May 2005 Medicare Bulletin - Idaho Insert

Posted May 4, 2005

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Table of Contents

• Azacitidine for Injectable Suspension (Vidaza^TM)- Revision
• Troubleshooting Claim Submission Errors - Idaho
• Idaho Health Professional Shortage Areas (HPSAs)
• Idaho Mental Health Professional Shortage Areas
• Remicade (Infliximab) (L12191) - LCD

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Troubleshooting Claim Submission Errors - Idaho

“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 for First Quarter FY2005. 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. 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. 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

4. Claim/Service Lacks Information Needed for Adjudication (MA67)
   Whenever CIGNA Government Services finds incomplete or invalid information reported on a claim, the claim will be denied with an unprocessable denial. These denials are recognized by a CO-16 denial (your claim lacks information for processing). With each CO-16 denial, a remark code is also used to tell what is missing. If the information contained in an item is not correct, then an invalid message will be received.

   Some examples of information that falls into this category could be:

• Missing UPIN number
• Truncated ICD.9 code
• Invalid two-digit place of service code
• Invalid Medicare Health Insurance Claim Number (HIC)
• Missing/incorrect modifier

Unprocessable claims are never considered for payment. Therefore, there are no appeal rights. All necessary corrections must be made and the claim must be resubmitted.

5. 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.

6. Did Not Complete or Enter Accurately the Date the Patient Was Last Seen and/or the UPIN of the Attending Physician (MA104)
   Claims for routine foot care must include the date the patient was last seen by a medical doctor (M.D.) or doctor of osteopathy (D.O.) and the unique physician identification number (UPIN) of the M.D or D.O. for treatment of the “severe peripheral complication.” The date last seen must be within the last six months. The date last seen and UPIN should be reported in Item 19 of the CMS-1500 claim form (or the equivalent electronic field). All claims for routine foot care requiring a date last seen must contain a 6-digit (MM/DD/YY) or 8-digit (MM/DD/CCYY) date.

If you are unsure of the exact day of the month and year being reported, you may use the first day of the month. If you are billing for non-covered routine foot care, for denial purposes only, enter “No date last seen.” For additional information regarding foot care coverage, refer to the CMS Manual System, Pub 100-2, Medicare Benefit Policy (basic coverage rules), Chapter 15, Section 290, (http://www.cms.hhs.gov/manuals/102_policy/bp102c15.pdf).

You may also view and/or download our specialty manual entitled “Podiatry” on the Internet at:
http://www.cignamedicare.com/partb/specman/clickwrap.html.

For physical and occupational therapists, entering this information certifies that the required physician certification (or recertification) is being kept on file. The name and UPIN of the attending physician should be reported in Items 17 and 17a of the CMS-1500 claim form (or the equivalent electronic field). In addition, the date the attending physician last saw the patient, must be reported in Item 19 of the CMS-1500 claim form (or the equivalent electronic field). For additional coverage information, refer to the CMS Manual System, Pub 100-2, Medicare Benefit Policy (basic coverage rules), Chapter 15, Section 220,
(http://www.cms.hhs.gov/manuals/102_policy/bp102c15.pdf).

For information concerning physicians certification and recertification for outpatient physical therapy, refer to the CMS Manual System, Pub 100-1, Medicare General Information, Eligibility, and Entitlement, Chapter 4, Section 50, (http://www.cms.hhs.gov/manuals/101_general/ge101c04.pdf).

You may also view and/or download our specialty manual entitled “Physical Therapy/Occupational Therapy” on the Internet at: http://www.cignamedicare.com/partb/specman/clickwrap.html.

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 2004 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 claim the 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.

9. 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.
10. This Claim/Service is not Payable Under Our Claims Jurisdiction Area (N104)
    This claim/service is not payable under CIGNA Government Services’s claims jurisdiction area. Part B services are paid based on the state in which services were rendered. You can identify the correct Medicare contractor to process this claim/service through the CMS Web site at: www.cms.hhs.gov.
    

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Remicade (Infliximab) (L12191) - LCD

Remicade (Infliximab) (L12191) - LCD

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Azacitidine for Injectable Suspension (Vidaza^TM) - Revision

Azacitidine for Injectable Suspension (Vidaza ^TM) - Revision

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Mental Health Professional Shortage Areas

Designated Geographic Areas

Effective July 1, 2004

Idaho

County	Area Name/Parts	Rural/Urban
Ada	Mental Hlth Region IV     Ada	Rural
Adams	Catchment Area # 3     Adams	Rural
Bannock	Mental Hlth Region VI     Bannock	Rural
Bear Lake	Mental Hlth Region VI     Bear Lake	Rural
Benewah	Mental Hlth Region I     Benewah	Urban
Bingham	Mental Hlth Region VI     Bingham	Rural
Blaine	Mental Hlth Region V      Blaine	Rural
Boise	Mental Hlth Region IV      Boise	Rural
Bonner	Mental Hlth Region I      Bonner	Urban
Bonneville	Mental Hlth Region VII     Bonneville	Rural
Boundary	Mental Hlth Region I      Boundary	Urban
Butte	Mental Hlth Region VII      Butte	Rural
Camas	Mental Hlth Region V      Camas	Rural
Canyon	Catchment Area # 3      Canyon	Rural
Caribou	Mental Hlth Region VI      Caribou	Rural
Cassia	Mental Hlth Region V      Cassia	Rural
Clark	Mental Hlth Region VII      Clark	Rural
Clearwater	Mental Hlth Region II     Clearwater	Rural
Custer	Mental Hlth Region VII      Custer	Rural
Elmore	Mental Hlth Region IV      Elmore	Rural
Franklin	Mental Hlth Region VI      Franklin	Rural
Fremont	Mental Hlth Region VII      Fremont	Rural
Gem	Catchment Area # 3      Gem	Rural
Gooding	Mental Hlth Region V      Gooding	Rural
Idaho	Mental Hlth Region II     Idaho	Rural
Jefferson	Mental Hlth Region VII      Jefferson	Rural
Jerome	Mental Hlth Region V      Jerome	Rural
Kootenai	Mental Hlth Region I      Kootenai	Urban
Latah	Mental Hlth Region II     Latah	Rural
Lemhi	Mental Hlth Region VII      Lemhi	Rural
Lewis	Mental Hlth Region II      Lewis	Rural
Lincoln	Mental Hlth Region V      Lincoln	Rural
Madison	Mental Hlth Region VII      Madison	Rural
Minidoka	Mental Hlth Region V      Minidoka	Rural
Nez Perce	Mental Hlth Region II      Nez Perce	Rural
Oneida	Mental Hlth REgion VI      Oneida	Rural
Owyhee	Catchment Area #3      Owyhee	Rural
Payette	Catchment Area # 3      Payette	Rural
Power	Mental Hlth Region VI      Power	Rural
Shoshone	Mental Hlth Region I      Shoshone	Urban
Teton	Mental Hlth Region VII      Teton	Rural
Twin Falls	Mental Hlth Region V      Twin Falls	Rural
Valley	Mental Hlth Region IV      Valley	Rural
Washington	Catchment Area # 3     Washington	Rural

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Idaho Health Professional Shortage Areas (HPSAs)

Designated Geographic Areas

COUNTY AREA NAME/PARTS Adams All Bannock South Bannock Division South Bannock Division Bear Lake1 Caribou/Georgetown Georgetown Division Blaine Carey Carey (CCD) Boise All Bonner Priest River Blanchard-Glengary (CCD) Priest River (CCD) Bonneville Swan Valley Division SA Swan Valley Division Boundary All Butte2 Arco/Mackay Camas All     Caribou1 Caribou/Georgetown SA Caribou     Clark All Clearwater11 Clearwater SA C.T. 9701.00 Elk River Elk River Division Custer1 Stanley Stanley/Challis SA Stanley (CCD) Challis Challis (CCD) Elmore All Franklin All Fremont All     Gooding3 All Idaho Riggins SA Riggins Division Elk City SA Elk City Division Jefferson5 C.T. 9601.00 Jerome4 All     Lemhi All Lewis Winchester Winchester Division Lincoln All     Oneida3 All Owyhee All Payette All     Teton All Washington All

¹Classified as HPSA, effective 3/1/02
² No longer classified as HPSA, effective 3/1/02
³ No longer classified as HPSA, effective 9/1/03
⁴ Classified as HPSA, effective 9/1/03
⁵ Classified as HPSA, effective 5/1/04

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