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June 2005 Part B Medicare Bulletin

Posted June 3, 2005

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Billing for Syringes Used in the Treatment of End Stage Renal Disease (ESRD) Patients

Provider Types Affected
Physicians, providers, and suppliers billing carriers and intermediaries for ESRD services and supplies

Provider Action Needed
Providers billing HCPCS code A4657 for ESRD patients need to be aware of the proper use of this code when billing for syringes, especially when a pre-filled syringe is used in the administration of the drug contained in the syringe and no other syringe is used. In such instances, the supply charge associated with A4657 cannot be billed to Medicare.

Background
In some previous Change Requests (CRs) relating to ESRD, there was mention that Healthcare Common Procedure Coding System (HCPCS) code A4657 (syringe – with or without needle) was allowed for Epoetin (EPO). However, physicians, providers, and suppliers should note that pre-filled syringes with medications used to administer the drug to an ESRD patient should not be billed with HCPCS code A4657 to Medicare.

Also note that HCPCS code A4657 (syringe – with or without needle) should be billed only when an actual syringe is taken from the provider’s supplies and used to administer the drug. Syringes that are pre-filled with medications should not require the use of another syringe to administer the medication.

When a drug is supplied in a pre-filled syringe (and no other syringe is used in the administration of the drug contained in the syringe) then the supply charge associated with HCPCS code A4657 cannot be billed to Medicare.

Only when a new syringe is used in the administration of the drug should HCPCS code A4657 be used.

Note that this special edition article relates to billing for syringes used in the treatment of ESRD patients.

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

 

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Medical Review Frequently Asked Questions - April 2005

The following represent a variety of questions the Medical Review department has received. CIGNA Medicare will address at least quarterly “Frequently Asked Questions” related to coverage and local medical review policy issues. Providers may submit questions to the Web site at: http://www.cignamedicare.com/customer_service/disclaimer.html.

1. Electronic Claims for Services requiring additional documentation?

Q: With enforcement of electronic claim filing going into effect this summer, how are providers supposed to file claims for modifier 22, unlisted codes, cosurgery, etc. that usually require additional information?

A: Providers should include a description of the service in the electronic equivalent of field 19 of the claim form. For example, if the provider is requesting additional reimbursement via use of modifier 22, then a description should be entered in the electronic notepad describing why the procedure was extraordinary meriting additional pay. The same guidelines can be used for those claims where providers must substantiate the medical necessity for an assistant at surgery or co-surgeon before Medicare can pay. For example, the notepad could say what/how the other provided assisted or served as a cosurgeon. Finally, in the case of unlisted codes, if there is no specific/listed code for a procedure performed, providers should bill an unlisted code. The procedure can be described in the electronic notepad. In all of these scenarios, the electronic notepad will be reviewed to determine if the information is sufficient to allow payment. If that is not the case, Medicare will develop for the additional information necessary. The amount of space available on the electronic notepad is limited, but we have encountered providers with even less space available per their electronic claim vendor. Providers may need to consult with their vendors to expand their notepads to match the space the contractor allows.

2. G0351

Q: If a patient requires more than one G0351 (therapeutic or diagnostic SQ/IM injection per encounter), how would you file the claim for these? Can an E&M be billed the same date of service as G0351?

A: If the injections are given for the same diagnosis, then the injections could be reported using G0351 on one line with multiple numbers of services equal to the number given. If the injections are for different indications, then providers should bill G0351 on the same claim but separate lines (using modifier 59 on each line after the first G0351) with each line referenced to the appropriate corresponding diagnosis.

If a significant separately identifiable evaluation and management (E&M) service is performed, the appropriate E&M service code should be reported utilizing modifier 25 in addition to codes G0347-G0354.

See also MedLearn Matters article via http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3631.pdf

3. Onsite Supervision for “Incident To” Services

Q: What does CIGNA consider as “on-site” supervision for “incident to” services?

A: Per CMS Publication 100, the Medicare Claims Processing Manual, Chapter 15, Section 60.1, Subsection B, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the auxiliary personnel is performing services. CIGNA Medicare would interpret this as in the same office suite which should furthermore be the same floor/building.

See CMS Internet Only Manuals http://www.cms.hhs.gov/manuals/102_policy/bp102c15.pdf

4. Miscellaneous Screening Services

Q: Does Medicare cover screening services such as ones for abdominal aortic aneurysms, fundus photography for diabetic retinopathy, or CT of chest/coronary arteries for calcium scoring of coronary arteries?

A: We have seen some providers billing for fundus photography as a screening tool for diabetic retinopathy which is not covered. Fundus photography may be reimbursable only when utilized by qualified providers (ophthalmologists and optometrists) for documenting a baseline in diagnosed retinopathy and follow up examinations as a part of an ophthalmologic evaluation. Other screening services beyond those specifically identified as Medicare benefits in the Medicare manuals are not covered by Medicare. That would include screening aortic aneurysm for beneficiary with history of smoking or family history of aortic aneurysm. CIGNA Medicare previously addressed calcium scoring of coronary arteries in a bulletin article attached via the following link: http://www.cignamedicare.com/partb/bltin/all/02bltin/02_5

Currently, this test is not considered a covered screening benefit by Medicare.

See CMS Publication 100-4, the Medicare Claims Processing Manual, Chapter 18 and CMS Publication 100-2, the Medicare Benefit Policy Manual, Chapter 15, Sections 280-280.4 for detail on screening services covered by Medicare (see respective links below). http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp
http://www.cms.hhs.gov/manuals/102_policy/bp102c15.pdf

5. Supervising Provider for Incident To Services

Q: If the supervising provider is different from the ordering provider, which provider number is used to report “incident to” services?

A: “Incident to” services should be billed under the supervising physician who would be covering for the patient’s normal physician and would be a member of the same group with the patient’s physician. If the supervising physician had no relationship with ordering physician, then “incident to” criteria would not be satisfied as supervising physician would have not had an initial service with the patient.

See also MedLearn Matters article via
http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3138.pdf

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New Remittance Advice (RA) Message for Referred Clinical Diagnostic/Purchased Diagnostic Service Duplicate Claims

NOTE: This article was revised on March 17, 2005, to reflect a change to CR 3679, which was reissued on February 25, 2005. The CR 3679 was modified to show that the effective date of this change applies to claims processed on or after July 1, 2005, without regard to the date of service on the claim.

Provider Types Affected
Physicians/suppliers who bill Medicare carriers (excluding DMERCs) for referred clinical diagnostic laboratory and purchased diagnostic services.

Provider Action Needed

STOP – Impact to You
Effective April 1, 2005, a claim for a referred clinical diagnostic/purchased diagnostic service that is identified as duplicate will be denied. For full details of this edit, please see Medlearn Matters article MM3551 at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3551.pdf

CAUTION – What You Need to Know
Effective with claims processed on or after July 1, 2005, CMS will implement a new Remittance Advice (RA) message for such duplicate claims. Carriers will use the following remark code on remittance advice notices generated for a referred clinical diagnostic/purchased diagnostic service claim line item denied as a duplicate of a previously paid service: “Your claim for a referred clinical diagnostic/purchased diagnostic service cannot be paid because payment has been made for this service in another carrier jurisdiction.”

GO – What You Need to Do
Be ready to accept this new remark code indicating a duplicate claim submission.

Background
Effective April 1, 2005, the Centers for Medicare & Medicaid Services (CMS) will implement a new Common Working File (CWF) edit to check for duplicate claims for referred clinical diagnostic laboratory services and purchased diagnostic services submitted by physicians/suppliers to more than one carrier. (Per Transmittal 124, Change Request 3551, published on October 29, 2004, and described in Medlearn Matters article MM3551)

As a reminder, claims submitted for referred clinical diagnostic/purchased diagnostic services will be considered duplicate when:

The CWF duplicate claim edit will apply only to:

Effective for claims processed on or after July 1, 2005, CMS will implement a new Remittance Advice (RA) message for claim items denied due to the CWF duplicate claim edit for referred clinical diagnostic/purchased diagnostic service claims:

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

On the above page, scroll down while referring to the CR NUM column on the right to find the link for CR 3679. Click on the link to open and view the file for the CR. CR 3551 may be accessed at:
http://www.cms.hhs.gov/manuals/pm_trans/R124OTN.pdf

If you have questions regarding this issue, you may also 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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CIGNA Medicare NetCourses Reminder

Sometimes it is hard to fit Medicare training into your busy schedule, so CIGNA Medicare has developed NetCourses. NetCourses are online tutorials and training courses available on demand, any time of the day. Each course contains a pre-test and a post-test so you can evaluate your knowledge of the subject. If you feel you missed something, you can go back and review the information at any time.

The following NetCourses are available at: http://www.cignamedicare.com/Webtraining/Logon.asp, to help meet your Medicare-related training needs.

General Courses

Part B Courses

CIGNA Medicare will continue to launch several NetCourses throughout the year. Be sure to sign-up for our E-Mail Express Notification System (ListServ) at: http://www.cignamedicare.com/medicare_dynamic/mailer/subscribe.asp so you can be notified via e-mail when new tutorials are available.

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Low Osmolar Contrast Media (LOCM) - Coding Guidelines

Low Osmolar Contrast Media (LOCM) - Coding Guidelines

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Billing for Hemophilia Blood Clotting Factors (Medicare Claims Processing Manual (Pub. 100-04), Chapter 17, Section 80.4)

Provider Types Affected
Physicians and providers billing Medicare carriers and intermediaries for blood clotting factors

Provider Action Needed

STOP – Physicians and providers should note that this instruction is based on information contained in Change Request (CR) 3755 which states that blood clotting factors not paid on a cost or prospective payment system basis are priced as a drug/biological under the drug pricing fee schedule effective for the specific date of service.

CAUTION – Note: 1) Medicare carriers process claims from noninstitutional providers for blood clotting factors, while 2) blood clotting factor claims from institutional (including claims from hospital-based hemophilia centers) are processed by Medicare Fiscal Intermediaries (FIs).

GO – Be sure billing staff is aware of this requirement.

Background
Blood clotting factors not paid on a cost or prospective payment system basis are priced as a drug/biological under the drug pricing fee schedule effective for the specific date of service. As of January 1, 2005, the ASP (average sales price) plus 6% is used.

If a beneficiary is in a covered Part A stay in a Prospective Payment System (PPS) hospital, the clotting factors are paid in addition to the DRG/HIPPS payment (For FY 2005, this payment is based on 95% of Average Wholesale Prices (AWP)). For a Skilled Nursing Facility (SNF) subject to SNF/PPS, the payment is bundled into the SNF/PPS rate.

For hospitals subject to the Outpatient Prospective Payment System (OPPS), the clotting factors, when paid under Part B, are paid based on an Ambulatory Payment Classification, or the APC. For SNFs, the clotting factors, when paid under Part B, are paid based on cost.

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

From that Web page, look for CR 3755 in the CR NUM column on the right, and click on the file for that CR.

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

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Skilled Nursing Facility Consolidated Billing and Erythropoietin (EPO, Epoetin Alfa) and Darbepoetin Alfa (Aranesp)

Note: This article was revised on March 1, 2005, to delete the reference to Chapter 17 of the Medicare Benefit Policy Manual in the Additional Information section of the article.

Provider Types Affected
Skilled Nursing Facilities (SNFs), physicians, suppliers, end-stage renal disease (ESRD) facilities, and hospitals

Provider Action Needed
This Special Edition is informational only and describes SNF Consolidated Billing (CB) as it applies to Erythropoietin (EPO, Epoetin Alfa) and Darbepoetin Alfa (Aranesp) and related services.

Clarification: The SNF CB requirement makes the SNF itself responsible for including on the Part A bill that it submits to its Medicare intermediary almost all of the services that a resident receives during the course of a Medicare covered stay, except for a small number of services that are specifically excluded from this provision. These excluded services can be separately furnished to the resident and billed under Medicare Part B by a variety of outside sources. These sources can include other providers of services (such as hospitals), which would submit the bill for Part B services to their Medicare intermediary, as well as practitioners and suppliers who would generally submit their bills to a Medicare Part B carrier. (Bills for certain types of items or equipment would be submitted by the supplier to their Medicare Durable Medical Equipment Regional Carrier (DMERC)).

Background
The original Balanced Budget Act of 1997 list of exclusions from the PPS and CB for SNF Part A residents specified the services described in section 1861(s)(2)(O) of the Social Security Act—the Part B erythropoietin (EPO) benefit. This benefit covers EPO and items related to its administration for those dialysis patients who can self-administer the drug, subject to methods and standards established by the Secretary for its safe and effective use (see 42 CFR 405.2163(g) and (h)). See Medlearn Matters Special Edition SE0431 for a detailed overview of SNF CB, including a section on services excluded from SNF CB. This article can be found at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0431.pdf

Regulations at 42 CFR 414.335 describe payment for EPO and require that EPO be furnished by either a Medicare-approved ESRD facility or a supplier of home dialysis equipment and supplies. The amount that Medicare pays is established by law. Thus, the law and implementing regulations permit an SNF to unbundle the cost of the Epogen drug when it is furnished by an ESRD facility or an outside supplier, which can then bill their carrier/intermediary for it.

An SNF that elects to furnish EPO to its Part A resident itself cannot be separately reimbursed over and above the Part A SNF PPS per diem payment amount for the Epogen drug. As explained above, the exclusion of EPO from CB and the SNF PPS applies only to those services that meet the requirements for coverage under the separate Part B EPO benefit, i.e., those services that are furnished and billed by an approved ESRD facility or an outside dialysis supplier.

By contrast, if the SNF itself elects to furnish EPO services (including furnishing the Epogen drug) to a resident during a covered Part A stay (either directly with its own resources, or under an “arrangement” with an outside supplier in which the SNF itself does the billing), the services are no longer considered Part B EPO services, but rather, become Part A SNF services. Accordingly, they would no longer qualify for the exclusion of Part B EPO services from CB, and would instead be bundled into the PPS per diem payment that the SNF receives for its Part A services.

Note: The Part B coverage rules that apply to EPO are applied in the same manner to Aranesp. (See Medicare Claims Processing Manual, Pub.100-04, Chapter 8 – Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, §60.7.2; see also Medicare Benefit Policy Manual, Pub. 100-02, Chapter 11 – End Stage Renal Disease (ESRD), §90). Accordingly, Aranesp is now excluded on the same basis as EPO.

Note: EPO (Epoetin Alfa, trade name Epogen)/DPA (Darbepoetin Alfa, trade name Aranesp) are not separately billable when provided as treatment for any illness other than ESRD. In this case, the SNF is responsible for reimbursing the supplier. The SNF should include the charges on the Part A bill filed with its intermediary for that beneficiary.

Additional Information
Medlearn Matters SE0431, containing the list of services excluded from SNF CB, can be found at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0431.pdf

The Medicare Renal Dialysis Facility Manual, Chapter II, Coverage of Services can be found at the following CMS Web site: http://www.cms.hhs.gov/manuals/29_rdf/rd200.asp?#_1_17

Also, the Medicare Benefit Policy Manual Chapter 11 regarding billing and payment details for EPO and DPA can be found at the following CMS Web site: http://www.cms.gov/manuals/102_policy/bp102c11.pdf

You can find the Medicare Claims Processing Manual, Pub. 100-04, Chapter 8, Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, at the following CMS Web site: http://www.cms.hhs.gov/manuals/104_claims/clm104c08.pdf

The CMS Consolidated Billing Web site can be found at: http://www.cms.hhs.gov/medlearn/snfcode.asp

It includes the following relevant information:

The CMS Skilled Nursing Facility Prospective Payment System (SNF PPS) Web site can be found at: http://www.cms.hhs.gov/providers/snfpps/cb

It includes the following relevant information:

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Importance of Supplying Correct Provider Identification Information Required in Items 17, 17a, 24K, and 33 of the Form CMS-1500, and the Electronic Equivalent

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

Provider Action Needed
The Centers for Medicare & Medicaid Services (CMS) would like to remind providers and their billing staffs of the importance of reporting the correct provider identification information in items 17, 17a, 24K, and 33 of the Form CMS-1500, or the electronic equivalent. This information is critical for accurate and timely processing and payment of your claims.

Additional Information
Please be aware of the following instructions:

Items 17 and 17a
On the Form CMS-1500, or electronic equivalent, the provider must submit the appropriate referring or ordering physician name in item 17, and the Unique Physician Identification Number (UPIN) of that referring/ordering physician in item 17a. These are required fields when a service was ordered or referred by a physician. When a claim involves multiple referring and/or ordering physicians, you must prepare a separate claim submission for each ordering/referring physician.

Item 17
Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician.

Item 17a
Enter the UPIN of the referring/ordering physician listed in item 17.

The ordering/referring requirement became effective January 1, 1992, and is required by §1833(q) of the Act. All claims for Medicare covered services and items that are the result of a physician’s order or referral shall include the ordering/referring physician’s name and UPIN. This includes parenteral and enteral nutrition, immunosuppressive drug claims, and the following:

Claims for other ordered/referred services not included in the preceding list shall also show the ordering/referring physician’s name and UPIN. For example, a surgeon shall complete items 17 and 17a when a physician refers the patient. When the ordering physician is also the performing physician (as often is the case with in-office clinical laboratory tests), the performing physician’s name and assigned UPIN appear in items 17 and 17a.

When a service is incident to the service of a physician or non-physician practitioner, the name and assigned UPIN of the physician or non-physician practitioner who performs the initial service and orders the non-physician service must appear in items 17 and 17a.

All physicians who order or refer Medicare beneficiaries or services must obtain a UPIN even though they may never bill Medicare directly. A physician who has not been assigned a UPIN must contact the local Medicare carrier to obtain the UPIN. A list of toll free numbers of the Medicare carriers is available at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

When a physician extender or other limited licensed practitioner refers a patient for consultative service, the name and UPIN of the physician supervising the limited licensed practitioner must appear in items 17 and 17a.

When a patient is referred to a physician who also orders and performs a diagnostic service, a separate claim form is required for the diagnostic service. Enter the original ordering/referring physician’s name and UPIN in items 17 and 17a of the first claim form. Enter the ordering (performing) physician’s name and UPIN in items 17 and 17a of the second claim form (the claim for reimbursement for the diagnostic service).

Item 24K
Enter the provider identification number (PIN) of the performing provider of service/supplier in item 24K if the provider is a member of a group practice. When several different providers of service or suppliers within a group are billing on the same Form CMS-1500, or electronic equivalent, show the individual PIN of each performing provider in the corresponding line item. In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the PIN of the supervisor in item 24K.

UPINs are not appropriate identifiers for item 24K.
Item 33
Enter the provider of service/supplier’s billing name, address, ZIP code, and telephone number. This is a required field.

For a provider who is not a member of a group practice (e.g., private practice), enter the PIN at the bottom of item 33 for paper claims. The PIN should be entered on the left side, next to the PIN# field.

If a group practice is billing, then the group PIN is to be placed in item 33 for paper claims. Enter the group PIN at the bottom of item 33 on the right side, next to the GRP# field. Enter the PIN for the performing provider of service/supplier who is a member of that group practice in item 24K.

Suppliers billing a DMERC will use the National Supplier Clearinghouse (NSC) number in this item.

NOTE: When implemented, the National Provider Identification (NPI) number will replace the PIN and UPIN. At that time, you will use the NPI number in items 17a, 24K, and 33.

The above instructions are included in Chapter 26 of the Medicare Claims Processing Manual. That manual is available at: http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp

The Medicare Benefit Policy Manual may be found at: http://www.cms.hhs.gov/manuals/102_policy/bp102index.asp

And, if you have questions, please contact your carrier/DMERC at their toll free number, available at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

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1st Update to the 2005 Medicare Physician Fee Schedule Database

Note: This instruction was revised on April 4, 2005, to show the effective date for the PET codes referenced in the Background section is January 28, 2005.

Provider Types Affected
Physicians and providers billing Medicare carriers or Fiscal Intermediaries (FIs) for services paid under the Medicare Physician Fee Schedule

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

Background
CR 3726 amends payment files issued based upon the November 15, 2004, Final Rules for the 2005 Medicare Physician Fee Schedule Database. Many of the changes relate to a National Coverage Determination (NCD) related to G codes and CPT codes for Positron Emission Tomography (PET), which was effective January 28, 2005.

Additional Information
The changes to the fee schedule involve numerous CPT/HCPCS codes. These changes to the 1st Update to the 2005 Medicare Physician Fee Schedule Database are described in an attachment to CR 3726.

For complete details, please see the official instruction issued to your carrier/FI regarding this change. That instruction may be viewed at: http://ww.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

From that Web page, look for CR 3726 in the CR NUM column on the right, and click on the file for that CR.

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

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July 2005 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing File, Effective July 1, 2005

Provider Types Affected
All Medicare providers

Provider Action Needed
No provider action is necessary. This article is informational only and explains how Medicare pays for certain drugs that are not paid on a cost or prospective payment basis, effective July 1, 2005.

Background
According to Section 303 of the Medicare Modernization Act of 2003 (MMA), beginning January 1, 2005, drugs and biologicals not paid on a cost or prospective payment basis will be paid based on the Average Sales Price (ASP) plus six (6) percent. The Centers for Medicare & Medicaid Services (CMS) supplies its carriers/intermediaries with the ASP drug pricing file for Medicare Part B drugs. The ASP is based on quarterly drug information supplied to CMS by drug manufacturers.

Thus, beginning January 1, 2005, the payment allowance limits for Medicare Part B drugs and biologicals that are not paid on a cost or prospective payment basis are 106 percent of the ASP. CMS will update the payment allowance limits quarterly.

Exceptions
There are exceptions to this general rule, as summarized below:

Note: The absence or presence of a HCPCS code and its associated payment limit in the payment files does not indicate Medicare coverage of the drug. Similarly, the inclusion of a payment limit within a specific column does not indicate Medicare coverage of the drug in that specific category. The local Medicare carrier/intermediary processing the claim shall make these determinations.

Implementation
The implementation date is July 5, 2005. The July 2005 ASP and NOC drug pricing files will be used by your carrier/intermediary to pay for Medicare Part B drugs from July 1, 2005, through September 30, 2005.

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

From that Web page, look for CR 3783 in the CR NUM column on the right and click on the file for that CR.

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

 

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Centers for Medicare & Medicaid Services (CMS) Comprehensive Error Rate Testing (CERT) Program - The Importance of Complying with Requests for Claim Documentation

Provider Types Affected
Medicare Fee-for-Service (FFS) physicians, providers and suppliers

Provider Action Needed

STOP – Impact to You
The net national claims error rate under CERT for fiscal year 2004 was 9.3%. A portion of this error rate was due to providers not sending requested supporting documentation to the designated CERT contractor. Medicare FFS physicians, providers and suppliers must provide documentation and medical records that support their claims for covered Medicare services to the designated CERT contractor upon request. If you fail to submit documentation, the claim will be considered an error and you will receive a demand letter requesting refund of payment received for the “erroneous” claim.

CAUTION – What You Need to Know
During a CERT review, you may be asked to provide more information related to a claim you submitted, such as medical records or certificates of medical necessity, so that the CERT review contractor (CRC) can verify that billing was proper. Be assured that forwarding specifically requested records to the designated CERT contractor does not violate privacy provisions under the Health Insurance Portability and Accountability (HIPAA) law.

GO – What You Need to Do
If you receive a letter from CMS regarding a CERT request for medical documentation, you should respond promptly by submitting the requested supporting documentation within the time frame outlined in the request. Physicians, providers and suppliers do not need to obtain additional beneficiary authorization to forward medical records to the designated CERT contractor. This special edition article provides an overview of the CERT program and stresses the importance of providing the requested medical documentation for the CERT review

Background
The Government Performance and Results Act of 1993 established performance measurement standards for Federal agencies. To achieve the goals of this Act, CMS established the Comprehensive Error Rate Testing (CERT) program in November 2003. The purpose of the CERT program is to measure and improve the quality and accuracy of Medicare claims submission, processing and payment. The results of these reviews are used to characterize and quantify local, regional, and national error rate patterns. CMS uses this information to address the error rate through appropriate educational and interventional programs.

Methodology
The CERT program was originally administered by the Department of Health and Human Services, Office of the Inspector General (OIG) from 1996 - 2002. During this period, the OIG designed a sampling method that estimated only a national FFS paid claims error rate (the percentage of dollars that Medicare contractors erroneously allowed). Currently, CMS calculates a national paid claims error rate, a contractor specific error rate, services processed error rate (which measures whether the Medicare contractor made appropriate payment decisions on claims) and a provider compliance error rate (which measures how well providers prepared claims for submission). The CMS methodology includes:

The designated CERT review contractor currently reviews over 140,000 randomly-selected claims and corresponding medical records each year, with a medical review staff that includes physicians and nurses who can use clinical judgment when necessary in reviewing medical records. Their medical review staff has access to national and local policies, contractor processing guidelines and automated edits.

If you fail to submit the requested information in a timely fashion, an “error” is registered against both the Medicare contractor (your Medicare Carrier or Fiscal Intermediary) and you, as the Medicare provider. (At this point, the CERT review contractor has no choice but to register the claim submission as “erroneous” because there is insufficient supporting documentation to determine otherwise.) These errors have a corresponding negative impact on the other error rates that are calculated under the CERT program.

Your Role Is Critical To Improvement
Our research has shown that providers do not comply with the requests for information because:

Medicare beneficiaries have consented to the release of medical information necessary to process their Medicare claims. Providers do not need to obtain additional beneficiary authorization to forward medical records to the designated CERT contractor. Be assured that forwarding specifically requested records to the designated CERT contractor does not violate HIPAA Privacy statutes.

If You Receive A Letter From CMS Regarding A CERT Medical Review…

  1. Don’t ignore it! Respond promptly by submitting the requested supporting documentation within the time frame outlined in the request. The letter will provide a clearly defined list of the documentation required and where to submit the information.
  2. Include any additional material that you believe supports the service(s) billed to the Medicare program.
  3. Make sure your address files and telephone numbers that are on file with your carrier or fiscal intermediary are accurate to ensure that CERT documentation requests are received and allow time for you to respond timely.
  4. Remember that physicians, providers and suppliers do not need to obtain additional beneficiary authorization to forward medical records to the designated CERT contractor.

Additional Information
In an effort to assist Medicare physicians, providers and suppliers with CERT compliance, we have several resources available to explain the CERT process and how your responsiveness is in everyone’s best interest.

In addition, we are preparing a series of Fact Sheets, Frequently-Asked Questions, and future Medlearn Matters articles to provide further guidance regarding the CERT process.

REMEMBER:
Review can result in identification of overpayments as well as underpayments.

If CERT changes the payment decision on your claim by denying or reducing payment, you can still file an appeal with your Medicare contractor.

It is in everyone’s interest to code and pay claims correctly. Your support of this process helps protect the solvency of the Medicare Program.

Your cooperation also allows your Medicare contractor to provide individualized education to you on your specific CERT errors.

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Electronically Requesting and Receiving Information Regarding Claims Using the ASC X12N276/277 Claims Status Inquiry/Response Transactions

Provider Types Affected
Physicians, providers and suppliers billing Medicare carriers and intermediaries.

Provider Action Needed

STOP – Impact to You
This special edition discusses how health care providers may want to implement the ASC X12N 276/277 Claims Status Inquiry/Response Transactions and benefit by being able to request and receive the status of claims in one standard format, for all health care plans.


CAUTION – What You Need to Know
Implementing the ASC X12N 276/277 would make electronic claim status requests and receipt of responses feasible for small providers, and eliminate the need to:

GO – What You Need to Do
Providers who implement the ASC X12N 276/277 may create a more efficient follow-up process and also achieve an increase in cash flow each month by greatly reducing the administrative costs incurred by supporting multiple formats and manually processing claim status requests.

Background
Even though there has been a significant increase in the number of providers who use electronic health care transactions, providers have faced the burden of sending information to various health plans in multiple formats. Even when different plans accept information in similar formats, they frequently have additional requirements that further complicate efficient information interchange. Consequently, providers have been burdened with additional administrative work in order to electronically process health care transactions (including claims status requests and responses). This has increased the costs and decreased the efficiency of processing claims status requests and responses.

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 includes administrative simplification provisions meant to reduce and simplify the administrative demands faced by healthcare providers. HIPAA:

  1. Directed the Federal government to adopt national standards for the transfer of certain health care data; and
  2. Requires all payers to use national standard transaction formats and code sets, such as the health care claims status category codes and the health care claim status codes issued by the Claim Adjustment Status Code Maintenance Committee.

Medicare carriers and intermediaries must periodically update their claims system with the most current health care claim status codes for use with:

Most health care providers who are currently using an electronic format and who wish to request claim status electronically using the ASC X12N 276/277 may incur some conversion costs.

However, after implementation, providers will benefit by being able to request and receive the status of claims in one standard format, from all health care plans. This would make electronic claim status requests and receipt of responses feasible for small providers, and eliminate the need to:

It is possible that providers who implement the ASC X12N 276/277 can create a more efficient follow-up process and also achieve an increase in cash flow each month by greatly reducing the administrative costs incurred by supporting multiple formats and manually processing claim status requests.

It’s time to start using this transaction.
Medicare can accept transmission of the ASC X12N 276 (your electronic request on the status of a previously submitted claim) and respond with an ASC X12N 277 (our electronic answer back to you).

Currently, CMS sends out over 10,000 responses (277s) per month, and you too can benefit from this process. It could help you reduce the time required to follow up with Medicare as well as with any payer from 20 minutes to a few seconds.

Additional Information
An informative article entitled “Realizing Savings from the HIPAA Transaction Standards: How to Get There from Here,” which was prepared by Martin A. Brutscher, Partner, McBee Associates, Inc., can be reviewed at the following Web site: http://www.mcbeeassociates.com/HFMA_white_paper.pdf

The article shows the types of results that may be available to providers who implement the ASC X12N 276/277 as well as other HIPAA transactions. Also, the Medicare Claims Processing Manual (Pub. 100-04), Chapter 31 (ANSI X12N Formats), Section 20 (ANSI X12N 276/277 Claims Status Request/Response Transaction Standard) can be reviewed at the following Centers for Medicare & Medicaid Services (CMS) Web site: http://www.cms.hhs.gov/manuals/104_claims/clm104c31.pdf

The X12 276/277 version 4010A1 implementation guide, as well as the claim status codes and category codes, may be downloaded without charge at: http://www.wpc-edi.com/hipaa.

If you have any questions regarding this issue, contact the EDI department of your carrier/intermediary at their toll-free number. If you bill for Medicare Part A services, including outpatient hospital services, that number may be found at: http://www.cms.hhs.gov/providers/edi/anum.asp

If you bill for Medicare Part B services, that number may be found at: http://www.cms.hhs.gov/providers/edi/bnum.asp

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Abarelix for the Treatment of Prostate Cancer

Provider Types Affected
Providers who care for Medicare beneficiaries with prostate cancer

Provider Action Needed

STOP – Impact to You
Effective March 15, 2005, you may bill for the use of abarelix (PlenaxisTM) for certain patients with advanced, symptomatic prostate cancer.

CAUTION – What You Need to Know
Effective March 15, 2005, CMS is extending national coverage for the use of abarelix (PlenaxisTM) as a palliative treatment, for the indications described below, in patients with advanced, symptomatic prostate cancer.

GO – What You Need to Do
Make sure that your billing staff is aware of this new coverage.

Background

Treatment Options for Prostate Cancer
Treatment options for prostate cancer vary depending on patient age, cancer stage, and individual medical conditions. Surgery (e.g., radical prostatectomy) or radiation is typically used for early-stage disease, whereas hormonal therapy, chemotherapy, and radiation (or combinations of these treatments) are used for more advanced disease.

Hormonal therapy for prostate cancer has evolved from orchiectomy and estrogens to the use, in recent years, of synthetic drugs known as gonadotropin-releasing hormone (GnRH) agonists, such as leuprolide (Lupron™) and goserelin (Zoladex™)

Abarelix
More recently, newer GnRH receptor antagonist compounds, such as abarelix (PlenaxisTM), are, in contrast, thought to be devoid of agonist activity and to lack an initial androgen-stimulating effect. Abarelix PlenaxisTM) has been proposed as a substitute for GnRH agonists (with and without antiandrogens) in the treatment of patients with advanced prostate cancer, for whom a surge in androgen blood levels may pose a risk of “clinical flare.” For this indication, abarelix is the first GnRH receptor antagonist that the Food and Drug Administration (FDA) has approved.

CMS determines that the evidence is adequate to conclude that abarelix (PlenaxisTM) is reasonable and necessary as a palliative treatment in patients with advanced symptomatic prostate cancer who: (1) decline surgical castration; (2) when GnRH therapy is not appropriate, and (3) who present with one of the following indications:

Please note that the following additional conditions for coverage must be met, in accordance with the Food and Drug Administration (FDA) labeling requirements, to ensure that abarelix (PlenaxisTM) is used only in patients for whom the drug is indicated:

In evaluating this prostate cancer patient, the physician must attest to, and accept the following qualifications and responsibilities, and must have enrolled in the post-marketing risk management program that the drug manufacturer has established.

The physician must attest willingness and ability to:

Finally, be aware that CMS has also determined that the evidence is not adequate to conclude that abarelix (PlenaxisTM) is reasonable and necessary for indications other than those specified above. Therefore, all other uses of abarelix (PlenaxisTM) are not covered. Further, in light of the concern regarding safety risks of abarelix (PlenaxisTM), off-label uses that may appear in listed statutory drug compendia on which Medicare and its contractors rely to make coverage determinations will remain non-covered until CMS completes a reconsideration of this National Coverage Determination.

Additional Information
The following claims processing points should be noted:

You can find more information about abarelix for the Treatment of Prostate Cancer by going to:
http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

From that Web page, look for CR 3775 in the CR NUM column on the right, and click on the file for that CR.

You might also want to look at Chapter 1, Part 2, Section 110.18 of the Medicare National Coverage Determinations Manual that is an attachment to CR 3775.

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

 

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Coverage by Medicare Advantage Organizations for National Coverage Determination (NCD) Services Not Previously Included in the Medicare Advantage’s Capitated Rates

Note: This article was revised on April 22, 2005, to reflect that the correct effective date for the NCD on ventricular assist devices is October 1, 2003.

Provider Types Affected
Physicians, providers, and suppliers billing for the services mentioned below

Provider Action Needed

STOP – Impact to You
Medicare Advantage (MA) rates were recently adjusted to account for three National Coverage Determination (NCD) services. These services are implantable automatic defibrillators (effective 10/1/03), ventricular assist devices (effective 10/1/03), and lung volume reduction surgery (effective 1/1/04). MA organizations are liable for payment for these NCD services beginning January 1, 2005.

CAUTION – What You Need to Know
For services rendered prior to January 1, 2005, payment for services relating to the three NCD services mentioned above are paid by Medicare on a fee-for-service basis for MA plan enrollees. Note that, prior to January 1, 2005, beneficiaries are not responsible for Part A or Part B deductibles associated with these services, though they are responsible for coinsurance amounts appropriate under Medicare fee-for-service rules.

GO – What You Need to Do
Be aware that these services will not be paid on a fee-for-service basis on or after January 1, 2005. Instead, the MA plan will be responsible for making payment. Note also that MA enrollees receiving services for lung volume reduction surgery services must receive these services in designated hospitals.

Background
When Medicare issued these NCDs initially, new coverage was introduced and the cost of that coverage was not reflected in the rates paid to MA plans. Thus, Medicare paid for these services separately on a fee-for-service basis until such time as the cost could be considered in determining MA rates. The Centers for Medicare & Medicaid Services will factor these costs into the MA payment rates as of January 1, 2005.

At that time, Medicare will no longer pay for these services on the fee-for-service basis.

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

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Infusion Pumps: C-Peptide Levels as a Criterion for Use

Note: This article was revised on April 1, 2005, to reflect a revised transmittal number, since CR 3705 was re-issued on March 30, 2005.

Provider Types Affected
Physicians, suppliers, and providers providing continuous subcutaneous insulin infusion and related drugs/supplies in the treatment of diabetic patients in the home setting and billing Medicare carriers or Fiscal Intermediaries (FIs)

Provider Action Needed

STOP – Impact to You
This article and related CR 3705 adds beta cell autoantibody testing as an alternative diagnostic per the updated C-peptide testing requirement for the use of insulin infusion pumps, effective for services performed on or after December 17, 2004.

CAUTION – What You Need to Know
Providers/suppliers treating Medicare diabetic patients with infusion pumps should be aware of this new Medicare coverage policy.

GO – What You Need to Do
Ensure that your staff is aware of this new coverage and that they bill according to the information in this article.

Background
On August 26, 1999, the Centers for Medicare & Medicaid Services (CMS) issued the first decision memorandum (DM) for continuous subcutaneous insulin infusion pumps (CSII) that utilized a C-peptide testing requirement for Medicare coverage of CSII pump therapy. On May 11, 2001, CMS issued a second DM for insulin pump: “C-Peptide Levels as a Criterion for Use,” and on January 1, 2002, CMS revised the laboratory value for the C-peptide testing requirement for Medicare coverage of CSII pump therapy.

Effective for services performed on or after December 17, 2004, in addition to meeting criterion A or B, the beneficiary with diabetes must be insulinopenic per the fasting C-peptide testing requirement or, as an alternative must be beta cell autoantibody positive. Insulinopenia is defined as a fasting C-peptide level that is less than or equal to 110% of the lower limit of normal of the laboratory’s measurement method. For patients with renal insufficiency and a creatinine clearance (actual or calculated from age, gender, weight, and serum creatinine) < 50 ml/minute, insulinopenia is defined as a fasting C-peptide level that is less than or equal to 200% of the lower limit of normal of the laboratory’s measurement method. CMS establishes that fasting C-peptide levels will only be considered valid when a concurrently obtained fasting glucose is < 225 mg/dL. Levels need only be documented once in the patient’s medical records.

Coverage of all other uses of CSII that adheres with the Category B IDE clinical trials regulation (42 CFR 405.201) or routine cost under the clinical trials policy (Medicare NCD Manual Chapter 1, Part 4, Section 310.1) will continue.

Those billing for these services should note that Medicare carriers/intermediaries will accept, effective for services on or after December 17, 2004, CPT code 84681 (C-peptide) or CPT code 86337 (insulin antibodies) when diagnosis codes 250.00-259.93 are also reported on a claim.

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

From that Web page, look for CR 3705 in the CR NUM column on the right, and click on the file for that CR.

If you have questions regarding this issue, contact your carrier/intermediary on their toll free number, which is available at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

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Obtaining Fee Schedule Information through the IVR

To obtain allowable information (i.e., fee schedule amounts) from our Interactive Voice Response System (IVR), you are now prompted to enter the corresponding type of service for the procedure code. This information is requested after you enter the procedure code and modifier (if applicable).

The most common Types of Service (TOS) for Part B are:

1 Medical Care
2 Surgery
3 Consultation
4 Diagnostic Radiology
5 Diagnostic Laboratory
6 Therapeutic Radiology
7 Anesthesia
8 Assistant Surgery
9 Other Medical Items or Services
B High Risk Screening Mammography
C Low Risk Screening Mammography
D Ambulance
F Ambulatory Surgical Center
M Monthly Capitation Payment for Dialysis
U Occupational Therapy
V Pneumoccoccal/Flu Vaccine
W Physical Therapy

For your convenience, fee schedule information is also available on the CIGNA Medicare Web site at the following Web address: http:/www.cignamedicare.com/partb/fsch/index.html

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List of Medicare Telehealth Services

Providers Affected
Physicians and providers billing Medicare carriers for telehealth services

Provider Action Needed

STOP – Impact to You
Effective for services provided on or after January 1, 2005, the Centers for Medicare & Medicaid Services (CMS) added Healthcare Common Procedure Coding System (HCPCS) codes G0308, G0309, G0311, G0312, G0314, G0315, G0317, and G0318 (for ESRD-related services) to the list of Medicare telehealth services, effective January 1, 2005. Medicare carriers will pay for these ESRD-related services when billed with the telehealth modifiers.

CAUTION – What You Need to Know
Providers treating ESRD beneficiaries should also be aware that the above telehealth modifiers “GT” or “GQ” are valid when billed with one of the above mentioned HCPCS codes.

GO – What You Need to Do
Be sure staff is aware of the addition of these ESRD-related services to the list of Medicare telehealth services and the appropriate billing procedures.

Background
In the final rule published November 7, 2003, (68 FR 63216) CMS established new G codes for managing patients on dialysis with payments varying based on the number of visits provided within each month. Under this methodology, separate codes are billed for providing one visit per month, two to three visits per month, and four or more visits per month.

The lowest payment amount applies when a physician provides one visit per month; a higher payment is provided for two to three visits per month. To receive the highest payment amount, a physician would have to provide at least four ESRD-related visits per month. The G codes are reported once per month for services performed in an outpatient setting that are related to the patient’s ESRD.

Since changing the payments for managing patients on dialysis, CMS has received a number of comments from the nephrology community expressing concerns that the change in payments results in hardships for rural and isolated areas, especially in frontier areas where physicians would be required to make multiple long-distance trips during a month to see their patient’s or vice versa.

To address this issue, CMS added ESRD-related services under the monthly capitation payment (MCP) to the list of Medicare telehealth services in the physician fee schedule fine rule published November 15, 2004 (69FR 66276). ESRD-related services included in the MCP with 2 or 3 visits per month, and ESRD-related services with 4 or more visits per month, may be paid as Medicare telehealth service.

To bill for ESRD-related services under the MCP as a telehealth service, at least one visit must be furnished face to face “hands on” to examine the patient’s vascular access site. Examination of the vascular access site must be done by a physician, clinical nurse, specialist, nurse practitioner, or physician assistant. Only the facilities, authorized under Section 1834 (m) of the Social Security Act, may serve as a Medicare telehealth-originating site.

Prior to the issuance of CR 3747, the list of Medicare telehealth services only included consultations (CPT codes 99241-99275); office and other outpatient visits (CPT codes 99201-99215); individual psychotherapy (CPT codes 90804 -90809); pharmacologic management (CPT code 90862); and psychiatric diagnostic interview examination (CPT code 90801), effective for services on or after March 1, 2003.

This article and related CR 3747 informs that the ESRD-related services (HCPCS codes G0308, G0309, G0311, G0312, G0314, G0315, G0317, and G0318) are added to the list of Medicare telehealth services, effective for services furnished on or after January 1, 2005. The telehealth modifier “GT” (providing visits through the use of interactive audio and video telecommunications system) and modifier “GQ” (providing visits through the use of asynchronous telecommunications system) are valid when billed with these ESRD-related service HCPCS codes. The use of the telehealth modifiers indicates that a clinical examination of the vascular access site was furnished face-to-face “hands on” by a physician clinical nurse specialist, nurse practitioner, or physician assistant.

Addition of the above ESRD-related services to the list of Medicare telehealth service does not change the eligibility criteria, conditions of payment, payment, or billing procedure regarding Medicare telehealth services as established in publication 100-2, Chapter 15, Section 270 and publication 100-4 Chapter 12, Section 190 of the Medicare Benefit Policy Manual. Thus, originating sites only include a physician’s or practitioner’s office, hospital, critical access hospital, rural health clinic, or Federally qualified health center.

Originating sites must be in a non-Metropolitans Statistical Area (MSA) county or a rural health professional shortage area. Also, the use of modifier “GQ” is only permitted in Federally funded telemedicine demonstration programs conducted in Alaska or Hawaii.

Clarification for originating sites billing for the telehealth originating site facility fee
With regard to ESRD-related services included in the MCP, the originating site facility fee payment may be made for each visit furnished through an interactive telecommunications system. When the physician or practitioner at the distant site furnishes an ESRD-related patient visit included in the MCP through an interactive telecommunications system, the originating site may bill for a telehealth facility fee.

Example: A 70-year-old ESRD beneficiary receives two ESRD-related visits through an interactive telecommunications system and the required face-to-face visit (to examine the vascular access site) during the month of November. In this scenario, the originating site should bill for two originating site facility fees as described by HCPCS code Q3014, and the MCP physician at the distant site should bill for ESRD-related services with 2 to 3 visits as a telehealth service, e.g. G3018 GT.

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

From that Web page, look for CR 3747 in the CR NUM column on the right, and then click on the file for that CR.

If you have questions regarding this issue, contact your carrier on their toll free number, which is available at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

 

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Payment Policy Clarification Regarding the Healthcare Common Procedure Coding System (HCPCS) Code Q3001 Performed in an Ambulatory Surgery Center (ASC)

Note: This article was revised on April 22, 2005, to show that it affects physicians billing for HCPCS code Q3001 and to clarify that the code is carrier priced on the 2005 Medicare Physician Fee Schedule.

Provider Types Affected
Physicians billing Medicare carriers for HCPCS code Q3001 performed in an ASC setting

Provider Action Needed

STOP – Impact to You
HCPCS code Q3001 should be used by providers on claims when billing for radio elements for brachytherapy performed in an ASC setting, instead of the Current Procedural Terminology (CPT) code 79900, effective January 1, 2005.

CAUTION – What You Need to Know
There has been confusion among ASCs and Medicare carriers regarding the use of HCPCS code Q3001. HCPCS Q3001 is carrier priced on the 2005 Medicare Physician Fee Schedule and should be used when billing for prostate brachytherapy procedures when performed in an ASC setting.

GO – What You Need to Do
Be aware of the current payment policy for Q3001 and Medicare carriers will process claims containing this code when the services are performed on or after January 1, 2005.

Background
The Centers for Medicare & Medicaid Services (CMS) is aware of confusion among carriers and providers when HCPCS code Q3001 is used to bill for prostate brachytherapy procedures performed in an ASC setting. Effective January 1, 2005, Q3001 is carrier priced under the 2005 Medicare Physician Fee Schedule Database (MPFSDB) and can be billed to Medicare carriers for Part B services. Previously, Q3001 was only paid under the Outpatient Prospective Payment System (OPPS) and billable only to Medicare fiscal intermediaries.

This instruction and CR 3789 clarify CMS’ payment policy decision regarding the use of Q3001 on Medicare claims. HCPCS code Q3001 should be used instead of CPT 79900 when billing for prostate brachytherapy procedures performed in an ASC, on and after January 1, 2005.

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

From that Web page, look for CR 3789 in the CR NUM column on the right, and then click on the file for that CR.

If you have questions regarding this issue, contact your carrier on their toll free number available at:
http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

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Expansion of Coverage for Percutaneous Transluminal Angioplasty (PTA)

Provider Types Affected
Hospitals, physicians, and suppliers billing Medicare carriers or Fiscal Intermediaries (FIs) for Percutaneous Transluminal Angioplasty (PTA) services provided to Medicare beneficiaries

Provider Action Needed

STOP – Impact to You
MM 3811 and related CR 3811 announce the expansion of Medicare coverage for PTA of the carotid artery.

CAUTION – What You Need to Know
Effective March 17, 2005, Medicare revised its coverage of PTA of the carotid artery as detailed in this article and CR 3811.

GO – What You Need to Do
If you are a provider of PTA services, be aware of the coverage changes and make certain that your billing staff is aware of the expanded national coverage allowed to Medicare beneficiaries receiving PTA services

Background
Medicare covers PTA of the carotid artery concurrent with carotid stent placement when all the requirements stipulated by the Food and Drug Administration (FDA)-approved policies for Category B Investigational Device Exemption (IDE) clinical trials are met, effective for dates of service on or after July 1, 2001.

PTA of the carotid artery concurrent with the placement of an FDA-approved carotid stent for an FDA approved indication is covered, when all the requirements stipulated by the FDA-approved policies for post approval studies are met, for dates of service on or after October 12, 2004.

Expanded Coverage
Effective March 17, 2005, The Centers for Medicare & Medicaid Services (CMS) expanded the coverage of PTA of the carotid artery concurrent with placement of an FDA-approved carotid stent with embolic protection for the following:


CMS defines high risk patients as those having significant comorbidities and/or anatomic risk factors and are considered by a surgeon to be poor candidates for CEA. The significant comorbidities, include, but are not limited to, those listed in Section 20.7 of the Medicare NCD Manual as follows:

Symptoms of carotid artery stenosis include carotid transient ischemic attack (distinct focal neurologic dysfunction persisting less than 24 hours), focal cerebral ischemia producing a non-disabling stroke (modified Rankin scale < 3 with symptoms for 24 hours or more), and transient molecular blindness (amaurosis fugax). Patients who have had a disabling stroke (modified Rankin > 3) would be excluded from coverage.

The appropriate documentation confirming that a patient is at high risk for CEA and records of the patient’s symptoms of carotid artery stenosis should be available in the patient medical records prior to performing any procedure. The degree of carotid artery stenosis should be measured by duplex Doppler ultrasound or carotid artery angiography and recorded in the patient medical records. If the stenosis is measured by ultrasound prior to the procedure, then the degree of stenosis must be confirmed by angiography at the start of the procedure. If the stenosis is determined to be less than 70% by angiography, the CAS should not proceed.

For evaluation purposes, all facilities must provide written documentation to CMS indicating it meets one of the following criteria:

The affidavit must include the facility’s name and complete address, Medicare provider number, point of-contact name and telephone number, CAS procedure data collection mechanism, and a senior facility administrative official’s signature. (Note that a new affidavit is required every 2 years.) The affidavit should be sent to:
Director, Coverage and Analysis Group
7500 Security Boulevard, Mail-stop C1-09-06
Baltimore, MD 21244

Note: Performance of PTA to treat obstructive lesions of the vertebral and cerebral arteries remains noncovered. All other indications of PTA for which CMS has not specifically indicated coverage remain noncovered.

Additional Information
All providers should note that the following relate to services on or after March 17, 2005:

Note: Providers must also bill V70.7 (Exam – clinical trial) as a secondary diagnosis for claims with “From” dates before October 1, 2005. Providers must bill V70.7 in order to avoid unintentional Medicare Code Editor (MCE) editing.

For claims that have “From” dates on or after October 1, 2005, hospitals are not required to bill V70.7 as the unintentional MCE editing will be corrected.

You may also want to review the following Medlearn Matters article 3489 and CR 3489 for additional information relating to Medicare coverage of PTA. They are available at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3489.pdf
http://www.cms.hhs.gov/manuals/pm_trans/R314CP.pdf

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

From that Web page, look for CR 3811 in the CR NUM column on the right, and then click on the files for that CR. You will see two versions of CR 3811. One version identified by transmittal number 33 contains the NCD Manual revision, and transmittal number 531 contains the revisions to the Medicare Claims Processing Manual.

If you have questions regarding this issue, contact your carrier/intermediary on their toll free number, which is available at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

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Correction to the Use of Group Codes for the Enforcement of Mandatory Electronic Submission of Medicare Claims

Provider Types Affected
All physicians, providers, and suppliers who bill Medicare Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs), Carriers, and Durable Medical Equipment Regional Carriers (DMERCs)

Provider Action Needed
Providers and suppliers need to be aware of the Administrative Simplification Compliance Act (ASCA) that requires all expenses for items and services billed to the Medicare Program be submitted electronically. Unless there is an exception in place for a given provider, paper claims will be denied.

Background
Section 3 of the ASCA, PL107-105, and the implementing regulation at 42 CFR 424.32, requires you—with limited exceptions—to submit all your initial claims for reimbursement under Medicare electronically, on or after October 16, 2003. Further, ASCA amendment to Section 1862(a) of the Act prescribes that “no payment may be made under Part A or Part B of the Medicare Program for any expenses incurred for items or services” for which a claim is submitted in a non-electronic form.

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

From that Web page, look for CR 3815 in the CR NUM column on the right, and click on the file for the desired CR.

For additional information relating to this issue, please refer to your local FI, Carrier, RHHI or DMERC.

Their toll free phone numbers may be found at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

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Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 2005

Provider Types Affected
Clinical diagnostic laboratories billing Medicare carriers or Fiscal Intermediaries (FIs)

Provider Action Needed
CR 3806 announces c hanges to the list of codes included in the July 2005 release of the Medicare Laboratory National Coverage Determination (NCD) edit module for clinical diagnostic laboratory services. These changes are a result of coding analysis completed by the Centers for Medicare & Medicaid Services (CMS).

Background
The NCD for clinical diagnostic laboratory services were developed by the laboratory negotiated rulemaking committee and published as a final rule on November 23, 2001. Nationally uniform software was developed by Computer Sciences Corporation and incorporated into Medicare claim processing systems so that laboratory claims subject to any of the 23 NCD are processed uniformly throughout the nation, effective January 1, 2003.

In addition, the laboratory edit module for the NCD is updated quarterly as necessary to reflect ministerial coding updates and substantive changes to the NCD developed through the NCD process. (See the Medicare Claims Processing Manual, Pub. 100-4, Chapter 16, Section, 120.2. This manual may be found at: http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp).

CR 3608 announces the changes that will be included in the July 2005 release of the edit module for clinical diagnostic laboratory services. Those changes are as follows:

In accordance with the coding analysis published on the coverage Internet site on November 23, 2004
(See http://cms.hhs.gov/mcd/viewdecisionmemo.asp?id=138), CMS is adding ICD-9-CM code 733.02, Idiopathic osteoporosis, to the list of “ICD-9-CM Codes Covered by Medicare” for the thyroid testing NCD.

In accordance with the coding analysis published on the coverage Internet site on March 14, 2005
(See http://cms.hhs.gov/mcd/viewdecisionmemo.asp?id=146), CMS is adding diagnosis code 156.0, Malignant neoplasm of the gallbladder, and code 156.2, Malignant neoplasm of the Ampulla of Vater, to the list of “ICD-9-CM Codes Covered by Medicare” for the tumor antigen by Immunoassay CA 19-9 NCD.

In accordance with the coding analysis published on the coverage Internet site on March 14, 2005
(See http://cms.hhs.gov/mcd/viewdecisionmemo.asp?id=147), CMS is deleting diagnosis code 784.69, Other symbolic dysfunction, from the list of “ICD-9-CM Codes Covered by Medicare” for the hepatitis panel NCD.

In accordance with the coding analysis published on the coverage Internet site on March 17, 2005
(See http://cms.hhs.gov/mcd/viewdecisionmemo.asp?id=149), CMS is adding diagnosis code 789.39, Abdominal or pelvic swelling, mass or lump of other specified site, to the list of “ICD-9-CM Codes Covered by Medicare” for the tumor antigen by Immunoassay CA 125 NCD.

In accordance with the coding analysis published on the coverage Internet site on March 17, 2005
(See http://cms.hhs.gov/mcd/viewdecisionmemo.asp?id=150), CMS is adding diagnosis codes V77.1, Special screening for diabetes mellitus, V81.0, Special screening for ischemic heart disease, V81.1, Special screening for hypertension, and V81.2, Special screening for other an unspecified cardiovascular conditions, to the list of “ICD-9-CM Codes That Do Not Support Medical Necessity” for the blood counts NCD.

Implementation Date
The implementation date for these changes is July 5, 2005.

Additional Information
For complete details, please see the official instruction issued to your carrier/FI regarding these changes at: http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

From that Web page, look for CR 3806 in the CR NUM column on the right, and then click on the file for that CR.

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

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Modified Edits for Matching Claims Data to Beneficiary Records

Note: This article was revised on April 22, 2005, to show that claims that fail the match