March 2005 Medicare Bulletin - Tennessee Insert
Posted March 4, 2005
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of this issue 
Table of Contents
- Removal or Destruction of Benign Skin Lesions - KX Modifier Reminder
- Tennessee Health Professional Shortage Areas
- Tennessee Mental Health Professional Shortage Areas
- Tennessee Part B Medicare Workshop Announcement
- Troubleshooting Claim Submission Errors - Tennessee
- Updated Surgical Add-On Code(s) Listing
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Tennessee Part B Medicare Workshop Announcement
CIGNA Government Services will host the Tennessee Part B Medicare Workshop, highlighting Medicare Updates and changes that affect all specialties. This annual event will also offer attendees the chance to receive additional training on Medicare resources. This year’s half-day workshop series will be held during April and May, and will cover the following topics:
- Coding Changes
- Enforcement of Mandatory Electronic Claim Submission
- Medical Review
- Provider Customer Service Program
- Provider Self-Service Technology
- Resources
The seminars will be held in the following cities: Chattanooga, Jackson, Johnson City, Knoxville, Memphis, and Nashville.
Watch for your ListServ announcement for the beginning of registration. Registration will be available by Internet only. Please visit www.cignamedicare.comEducation/Workshops for more information. If you do not have Internet access, please call 615.782.4562, after March 11, 2005.
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Removal or Destruction of Benign Skin Lesions – KX Modifier Reminder
Modifier –KX is required only on claims where national policy or local coverage determination (LCD) specifically require its use for a particular item or service. The use of this modifier constitutes a statement that the appropriate supportive documentation of medical necessity is contained in the patient’s medical record, and on file in the provider’s office should Medicare wish to review.
“Modifier KX: Specific Required Documentation on File”
Providers submitting claims for the medically necessary non–cosmetic removal of benign skin lesions should append the –KX modifier to the procedure code, indicating that the appropriate supportive documentation of medical necessity is contained in the patient’s medical record, and on file in the provider’s office should Medicare wish to review. Only claims with the –KX modifier will be reimbursed.
Cosmetic procedures are not covered. If a beneficiary wishes a lesion removed for cosmetic purposes, the beneficiary becomes liable for the service rendered. The physician has the responsibility to notify the patient in advance that Medicare will not cover cosmetic dermatological surgery and that the beneficiary will be liable for the cost of the service. It is advised that the beneficiary be provided with a written notification of this fact and that the beneficiary, by his or her signature, accepts responsibility for payment. Charges should be clearly stated as well. Providers should use the Notice of Exclusion from Medicare Benefits (NEMB) form to inform beneficiaries. The NEMB form can be found at: http://www.cms.hhs.gov/medlearn/refABN.asp.
A claim need not necessarily be submitted to Medicare for this service unless the patient requests that you file or believes he or she has supplementary insurance coverage, which will pay for the service after a formal Medicare denial is issued. If a claim is filed, please use ICD–9– CM diagnostic code V50.1 – “Other plastic surgery for unacceptable cosmetic appearance” in conjunction with the appropriate CPT or HCPCS code. Also, append modifier –GY to indicate the claim should not be covered by Medicare.
The LCD may be viewed on the CIGNA Government Services Web site at www.cignamedicare.com. Click on Part B, click on Local Medical Review Policies, then click on Tennessee current policies and scroll down to the Benign Skin Lesion Policy.
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Troubleshooting Claim Submission Errors – Tennessee
“Getting it right the first time” is a cost– and time– saving efficiency for your office and the Medicare Program. We have compiled a listing of recent top ten claim submission errors. Please review the following recommendations for eliminating these errors to ensure that you receive appropriate reimbursement at the time of initial claim submission. The following claim submission errors will have a Group/Reason Code CO–16 with the exception of item number 9 (CLIA) which has Group/Reason Code CO–96. The Group/Reason Code will be accompanied by either a Remarks Code or MOA Code identifying the missing/invalid information needed to process the claim.
For complete CMS–1500 Instructions, refer to the CMS Manual System, Pub 100–4, Medicare Claims Processing (includes appeals, contractor interface with CWF, and MSN), Chapter 26, Section 10, (http://www.cms.hhs.gov/manuals/104_claims/clm104c26.pdf).
Web based training for completion of the CMS–1500 is available on the Internet at: http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=1
1. Incorrect Entitlement Number (MA27)
2. Incomplete/Invalid Patient’s Name (31)
Providers are encouraged to keep a copy of each patient’s Medicare card and other insurance cards on file. The Medicare card shows the beneficiary’s Medicare coverage (Hospital, Medical) and the effective dates. Be sure to report the patient’s name and Medicare Health Insurance Claim Number (HICN) exactly as they appear on the Medicare card. No special characters (such as hyphens) should be used in an electronic claim submission even when the patient’s name includes a hyphen. Do not place hyphens or blanks in the HICN field.
3. Incomplete/Invalid Diagnosis Code (M76)
Enter the patient’s diagnosis/condition in Item 21 of the CMS–1500 claim form (or the equivalent electronic field). With the exception of claims submitted by ambulance suppliers (specialty type 59), all physician and nonphysician specialties (i.e., PA, NP, CNS, CRNA) use an ICD–9–CM code number and code to the highest level of specificity. Enter up to four codes in priority order (primary, secondary condition).
The full ICD–9–CM (International Classification of Diseases, Ninth Revision, Clinical Modification) system consists of three volumes. For Medicare purposes, providers should only use the first two volumes.
- Numeric codes (001.0 to 999.9) are broken down into 17 classifications of diseases and injuries.
- V codes (V01.0 to V82.9) describe circumstances of a patient visit for reasons other than disease or injury.
The Health Insurance Portability and Accountability Act (HIPAA) require that medical code sets must be date of service compliant. Since ICD–9–CM is a medical code set, effective for dates of service on and after October 1, 2004, CMS will no longer provide a 90–day grace period for providers to use in billing discontinued ICD–9–CM diagnosis codes on Medicare claims.
The updated ICD–9–CM codes are published in the Federal Register in April/May of each year as part of the Proposed Changes to the Hospital Inpatient Prospective Payment Systems in Table 6 and effective each October 1.
Claims containing a discontinued ICD–9–CM diagnosis code will be returned as unprocessable. Physicians, practitioners, and suppliers must use the current and valid diagnosis code that is in effect beginning October 1, 2004. After the ICD–9–CM codes are published in the Federal Register, CMS places the new, revised, and discontinued codes on the following Web site: http://www.cms.hhs.gov/medlearn/icd9code.asp.
For additional ICD–9 Coding resources and Web Based Training (WBT), you may access the following on the Internet at: http://www.cms.hhs.gov/medlearn/icd9code.asp.
4. Incorrect/Invalid UPIN and/or Name (M68)
The name and Unique Physician Identification Number (UPIN) are required on all claims for Medicare covered services and items that are the result of a physician’s referral. This includes all claims that contain diagnostic tests, clinical laboratory services, consultations and other referrals. The name and UPIN identify the referring/ordering physician for the consultation, diagnostic test or other referred/ordered service.
Enter the referring/ordering physician’s name and UPIN in Items 17 and 17a of the CMS–1500 claim form (or the equivalent electronic field). For additional information regarding UPINs, including appropriate surrogate UPINs when an individual UPIN is not available, refer to the CMS Manual System, Pub 100–4, Medicare Claims Processing (includes appeals, contractor interface with CWF, and MSN), Chapter 26, Section 10, (http://www.cms.hhs.gov/manuals/104_claims/clm104c26.pdf).
A UPIN directory is also available on CIGNA Government Services’s Web site at: http://www.cignamedicare.com/links.html
5. Incomplete/Invalid Group Practice Information (MA112)
Enter the provider of service/supplier’s billing name, address, ZIP code, and telephone number in Item 33 of the CMS–1500 claim form (or equivalent electronic field). In addition, enter the Provider Identification Number (PIN) for the performing provider of service/supplier who is not a member of a group practice.
6. Did Not Indicate Whether Medicare is Primary or Secondary Payer (MA83)
Item 11 of the CMS–1500 claim form (or the equivalent electronic field) must be completed. By completing this item, the physician/supplier acknowledges having made a good faith effort to determine whether Medicare is the primary or secondary payer.
If there is insurance primary to Medicare, enter the insured’s policy or group number and proceed to Items 11a – 11c of the CMS–1500 claim form (or the equivalent electronic field).
If Medicare is primary, enter the word “NONE” in Item 11 of the CMS–1500 claim form. Please note the requirements are different for electronic claims. Electronic claims do not require the word “NONE.” The Primary Payer information is indicated in the SBR segment of Loop 2000B with a “P” code in SBR01. This information can be found on page 110 of the 837 Professional Implementation Guide. The name of the payer will go in the Payer Name segment in Loop 2010BB as referenced on page 130. Specifications may be downloaded free of charge on the Internet at: http://www.wpc–edi.com/hipaa/HIPAA_40.asp.
For additional information on Medicare Secondary Payer, refer to the CMS Manual System, Pub 100–4, Medicare Claims Processing (includes appeals, contractor interface with CWF, and MSN), Chapter 1, Section 100, (http://www.cms.hhs.gov/manuals/104_claims/clm104c01.pdf).
7. Incomplete/Invalid Procedure Code (M51)
Enter the procedures, services, or supplies using the CMS Healthcare Common Procedure Coding System (HCPCS) code in Item 24d of the CMS–1500 claim form (or equivalent electronic field) without a narrative description. When applicable, show HCPCS code modifiers with the HCPCS code.
In the event that a physician performs a procedure that does not have a designated CPT code, the physician should then bill the procedure using an “unlisted procedure code” or a NOC code, and include a narrative description in Item19 of the CMS–1500 claim form (or the equivalent electronic field) if a coherent description can be given within the confines of that box. Otherwise, an attachment must be submitted with the claim. In addition, if a surgical procedure is submitted, the operative report should clearly indicate what the unlisted code is for by describing in detail the procedure being performed. If the unlisted code being used is for a non–surgical procedure and no other instructions have been published pertaining to that procedure then the provider should submit supporting documentation with an explanation of what the unlisted code is for.
Procedure code changes are effective January 1 of each year. Codes are deleted, added, or modified. It is important to update your billing system to reflect these changes.
Effective January 1, 2005, Medicare providers will no longer have a 90–day grace period to use discontinued HCPCS codes for services rendered in the first 90 days of the year. The Health Insurance Portability and Accountability Act (HIPAA) require that medical codes sets must be date of service compliant. Use of such codes to bill services provided after the date on which the codes are discontinued will cause your claims to be returned as unprocessable and not paid. In essence, HCPCS codes must be valid at the time the service is rendered.
HCPCS codes (Level I CPT–4 and Level II alpha–numeric) are updated on an annual basis. The elimination of the grace period applies to the annual HCPCS update and to any mid–year coding changes. Providers can purchase the American Medical Association’s CPT–4 coding book that is published each October that contains new, revised, and discontinued CPT–4 codes for the upcoming year. In addition, CMS posts on its Web site the annual alpha–numeric HCPCS file for the upcoming year at the end of each October.
To determine the status of codes under Medicare rules, access the 2005 Medicare Physician Fee Schedule Database (MPFSDB) on the Internet at: http://www.cms.gov/providers/pufdownload/rvudown.asp.
Providers are encouraged to access CMS Web site to see the new, revised, and discontinued alpha – numeric codes for the upcoming year. The CMS Web site to view the annual HCPCS update is http://www.cms.hhs.gov/providers/pufdownload/anhcpcdl.asp.
8. Missing/Incomplete/Invalid HCPCS Modifier (M78)
Modifiers are two–character codes that are appended to procedure codes to further describe the procedure or service in Item 24d of the CMS–1500 claim form (or the equivalent electronic field). Modifiers may be alpha–alpha (JJ), or numeric–numeric (33). Some modifiers describe additional work or circumstances that could impact reimbursement. Other modifiers simply provide additional information and do not impact reimbursement. CPT (Level 1) modifiers are published in the CPT manual. HCPCS Level II (CMS–assigned) is published in the HCPCS book.
Only two modifiers can be reported per service line in the claim submission. If the service or procedure requires more than two modifiers then modifier “99” should be appended to the procedure code and all modifiers indicated in Item 19 of the CMS–1500 claim form (or the equivalent electronic field) as follows: 1=(mod), where the number 1 represents the line item and “mod” represents all modifiers applicable to the referenced line item.
Note: With the implementation of the CMS Multi–Carrier System (MCS), electronic claims may include up to four modifiers per service line, if necessary.
9. Misdirected Claims for Railroad Retirement Beneficiaries (N105)
Most Health Insurance Claim Numbers (HICNs) are 9–digit numbers with letter suffixes, e.g., 000–00–0000–A. However, when a Medicare beneficiary has entitlement through the Railroad Retirement Board (RRB), their HICN will be a 6– or 9–digit number with letter prefixes, e.g., A–000000, A–000–00–0000; or WD–000000, WD–000–00–0000. When the HICN begins with an alpha character, please submit paper claims to the RRB carrier: Palmetto GBA, P.O. Box 10066, Augusta, GA 30999.
Call 866.749.4301 for RRB Electronic Data Interchange (EDI) information for electronic claims processing.
10. Missing/Incomplete/Invalid CLIA Certification Number (MA120)
Enter the 10–digit CLIA certification number for laboratory services billed by an entity performing CLIA covered procedures in Item 23 of the CMS–1500 claim form (or the equivalent electronic field).
For additional information, refer to the CMS Manual System, Pub 100–4, Medicare Claims Processing (includes appeals, contractor interface with CWF, and MSN), Chapter 16, Section 70, (http://www.cms.hhs.gov/manuals/104_claims/clm104c16.pdf).
You may also view or download our specialty manual entitled “Laboratory/Pathology” on the Internet at: http://www.cignamedicare.com/partb/specman/clickwrap.html.
Updated Surgical Add-On Code(s) Listing
Certain surgical procedure codes are add-on codes that are always billed with another service. These add-on codes have a ZZZ indicated in the post-operative period. Post-operative work is not included in the fee schedule payment for the ZZZ codes.
Listed below are the surgical add-on codes and their primary procedure codes. Payment will not be made for these add-on codes unless billed in addition to accompanying primary procedure.
CHART FOR ZZZ (ADD-ON) CODES
ZZZ ADD-ON CODE |
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Top
Tennessee Mental Health Professional Shortage Areas (HPSAs)
Designated Geographic Areas
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Tennessee Health Professional Shortage Areas (HPSAs)
Designated Geographic Areas
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1 Classified as a HPSA, effective March 1, 2002.
2 No longer classified as a HPSA, effective March 1, 2002.
3 Classified as a HPSA, effective June 1, 2002.
4 Classified as a HPSA, effective February 1, 2004.
