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December 2004 Part B Medicare Bulletin

Posted December 3, 2004

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Table of Contents

• 2005 Fees for R0075
• 2005 Medicare Allowable for Daily Hospital Management of Epidural or Subarachnoid Continuous Drug Administration
• 3rd Update to the 2004 Medicare Physician Fee Schedule Database
• 4th Quarter Update to External NOC List
• Billing Instructions for ADVATE rAHF-PFM on Medicare Claims - Revised
• Billing Requirements for Positron Emission Tomography (PET)Scans for Dementia and Neurodegenerative Diseases
• Guidelines to Roster Billing
• Help Us Help You
• Important News about Flu Shots for Medicare Beneficiaries
• Invalid Diagnosis Code Editing - Second Phase
• Low Osmolar Contrast Materials
• Manual Revision Regarding Waiver of Annual Deductible and Coinsurance for Both Ambulatory Surgery Centers (ASCs) and ASC/ Hospital Outpatient Department
• Medical Review Frequently Asked Questions, October 2004 (A23765)
• Medicare - Approved Drug Discount Card & Transitional Assistance (TA) Program Information for Providers
• Medicare - Approved Drug Discount Cards & Transitional Assistance Program: A Summary of New Initiative of Interest to Physicians and Other Health Care Professionals
• Medicare Launches Efforts to Improve Care for Cancer Patients
• Message to Pharmacists Regarding Medicare Approved Discount Drug Card Automatic Enrollment
• New Medicare - Approved Drug Discount Cards and Transitional Assistance Program: A Summary for Pharmacists and Other Pharmacy Professionals
• New Medicare Approved Drug Discount Cards and Transitional Assistance Program: A Summary for Physicians and Other Health Care Professionals
• Nurse Practitioners as Attending Physicians in the Medicare Hospice Benefit Revised
• Nursing Facility Visits (Codes 99301-99313)
• Payment Amounts for the Influenza Virus Vaccine (CPT 97658) and the Pneumoccocal Vaccine (CPT 97032)
• Percutaneous Transluminal Angioplasty (PTA)
• PET Scans Payable Diagnosis Codes (A234528) - Article
• Progressive Corrective Action Review - CPT - 99255
• Progressive Corrective Action on Initial Hospital Visits, CPT Codes 99221-99223
• Quarterly Update to Correct Coding Initiative (CCI) Edits, Version 11.0 Effective January 1, 2005
• Submitting Claims for Cardiac Pacemaker Evaluation Services
• Temporary Change in Carrier Jurisdictional Pricing Rules for Purchased Diagnostic Services
• Tips for Completing an EFT (Electronic Funds Transfer) Agreement
• Treatment of Obesity
• Valuable Tools of Electronic Billing
• What is an Authorized Official?

 

4rd Quarter Update
Part B Not Otherwise Classified Drug Fee Schedule

2004 DIMA Drug Payment Limits & Carrier Priced NOC Drugs

Revised 10/28/2004

Name of Drug and Exact Dosage Given in Block 19 (paper) or Narrative Field (EMC)

** Carrier Priced	Changes In Bold
DRUG NAME	DOSAGE	Current PAR	Current NONPAR	*Price Change
**Abarelix/Sodium Chloride (Plenaxis) will be covered for the labeled indication of advanced symptomatic prostate cancer (ICD-9 code 185) under the miscellaneous HCPCS code J9999. The name of the drug and exact dosage administered must be entered in block 19 or its electronic equivalent and the manufacturer invoice information must be submitted with the claim (attachment for paper claims and in the narrative field for EMC claims).	100 mg-9% SDV	897.18	852.32
**Advate-rAHF-PFM (anti-hemophilic factor VIII) J7199(Effective 09/27/04, for dates of service on or after 07/25/03, use J7192 per 1 i.u.)	Per 1 IU	1.58	1.50
**Alfentanil HCL (Alfenta)	500 mcg/5 ml	2.29	2.18
** Alimta (see pemetrexed)
Allopurinol Sodium (Aloprim) ICD-9's 274.9 or 790.6 plus the ICD-9 for the neoplasm. Need name of chemotherapy agent causing the elevation of uric acid and a statement as to why patient can not tolerate oral form of the drug.	500 mg/SDV	425.00	403.75
Amikacin Sulfate (Amikin)	500 mg	5.10	4.85
Amino Acid	500 ml	21.11	20.05
Amino Acid	1000 ml	35.19	33.43
**Arginine HCL (R-Gene 10) A4641 Diagnostic Agent		Invoice	Invoice
**Atenolol (Tenormin) ICD-9's = 401.0 - 429.9	0.5 mg/ml	0.80	0.76
** Avastin (see bevacizumab)
**Azacitidine (See Vidaza)
Aztreonam (Azactam)	500 mg	9.89	9.40
** Bacitracin (Bacim)	50,000 U	10.17	9.66
** Bevacizumab (Avastin) J9999 Covered for colorectal cancer     ICD-9 codes 153.0 through 154.8	10 mg	65.31	62.04
** Bortezomib (Velcade) Covered for patients with relapsed Multiple Myeloma (203.00)	3.5mg/ SDV	1,039.68	987.70
Bretylium Tosylate (Bretylol)	500 mg	19.07	18.12
** Brevibloc (See Esmolol HCL)
Bumetanide (Bumex)	1 mg	1.43	1.36
Bupivacaine Hcl, 0..25%, 2 ml  (Considered Part of Procedure)	2 ml	0.14	0.13
Bupivacaine Hcl, 0.50%, 2 ml  (Considered Part of Procedure)	2 ml	0.26	0.25
** Bupivacaine, Sterile, 0.25%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530, 76005, 95990, or 96530. When billed with other procedures, considered part of procedure performed.	10 ml	1.95	1.85
** Bupivacaine, Sterile, 0.50%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530, 76005, 95990, or 96530. When billed with other procedures, considered part of procedure performed.	10 ml	2.21	2.10
** Bupivacaine, Sterile, 0.75%/10ml (Sensorcaine, Sterile) Allowed when billed with 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400-64484, 64505-64530, 76005, 95990, or 96530. When billed with other procedures, considered part of procedure performed.	10 ml	2.48	2.36
** Calcium Chloride	100 mg/ml	0.14	0.13
** Cefamanadole Nafate (Mandol)	1 gm	8.61	8.18
Cefepime Hydrochloride	1 mg	0.02	0.02
** Cefoperazone Sodium  (Cefobid)	1 gram	16.38	15.56
Cefotetan Disodium (Cefotan)	1 gram	9.49	9.02
** Cetuximab (Erbitux) Covered indications 153.0 through 154.8	10mg/50ml SDV	54.72	51.98
Cimetidine Hcl.(Tagamet) Covered ICD-9's = 787.01, 787.02 or 787.03	150 mg	1.27	1.21
Cimetidine Hcl.(Tagamet) Covered ICD-9's = 787.01, 787.02 or 787.03	300 mg	2.65	2.52
Clavulanate Potassium	100 mg	12.81	12.17
Clindamycin Phosphate (Cleocin) (Dosage change from 300 mg to 150 mg)	150 mg	1.19	1.13
** Cubicin (See Daptomycin)
Dantrolene Sodium	20 mg	73.00	69.35
** Daptomycin (Cubicin) - A lipopeptide antibiotic injection-Covered     ICD-9's - 035, 373.13, 376.01, 380.10 - 380.16, 528.5, 608.4, 616.4, 680.0 - 680.9, 681.0 - 681.9, 682.0 - 682.9, 685.0, 686.00 - 686.09, 686.1 - 686.9	500mg	153.32	145.65
Denileukin Difitox, Ontak (For 300 mcg, see J9160)	150 mcg	595.43	565.66
Dextrose 2.5%	2.50%	7.68	7.30
Dextrose 5%	5%	7.86	7.47
Dextrose 10%	500 ml	10.00	9.50
Dextrose 50%	50%	10.32	9.80
**Dextrose/Nitroglycerin 5%-20 mg/ 100 ml/250 ml	20 mg/100 ml/250 ml	6.32	6.00
**Dextrose 5%/ Sodium Chloride	1000 ml	11.22	10.66
Diltiazem Hcl. (Cardizem IV)	5 mg	1.73	1.64
** Doxycycline Hyclate	100 mg	13.45	12.78
Edrophonium Chloride (Tensilon) (Allow for ICD9—358.0)	10 mg	0.59	0.56
** Enalaprilat (Vasotec IV)	1.25 mg	3.65	3.47
** Erbitux (see Cetuximab)
Ergocalciferol D2 (Calciferol) ICD-9's = 579.8 or 579.9 Allowed when administered in physician's office	500,000 IU/ 1ml	29.84	28.35
Esmolol Hcl. (Brevibloc) Covered when administered in the doctor office or ambulance. Covered  ICD-9 = 427.89 (Dosage change from 10 mg to 100 mg)	100 mg	18.76	17.82
Estradiol	1 gram	13.30	12.64
** Estradiol Pellets	Per Pellet	Invoice	Invoice
** Ethiodized Oil (Ethiodol)	1 ml	8.06	7.66
Ethracrynate Sodium (Edecrin Sodium)	50 mg	20.23	19.22
** Etoposide Phosphate (Etopophus) J9999 covered diagnoses = 151.0-151.9, 155.0, 155.2, 160.0-160.9, 162.0-162.9, 170.0-171.9, 173.0-176.9, 182.0-183.9, 186.0-186.9, 188.0-189.9, 190.5, 191.0-191.9, 194.0-195.8, 200.00 to 207.01, 236.1.	100mg	126.19	119.88
Famotidine (Pepcid) Covered ICD-9's = 787.01, 787.03 or 995.2	10 mg	1.60	1.52
** Flumazenil (Mazicon, Romazicon)	0.1 mg/ml	9.57	9.09
Flumazenil (Mazicon, Romazicon)	0.5 mg/ml	42.83	40.69
Folic Acid	5 mg	1.02	0.97
Gallium Nitrate (Ganite) ICD'9 275.42 plus secondary DX for malignancy	25mg/ml	7.24	6.88
** Gatifloxacin (Tequin)	200 mg	18.15	17.24
Glycopyrrolate (Robinul)	0.2mg	0.71	0.67
Goserelin Acetate  (use code J9202 per 3.6mg)	10.8 mg	1,198.48	1,138.56
Heparin Sodium	100 units	0.47	0.45
Hetastarch Sodium Cl., 6 gm/500 ml	6 gm/500 ml	4.89	4.65
**J3590 Hyaluronan, High Molecular Weight (Orthovisc®) 30 mg/2ml Billed with CPT code 20610 for coverered indications of osteoarthritis of the knee (715.16, 715.26, 715.36, or 715.96). One injection per week per knee.	30mg/2ml	238.36	226.44
** Inamrinone Lactate	5 mg	4.05	3.85
** Isopropyl Alchol/Peginterferon Alfa-2A (Pegasys) Covered indication 070.54 when administered in the office	180 mcg/ml	331.74	315.15
Isoproterenol Hydrochloride (Considered Part of Procedure)	0.2 mg	0.65	0.62
** Ketamine Hcl. (Ketalar) Allowed when billed on same day as 20550-20610, 62289, 62298, 62368, 95990, or 96530.	50 mg/ml	0.73	0.69
**Labetalol Hcl (Trandate, Normodyne) Covered if given IV in the office for control of BP in severe hypertension. Patient is normally switched to oral for maintainance doses.	20 mg	1.00	0.95
** Laronidase ( Aldurazyme)	0.58mg/ml	128.82	122.38
** Levobupivacaine Hydrochloride (Chirocaine) Allowed separately when billed on same day as 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530, 76005, 95990, or 96530. Not payable separately when billed with any other procedures	2.5 mg/ml	0.31	0.29
** Levothyroxine Sodium (Synthroid) Need statemnt on claim as to why patient can't take oral form of drug.	0.5 mg	62.01	58.91
Lidocaine Hcl. (Xylocaine-MPF) Allowed  separately when billed on same day as 51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530, 76005, 95990, or 96530. Not payable when billed with any other procedure.	2% 5 ml	3.57	3.39
Metoprolol Tartrate (Lopressor) Covered when given IV with Dobutamine J1250 during Dobutamine Stress Test.	1 mg	0.68	0.65
Metronidazole Hcl. (Flagyl IV) IV in the office	500 mg	21.71	20.62
Miconazole (Monistat IV) 10 mg		Invoice	Invoice
Minocycline Hydrochloride	100 mg	39.42	37.45
Morrhuate Sodium	50 mg	1.40	1.33
Nafcillin (Nallpen) (Dosage Change from 500 mg to 1 gm)	1 gm	2.41	2.29
Netilmicin Sulfate (Netromycin), 150 mg		Invoice	Invoice
Nitroglycerin IV – Allowed in the Office or Ambulance – In emergency situation. (Dosage Change from 25 mg to 5 mg)	5 mg	0.42	0.40
**Normal Saline (Sterile Water)	50 ml	1.43	1.36
Ofloxacin (Floxin IV), 20 mg		Invoice	Invoice
** Omalizumab (Xolair) J3490 Covered indication Extrinsic Asthma Unspecified (493.00).	150 mg	514.19	488.48
**J3590 Orthovisc® (See High Molecular Weight Hyaluronan)
**Oxychlorosene Sodium (Clorpactin WCS-90)	1GM	1.85	1.76
** Palonosetron Hcl. (Aloxi)	0.25mg/5ml SDV	307.80	292.41
** Pantoprazole Sodium, IV (Protonix IV) Need statement as to why patient is not able to take oral form.	40 mg	22.80	21.66
** Peginterferon Alfa-2A/Isopropyl Alchol (Pegasys) Covered indication 070.54 when administered in the office	180mcg/ml	331.74	315.15
** Peginterferon Alfa-2B (PEG-Intron) 50 mcg Covered indication 070.54 when administered in the office.	50 mcg	320.61	304.58
** Peginterferon Alfa-2B, 80mcg	80 mcg	336.60	319.77
** Peginterferon Alfa-2B, 120mcg	120 mcg	353.46	335.79
** Peginterferon Alfa-2B, 150mcg	150 mcg	371.12	352.56
** Pegvisomant for Injection (Somavert) Considered Usually Self-Administered		0.00	0.00
** Pemetrexed (Alimta) Covered indications = 162.0 - 162.9 &  163.0-163.8	500 mg/SDV	2,315.63	2,199.85
** Piperacillin Sodium (Pipracil)	1 gm	7.00	6.65
**Plenaxis (See Abarelix)
Potassium Acetate	2 meq	0.07	0.07
Procaine Hydrochloride	1%	2.36	2.24
Procaine Hydrochloride	2%	3.40	3.23
Propofol (Diprivan) (Carrier does not pay separately)	10 mg	0.04	0.04
Rifampin	600 mg	76.74	72.90
**Risperdal Consta (See Risperidone)
**Risperidone (Risperdal Consta) Long-Acting Antipsychotic Injection for the treatment of schizophrenia and mania associated with bipolar disorder.	.5mg
**Secretin (SecreFlo) Used in secretin stimulation testing		Invoice	Invoice
** SMZ-TMP (Sulfamethoxazole/Trimethoprim) Documentation as to why the patient needs to be on IV infusion instead of oral medication, must be in block 19 or as an attachment for paper claims or in the notepad for EMC claims.	5ml	3.05	2.90
Sincalide (Kinevac) (Use A4641/Carrier Pays Radiopharmaceuticals by Invoice)	5 mcg	29.41	27.94
Sodium Acetate	100 meq	3.49	3.32
** Sodium Bicarbonate, PF (NACH03)	7.5%/50 ml	2.73	2.59
Sodium Bicarbonate (NACH03)	8.4%/1ml	0.04	0.04
Sodium Tetradecyl Sulfate (Sotradecol)		Invoice	Invoice
** Sodium Thiosalicylate (Rexolate & Arthrolate, Nodolo & Tusal)	50 mg	0.97	0.92
**Somavert (See Pegvisomant for Injection)
** Sufentanil Citrate (Sufenta) Separate payment allowed when billed with 62310, 62311, 62318, 62319, 76005, 95990, or 96530. If billed with any other procedures, it will be considered part of the procedure and  separate payment will not be allowed.	50mcg/ml	9.81	9.32
Tagamet (See Cimetidine)
Testosterone	37.5 mg	0.11	0.10
** Testosterone Pellets (Testopel)	Per Pellet	Invoice	Invoice
Tetanus Toxoid (use codes 90702, 90703, and 90718)		12.86	12.22
Valproate Sodium (Depacon) IV, Covered ICD9's = 345.00 - 345.91, Allowed when administered IV, in the physician's office. (Dosage change from 500 mg to 100 mg)	100 mg	2.02	1.92
Vasopressin	20 units/ml	5.91	5.61
Verapamil Hcl. (Isoptin IV) (Dosage Change from 5 mg to 2.5 mg)	2.5 mg	0.98	0.93
Vidaza (Azacitidine) Covered for Myelodysplastic Syndrome, ICD-9 238.7	25mg	113.05	107.40
** Vitamin B Complex (Follow B-12 guidelines)	Up to 3ml	0.93	0.88
Vitamin C (Ascorbic Acid) (Non-covered by Carrier)	500 mg	0.59	0.56
**Water, Sterile, 1000 ml	1000 ml	5.64	5.36
** Xolair (See Omalizumab)

NOTE: Although this file may list a drug and an associated Medicare allowed amount, it does not necessarily follow that the drug is covered by Medicare and, if covered, whether payment may be due in a particular circumstance. Medicare contractors separately determine whether a particular drug meets the program's requirements for coverage and, if covered, whether payment may be made for the drug in the circumstance under which it was furnished.

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

Provider Types Affected
Hospitals, Providers, and Independent 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 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, claims submitted to Medicare fiscal intermediaries for Advate will be rejected if reported with any other code except J7192. Claims submitted to carriers for dates of service on or after July 25, 2003, without J7192 will be adjusted to reflect J7192 and carriers will append modifier “CC” to reflect this adjustment.

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 persons 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 1/1/2004 and after are available at:
http://cms.hhs.gov/providers/drugs/default.asp

For 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 Website.

The CMS Hospital Outpatient Prospective Payment System Website can be found at: http://www.cms.hhs.gov/providers/hopps/

If you have any questions regarding this issue, 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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MMA - Medicare-Approved Drug Discount Cards and Transitional Assistance Program: A Summary of New Initiative of Interest to Physicians and Other Health Care Professionals

Note: This article was revised on October 22, to correct the Web address for State Health Insurance
Counseling and Assistance Programs.

Provider Types Affected
Physicians and other health care professionals

Provider Action Needed
This instruction provides important information on a new initiative to automatically enroll certain Medicare beneficiaries in the Medicare-Approved Drug Discount Card program.

Background
In an earlier Medlearn Matters article, an overview of the Medicare-Approved Drug Discount Card Program was provided.

(See SE0422 at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0422.pdf)

This program is authorized by the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA). The program is designed to help people who are covered by Medicare with the cost of prescription drugs, and the regulation outlining the new drug discount card program is the first action resulting from the MMA. It emphasizes the importance of eliminating the practice of Medicare beneficiaries having to pay full price for prescription drugs. Beginning in May 2004, individuals began enrolling in the program.

Seniors and individuals with disabilities will be able to use these cards to save 10 to 15 percent on their total drug costs, with savings of up to 25 percent or more on individual prescriptions. All Medicare beneficiaries, except those who already have Medicaid outpatient drug coverage, will be able to enroll in Medicare-approved drug discount card programs with benefits beginning in June 2004, and possibly continuing until the Medicare prescription drug benefit is implemented in 2006.

Medicare beneficiaries will also have a choice of at least two Medicare-approved cards, but they will be allowed to enroll in only one drug card program at a time. The cost of enrollment can be no more than $30 annually, and beneficiaries can change cards during an open enrollment period prior to 2005 or under special circumstances. Beginning in 2006, all people with Medicare will have access to a voluntary prescription drug benefit.

Transitional Assistance Program
A key part of the Medicare-approved prescription drug discount card program is a subsidy of up to $600 a year for eligible low-income beneficiaries. Individuals may qualify for the $600 credit on their discount card to help pay for prescription drugs if they:

• Have an annual income in 2004 of no more than $12,569 if single or $16,862 if married; and
• Receive help from their state in paying their Medicare premiums or cost sharing.

Note that these income limits can change every year. Also, 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.

Under the Medicare-Approved Drug Discount Card Program, Medicare beneficiaries are deemed to meet the income requirement for the $600 credit in 2004 and 2005 if they are:

• Enrolled in Medicare Savings Programs as Qualified Medicare Beneficiaries (QMBs);
• Specified Low-income Medicare Beneficiaries (SLMBs); or
• Qualifying Individuals (QI-1s).

Current Initiative
The Centers for Medicare & Medicaid Services (CMS) has launched a new initiative to facilitate enrollment and provide a streamlined process for the $600 credit. Under this initiative, participating national Medicare approved drug discount card sponsors will agree to follow simple procedures to facilitate the $600 credit enrollment for about 1.1 million Medicare Savings Programs beneficiaries.

• On September 14, 2004, CMS issued interim guidance to all Medicare-approved drug discount card sponsors outlining the process for Medicare Savings Programs auto-enrollment. National sponsors have notified CMS of their intention to participate.
• If these beneficiaries have not already enrolled in this card program, CMS will randomly assign those eligible Medicare Savings Programs beneficiaries to participating Medicare-approved drug discount card sponsors.
• Starting in mid-October, card sponsors will mail an enrollment kit to each Medicare Savings Programs enrolled individual. The enrollment kit will contain the following nformation:
• Pre-enrollment materials: Card Program, Member Handbook, Membership Card,Discount Drug List, Pharmacy Directory.
• A notice advising the Medicare Savings Programs beneficiary of the automatic assignment, effective date of enrollment, eligibility for the $600 credit, information about their right to decline and/or switch to another Medicare-approved drug discount card, and a toll-free number.
• The card begins providing discounts on November 1. To activate the $600 credit, the beneficiary makes one call to 1.800.MEDICARE or to the card sponsor’s 800 number. On the call, the beneficiary answers two questions to confirm they are eligible for the credit:
• Does the beneficiary have other health insurance with any outpatient prescription drug coverage?; and
• Does the beneficiary have annual income (including spouse, if married) above or below $12,569 for singles and $16,862 for couples?
• Medicare Savings Programs beneficiaries who wish to choose another card can call 1-800- MEDICARE to learn about their other choices.
• If a beneficiary is not eligible for the $600 credit because of other drug coverage, they will still be able to use the drug card they received and benefit from any associated discounts.
• Medicare Savings Programs beneficiaries who wish to cancel enrollment in a card must call the drug card sponsor at the toll free number provided and request their enrollment be canceled. As a result of this new program for enrollment in the drug card program, all beneficiaries in Medicare Savings Programs can start getting large savings on their drug costs.

Additional Information
Where to 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. Therefore, 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:
  Beneficiaries can get information about how the discount drug card program operates, who can qualify and how to join, as well as some comparative information on card sponsors at 1.800 MEDICARE (1.800.633.4227; TTY users should call 1.877.486.2048).
  
  This Call Center is available 24 hours per day, 7 days per week, and 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. Also, beneficiaries may request a copy of their individualized price comparison results.
• The Prescription Drug and Other Assistance Programs Web site at:
  http://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:
  This resource can be found at: http://www.medicare.gov/publications. It 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: http://www.medicare.gov/contacts/Static/SHIPs.asp?dest=NAV

For More Information

The following information resources are available for physicians and other health care professionals:

• Download a free patient-education brochure at: http://www.medicare.gov (or call 1-800- MEDICARE to order a limited number of free copies).
• Read the materials on the Medicare-Approved Drug Discount Cards and Transitional Assistance
  Program web page, at http://www.cms.hhs.gov/medlearn/drugcard.asp. This page includes a variety of useful publications.
• 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: http://www.cms.hhs.gov/opendoor for further details.
• Visit: http://www.cms.hhs.gov/medicarereform for the latest information on MMA.
• Contact your carrier for information by using the toll-free provider lines. Visit http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf for your carrier’s toll-free number.

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2005 Medicare Allowable for Daily Hospital Management of Epidural or Subarachnoid Continuous Drug Administration

The 2005 allowable for 01996 is as follows:

Tennessee	$50.88
Idaho	$49.94
North Carolina	$51.13

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2005 Fees for R0075

Code	TN Par	TN Non Par	NC Par	NC Non Par	ID Par	ID Non Par
R0075UN	49.38	46.91	53.28	50.62	40.13	38.12
R0075UP	32.92	31.27	35.51	33.74	26.76	25.42
R0075UQ	24.69	23.46	26.63	25.30	20.07	19.06
R0075UR	19.75	18.77	21.3	20.24	16.05	15.25
R0075US	16.46	15.64	17.26	16.88	13.38	12.71

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Billing Requirements for Positron Emission Tomography (PET) Scans for Dementia and Neurodegenerative Diseases

Provider Types Affected
Physicians and providers.

Provider Action Needed
This instruction notifies physicians and providers that Medicare will provide coverage for 2-deoxy-2- [F-18] fluoro-D-glucose (FDG)-PET scans for beneficiaries with a recent diagnosis of dementia and documented cognitive decline of at least 6 months duration. This service may be covered:

• When the patient meets diagnostic criteria for both fronto-temporal dementia (FTD) and Alzheimer’s disease (AD) under specific requirements, or
• For use in a Centers for Medicare & Medicaid Services (CMS)-approved practical clinical trial focused on the utility of FDG-PET in the diagnosis or treatment of dementing neurodegenerative diseases.

Background
Effective for dates of service on or after September 15, 2004, Medicare will provide coverage for FDG Positron Emission Tomography PET for one of the following:

• When the patient meets diagnostic criteria for both fronto-temporal dementia (FTD) and Alzheimer’s disease; or
• When used in a CMS-approved practical neurodegenerative disease clinical trial. Clinical trial results are expected to help in determining if PET scans contribute to the effective diagnosis and treatment of Medicare beneficiaries with mild cognitive impairment or early dementia, and add information that will help monitor, evaluate, and improve clinical outcomes of patients with this disease.

Refer to the “Medicare Claims Processing Manual,” Publication 100-04, Chapter 13, Section 60, for general Medicare coverage and billing requirements for PET scans for dementia and neurodegenerative diseases.

Also, refer to the “Medicare National Coverage Determinations (NCD) Manual,” Publication 100-03, Section 220.6 for complete coverage policy and clinical trial requirements. The revision to the “NCD Manual,” Pub. 100-03, Section 220.6 is an NCD. NCDs are binding on all carriers, fiscal intermediaries, quality improvement organizations, health maintenance organizations, competitive medical plans, and health care prepayment plans.

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

Key portions of these revised manuals are as follows:
FDG-PET Requirements for Use in the Differential Diagnosis of AD and FTD

According to the NCD on this issue, Medicare covers FDG-PET scans for either a) the differential diagnosis of both FTD and Alzheimer’s disease AD under specific requirements or, b) its use in a CMS-approved practical clinical trial focused on the utility of FDG-PET in the diagnosis or treatment of dementing neurodegenerative diseases.

For use in the differential diagnosis of FTD and AD, an FDG-PET scan is considered reasonable and necessary for patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both AD and FTD. These patients have been evaluated for specific alternative neurodegenerative diseases or causative factors, but the cause of the clinical symptoms remains uncertain.

The following additional conditions must be met before an FDG-PET scan can be ordered:

1. The patient’s onset, clinical presentation, or course of cognitive impairment is such that FTD is suspected as an alternative neurodegenerative cause of the cognitive decline. Specifically, symptoms such as social disinhibition, awkwardness, difficulties with language, or loss of executive function are more prominent early in the course of FTD than the memory loss typical of AD; (MRI) or computed tomography (CT);
2. The patient has had a comprehensive clinical evaluation (as defined by the American Academy of Neurology (AAN)) encompassing a medical history from the patient and a well-acquainted informant (including assessment of activities of daily living), physical and mental status examination (including formal documentation of cognitive decline occurring over at least 6 months) aided by cognitive scales or neuropsychological testing, laboratory tests, and structural imaging such as magnetic resonance imaging (MRI) or computed tomography (CT);
3. The evaluation of the patient has been conducted by a physician experienced in the diagnosis and assessment of dementia;
4. The evaluation of the patient did not clearly determine a specific neurodegenerative disease or other cause for the clinical symptoms, and information available through FDG-PET is reasonably expected to help clarify the diagnosis between FTD and AD and help guide future treatment;
5. The FDG-PET scan is performed in a facility that has all the accreditation necessary to operate nuclear medicine equipment. The reading of the scan should be done by an expert in nuclear medicine, radiology, neurology, or psychiatry, with experience interpreting such scans in the presence of dementia;
6. A brain single photon emission computed tomography (SPECT) or FDG-PET scan has not been obtained for the same indication.

The indication can be considered to be different in patients who exhibit important changes in scope or severity of cognitive decline, and meet all other qualifying criteria listed above and below (including the judgment that the likely diagnosis remains uncertain). The results of a prior SPECT or FDG-PET scan must have been inconclusive or, in the case of SPECT, difficult to interpret due to immature or inadequate technology. In these instances, an FDG-PET scan may be covered after 1 year has passed from the time the first SPECT or FDG-PET scan was performed.

7. The referring and billing provider(s) have documented the appropriate evaluation of the Medicare beneficiary. Providers should establish the medical necessity of an FDG-PET scan by ensuring that the following information has been collected and is maintained in the beneficiary medical record:

• Date of onset of symptoms;
• Diagnosis of clinical syndrome (normal aging; mild cognitive impairment or MCI; mild, moderate or severe dementia);
• Mini mental status exam (MMSE) or similar test score;
• Presumptive cause (possible, probable, uncertain AD);
• Any neuropsychological testing performed;
• Results of any structural imaging (MRI or CT) performed;
• Relevant laboratory tests (B12, thyroid hormone); and, Number and name of prescribed medications.
• The billing provider must furnish a copy of the FDG-PET scan result for use by CMS and its contractors upon request.

These services should be billed with HCPCS code of G0336 (Pet imaging, brain imaging for the differential diagnosis of Alzheimer’s disease with aberrant features vs. FTD).

FDG-PET Requirements for Use in the Context of a CMS-Approved Neurodegenerative Disease Practical Clinical Trial Utilizing Specific Protocol With regard to use of the FDG-PET in the context of a CMS-approved clinical trial, the clinical trial must compare patients who do and those who do not receive an FDG-PET scan and have as its goal to monitor, evaluate, and improve clinical outcomes. In addition, it must meet the following basic criteria:

• Written protocol on file;
• Institutional Review Board review and approval;
• Scientific review and approval by two or more qualified individuals who are not part of the research team; and
• Certification that investigators have not been disqualified.

Physicians should note that a QV modifier must be used when billing Medicare carriers for a CMS- approved neurodegenerative disease practical clinical trial. In addition, on such claims from trials that are billed to Medicare intermediaries, a second diagnosis code (ICD-9) of V70, 7, along with the appropriate principal diagnosis code and HCPCS code G0336 must be entered on the CMS-1450 or its electronic equivalent. There will be a link on the cms.hhs.gov/coverage Web site that will have a list of all the participating trial facilities once they have been selected.

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

Additional Information
As previously mentioned, the “Medicare Claims Processing Manual” (Pub. 100-04), Chapter 13 (Radiology Services), Section 60 (Positron Emission Tomography (PET) Scans, is being updated by this instruction. It includes billing and claims processing requirements for PET Scans for beneficiaries with a recent diagnosis of dementia and documented cognitive decline of at least 6 months duration who meet diagnostic criteria for both FTD and AD, or its use in a CMS-approved practical clinical trial focused on the utility of FDG-PET in the diagnosis or treatment of dementing neurodegenerative diseases.

In addition, the “Medicare NCD Manual” (Pub. 100-03), Chapter 1 (Coverage Determinations) Section 220 (Radiology), Subsection 6 (Positron Emission Tomography (PET)) Scans, is being updated by this instruction to include complete coverage policy and requirements for related clinical trials. These updated manual instructions are included in the official instruction issued to your carrier/intermediary, which can be found by going to: http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

From that Web page, look for CR 3426 in the CR NUM column on the right, and click on the file for that CR.

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

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Help Us Help You!

Provider Enrollment wants you, the provider community, to help us help you. When we receive a CMS application that is incomplete, this delays the credentialing process. Our focus is to process your enrollment application quickly and accurately. Below are common errors that delay the processing of applications.

Common Errors CMS - 855B Application

• Section 2B.1 (Supplier Identification Information) of the CMS 855B application should be completed with the legal business name exactly as it appears on your IRS documentation. In addition, a copy of this pre- printed IRS document is needed to verify such.
• If you are completing the CMS 855I or the CMS 855B Application as a “Change of Information,” please check the “add, change or delete” box. Provide the effective date of the change as well.
• Section 6 (Ownership Interest and/or Managing Control Information) of the CMS 855B application must be completed with information about any individual that has 5% or greater (direct or indirect ownership interest in, or any partnership interest in, the supplier identified in section 2B. In addition, all officers, directors and managing employees of the supplier must be reported in this section. The supplier must have at least one managing employee. Please make sure all boxes in this section are marked to identify the relationship with the supplier.

Common Errors CMS - 855R Application

• Section 4 (Practice Location) of the CMS 855R identifies all practice locations where the provider will be rendering services on a regular basis. This also requires a date in which the provider will start or has already begun rendering these services. This section must be completed in its entirety.
• Section 2 (Provider/Supplier Identification) of the CMS 855R is to be completed with identifying information about the supplier/provider to which the individual practitioner is reassigning their benefits. You should list the legal business name exactly as it appears on your IRS documentation.
• Section 6 (Reassignment of Benefits Statement) of the CMS 855R requires the provider’s original signature as well as the supplier’s legal business name. You should list the legal business name exactly as it appears on your IRS documentation.
• Section 7 (Attestation Statement) of the CMS 855R must be signed by the authorized and/or delegated official who has been identified on the provider/ supplier’s CMS 855B application. All signatures must be an original.

Common Errors on All CMS Applications

• All signatures on the CMS applications must be dated. If you fail to date your signature, we will request that you resign and date the section(s) needed.

Remember, if any of these sections are incomplete on the CMS application, your application process will be delayed. If you need assistance with completing the CMS applications or have any questions, please contact Provider Enrollment at 1.866.520.4007.

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Important News about Flu Shots for Medicare Beneficiaries

Provider Types Affected
Physicians, providers, and suppliers

Provider Action Needed
This instruction provides important information to physicians and other providers regarding flu vaccinations for Medicare beneficiaries for the 2004 – 2005 influenza season. Despite the flu vaccine shortage, Medicare beneficiaries are being encouraged to obtain the flu vaccine from their regular physician.

Background
One of the principal pharmaceutical companies manufacturing flu vaccine was unable to provide the quantity of vaccine needed for this flu season, and this caused the flu vaccine supply to be reduced by almost one half of the expected amount. This shortage does not, however, include pneumococcal vaccine.

Because of the limited availability of flu vaccines this season, the Centers for Disease Control and Prevention (CDC) is recommending that individuals be given priority for getting the flu vaccine who are 1) at high risk for serious flu complications; or 2) in contact with people at high risk for serious flu complications.

Individuals in the following groups are included in the high-risk category, and they should receive a flu vaccination this season:

• Individuals age 65 or older
• Individuals with a chronic condition such as heart or lung disease
• Nursing home residents
• Pregnant women
• Health care workers who provide direct patient care
• Infants and toddlers ages 6-23 months
• Children on aspirin therapy
• Individuals who care for or live with infants younger than 6 months of age.

Please note that CDC also recommends that the majority of individuals with Medicare should not take FluMist because it is approved only for people ages 5 - 49. The only Medicare beneficiaries who should take FluMist are healthy disabled persons ages 5 - 49.

These recommendations and other information for health care professionals, including Qs & As developed by CDC, can be found at: http://www.cdc.gov/flu/ on the Web.

Medicare Billing for Flu Vaccines
Because Medicare beneficiaries generally fall into this high-risk category, they are being encouraged to obtain the flu vaccine from their regular physician. Beneficiaries can receive a flu vaccine from any licensed physician or provider. However, the billing procedure will vary depending on whether the physician or provider is enrolled in the Medicare Program.

If you are a Medicare-enrolled physician or provider and have the flu vaccine available, you must bill Medicare for the cost of the vaccine and the beneficiary will pay nothing; i.e., there is no deductible or coinsurance payment. Medicare rules require you to bill the Medicare Program on an assignment basis.

Please remember that Medicare allows for roster billing when you administer flu vaccine to a number of beneficiaries at one location (e.g., a physician’s office).

The specific rules to follow for roster billing can be found in Chapter 18, Section 10.3 of the “Claims Processing Manual,” at: http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp

If you do not have the vaccine available, you should refer your patients to 1.800.MEDICARE (1.800.633.4227; TTY users should call 1.877.486.2048) or to http://www.medicare.gov where they can get the phone number for their state health department. Health departments throughout the United States are attempting to ensure that as many high-risk individuals as possible will get a flu vaccine. If you are not a Medicare-enrolled physician or provider who gives a flu vaccine to a Medicare beneficiary, you can ask the beneficiary for payment at the time of service. The beneficiary can then request Medicare reimbursement. Medicare reimbursement will be approximately $18 for each flu vaccine.

To request reimbursement, the beneficiary will need to obtain and complete form CMS 1490S by calling 1.800.MEDICARE, or they may access and download the form at http://www.cms.hhs.gov/forms on the Web.

In order to receive reimbursement, you will need to provide the beneficiary with a receipt for the flu vaccine that has the following information written or printed on it:

• The doctor’s or provider’s name and address
• Service provided (“flu vaccine”)
• Date flu vaccine received
• Amount paid.

If you are currently not enrolled in Medicare but want to enroll to bill Medicare directly for the flu vaccine, your enrollment application will be expedited. CMS 855 enrollment applications and carrier contact information can be found on the following CMS Web site: http://www.cms.hhs.gov/providers/enrollment

Additional Information
Please note that beneficiaries have been advised to contact the Inspector General’s hotline at 1-800-HHSTIPS (1.800.447.8477) to file a complaint if they believe their physician or provider charged an unfair amount for a flu vaccine.

If your patients have questions regarding flu vaccine, please refer them to http://www.medicare.gov on the Web or 1.800.MEDICARE (1.800.633.4227). TTY users should call 1.877.486.2048.

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Invalid Diagnosis Code Editing – Second Phase

Provider Types Affected
All physicians, providers, and suppliers who bill Medicare carriers, including Durable Medical Equipment Regional Carriers (DMERCs)

Provider Action Needed

STOP – Impact to You
New edits will be added to the Medicare claims processing systems to prevent acceptance of inbound claims with invalid diagnosis codes.

CAUTION – What You Need to Know
Diagnosis codes must always be valid on the date that the service was provided. Medicare systems will reject claims with diagnosis codes that were not valid on the date of service.

GO – What You Need to Do
As Medicare strengthens its edit processes to detect and reject claims with invalid diagnosis codes, ensure that your billing staff know the rules for diagnosis codes and that they submit diagnosis codes that are in compliance with HIPAA.

Background
To edit diagnosis accurately codes for validity, Medicare systems will apply date range edits to ensure that diagnosis codes are valid for the period of time for which they are reported on claims sent to Medicare.

These edits will apply whether or not Medicare actually uses the reported diagnosis code in its claims processing. HIPAA rules require that Medicare make sure that such codes are HIPAA-compliant, especially because these codes are passed on to other payers under Medicare’s Coordination of Benefits processes. To be compliant, the diagnosis code must be valid on the date for which it is reported. These policy changes include validation of diagnosis codes on the National Council for Prescription Drug Program (NCPDP) claims and on 837 professional claims.

Additional Information
Additional information regarding this topic can be found in Transmittal 86 (CR 3050). 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 3260 in the CR NUM column on the right, and click on the file for that CR.

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Low Osmolar Contrast Materials

***REMINDER***

Effective January 1, 2004, CMS determined that using code A9525 could result in incorrect coding of low osmolar contrast materials and was deleted; subsequently, we have noticed that providers began using the incorrect code of A4641; this code should be used to bill for a “supply of radiopharmaceutical diagnostic imaging agent” which still requires an invoice copy for paper claims or manufacturer’s information for EMC claims. The correct codes to use for “Low Osmolar Contrast Materials” such as Omnipaque, Visipaque, Isovue, Optiray, etc., are A4644 (100-199mg), A4645 (200-299mg) & A4666 (300-399mg).

Beginning November 8, 2004, we will begin denying code A4641 as a billing error if used for the contrast materials listed above.

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Manual Revision Regarding Waiver of Annual Deductible and Coinsurance for Both Ambulatory Surgery Centers (ASCs) and ASC/Hospital Outpatient Department

Physician Services

Provider Types Affected
Hospitals outpatient departments billing for physician services, ASCs, and physicians.

STOP – Impact to You
The Omnibus Budget Reconciliation Act (OBRA) 1986 and OBRA 1987 rescinded the waiver of the Medicare Part B coinsurance and deductible requirements for ASC facility services and ASC/hospital outpatient department physician services.

CAUTION – What You Need to Know
Medicare is updating language in its manuals to ensure consistency with these legislative changes and this change.

GO – What You Need to Do
ASCs and hospital outpatient department billing staffs are reminded to be familiar with these policies.

Background
Effective April 1, 1988, section 4054 of OBRA 1987 (Public Law 100-203) imposed the Medicare Part B coinsurance and deductible requirements for physician services in connection with an ASC covered procedure that is performed in an ambulatory setting.

For any physician services furnished on or after April 1, 1988, in connection with an ASC covered procedure, performed in an ASC or in a hospital on an outpatient basis, Medicare pays 80 percent of the physician fee schedule amount. After the beneficiary deductible is met, the beneficiary is responsible for 20 percent of the physician fee schedule amount.

Section 9343(e) of OBRA 1986 (Public Law 99-509) imposed that for any procedure on the ASC list furnished in an ASC, Medicare pays 80 percent of the applicable ASC fee schedule amount for such services furnished to Medicare patients. After the beneficiary’s deductible is met, the beneficiary is responsible for 20 percent of the applicable facility fee schedule amount for that facility service. This provision was made for services furnished on or after July 1, 1987.

Additional Information
If you have additional 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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Medical Review Frequently Asked Questions, October 2004 (A23765)

Article Text
The following represent a variety of questions the Medical Review departments in Idaho, Tennessee, and North Carolina have received. CIGNA Government Services will address at least quarterly “Frequently Asked Questions” related to coverage and local coverage decision issues. Providers may submit questions to the Web site at http://www.cignamedicare.com/customer_service/disclaimer.html

1. Denials for Hospital Observation

Q: Why would observation services deny when rendered in a hospital?
A: Denials may be due to the place of service reported. Observation services should be reported as place of service 22, outpatient hospital, and not place of service 21, inpatient hospital. This is supported by CMS Publication 100-4, The Medicare Claims Processing Manual, Chapter 12, Section 30.6.8 that you can access through the following link:

http://www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf

Visits by other physicians while the patient is in observation status should be billed using the office and other outpatient service codes or outpatient consultation codes as appropriate. In the rare circumstance when a patient is held in observation status for more than two calendar dates, the physician must bill subsequent services furnished before the date of discharge using the outpatient/office visit codes. The physician may not use the subsequent hospital care codes since the patient is not an inpatient of the hospital.

2. Team Conferences in a Rehab Hospital

Q: Can a subsequent hospital visit be billed for team conferences in a rehabilitation hospital?

A: No, as the subsequent hospital visits codes, 99231-99233, require a face-to-face encounter with the patient and two of the three key components performed (i.e. history of present illness, an exam and medical decision-making). See CMS Publication 100-4, The Medicare Claims Processing Manual, Chapter 12, Section 30.6.16, Subsection A that addresses team conferences that may also be billed with CPT codes 99361-99362 (which are bundled/not separately payable codes):

http://www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf

3. E&M Services for pronouncement of death?

Q: Can CPT codes 99238-99239 be billed for pronouncement of death
A: Reasonable and necessary medical services rendered up to and including pronouncement of death by a physician are covered diagnostic or therapeutic services. [“CMS Manual System,” Pub 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 70.4 (http://www.cms.hhs.gov/manuals)]. The above codes may be billed for this reason as long as the provisions of the code descriptor are met as documented in the medical record. Please see the following article published on our Web site 0323.4:

http://www.cignamedicare.com/articles/march04/cope766.html.

4. Aranesp for Non-ESRD Use

Q: Why doesn’t the local coverage decision for Aranesp/Darbepoetin include anemia due to End Stage Renal Disease?

A: CMS addresses coverage of Aranesp on patients with ESRD (both on and not yet on dialysis) in CMS Publication 100-2, “The Medicare Benefit Policy Manual,” Chapter 11, Section 90:

http://www.cms.hhs.gov/manuals/102_policy/bp102c11.pdf

Each state’s LCD is written to address those indications outside of ESRD use.

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Medicare-Approved Drug Discount Card & Transitional Assistance (TA) Program Information for Providers

Under the Medicare-Approved Drug Discount Card Program & Transitional Assistance (TA) Program, Medicare beneficiaries who are enrolled in Medicare Savings Programs (MSPs) as Qualified Medicare Beneficiaries (QMBs), Specified Low-income Medicare Beneficiaries (SLMBs), or Qualifying Individuals (QI-1s) are deemed to meet the income requirement to receive TA ($600/year both in 2004 and in 2005 toward the purchase of prescription drugs).

CMS is undertaking an initiative to increase TA enrollment for this low-income population by facilitating enrollment and providing a streamlined process for making the required attestations for TA. National drug card sponsors that are willing to participate will agree to follow simple procedures to facilitate TA enrollment for MSP beneficiaries.

Starting in mid-October, over one million people with Medicare will receive an “Important Message from Medicare” and a Medicare-approved discount drug card in the mail. People receiving this important message are likely to qualify for up to $1,200 in credits from Medicare to help pay for their prescription drug costs.

CMS has developed a “tool kit” of materials for health care professionals, and other partners to assist people with Medicare who can benefit from this opportunity to save money on their prescription drugs. Visit http://www.cms.hhs.gov/partnerships/news/autoenroll/default.asp to access the tool kit, which includes downloadable, printable materials:

• MSP Facilitated Enrollment Flyer - A flier suitable for distribution in pharmacies, physician offices, and other public places.
• Letter to Beneficiaries - This letter has been sent to people with Medicare from all approved drug card sponsors involved in the Automatic enrollment effort.
• ABC Coalition Partners - Listing of the Access to Benefits Coalition (ABC) members who are partnering with CMS to help beneficiaries understand the new choices coming their way.
• Article from the Secretary - A question and answer with Secretary Tommy Thompson. This article is suitable for placement in community and local papers.
• Public Service Announcements (PSAs) - The public service announcements are suitable for reading on the radio, and are 10, 30 and 60-second spots. (English version) (Spanish version)
• Call! Enroll! Save! - This pamphlet provides basic information about the simple steps to get a Medicare-approved drug discount card and encourages people to enroll. It was mailed to low- income beneficiaries in early October.
• Letter to Pharmacists - This letter has been electronically distributed through national pharmacy organizations and other interested parties to individual pharmacists, providing them with the letter to beneficiaries, and asking them to distribute a fact sheet.
• MedLearn Matters Articles for Physicians & Other Health Care Professionals, and Pharmacists and Other Pharmacy Professionals - Articles from MedLearn (http://www.cms.hhs.gov/medlearn/matters) targeted to physicians and other health care professionals (SE0457) and at pharmacists (SE0458) with information about the discount card and $600 credit.

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MMA - New Medicare-Approved Drug Discount Cards and Transitional Assistance Program: A Summary for Pharmacists and Other Pharmacy Professionals

Note: This article was revised on October 27, 2004 to correct the Web address for State Health Insurance Counseling and Assistance Programs (SHIPs).

Provider Types Affected
Pharmacists and other pharmacy 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 beneficiaries for information on selecting and enrolling in the drug discount card program that best suits their needs.