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October 2004 Part B Medicare Bulletin

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3rd Update to the 2004 Medicare Physician Fee Schedule Database

Provider Types Affected
Physicians, providers, and suppliers

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

Background
Payment files were issued to carriers based upon the November 7, 2003, and January 7, 2004, Final Rules. This instruction amends those payment files and requires that carriers give providers 30 days notice before implementing the revised payment amounts reflected in this instruction. Carriers will not search their files to either retract payment for claims already paid or to retroactively pay claims. However, carriers will adjust claims brought to their attention.

Unless otherwise stated in this instruction, changes will be retroactive to January 1, 2004.

Implementation
The implementation date for this instruction is October 4, 2004.

Additional Information
The actual changes to the fee schedule involve numerous CPT/HCPCS codes and the actual effective dates vary. These are all included in the table below. You may view the official instruction issued to your carrier by going to: http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

From that Web page, look for CR3415 in the CR NUM column on the right, and click on the file for that CR.

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

Changes to 3rd Update to the 2004 Medicare Physician Fee Schedule Database

CPT/HCPCS ACTION
G0336 Description: PET imaging, brain imaging for the differential diagnosis of Alzheimer’s disease with aberrant features vs. fronto-temporal dementia
  Short Descriptor: PET imaging brain Alzheimer’s
  Procedure Status = C
  PC/TC = 1
  Site of Service = 1
  Global Surgery = XXX
  Multiple Procedure Indicator = 0
  Bilateral Procedure Indicator = 0
  Assistant at Surgery Indicator = 9
  Co-Surgery Indicator = 0
  Team Surgery Indicator = 0
  Type of Service = 4
  Diagnostic Supervision = 9
  Note: Effective for services performed on or after September 15, 2004.
G0336 - TC Description: PET imaging, brain imaging for the differential diagnosis of Alzheimer’s disease with aberrant features vs. fronto-temporal dementia
  Short Descriptor: PET imaging brain Alzheimer’s
  Procedure Status = C
  PC/TC = 1
  Site of Service = 1
  Global Surgery = XXX
  Multiple Procedure Indicator = 0
  Bilateral Procedure Indicator = 0
  Assistant at Surgery Indicator =9
  Co-Surgery Indicator = 0
  Team Surgery Indicator = 0
  Type of Service = 4
  Diagnostic Supervision = 9
  Note: Effective for services performed on or after September 15, 2004
G0336 - 26 Description: PET imaging, brain imaging for the differential diagnosis of Alzheimer’s disease with aberrant features vs. fronto-temporal dementia
  Short Descriptor: PET imaging brain Alzheimer’s
  Procedure Status = A
  WRVU = 1.50
  Non-Facility PE RVU = .51
  Facility PE RVU = .51
  Malpractice RVU = .05
  PC/TC = 1
  Site of Service = 1
  Global Surgery = XXX
  Multiple Procedure Indicator = 0
  Bilateral Procedure Indicator = 0
  Assistant at Surgery Indicator = 9
  Co-Surgery Indicator = 0
  Team Surgery Indicator = 0
  Type of Service = 4
  Diagnostic Supervision = 9
  Note: Effective for services performed on or after September 15, 2004
G0341 Description: Percutaneous islet cell transplant, includes portal vein catheterization and infusion (To report imaging bill 75887 or 75885)
  Short Descriptor: Percutaneous islet cell trans
  Procedure Status = A
  WRVU = 6.98
  Non-Facility PE RVU = 2.73
  Facility PE RVU = 2.73
  Malpractice RVU = 0.48
  PC/TC = 0
  Site of Service = 1
  Global Surgery = 000
  Multiple Procedure Indicator = 2
  Bilateral Procedure Indicator = 0
  Assistant at Surgery Indicator = 9
  Co-Surgery Indicator = 1
  Team Surgery Indicator = 0
  Type of Service = 2
  Diagnostic Supervision = 9
  Note: Effective for services performed on or after October 1, 2004
G0342 Description: Laparoscopy for Islet Cell Transplant, includes portal vein catheterization and infusion
  Short Descriptor: Laparoscopy Islet cell Trans
  Procedure Status = A
  WRVU = 11.92
  Non-Facility PE RVU = 5.32
  Facility PE RVU = 5.32
  Malpractice RVU = 1.46
  PC/TC = 0
  Site of Service = 1
  Global Surgery = 090
  Pre Op = 0.09
  Intra Op = 0.81
G0342 Post Op = 0.10
  Multiple Procedure Indicator = 2
  Bilateral Procedure Indicator = 0
  Assistant at Surgery Indicator = 2
  Co-Surgery Indicator = 1
  Team Surgery Indicator = 0
  Type of Service = 2
  Diagnostic Supervision = 9
  Note: Effective for services performed on or after October 1, 2004
G0343 Description: Laparotomy for Islet Cell transplant, includes portal vein catheterization and infusion
  Short Descriptor: Laparotomy Islet cell transp
  Procedure Status =A
  WRVU = 19.85
  Non-Facility PE RVU = 8.82
  Facility PE RVU = 8.82
  PC/TC = 0
  Malpractice RVU = 2.05
  Site of Service = 1
  Global Surgery = 090
  Pre Op = 0.09
  Intra Op = 0.81
  Post Op = .10
  Multiple Procedure Indicator = 2
  Bilateral Procedure Indicator = 0
  Assistant at Surgery Indicator = 2
  Co-Surgery Indicator = 1
  Team Surgery Indicator = 0
  Type of Service = 2
  Diagnostic Supervision = 9
  Note: Effective for services performed on or after October 1, 2004
23410 Bilateral Status Indicator = 1
33979 Bilateral Status Indicator = 0
33980 Bilateral Status Indicator = 0
52320 Endobase Code = 52000
52325 Endobase Code = 52000
52327 Endobase Code = 52000
52327 Bilateral Status Indicator = 1
52330 Endobase Code = 52000
52332 Endobase Code = 52000
52334 Endobase Code = 52000
52341 Endobase Code = 52000
52342 Endobase Code = 52000
52343 Endobase Code = 52000
52344 Endobase Code = 52000
69440 Bilateral Surgery Indicator = 1
69450 Bilateral Surgery Indicator = 1
69501 Bilateral Surgery Indicator = 1
69502 Bilateral Surgery Indicator = 1
69505 Bilateral Surgery Indicator = 1
69511 Bilateral Surgery Indicator = 1
69530 Bilateral Surgery Indicator = 1
69535 Bilateral Surgery Indicator = 1
69540 Bilateral Surgery Indicator = 1
69550 Bilateral Surgery Indicator = 1
69552 Bilateral Surgery Indicator = 1
69554 Bilateral Surgery Indicator = 1
69601 Bilateral Surgery Indicator = 1
69602 Bilateral Surgery Indicator = 1
69603 Bilateral Surgery Indicator = 1
69604 bilateral"bilateral" surgery"surgery" indicator = "1
69605 Bilateral Surgery Indicator = 1
69610 Bilateral Surgery Indicator = 1
69620 Bilateral Surgery Indicator = 1
69631 Bilateral Surgery Indicator = 1
69632 Bilateral Surgery Indicator = 1
69633 Bilateral Surgery Indicator = 1
69635 Bilateral Surgery Indicator = 1
69636 Bilateral Surgery Indicator = 1
69637 Bilateral Surgery Indicator = 1
69641 Bilateral Surgery Indicator = 1
69642 Bilateral Surgery Indicator = 1
69643 Bilateral Surgery Indicator = 1
69644 Bilateral Surgery Indicator = 1
69645 Bilateral Surgery Indicator = 1
69646 Bilateral Surgery Indicator = 1
69650 Bilateral Surgery Indicator = 1
69660 Bilateral Surgery Indicator = 1
69661 Bilateral Surgery Indicator = 1
69662 Bilateral Surgery Indicator = 1
69666 Bilateral Surgery Indicator = 1
69667 Bilateral Surgery Indicator = 1
69670 Bilateral Surgery Indicator = 1
69700 Bilateral Surgery Indicator = 1
69711 Bilateral Surgery Indicator = 1
69714 Bilateral Surgery Indicator = 1
69715 Bilateral Surgery Indicator = 1
69717 Bilateral Surgery Indicator = 1
69718 Bilateral Surgery Indicator = 1
69720 Bilateral Surgery Indicator = 1
69725 Bilateral Surgery Indicator = 1
69740 Bilateral Surgery Indicator = 1
69745 Bilateral Surgery Indicator = 1
69799 Bilateral Surgery Indicator = 1
69801 Bilateral Surgery Indicator = 1
69802 Bilateral Surgery Indicator = 1
69805 Bilateral Surgery Indicator = 1
69806 Bilateral Surgery Indicator = 1
69820 Bilateral Surgery Indicator = 1
69840 Bilateral Surgery Indicator = 1
69905 Bilateral Surgery Indicator = 1
69910 Bilateral Surgery Indicator = 1
69915 Bilateral Surgery Indicator = 1
69930 Bilateral Surgery Indicator = 1
69949 Bilateral Surgery Indicator = 1
69950 Bilateral Surgery Indicator = 1
69955 Bilateral Surgery Indicator = 1
69960 Bilateral Surgery Indicator = 1
69970 Bilateral Surgery Indicator = 1
69979 Bilateral Surgery Indicator = 1
96400 PC/TC = 0
96408 PC/TC = 0
96425 PC/TC = 0
96520 PC/TC = 0
96530 PC/TC = 0
0001T Co-Surgery Indicator = 2
   
   
   
   
   

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Drug Pricing Update—Payment Limits for J7308 (Levulan Kerastick) and J9395 (Faslodex)

Provider Types Affected
Physicians, suppliers, and providers

Provider Action Needed

STOP – Impact to You
New payment limits have been set for HCPCS drug codes J7308 (Levulan Kerastick) and J9395 (Faslodex) when these codes are not paid on a cost or prospective payment basis.

CAUTION – What You Need to Know
Medicare Carriers are instructed to replace the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) payment limits for HCPCS drug codes J7308 (Levulan Kerastick) and J9395 (Faslodex) with the new rates listed in this instruction for dates of service on or after January 1, 2004.

GO – What You Need to Do
Be aware of the new payment limits for these two codes.

Background
This article informs providers that Medicare carriers will apply new payment limits for these HCPCS codes (J7308 (Levulan Kerastick) and J9395 (Faslodex)) for claims processed with dates of service on or after January 1, 2004, and on or before December 31, 2004.

From January 1, 2004, through December 31, 2004, the Medicare payment limits for the specific HCPCS drug codes listed below (that are not paid on a cost or prospective payment basis) apply.

Average 2004 Payment Limit for Drugs (other than End Wholesale Price Stage Renal disease (ESRD) drugs separately (AWP) % billed by independent ESRD Facilities and drugs infused through Durable Medical Equipment (DME)

HCPCS Short Description Average Wholesale Price (AWP) % 2004 Payment Limit for Drugs (other than End Stage Renal disease (ESRD) drugs separately billed by independent ESRD Facilities and drugs infused through Durable Medical Equipment (DME)
J7308 Aminolevulinic acid hcl top
85
$111.47
J9395 Injeciton, Fulvestrant
85
$81.57

Note: The payment limits listed in the table above supercede the payment limits published in Change Request 3105 (Transmittal 75) dated January 30, 2004, only for these particular HCPCS drug codes for this time period. Also note that the absence or presence of an HCPCS code and its associated payment limit does not indicate Medicare coverage of the drug.

Implementation
The implementation date for this instruction is July 25, 2004. The effective date of the change is January 1, 2004. However, Medicare contractors will not adjust any claims previously processed in order to apply these new payment limits unless the provider requests such an adjustment.

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MMA Drug Pricing Update – Payment Limit for J9045 (Carboplatin Injection) and J9310 (Rituximab Cancer Treatment)

Provider Types Affected
Physicians, suppliers, and providers.

Provider Action Needed
Affected providers are advised that Medicare carriers are updating the payment limits (listed in this article) for HCPCS drug code J9045 (Carboplatin injection) and J9310 (Rituximab cancer treatment), effective with dates of service on or after April 1, 2004, and on or before December 31, 2004.

Background
The payment limits for Carboplatin injection and Rituximab cancer treatment, Medicare Part B drugs meeting the exceptions process described in Section 303(b) of Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) are being updated for claims with such services provided between April 1, 2004, through December 31, 2004, inclusive. The old and new rates for J9045 (Carboplatin injection) and J9310 (Rituximab cancer treatment) with the new rate for dates of service on or after April 1, 2004, and on or before December 31, 2004, are as follows where payment is not made on a cost or prospective payment basis:

Status
HCPCS
Short Description
AWP %
2004 Payment Limit for Drugs (other than ESRD drugs separately billed by independent ESRD Facilities and drugs infused through DME)
OLD J9045 Carboplatin injection
88
$137.54
NEW J9045 Carboplatin injection
86
$135.15
OLD J9310 Rituximab cancer treatment
81
$427.28
NEW J9310 Rituximab cancer treatment
83
$438.38

The payment limits for J9045 and J9310 supercede the payment limits published in Change Request (CR) 3161 (Transmittal 119) dated March 15, 2004. Note that the absence or presence of a HCPCS code and its associated payment limit does not indicate Medicare coverage of the drug.

Implementation
The implementation date for this instruction is September 24, 2004.

Additional Information
For complete details, please see the official instruction issued to your carrier regarding this change. That instruction may be viewed by going to: http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

From that Web page, look for CR3419 in the CR NUM column on the right, and click on the file for that CR.

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

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MMA Drug Pricing Update – Payment Limits for J1000 (Depo-estradiol cypionate inj)

Provider Types Affected
Physicians, providers, and independent End Stage Renal Disease (ESRD) facilities

Provider Action Needed
Providers should be aware that payment limits for Healthcare Common Procedure Coding System (HCPCS) drug code J1000 (Depo-estradiol cypionate inj) are changing for services furnished on or after January 1, 2004, and on or before December 31, 2004.

Background
This article advises providers that Medicare carriers and fiscal intermediaries (FIs) will update the payment limits for HCPCS drug code J1000 (Depo-estradiol cypionate inj) effective with dates of service on or after January 1, 2004, and on or before December 31, 2004.

From January 1, 2004, through December 31, 2004, the Medicare payment limits apply for the specific HCPCS drug codes listed below that are not paid on a cost or prospective payment basis. The payment limit listed in the table for J1000 supersedes the payment limit published in Change Request (CR) 3105, dated January 30, 2004.

NOTE: The absence or presence of an HCPCS code and its associated payment limit does not indicate Medicare coverage of the drug.

 
HCPCS
Average Wholesale Price %
2004
Payment Limit
Other than ESRD Drugs Separately Billed by Independent ESRD Facilities
J1000
85
$2.33
ESRD Drugs Separately Billed by Independent ESRD Facilities
J1000
95
$2.60

Carriers and FIs will not search and adjust claims that have already been processed unless brought to their attention.

Implementation
The implementation date for this instruction is September 27, 2004.

Related Instructions
CR3105, Transmittal 75, dated January 30, 2004, can be found at the following Centers for Medicare & Medicaid Services (CMS) Web site: http://www.cms.hhs.gov/manuals/pm_trans/R75CP.pdf

Additional Information
The official instruction issued to your carrier/intermediary 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 3418 in the CR NUM column on the right, and then 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

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2005 Healthcare Common Procedure Coding System (HCPCS) Annual Update Reminder

Provider Types Affected
Physicians, providers, and suppliers

Provider Action Needed
This instruction is a reminder that the complete HCPCS file is updated and released annually by the Centers for Medicare & Medicaid Services (CMS) to the Medicare contractors. The 2005 version of the HCPCS file contains existing, new, revised, and discontinued HCPCS codes for 2005. Your Medicare contractor will use the file for processing claims for services on or after January 1, 2005.

All Medicare physicians, providers, and suppliers: there is no longer a 90-day grace period for billing discontinued HCPCS codes as of January 1, 2005.

Background
Medicare providers submitting claims to Medicare contractors for Part B services use a HCPCS code to indicate the service that was provided. HCPCS consist of Level I codes, which are the American Medical Association’s (AMA’s) Current Physician Terminology Codes (CPT-4) and Level II codes, which are alphanumeric and maintained by CMS.

The alpha-numeric index and the table of drugs will be posted to the CMS Web site by the end of October. The CMS Web site address for that posting will be: http://www.cms.hhs.gov/providers/pufdownload/default.asp#alphanu

There is no longer a 90-day grace period for discontinued codes in order to be compliant with HIPAA standards. To view further information regarding the elimination of this 90-day grace period, see the Medlearn Matters article MM3093, which may be found at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3093.pdf

Implementation
The implementation date for this instruction is January 3, 2005.

Additional Information
For complete details, please see the official instruction issued to your carrier and fiscal intermediary regarding this change. That instruction may be viewed by going to: http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

From that Web page, look for CR3422 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

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Application of the Medicare Secondary Payer for the Working Aged Provision to Former Spouses and the Medicare Secondary Payer for the Disabled Provision to Former Spouses and Certain Family Members with Coverage Under the Federal Employees Health Benefits (FEHB) Program

Provider Types Affected
All Medicare providers

Provider Action Needed
This is an informational article to alert providers that former spouses of certain federal employees, former employees, or annuitants, may qualify to enroll in a health benefits plan under the Federal Employees Health Benefit Plan (FEHB) and the correct order of payment.

A determination has been made that Medicare will be the primary payer for such former spouses, once they are entitled to Medicare based on age or disability.

Background
Certain former spouses of people who have Federal Employees Health Benefits are entitled to coverage under the Spouse Equity Act because their divorce decree gives them the right to a portion of a future retirement annuity and/or to a survivor annuity, and because their former spouse is either an active worker, someone who is entitled to a future annuity, or is an annuitant.

The Medicare law in Section 1862 (b)(1)(A) of the Social Security Act, states that Medicare is secondary payer for individuals age 65 or over who have group health coverage by virtue of their own or a spouse’s current employment status. The question was raised as to whether FEHB coverage provided to former spouses under the Spouse Equity Act is secondary to Medicare under this provision. Also, the question has been raised as to whether FEHB coverage provided to the spouse and family members under the Spouse Equity Act is secondary to Medicare under the disability provision.

Under the Spouse Equity Act, the individual is no longer on the former spouse’s policy. The coverage is considered to be a separate, self-only policy, i.e., not dependent coverage but a policy separate from the former spouse. The employer makes no contributions to the coverage. Since the language in the Spouse Equity Act gives the former spouse the right to enroll in FEHB whether or not the spouse himself or herself is enrolled, the FEHB former spouse coverage is not considered employment based. Consequently, Medicare is the primary payer for the former spouse, once they are entitled to Medicare under the working aged provision. Under the Medicare secondary for the disabled provision, Medicare would be primary for the former spouse as well as any covered family members since the coverage is not considered employment based.

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 3120 in the CR NUM column on the right, and click on the file for that CR.

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Autologous Blood-Derived Products for Chronic, Non-Healing Wounds

Provider Types Affected
All Medicare providers

Provider Action Needed
No action is necessary. This article is informational only. The Centers for Medicare & Medicaid Services (CMS) has determined, upon reconsideration of existing policy, that Autologous Blood-Derived Products for Chronic Non-Healing Cutaneous Wounds, both platelet-derived growth factor (PDGF) in platelet-poor plasma and platelet-rich plasma (PRP), will remain non-covered as CMS continues to believe that the clinical effectiveness of these autologous blood-derived products is not adequately proven in scientific literature.

Background
Patient-donated blood is centrifuged to produce an autologous gel for the treatment of chronic non-healing cutaneous wounds that persist for 30 days or longer and fail to complete the healing process properly. Autologous blood-derived products for chronic non-healing wounds include both PDGF products, such as Procuren and more recent products, and PRP products.

PRP differs from previous products because it contains whole cells, including white cells, red cells, plasma, platelets, fibrinogen, stem cells, macrophages, and fibroblasts. PRP is used by physicians in clinical settings. PDGF does not contain cells and was marketed as a product to be used by patients at home.

In 1992 CMS issued a national Medicare non-coverage determination in relation to platelet-derived wound healing formulas containing growth factors in the treatment of non-healing wounds. The determination was based on a lack of sufficient published data to determine the safety and efficacy of such formulas, and a Public Health Service technology assessment.

Recently, CMS reconsidered that 1992 decision and concluded that the clinical effectiveness of autologous PDGF products continues to be inadequately proven in scientific literature, and it remains non-covered for treatment of chronic, non-healing cutaneous wounds. Additionally, the clinical evidence does not support a benefit in the application of autologous PRP for the treatment of chronic, non-healing wounds, and CMS has determined it is not reasonable and necessary and is nationally non-covered.

It will remain at the local carrier’s discretion whether to pay for Becaplermin, a non-autologous growth factor product approved by the FDA for the treatment of chronic non-healing subcutaneous wounds. Also, the routine costs of autologous PRP products for the treatment of chronic non-healing wounds associated with Category B Investigational Device Exemption clinical trials are covered by Medicare in accordance with 42 CFR 405.201 – 405.215, 411.15, and 411.406 or section 310.1 of the National Coverage Determinations Manual.

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

From that Web page, look for CR 3384 in the CR NUM column on the right and click on the file for that CR. Also 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

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Changes Based On The 3rd Update To The MPFSDB

Code State Facility/Nonfacility Amount
G033626

NC
TN
ID

$74.89
$74.29
$73.67
G0341

NC
TN
ID

$366.59
$363.32
$358.98
G0342

NC
TN
ID

$663.68
$659.19
$646.12
G0343

NC
TN
ID

$1095.04
$1084.38
$1067.86

THE PC/TC INDICATOR FOR CODES 96400, 96408, 96425, 96520, AND 96530 WILL REMAIN A 5.

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Correct Coding & Billing for Endoluminal Radiofrequency and Endoluminal Laser Ablation of Varicose Veins (A22239) - Article

Contractor Information

Contractor Name
CIGNA Government Services

Contractor Number
05535

Contractor Type
Carrier

Article Information

Article Database ID Number
A22239

Article Type
Basic Article

Article Title
Correct Coding & Billing for Endoluminal Radiofrequency and Endoluminal Laser Ablation of Varicose Veins

Primary Geographic Jurisdiction
NC

Article Publication Date
08/18/2004

Article Beginning Effective Date
08/18/2004

Article Text
Claims review of these procedures is indicating that some providers are billing for a variety of claims that are non-payable for this procedure under our current coverage policy. We are even finding upon record review that some procedures billed are not actually performed, a situation that could represent abusive or fraudulent activity. Providers and billers are cautioned to use proper billing methods.

The CIGNA Government Services policy for coverage of Endoluminal Radiofrequency Ablation (ERFA) and Endoluminal Laser System Ablation (ELSA) of varicose veins is specific (please see http://www.cignamedicare.com/partb/lmrp_lcd/nc/cms_fu/2003-002.html). Appropriate conservative measures must be tried without success and documented in the medical record before these procedures will be covered. These procedures are to be billed with the non-specific vascular surgery CPT code 37799, and the particular procedure (ERFA or ELSA) is to be specified in Box 19 of the CMS-1500 or the electronic equivalent of the claim.

The 37799 is intended to be all-inclusive of the procedure. The procedures have a technical and professional portion, and the equipment and catheters are priced in the technical portion. If performed in a facility other than the physician’s office, the physician will receive the professional portion. One pre-procedural ultrasound for “mapping” (CPT 93970 or 93971 as appropriate) will be allowed, and intra-operative ultrasound guidance (CPT 76986) will be allowed with each procedure. Any other procedures billed are non-covered, and must have medical necessity justified in the medical record for possible payment. Please review the policy and these guidelines to correctly submit claims for these procedures.

Coverage Topic
Surgical Services

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End Stage Renal Disease (ESRD) Reimbursement for Automated Multi-Channel Chemistry Tests (AMCC)

Provider Types Affected
Physicians, suppliers, and ESRD facilities.

Provider Action Needed
Affected providers should note that this instruction begins the implementation of procedures to enforce compliance with the 50/50 payment policy for End Stage Renal Disease (ESRD)-related laboratory services. The Centers for Medicare & Medicaid Services (CMS) is staggering the programming for this payment policy over multiple releases. Independent labs are not to revise their billing procedures at this time. CMS will release additional provider education in the future to educate providers regarding the effective date of revised billing procedures. Medicare carriers will have front-end edits to reject any line items containing the “CD,” “CE,” or “CF” modifiers, as referenced in this article, until further notice.

Background
Medicare’s composite rate payment to an ESRD facility or Monthly Capitation Payment (MCP) to a
physician includes reimbursement for certain routine clinical laboratory tests furnished to an ESRD
beneficiary.

In other words, if 50 percent or more of the covered tests are included under composite payment rate tests, then all submitted claims are included within the composite payment. In this case, no separate payment in addition to the composite payment rate is made for any of the separately billable tests.

However, if more than 50 percent of the covered tests are non-composite payment rate tests, then all AMCC tests submitted for that date of service are separately payable.

Defining Non-Composite Payment Rate Tests
A non-composite payment rate test is defined as any test separately reimbursable outside of the composite payment rate or beyond the normal frequency covered under the composite payment rate that is reasonable and necessary. Also, all chemistries ordered for beneficiaries with chronic dialysis for ESRD must be billed individually and must be rejected when billed as a panel.

The physician who orders the tests is responsible for identifying the appropriate modifier when ordering the test(s), and three pricing modifiers discreetly identify the different payment situations for ESRD AMCC services as follows:

In addition, the ESRD clinical laboratory test identified with modifiers “CD,” “CE,” or “CF” may not be billed as organ or disease panels. Upon the effective date of this requirement, all ESRD clinical laboratory tests must be billed individually.

Carrier Standard System Calculation
The Medicare carrier’s standard system will calculate the number of AMCC services provided for any given date of service. For a date of service, it should add all AMCC tests that have a CD modifier and divide by the sum of all line items with a CD, CE or CF modifier for the same beneficiary and billing supplier/provider for any given date of service.

The carrier will adjust a previous claim when the incoming claim for a date of service is compared to a claim on history and the action is to pay a previously denied claim. The Medicare carrier will spread the payment amount over each line item on both claims (the claim on history and the incoming claim).

ESRD Facilities
ESRD facilities must specify for each test, when ordering an ESRD-related AMCC tests, whether the test is:

Laboratories
Laboratories must identify the following:

Implementation
The implementation date is January 3, 2005. The partial implementation on October 4, 2004, includes the calculation of payments at the lowest rate for these automated tests, application of the 50/50 rule, comparing claims to prior claims in history for the same date of service, and the rejection of any line items with the “CD,” “CE,” and “CF” modifiers.

Related Instructions
The Medicare Claims Processing Manual, Chapter 16 (Laboratory Services from Independent Labs, Physicians, and Providers), Section 40 (Billing for Clinical Laboratory Tests), Subsection 6.1 (Billing for End Stage Renal Disease (ESRD) Related Laboratory Tests) was revised and can be found in Transmittal 79 of Pub 100-04, the original release of CR2813. This original CR may be found at: http://www.cms.hhs.gov/manuals/pm_trans/R79CP.pdf

The official instruction issued to your carrier on these changes may be found at: http://www.cms.hhs.gov/manuals/pm_trans/R198CP.pdf

This transmittal, which is Transmittal 198, also has some helpful examples of billing these tests as well as tables to show which tests is part of the composite rate and which are not.

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

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NEW UPDATE!! CIGNA Government Services Free Billing Software Requirements:

The Administrative Simplification Compliance Act (ASCA) requires most providers to send all claims electronically, including certain Medicare Secondary Payer (MSP) claims. Therefore, CMS mandated that the Medicare Claims Express (MCE) HIPAA compliant software program be modified to allow MSP claims to be submitted electronically when there is only one payer primary to Medicare.

Per a recent directive from CMS, all providers using the HIPAA compliant free billing software, furnished by a Medicare contractor are required to ensure that only the most current version of their software is being used.

All previous versions are to be eliminated from use within 90 days of this notification. Once MCE version 3.0 is available, you will have 90 days to upgrade to the most recent version. We will no longer support any old versions of the MCE software after this release.

The current version in use is MCE 2.1, which was released October 2003.

To ensure that users of the free software are using our most recent version, please visit the CIGNA Government Services Web site: www.cignamedicare.com/edi

MCE 3.0 is expected to be available October 2004.

The upgrade will be available via an Internet download or a CD-ROM. We will notify you when MCE 3.0 is available, at which time you will be able to request MCE 3.0 Internet download instructions or MCE 3.0 on CD-ROM.

The new MCE 3.0 HIPAA compliant software program will have the same look and feel as MCE 2.1, however it will also have the capability to submit MSP claims electronically to Medicare.

Only the patient profile data (patient name, HICN#, DOB, address) that you have entered in your current version of MCE, will transport into the upgrade version once loaded.)

Attention!
If you are not a current user of the MCE free billing software and are interested in obtaining it; please visit: www.cignamedicare.com/edi/partb/billing.html

Operating System:
Windows 98, Windows Me, Windows NT, Windows 2000, Windows XP

Microprocessor:
Pentium 100 or higher required

Conventional Memory (RAM):
Minimum of 64 MB required

Hard Disk Space:
Minimum of 100 MB required

Modem Type:
Must support Hayes Z Protocol

Floppy Drive:
CD-ROM drive (if installing from a CD)

Printer:
IBM or fully IBM compatible

*If minimum memory requirements are not met, check the owner’s manual to see if your system has expansion capabilities.

It is highly recommended, that EDI submitters, whom are using commercial software provided by an external supplier, should verify if the most recent HIPAA compliant version of that software is what they are currently using.

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Illegible Claims

Over time, the processing of paper Medicare claims received on the standard red CMS-1500 form has been improved greatly through a combination of education and improved technology. However, some claim forms are still being received that cannot be read by digital imaging/recognition technology, and in some cases not even by the human eye. These claims are considered to be illegible, and while every effort is made to process them, they are typically delayed significantly in terms of processing and payment.

CMS-1500 forms that cannot be read by the Optical Character Recognition (OCR) technology are rejected and must be keyed from the actual paper document. This bypasses vital automation systems and can cause the processing to be delayed. Further, if the document cannot be read clearly by data entry personnel, then the claim may be processed incorrectly or even be erroneously denied and returned to the provider for resubmission.

The cause of illegible paper claims ranges from handwritten forms that cannot be accurately read to printed forms where a printer cartridge needs to be replaced. We are asking for your help to ensure that CMS-1500 forms sent from your offices are completed clearly and are legible. We will make every effort to process your paper claim forms quickly and accurately. While we do not want to return unprocessed forms to you, it may sometimes be necessary. We will work with you in the future to identify the underlying causes of illegible claims.

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Implementation of Skilled Nursing Facility (SNF) Claim Edits for Therapy Codes Considered Separately Payable Physician Services

IMPORTANT NOTE: MM3333 corrects MM2944, which incorrectly indicates that services provided in a non-covered SNF stay are both subject to consolidated billing and reimbursed through the prospective payment system. MM3333 provides the corrected language (by removing the language indicating that the services are subject to the prospective payment system when provided to beneficiaries in a noncovered SNF stay) as follows:

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

To see MM3333, go to: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3333.pdf

Provider Types Affected
Physicians and other providers billing Medicare carriers for services provided at SNFs.

Provider Action Needed
Providers billing for services rendered to Medicare beneficiaries in a SNF stay should note changes in the Medicare claims processing systems that will allow certain therapy services to be separately payable when provided by physicians. These same services will be considered therapy services when provided by therapists and will be subject to SNF consolidated billing.

Background
Physical, occupational, and speech therapy services are subject to consolidated billing when provided to beneficiaries in either a Part A covered SNF stay or during a non-covered stay. (The preceding sentence is an amendment to the original language, per MM3333.) A small number of these services are considered surgery when performed by a physician, and may be separately paid by Medicare. When these services are performed by a physical or occupational therapist, they are considered therapy and continue to be subject to consolidated billing.

Effective for claims with dates of service on or after July 1, 2004, these changes to Medicare claims processing rules will prevent incorrect payment. Basically, the Medicare claims systems will allow separate payment to providers, other than physical and occupational therapists, for services provided to Medicare beneficiaries in a Part A covered SNF stay or a non-covered SNF stay for the Healthcare Common Procedure Coding System (HCPCS) codes in the following table:

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

When physical and occupational therapists submit claims for these services for Medicare patients in a SNF stay, the claim will not be paid and the billing provider will receive a remittance message with remarks code N121, which states that there is “No coverage for items or services by this type of practitioner for patients in a covered Skilled Nursing Facility (SNF) stay.”

Implementation
The implementation date is July 6, 2004, and applies to claims with dates of service of July 1, 2004, or later.

Related Instructions
The following will be added to the Medicare Claims Processing Manual, Chapter 6, Section 110, Subsection 2.6, Edit for Therapy Services Separately Payable When Furnished by a Physician: “A number of therapy services are considered separately payable when provided by a physician and shall be paid separately by the Medicare carrier. However, these services are considered therapy when provided by a physical or occupational therapist; will be subject to consolidated billing; and payment for them is included in the prospective payment rate provided to the SNF by the FI (Medicare fiscal intermediary).”

Effective July 1, 2004, edits will be implemented in the claims processing system to correctly process claims for these services. A complete list of these services can be found on the CMS Web site at www.cms.gov/medlearn/snfcode.asp.

For additional information on SNF Inpatient Part A Billing, please see Chapter 6 of the Medicare Claims Processing Manual (Pub 100-04), which may be found at: http://www.cms.hhs.gov/manuals/104_claims/clm104c06.pdf

To view the actual instructions issued to your carrier, please visit:
http://www.cms.hhs.gov/manuals/transmittals/pm_trans/R90CP.pdf

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“Incident to” Services

Provider Types Affected
All Medicare providers of professional services

Provider Action Needed
None. This article is for your information only. It clarifies when and how to bill for services “incident to” professional services.

Background
The intent of this article is to clarify “incident to” services billed by physicians and non-physician practitioners to carriers. Incident to” services are defined as those services that are furnished incident to physician professional services in the physician’s office (whether the office is located in a separate building or is an office within an institution) or in a patient’s home. These services are billed as Part B services to your carrier as if you personally provided them, and are paid under the physician fee schedule.

Note: “Incident to” services are also relevant to services supervised by certain nonphysician
practitioners such as physician’s assistants, nurse practitioners, clinical nurse specialists, nurse midwives, or clinical psychologists. These services are subject to the same requirements as physician-supervised services. The service is priced at the rate paid to the supervisor, who is the person responsible for the appropriate rendering of the service. Remember that “incident services” supervised by non-physician practitioners are reimbursed at the rate paid the supervisor and not at the physician fee schedule rate. For clarity’s sake, this article will refer to “physician” services as inclusive of non-physician practitioners.

To qualify as “incident to,” services must be part of your patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment. You do not have to be physically present in the patient’s treatment room while these services are provided, but you must provide direct supervision, that is, you must be present in the office suite to render assistance, if necessary. The patient record should document the essential requirements for incident to service.

More specifically, these services must be all of the following:

Examples of qualifying “incident to” services include providing non-self-administrable drugs and other biologicals, and supplies usually furnished by the physician in the course of performing his/her services, e.g., gauze, ointments, bandages, and oxygen.

The following paragraphs discuss the various care settings, which are important to note because the processes for billing vary somewhat depending on the care site.

Your Office
In your office, qualifying “incident to” services must be provided by a caregiver qualified to provide the service, whom you directly supervise, and who represents a direct financial expense to you (such as a “W-2” or leased employee, or an independent contractor).

You do not have to be physically present in the treatment room while the service is being provided, but you must be present in the immediate office suite to render assistance if needed. If you are a solo practitioner, you must directly supervise the care. If you are in a group, any physician member of the group may be present in the office to supervise.

Hospital or SNF
For inpatient or outpatient hospital services and services to residents in a Part A covered stay in a SNF the unbundling provision (1862 (a)(14) provides that payment for all services are made to the hospital or SNF by a Medicare intermediary (except for certain professional services personally performed by physicians and other allied health professionals). Therefore, incident to services are not separately billable to the carrier or payable under the physician fee schedule.

Offices in Institutions
In institutions including SNF, your office must be confined to a separately identifiable part of the facility and cannot be construed to extend throughout the entire facility. Your staff may provide service incident to your service in the office to outpatients, to patients who are not in a Medicare covered stay or in a Medicare certified part of a SNF. If your employee (or contractor) provides services outside of your “office” area, these services would not qualify as “incident to” unless you are physically present where the service is being provided. One exception is that certain chemotherapy “incident to” services are excluded from the bundled SNF payments and may be separately billable to the carrier.

In Patients’ Homes
In general, you must be present in the patient’s home for the service to qualify as an “incident to” service. There are some exceptions to this direct supervision requirement that apply to homebound patients in medically underserved areas where there are no available home health services only for certain limited services found in Pub 100-02. Chapter 15 Section 60.4 (B). In this instance, you need not be physically present in the home when the service is performed, although general supervision of the service is required. You must order the services, maintain contact with the nurse or other employee, and retain professional responsibility for the service. All other incident to requirements must be met. A second exception applies when the service at home is an individual or intermittent service performed by personnel meeting pertinent state requirements (e.g., nurse, technician, or physician extender), and is an integral part of the physician’s services to the patient.

Ambulance Service
Neither ambulance services nor EMT services performed under your telephone supervision are billable as “incident to” services.

Additional Information
To provide additional clarity, we present the following scenarios:

Must a supervising physician be physically present when flu shots, EKGs, Laboratory tests, or X-rays are performed in an office setting in order to be billed as “incident to” services?
“These services have their own statutory benefit categories and are subject to the rules applicable to their specific category. They are not “incident to” services and the “incident to” rules do not apply.”

Can anti-coagulation monitoring be provided “incident to” a physician’s services in an office?
Yes, if the requirements are met, i.e., the services are part of a course of treatment during which the physician personally performs the initial service and is actively involved in the course of treatment, is physically present in the immediate office when services are rendered by the employee, and the service represents an expense to the physician or other legal entity that bills for the service.

If the treating physician (Doctor X) refers a patient to an anti-coagulation monitoring clinic, can Doctor X bill these services as “incident to?” No, because the services are not being provided by an employee under supervision of Doctor X.

Can the supervising physician (Doctor Y) at the anti-coagulation monitoring clinic (a physician group) bill the services as “incident to” if Doctor Y directly supervises those services at the clinic?
No, because Doctor Y is not treating the patient for the underlying condition. However, If Doctor Y receives a referral from Dr. X, and Dr. Y performs an initial evaluation of the patient and then orders and supervises the services, they may be billed by Doctor Y incident to her initial service.

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

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MMA - Billing Instructions for ADVATE rAHF-PFM on Medicare Claims

Provider Types Affected
Hospitals, providers, and independent End Stage Renal Disease (ESRD) facilities

Provider Action Needed

STOP – Impact to You
This is a one-time notification to ensure that providers, hospitals, and independent ESRD facilities are aware of the correct HCPCS code to use when billing for Advate.

CAUTION – What You Need to Know
ADVATE rAHF-PFM was approved by the Food and Drug Administration (FDA) on July 25, 2003; the payment limit that should be used for Advate is the same payment limit that is currently assigned to HCPCS code J7192. This payment limit will apply to all Advate claims submitted for services from January 1, 2004, through December 31, 2004. Also, effective for dates of services on or after July 25, 2003, payment for Advate will be rejected if reported with any other code except J7192.

GO – What You Need to Do
Make sure that your billing staff knows that HCPCS code J7192 must be used when billing for the drug Advate, effective for dates of services on or after July 25, 2003.

Background
Beginning January 1, 2004, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) provides that the payment limits for most drugs and biologicals not paid on a cost or prospective payment basis are based on 85 percent of the Average Wholesale Price (AWP) reflected in the published compendia as of April 1, 2003, for those drugs and biologicals furnished on and after January 1, 2004.

However, one of the exceptions to this general rule is the payment limit for blood clotting factors. Specifically, the payment limits for blood clotting factors are 95 percent of the AWP reflected in the published compendia as of September 1, 2003.

Advate is a blood clotting factor that was approved by the FDA on July 25, 2003, for the treatment of people with hemophilia A. Advate should be reported using the existing HCPCS code J7192.

Implementation Date
This change will be implemented in Medicare claims processing systems on September 27, 2004.

Additional Information
For the calendar year 2004, the Advate payment limit for providers and for independent ESRD facilities can be found in the 2004 MMA drug pricing file that was issued in CR 3105. A Medlearn Matters article on this CR can be found at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3105.pdf

The MMA Drug Payment Limits Pricing Files for Dates of Service January 1, 2004, and after are available at: http://cms.hhs.gov/providers/drugs/default.asp

For the hospital Outpatient Prospective Payment System (OPPS), the payment rate for Advate can be found in the latest quarterly update of the OPPS Outpatient Code Editor that is posted on the CMS OPPS Web site. The CMS Hospital Outpatient Prospective Payment System Web site can be found at: http://www.cms.hhs.gov/providers/hopps/

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MMA-Billing Requirements for Islet Cell Transplantation for Beneficiaries in a National Institutes of Health (NIH) Clinical Trial

Provider Types Affected
All providers involved in an NIH sponsored clinical trial

Provider Action Needed

STOP – Impact to You

In the specific context of an NIH sponsored clinical trial:
For services performed on or after October 1, 2004, Medicare will cover islet cell transplantation for trial participants (patients) with Type I diabetes. The islet cell transplant may be done alone or in combination with a kidney transplant.

Immunosuppressive therapy to prevent rejection of the transplanted islet cells and routine follow-up care will be necessary for each trial participant.

CAUTION – What You Need to Know
Partial pancreatic tissue transplantation or islet cell transplantation performed outside the context of a clinical trial continues to be non-covered.

GO – What You Need to Do
Please stay current on instructions pertaining to NIH sponsored clinical trials to ensure accurate claims processing.

Background
As a result of Section 733 of the Medicare Modernization Act (MMA), for services performed/discharged on or after October 1, 2004, Medicare will cover islet cell transplantation for patients with Type I diabetes who are participating in an NIH sponsored clinical trial.

For dates of service on and after October 1, 2004, for such beneficiaries, Medicare carriers will accept claims for islet cell transplantation with a type of service code of 2 and a HCPCS of G0341 (Percutaneous islet cell trans), G0342 (Laparoscopy islet cell trans), or G0343 (Laparotomy islet cell transp). Physicians should also use the QV modifier for islet cell transplantation and routine follow-up care related to this NIH trial.

Where beneficiaries are enrolled in a Medicare Advantage (MA) plan, Medicare carriers or intermediaries should make payment directly to providers of these islet cell transplants in accordance with Medicare payment rules, except that MA beneficiaries receiving the services are not responsible for the Part A and Part B deductibles. Such beneficiaries will be liable, however, for any applicable coinsurance amounts that the MA organization has in place for clinical trial benefits.

Providers billing Medicare intermediaries for these services should do so on an 11x type of bill. Such claims will be paid by the intermediary only for IPPS hospitals participating in the trial, and claims for beneficiaries in MA plans should also include condition code 30 so the deductible will not be applied. For fee-for-service beneficiaries, deductibles and coinsurance will apply.

Additional Information
The official instruction issued to the intermediary regarding this change can be found online, referenced via CR 3385, at: http://www.cms.hhs.gov/manuals/pm_trans/R261Cp.pdf

If you have questions regarding this issue, you may also contact your carrier or fiscal intermediary at their toll-free number, which may be found at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

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MMA - Physician Education for the Revisions to the Health Professional Shortage Area (HPSA) Bonus Payment Processes and Implementation of the Physician Scarcity Area (PSA) Bonus Payments

SPECIAL NOTE: The language contained in this Medlearn Matters article reflects proposed billing and claims processing guidance consistent with the Health Professional Shortage Area (HPSA) and Physician Scarcity Area (PSA) bonus requirements discussed in the Notice of Proposed Rulemaking (NPRM) for the 2005 Physician Fee Schedule which was published on August 5, 2004. This language reflects our current implementation efforts and is subject to change consistent with publication of the final rule. Additional information will be posted when the final rule is published.

Provider Types Affected
Physicians who provide services in designated HPSAs or in PSAs

Provider Action Needed

STOP – Impact to You
Medicare is revising the processes for paying HPSA bonuses and will be implementing the provision of the Medicare Modernization Act (MMA) that authorizes bonus payments for physician services in PSAs. This article conveys information based on the NPRM published on August 5, 2004.

CAUTION – What You Need to Know
These proposed policies apply to relevant services provided in HPSAs or PSAs on or after January 1, 2005.

GO – What You Need to Do
Affected physicians should make sure that their billing staffs are aware of the pending HPSA and PSA bonus payment policy changes and are prepared to bill Medicare in accordance with the final rule, when published, in order to receive the correct bonus payments for services rendered on or after January 1, 2005. Understanding the areas that qualify for the bonus payments, knowing when to use related modifiers, and knowing what information is available from your Medicare carrier are essential to submitting correct claims. This article will provide and overview of these requirements.

Background

PSA Overview
MMA Section 413(a) requires that a new five-percent bonus payment be established and paid for services rendered by physicians in geographic areas designated as PSAs. Under the NPRM, physician scarcity designations will be based on the lowest primary care and specialty care ratios of Medicare beneficiaries to active physicians in every county. In addition, based on rural census tracts of metropolitan statistical areas identified through the latest modification of the Goldsmith Modification (i.e., the Rural-Urban Commuting Area Codes), additional PSAs will be identified based on the lowest primary care and specialty care ratios of Medicare beneficiaries to active physicians in each identified rural area.

Medicare will automatically pay this new bonus on a quarterly basis without the need for a modifier on the claim for services provided in zip code areas that:

In some cases, a service may be provided in a county that is considered to be a PSA, but the zip code is not considered to be dominant for that area. In these cases, the bonus payment cannot be made automatically. In order to receive the bonus for such services, physicians will need to include a new modifier of AR to reflect a physician service provided in a PSA.

Some key points to remember regarding the PSA bonus are the following:

HPSA Overview
MMA Section 413(b) requires CMS to revise some of the policies that address HPSA bonus payments.

Section 1833(m) of the Social Security Act provides bonus payments for physicians who furnish medical care services in geographic areas that are designated by the HRSA as primary medical care HPSAs under section 332 (a)(1)(A) of the Public Health Service (PHS) Act.

In addition, for claims with dates of service on or after July 1, 2004, psychiatrists (provider specialty 26) furnishing services in mental health HPSAs are also eligible to receive bonus payments. But keep in mind that if a zip code falls within both a primary care and mental health HPSA, only one bonus will be paid on the service.

MMA Changes
Effective January 1, 2005, you no longer have to include the QB (physician providing a service in a rural HPSA) or QU (physician providing a service in an urban HPSA) modifier on claims to receive your HPSA bonus payment, which will be paid to you automatically, if you provide care in zip code areas that either:

However, if you provide care in zip code areas that do not fall entirely within a full county HPSA or partial county HPSA, you must continue to enter either the QB or QU modifier on your claim to receive the bonus.

The following are the specific instances in which you will need to enter a modifier:

To determine if you qualify to automatically receive the bonus payment, you can review the information provided on the CMS Web site. If the zip code of the location where you render services does not appear there, you should check your carrier’s Web site for HPSA designations to determine if the location where you render services is within a HPSA bonus area, but still requires the submission of a modifier. More information on these Web aids will be provided in the Additional Information section of this article.

Some points to remember include the following:

Additional Information
CMS will make substantial revisions to Section 90 of Chapter 12 of the Medicare Claims Processing Manual. An official Change Request (CR) will be released at a later date. We will provide instructions later on how to access that CR, but key revisions/addition