to maintain accurate, up-to-date information about Medicare beneficiaries is critical. Fulfilling the data gathering responsibilities required by the MSP Program can benefit providers, as well as help Medicare remain viable for future beneficiaries. The Centers for Medicare & Medicaid Services (CMS) estimates that the MSP Program has resulted in an annual savings in excess of $4.5 billion.

How Does MSP Benefit Providers?
Providers have several valid reasons to comply with MSP data gathering requirements:

• Providers are required to comply with all Medicare laws and regulation. Failure to comply could result in fines and penalties, including but not limited to, the return of payments made by Medicare.
• Providers may receive more favorable reimbursement rates by billing both primary and secondary payers, as appropriate.
• Providers may reduce the number of Development Questionnaires they receive by spending a few minutes at the beginning of each patient visit to collect current insurance information. The few minutes spent with each patient may take less time than responding to a Development Questionnaire.

What Are the MSP Requirements for Providers?
Providers are responsible for maintaining a system that identifies any primary payer other than Medicare for each beneficiary. To fulfill this responsibility, providers must determine if Medicare is the primary or secondary payer for each service.

How Do Providers Determine Who Pays First?
To determine if Medicare is the primary payer, providers must ask the beneficiary about any additional health insurance coverage that he or she may have. To obtain the most updated information, providers should ask about any other health insurance coverage at each patient visit. Some suggested questions that providers should ask are:

• Is the patient covered by any GHP based on his or her current or former employment? If so, how many employees work for the employer providing coverage?
• Is the patient covered by any GHP based on a family member’s current or former employment? If so, how many employees work for the employer providing the GHP?

What is the Medicare Coordination of benefits (COB)?
Coordination of Benefits (COB) is a CMS effort to identify additional health benefits available to a Medicare beneficiary, and coordinate the payment process to prevent and minimize mistaken Medicare payments. The COB contractor collects, manages, and maintains information on Medicare’s Common working file (CWF) regarding other health insurance coverage for Medicare beneficiaries. The COB Contractor also initiates all MSP claims investigations. The COB contractor does not process claims and cannot provide information regarding specific, ongoing cases. Questions about claims and specific, ongoing cases should be directed to the local Medicare claims processing contractor.

What Is an MSP Claims Investigation?
The COB Contractor initiates an MSP investigation when there is an indication that a beneficiary has other health insurance. This investigation may occur if a provider submits a claim that contains new health insurance information that conflicts with what currently exists on Medicare’s beneficiary records. This investigation determines if Medicare or the other health insurance is the primary payer for a beneficiary’s claims MSP claims investigations usually begin with Development Questionnaires.

What Types of Development Questionnaires Are Sent to Providers?
Two types of Development Questionnaires are sent to providers:

• Secondary Claim Development (SCD) Questionnaire -
  An SCD Questionnaire may be sent to the provider when a claim is submitted with an Explanation of Benefits (EOB) attached from an insurer other than Medicare, and pertinent information was not submitted to properly adjudicate the submitted claim. The COB contractor provides the name and Health Insurance Claim Number (HICN) of each beneficiary for which the provider is requested to complete an SCD Questionnaire. The provider should complete and return the SCD Questionnaire to the COB Contractor
• Trauma Development (TD) Questionnaire -
  A TD Questionnaire may be sent when information regarding an accident, illness, or injury is received and/or a diagnosis appears on a claim that indicates an accident, illness, or injury has occurred. This incident may be related to a WC, automobile accident, or other liability situation. The TD questionnaire may be sent to the beneficiary, provider, attorney, or insurer to collect information on the existence of other insurance that may be primary to Medicare. If an MSP situation is identified after Medicare pays the claim, Medicare has the right to recover any conditional payments made on behalf of the beneficiary.

If a provider gathers information about a beneficiary’s other insurance and uses that information to complete the claim properly, Development Questionnaires may not be necessary. Accurate submittal of claims may accelerate the processing of the provider’s claim.

How Do Providers Contact the COB Contractor?

Providers can contact the COB Contractor at 1.800.999.1118 (TTY/TDD: 1.800.318.8782), Monday - Friday, 8 a.m. to 8 p.m. Eastern Time (excluding holidays). Providers may contact the COB Contractor to:

• Report potential MSP situations:
• Report incorrect insurance information; or
• Address general MSP questions/concerns

Specific claim-based issues (including claim processing) should still be addressed to Intermediaries and/or Carriers.

Where Can I Find More Information on the Provider’s Role in MSP and COB?
CMS offers several online references for information about MSP, COB, and the Medicare program:

The Medicare Learning Network Home Page
www.cms.hhs.gov/medlearn/
The Medlearn home page features CMS provider education materials for COB and MSP issues, including a link to the Physicians Information Resources for Medicare home page.

The Medicare Secondary Payer and You Home Page
www.cms.hhs.gov/medicare/cob/msp/msp_home.asp
The Medicare Secondary Payer and You home page contains many useful resources for the MSP Program, including information on data gathering for providers, claims investigation, and contact information for the COB Contractor.

The Medicare Coordination of Benefits Home Page
www.cms.hhs.gov/medicare/cob
The Medicare coordination of Benefits home page features MSP Program materials for providers such as the COB Contractor MSP Claims Investigation Fact Sheet for Providers and quarterly newsletters.

Written inquiries or requests for hardcopy COB newsletters can be sent to:

Medicare - COB
P.O. Box 125
New York, NY 10274-1025

(04-0922)

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The Consolidation of the Claims Crossover Process: Smaller-Scale Initial Implementation

Providers Affected
All Medicare physicians, providers, and suppliers.

Provider Action Needed
In recent instructions to Medicare carriers, including Durable Medical Equipment Carriers (DMERCs) and Fiscal Intermediaries (FIs), the Centers for Medicare & Medicaid Services (CMS) presented the requirements for a redesigned process for coordination of benefits activities. (For an explanation of these requirements/instructions, see Medlearn Matters article MM3109.)

In CR 3218, CMS is advising the carriers, FIs, and DMERCs that the implementation schedule is being altered and some requirements have changed. Providers need to be aware of how these changes, as described below, may affect them.

The key message is that the impact of this change on providers is delayed from July 6 until further notice.

Background
CMS is starting the consolidation of the claims crossover process by beginning with a smaller-scale implementation on July 6, 2004. Through this instruction, CMS announces which portions of Transmittal R-98 (Change Request (CR) 3109) are:

• Still applicable;
• Which requirements have changed; and
• Which requirements are being moved to the October 4, 2004 systems release or to another future release.

Details regarding the requirements that have changed, and which are being moved to the October 4, 2004 systems release or to another future release, are listed in CR3218, which can be found at the CMS Web site address that is included in the Additional Information section of this article.

A key change is that the entire process will not be implemented on July 6, 2004, as mentioned in CR3109 and Medlearn Matters article MM3109.

Instead, a pilot test will be conducted from July 6, 2004 through October 1, 2004, when approximately eight Coordination of Benefits Agreement (COBA) trading partners will participate as beta-testers in a parallel production crossover environment.

During the parallel production period, the eight COBA trading partners will continue to receive crossover claims from Medicare contractors and will also receive crossover claims as part of the COBA process.

In light of CMS’ decision to implement the COBA crossover consolidation project on a smaller scale within a parallel environment, Medicare carriers/FIs/DMERCs will continue to follow their current processes for the printing of Medicare Summary Notice (MSN) and Electronic Remittance Advice (ERA) crossover messages throughout the period from July 6, 2004 to October 1, 2004. Medicare contractors will also continue to charge all trading partners to whom they cross Medicare claims.

During the parallel production period, CMS’ Medicare Coordination of Benefits Contractor (COBC) will not be charging the trading partners that participate in the COBA beta-site testing for claims that it crosses to them.

The eligibility-based crossover process will begin to be implemented on a larger scale on October 4, 2004.

Also on October 4, 2004, the initial eight COBA beta-site testers will be converted to full production and will begin to be charged for claims that the COBC crosses over to them.
CMS’ claim-based COBA crossover process is being delayed until a future systems release.

This process previously had a major impact on the provider community as of October 2004
and that will not occur in October 2004 as previously planned.

Implementation
The implementation date for this instruction is July 6, 2004. This means that only those participating in the pilot phase are affected on that date. All other trading partners will not be affected until October 1, 2004, at the earliest. Additional instructions will be issued as new implementation dates are established for moving from the pilot phase to full implementation.

Additional Information
The official instruction issued to your Medicare contractor regarding this change may be found by going to: http://www.cms.hhs.gov/manuals/pm_trans/R138CP.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.

Also, Transmittal R-98, Change Request 3109, Consolidation of the Claims Crossover Process: Additional Common Working File (CWF) Functionality, dated February 6, 2004, can be found at the following CMS Web site: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3109.pdf.

Change Request 3218 supercedes CR 3109 and deletes the impact on provider requirements listed in requirements 20 and 21 in CR 3109. Consolidated claim-based crossovers have been delayed until further notice. The claim-based crossover process remains unchanged at the Medicare contractors.

(04-0858)

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Diabetes Self-Management Training Services

Provider Types Affected
Physicians, suppliers, and providers.

Provider Action Needed

STOP – Impact to You
Physicians, suppliers, and providers should note that the definition for diabetes mellitus has been changed.

CAUTION – What You Need to Know
This instruction revises the current Internet Only Manual (IOM) for Diabetes Self-Management Training (DSMT), and changes the definition for diabetes mellitus. Also, material that was not originally included from previous instructions has been added to the IOM.

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

Background
This instruction, recently issued by the Centers for Medicare & Medicaid Services (CMS), revises the current Internet Only Manual (IOM) for diabetes self-management training (DSMT) (Section 300 through 300.5), and the definition for diabetes mellitus has been changed per Volume 68, #216, November 7, 2003, page 63261 of the Federal Register. Section 4105 of the Balanced Budget Act of 1997 permits Medicare coverage of Diabetes Self-Management Training (DSMT) services when these services are furnished by a certified provider who meets certain quality standards. This program is intended to educate beneficiaries in the successful self management of diabetes. The program includes instructions in self-monitoring of blood glucose; education about diet and exercise; an insulin treatment plan developed specifically for the patient who is insulin dependent; and motivation for patients to use the skills for self-management.

Diabetes self-management training services may be covered by Medicare only if the treating physician or treating qualified nonphysician practitioner who is managing the beneficiary’s diabetic condition certifies that such services are needed. The referring physician or qualified nonphysician practitioner must maintain the plan of care in the beneficiary’s medical record and documentation substantiating the need for training on an individual basis when group training is typically covered, if so ordered. The order must also include a statement signed by the physician that the service is needed as well as the following:

• The number of initial or follow-up hours ordered (the physician can order less than 10 hours of training);
• The topics to be covered in training (initial training hours can be used for the full initial training program or specific areas such as nutrition or insulin training); and
• A determination that the beneficiary should receive individual or group training. The provider of the service must maintain documentation in file that includes the original order from the physician and any special conditions noted by the physician.

Beneficiaries Eligible for Coverage and Definition of Diabetes
Medicare Part B covers (not to exceed) 10 hours of initial training for a beneficiary who has been diagnosed with diabetes. Diabetes is defined as diabetes mellitus, a condition of abnormal glucose metabolism diagnosed using the following criteria:

A fasting blood sugar greater than or equal to 126 mg/dL on two different occasions;

• A two-hour post-glucose challenge greater than or equal to 200 mg/dL on two different occasions; or
• A random glucose test over 200 mg/dL for a person with symptoms of uncontrolled diabetes.

Related Instructions
The following sections of the Medicare Benefit Policy Manual (Pub 100-2), Chapter 15 (Covered Medical and Other Health Services) have been revised:

• Section 300 (Diabetes Outpatient Self-Management Training Services)
• Subsections 300.1 (Coverage Requirements)
• 300.2 (Certified Providers)
• 300.3 (Frequency of Training)
• 300.4 (Outpatient Diabetes Self-Management Training).

The Medicare Benefit Policy Manual, Chapter 15 can be found at the following CMS Web site:
http://www.cms.hhs.gov/manuals/102_policy/bp102c15.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/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.

(04-1021)

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Healthcare Common Procedure Coding System Corrections Involving 0040T and A9603

Provider Types Affected
Physicians and providers

Provider Action Needed

STOP – Impact to You
Physicians and providers should note that this instruction includes Healthcare Common Procedure Coding System (HCPCS) corrections involving HCPCS codes 0040T and A9603.

CAUTION – What You Need to Know
This instruction places an end date on HCPCS code A9603 as of December 31, 2003. Also, HCPCS code A9603 is a duplicate of HCPCS code A9517, and HCPCS code A9517 is the correct HCPCS code that must be billed for this service. HCPCS code 0040T was incorrectly categorized in the HCPCS database as a laboratory service and given a lab certification number. The lab certification number and category are being removed from the Medicare claims processing system so claims containing HCPCS code 0040T can be processed for payment, as of July 6, 2004.

GO – What You Need to Do
In reference to HCPCS code 0040T, there is nothing you need to do. The error mentioned above is being corrected in the Medicare claims processing system. However, when billing for “Radiopharmaceutical Therapeutic Imaging Agent, I-131 Sodium Iodide Capsule, Per MCI,” use HCPCS code A9517 and not A9603. Refer to the Background and Additional Information sections of this instruction for further details regarding these changes.

Background
Each year in the United States, health care insurers process over 5 billion claims for payment. For
Medicare and other health insurance programs to ensure that these claims are processed in an orderly and consistent manner, standardized coding systems are essential. The Healthcare Common Procedure Coding System (HCPCS) was developed for this purpose, and it is used for identifying items and services.

The HCPCS is not a methodology or system for making coverage or payment determinations. The
existence of a code does not, of itself, determine coverage or noncoverage for an item or service. While these codes are used for billing purposes, decisions regarding the addition, deletion, or modification of HCPCS codes are made independent of the process for making determinations regarding coverage and payment.

Implementation Date
This instruction has an implementation date of July 6, 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 CR3258 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.

In addition, a comprehensive overview of the HCPCS can be found at the following Centers for Medicare & Medicaid Services (CMS) Web site:
http://www.cms.hhs.gov/medicare/hcpcs/codpayproc.asp.

(04-0995)

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MMA - 2nd Update to the 2004 Medicare Physician Fee Schedule Database

Provider Types Affected
Physicians, suppliers, and providers

Provider Action Needed
Physicians, suppliers, and providers should note the changes to the Medicare Physician Fee Schedule Database, and identify those changes that impact their practice.

Background
This instruction corrects errors in payment files issued to carriers based upon the November 7, 2003, and January 7, 2004, Final Rules for the 2004 Medicare Physician Fee Schedule Database. Details of the changes in this second update of the year may be found in the Additional Information section below.

Also, unless otherwise stated, these changes are retroactive to January 1, 2004. However, carriers and fiscal intermediaries will not search their files to either retract payment for claims already paid or to retroactively pay claims based on the corrected rates. Carriers will adjust claims brought to their attention by the provider.

Implementation
The implementation date for this instruction is July 6, 2004.

Additional Information
The official instruction issued to your carrier regarding this change may be found at:
http://www.cms.hhs.gov/manuals/pm_trans/R173CP.pdf. Changes included in this instruction to the 2nd Update to the 2004 Medicare Physician Fee Schedule Database are shown in the following table.

Changes to 2nd Update to the 2004 Medicare Physician Fee Schedule Database
CPT/HCPCS ACTION

A9603	Procedure Status = F Note: Effective for services performed on or after January 1, 2004. Currently, A9603 is not on the 2004 Medicare Physician Fee Schedule Database.
G0295	Description change: Electromagnetic therapy, to one or more areas, for wound care other than described in G0329, or for other uses Note: Description change effective for services performed on or after July 1, 2004.
G0321	Short Descriptor: ESRDrelatedsvs home mo 2-11y WRVU = 8.11 Non-Facility PE RVU = 3.92 Facility PE RVU = 3.92 Malpractice RVU = 0.29
G0322	WRVU = 6.90 Non-Facility PE RVU = 3.67 Facility PE RVU = 3.67 Malpractice RVU = 0.23
G0329	Description: 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. Short Descriptor: Electromagntic tx for ulcers Procedure Status = A WRVU = 0.06 Non-Facility PE RVU = 0.17 Facility PE RVU = 0.17 Malpractice RVU = 0.01 PC/TC = 7 Site of Service = 1 Global = XXX Multiple Procedure Indicator = 0 Bilateral Procedure Indicator = 0 Assistant at Surgery Indicator = 0 Co-Surgery Indicator = 0 Team Surgery Indicator = 0 Type of Service = 1, U, W Note: Effective for services performed on or after July 1, 2004.
28304	Bilateral Surgery Indicator = 1
28305	Bilateral Surgery Indicator = 1
28306	Bilateral Surgery Indicator = 1
28307	Bilateral Surgery Indicator = 1
28308	Bilateral Surgery Indicator = 1
31629	WRVU = 4.09 Non-Facility PE RVU = 12.79 Facility PE RVU = 1.45
36416	Procedure Status = B
61863	Non-Facility PE RVU = 11.80 Facility PE RVU = 11.80
61867	Non-Facility PE RVU = 18.08 Facility PE RVU = 18.08
63048	Bilateral Surgery Indicator = 0
73218	Bilateral Surgery Indicator = 3
73218 - TC	Bilateral Surgery Indicator = 3
73218 - 26	Bilateral Surgery Indicator = 3
73219	Bilateral Surgery Indicator = 3
73219 - TC	Bilateral Surgery Indicator = 3
73219 - 26	Bilateral Surgery Indicator = 3
73222	Bilateral Surgery Indicator = 3
73222 - TC	Bilateral Surgery Indicator = 3
73222 - 26	Bilateral Surgery Indicator = 3
73223	Bilateral Surgery Indicator = 3
73223 - TC	Bilateral Surgery Indicator = 3
73223 - 26	Bilateral Surgery Indicator = 3
73718	Bilateral Surgery Indicator = 3
73718 - TC	Bilateral Surgery Indicator = 3
73718 - 26	Bilateral Surgery Indicator = 3
73719	Bilateral Surgery Indicator = 3
73719 - TC	Bilateral Surgery Indicator = 3
73719 - 26	Bilateral Surgery Indicator = 3
73720	Bilateral Surgery Indicator = 3
73720 - TC	Bilateral Surgery Indicator = 3
73720 - 26	Bilateral Surgery Indicator = 3
73722	Bilateral Surgery Indicator = 3
73722 - TC	Bilateral Surgery Indicator = 3
73722 - 26	Bilateral Surgery Indicator = 3
73723	Bilateral Surgery Indicator = 3
73723 - TC	Bilateral Surgery Indicator = 3
73723 - 26	Bilateral Surgery Indicator = 3
73725	Bilateral Surgery Indicator = 3
73725 – TC	Bilateral Surgery Indicator = 3
73725 – 26	Bilateral Surgery Indicator = 3
78804	Non-Facility PE RVU = 11.47 Facility PE RVU = 11.47 Multiple Surgery Indicator = 9
78804 – TC	Non-Facility PE RVU = 11.10 Facility PE RVU = 11.10 Multiple Surgery Indicator = 9
78804 – 26	Multiple Surgery Indicator = 9
88358	Non-Facility PE RVU = 0.56 Facility PE RVU = 0.56
88358 – 26	Non-Facility PE RVU = 0.42 Facility PE RVU = 0.42
88358 – TC	Non-Facility PE RVU = 0.14 Facility PE RVU = 0.14
95144	Non-Facility PE RVU = 0.19

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

(04-0967)

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MMA - National 1.800.MEDICARE (1.800.633.4227) Implementation (Section 923(d) of MMA)

Provider Types Affected
All providers

Provider Action Needed

STOP – Impact to You
Medicare carriers (including DMERCs) and fiscal intermediaries will no longer maintain their own individual beneficiary toll-free telephone numbers. Instead, all beneficiary calls should be directed to 1.800.MEDICARE.

CAUTION – What You Need to Know
Effective June 1, 2004, carriers and FIs will begin to transition to 1.800.MEDICARE for all beneficiary questions that pertain to Medicare claims and services. The Centers for Medicare & Medicaid Services (CMS) will contact each carrier/FI on an individual basis to provide the specific migration/implementation date for that contractor (phase-in is planned for June - July 2004). As calls come in to the new centralized number, questions regarding specific claims will be routed to the appropriate Medicare carrier/FI for response.

GO – What You Need to Do
Medicare carriers/FIs will publish the new beneficiary toll-free telephone number on Medicare Summary Notices (MSNs), beneficiary correspondence, Medicare Redetermination Notices (formerly, appeals letters) and, if applicable, on Medicare beneficiary Web sites. On or after August 1, 2004, when you advise your patients to call Medicare with questions, direct them to 1.800.MEDICARE. However, for calls regarding eligibility status or claims status, and other provider-initiated inquiries, providers should continue to use the existing provider toll-free numbers.

Background
The change in policy, driven by the Medicare Modernization Act (MMA) of 2003 (section 923 (d)), requires all Medicare carriers/FIs to use one number—1.800.MEDICARE for all Medicare questions from beneficiaries. By providing a single call-in number, Medicare aims to improve customer telephone service by connecting callers quickly with the correct Medicare contractor for their case and question, thereby reducing the number of calls and referrals overall.

Currently, an internal CMS workgroup is developing standard operating procedures for processes and exceptions to this new policy. All procedures will be communicated to contractors as soon as final decisions are made.

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 CR 3195 in the CR NUM column on the right, and click on the file for that CR number.

Also, remember that 1.800.MEDICARE is for beneficiary-initiated calls. Providers calling Medicare should continue using the numbers currently in use. If you do not have that number, you may find it at: http://www.cms.hhs.gov/tollnums.asp.

(04-0925)

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MMA-New Medicare-Approved Drug Discount Cards and Transitional Assistance Program: A Summary for Physicians and Other Health Care Professionals

Provider Types Affected
Physicians and other health care professionals

Provider Action Needed
Understand the Medicare-Approved Drug Discount Cards and Transitional Assistance Program that begins in 2004 to help Medicare beneficiaries save on prescription drugs.

Background
As part of the Medicare Modernization Act of 2003 (MMA), the Medicare-Approved Drug Discount Cards and Transitional Assistance Program begins in 2004 to help Medicare beneficiaries save on prescription drugs. Medicare will contract with private companies to offer new drug discount cards until a Medicare prescription drug benefit starts in 2006. A discount card with Medicare’s seal of approval can help Medicare beneficiaries save on prescription drug costs. This article is designed to give an overview of the new Medicare-Approved Drug Discount Cards and Transitional Assistance Program. It will also explain where you may refer Medicare patients for information on selecting and enrolling in the drug discount card that best suits their needs.

Medicare-Approved Drug Discount Cards

• Open enrollment started in May 2004
• Available to qualified beneficiaries regardless of income
• Represent a variety of discount and drug options from private companies
• Available to beneficiaries eligible for or enrolled in Medicare Part A or enrolled in Medicare Part B, unless receiving outpatient prescription drug coverage through State Medicaid programs
• May charge an annual enrollment fee of no more than $30, which may be paid by Medicare for some low-income beneficiaries
• Do not require that beneficiaries purchase discount drugs through mail-order pharmacies
• Provide beneficiaries the ability to use their discount cards in pharmacies near their homes.

Transitional Assistance Program
Beneficiaries with the greatest need will have the greatest help available to them. Individuals with an annual income in 2004 of no more than $12,569 if single or $16,862 if married, and individuals receiving help from their state in paying their Medicare premiums or cost sharing, may qualify for a $600 credit on their discount card to help pay for prescription drugs. These income limits change every year. Residents of Puerto Rico or a U.S. territory are not eligible for the $600 credit from Medicare. However, they may be eligible for similar assistance provided by the territory in which they reside. Beneficiaries cannot qualify for the $600 if they already have outpatient prescription drug coverage from certain other sources.

Where Do I Refer Medicare Beneficiaries for Information on Prescription Drug Discount Programs?
In addition to the Medicare-approved drug discount cards, there are other programs available that provide assistance in paying for prescription drugs. Alternatives such as individual state pharmacy assistance programs and manufacturers’ discount programs may be a better fit for certain individuals.

Medicare recognizes that physicians and other health care professionals have limited time available to counsel patients.

The following resources are available to help individuals with questions about the Medicare-approved drug discount cards:

The 1.800.MEDICARE (1.800.633.4227) Toll-Free Call Center
This Call Center is available 24 hours per day and 7 days per week. It connects beneficiaries with
customer service representatives who can answer questions and perform price comparisons for discount cards and other assistance programs. Beneficiaries should prepare a list of current prescription drugs and dosages prior to contacting the Call Center. Beneficiaries may request a copy of their individualized price comparison results. TTY users should call 1.877.486.2048.

The Prescription Drug and Other Assistance Programs Web site at Medicare.gov www.medicare.gov/AssistancePrograms/home.asp - For beneficiaries who use the Internet, this site features eligibility, enrollment, and price comparison information for each available discount card in a particular area, as well as their state pharmacy assistance programs. It also has a tool that helps beneficiaries determine the best savings program based on their prescription drug needs.

Medicare’s Guide to Choosing a Medicare-Approved Drug Discount Card
www.medicare.gov - This resource provides beneficiaries with information on choosing a card, enrolling, and submitting complaints. This guide also features sample enrollment forms and worksheets to assist beneficiaries in selecting the discount card that is right for them.

State Health Insurance Counseling and Assistance Programs (SHIP)
Beneficiaries may also contact their SHIP counselor for information on prescription drug cost assistance programs. To find the telephone number for the nearest SHIP, call 1.800.MEDICARE (1.800.633.4227) or visit www.medicare.gov/Contacts/Related/Ships.asp on the Web.

Information Resources for Physicians and Other Health Care Professionals

• Download a free patient-education brochure at www.medicare.gov (or call 1.800.MEDICARE to order a limited number of free copies).
• Read “The Medicare-Approved Drug Discount Cards and Transitional Assistance Program”- A Brochure for Physicians and Other Health Care Professionals at www.cms.hhs.gov/medlearn.
• Attend CMS Open Door Forums in person or by telephone (toll-free). These forums address concerns and issues of physicians, nurses, and allied health professionals. Visit www.cms.hhs.gov/opendoor for further details.
• Visit www.cms.hhs.gov/medicarereform for the latest information on MMA.
• Contact your carrier for information by using the toll-free provider lines. Visit www.cms.hhs.gov/medlearn/tollnums.asp for your carrier’s toll-free number.

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MMA – Payment for Chemotherapy Administration Services, Nonchemotherapy Drug Infusion Services, and Drug Injection Services

Provider Types Affected
Physicians

Provider Action Needed

STOP – Impact to You
Physicians should note that this instruction affects payment for chemotherapy administration and nonchemotherapy drug infusion services furnished on or after January 1, 2004.

CAUTION – What You Need to Know
Understand the revised payment policy for chemotherapy administration and nonchemotherapy drug infusion services.

GO – What You Need to Do
Be sure that billing staff are aware of these changes and code claims accordingly.

Background
This instruction incorporates the policy included in Change Request (CR) 3028 (Transmittal 34, dated December 24, 2003) pursuant to the Medicare Modernization Act of 2003 (MMA, Section 303), which affects payment for chemotherapy administration and nonchemotherapy drug infusion services furnished on or after January 1, 2004. In addition, this instruction includes all the necessary business requirements for the payment policy on chemotherapy administration and nonchemotherapy drug infusion services not originally included in CR3028.

The Medicare physician fee schedule is used to pay for services that correspond to Current Procedural Terminology (CPT) codes for:

• Chemotherapy administration services;
• Therapeutic or diagnostic infusions (excluding chemotherapy); and
• Drug injection codes.

In addition, these CPT codes have had:

• Practice expense relative value units;
• Malpractice relative value units; but
• Zero physician work relative value units.

For services furnished prior to January 1, 2004, carriers allowed:

• Chemotherapy administration services CPT code 96408 (Chemotherapy administration, intravenous; push technique) to be billed and paid only once per day (even if the physician administered multiple drugs).
• Drug injection codes (90782 to 90788) to be billed and paid separately (only if no other physician fee schedule service was being paid at the same time). For example, if CPT code 99211 was billed with a drug injection code, the carrier paid only for CPT code 99211.

For services furnished on or after January 1, 2004, carriers shall allow:

• Chemotherapy administration services CPT code 96408 (Chemotherapy administration, intravenous; push technique) to be billed and paid more than once per day. Payment shall be allowed for CPT code 96408 for each drug administered.
• Drug injection codes to be billed and paid separately (only if no other physician fee schedule service is being paid at the same time). If CPT code 99211 is billed with a drug injection code, the carrier pays only for CPT code 99211.
  For services furnished on or after January 1, 2004, carriers shall not allow:
• CPT code 99211 (with or without modifier 25) to be billed or paid on the same day as a chemotherapy administration service or a nonchemotherapy drug infusion service.

In addition, Medicare carriers have been instructed:

• To pay for evaluation and management services, other than 99211, provided by the physician on the same day as the chemotherapy administration codes of 96400, 96408 to 96425, 96520 or 96530 if the evaluation and management service meets the requirements of Chapter 12, Section 30.6.6 of the Medicare Claims Processing Manual (Pub 100-04) even though the underlying codes do not have global periods.
• To pay for evaluation and management services, other than 99211, provided by the physician on the same day as the nonchemotherapy drug infusion service (90780 or 90781), if the evaluation and management service meets the requirements of Chapter 12, Section 30.6.6 even though the underlying codes do not have global periods.
• To use an appropriate adjustment reason code when denying a service that is not separately payable. Medicare carriers will not adjust claims already processed unless such claims are brought to the attention of the carrier by the physician.

Also, pursuant to Section 303 of the MMA, CMS has established work relative value units for:

• Chemotherapy administration services (CPT codes 96400, 96408 to 96425, 96520 and 96530);
• Nonchemotherapy drug infusion services (CPT codes 90780 to 90781); and
• Drug injection codes (CPT codes 90782 to 90788).

The work relative value for each code is equal to the work relative value unit for a level 1 office medical visit for an established patient (CPT code 99211). CPT code 99211 is a level 1 established patient office visit with physician work relative values of 17.

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 CR3192 in the CR NUM column on the right, and click on the file for that CR. Revised portions of Chapter 12, Sections 20.3, and 30.5 are attached to the instruction at this Web site.

For other information from Chapter 12 and other portions of the Medicare Claims Processing Manual, visit: http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp.

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.

In addition, CR3028, Transmittal 34, dated December 24, 2003, can be reviewed at the following CMS Web site: http://www.cms.hhs.gov/manuals/pm_trans/r34otn.pdf.

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New Requirements for Chiropractic Billing of Active/Corrective Treatment and Maintenance Therapy

Provider Types Affected
Chiropractic care providers.

Provider Action Needed

STOP – Impact to You
Chiropractors have been submitting a very high rate of incorrect claims to Medicare. Medicare only pays for chiropractic services for active/corrective treatment (those using HCPCS codes 98940, 98941, or 98942). Claims for medically necessary services rendered on or after October 1, 2004, must contain the Acute Treatment (AT) modifier to reflect such services provided or the claim will be denied.

CAUTION – What You Need to Know
On or after October 1, 2004, when you provide acute or chronic active/corrective treatment to Medicare patients, you must add the AT modifier to every one of your claims that use HCPCS codes 98940, 98941, or 98942. If you don’t add this modifier, your care will be considered maintenance therapy and will be denied because maintenance chiropractic therapy is not medically reasonable or necessary under Med