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July 2005 Part B Medicare Bulletin

Revised July 7, 2005

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

Note: This article was revised on May 12, 2005, to correct the Web address for the Medicare Claims Processing Manual.

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

Provider Action Needed
CR 3806 announces changes 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/104_claims/clm104index.asp).

CR 3806 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:

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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3rd Update to the 2004 Medicare

Physician Fee Schedule Database

IMPORTANT NOTE: This instruction (MM 3415) was based on Change Request (CR) 3415 which has been fully replaced by CR 3505 (Transmittal 306, dated October 1, 2004, Subject: Full Replacement of CR 3415, 3rd Update to the 2004 Medicare Physician Fee Schedule Database. CR 3415 is rescinded).

See CR 3505 (Transmittal 306) at: http://www.cms.hhs.gov/manuals/pm_trans/R306CP.pdf

Also, see the Medlearn Matters article related to CR 3505 (Transmittal 306) at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3505.pdf

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July Quarterly Update for 2005 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule

Note: This article was revised on May 11, 2005, to provide the correct code descriptors for K0731 and K0732.

Provider Types Affected
Physicians, suppliers, and providers billing Medicare carriers, including Durable Medical Equipment
Regional Carriers (DMERCs) and/or Fiscal Intermediaries (FIs)

Provider Action Needed
This article is based on CR 3779 and provides specific information regarding the July quarterly update of the 2005 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) fee schedule.

Background
The DMEPOS fee schedules are updated on a quarterly basis in order to implement fee schedule amounts for new codes and to revise any fee schedule amounts for existing codes that were calculated in error.

Payment on a fee schedule basis is required for Durable Medical Equipment (DME), prosthetic devices, orthotics, prosthetics, and surgical dressings by the Social Security Act (Section 1834 (a), (h), and (i), and payment of a fee schedule basis is required for parenteral and enteral nutrition (PEN) by regulations contained in the Code of Federal Regulations (42 CFR 414.102).

CR 3779 provides specific details regarding the July quarterly update for the 2005 DMEPOS fee schedule, which are as follows:

Batteries Used with Cochlear Implant Devices
Code L8620 with the description of “Lithium Ion Battery for Use with the Cochlear Implant Device” was added to the HCPCS effective January 1, 2005. When the fee schedule amounts were calculated and implemented for this code on January 1, 2005, pricing information for the different types of batteries used with cochlear implant devices was not included.

The fee schedule amounts for L8620 are being revised as part of the quarterly update to include pricing information for the different types of lithium ion batteries used with cochlear implant devices. CMS is revising the fee schedule for the code using the standard gap-filling process. Local carriers, therefore, do not need to gap fill fees for this code.

Note: Previously paid claims for L8620 with dates of service from January 1, 2005 thru June 30, 2005 will be adjusted if resubmitted by suppliers as adjustments on or after July 1, 2005.

Code L8620 is being made invalid for Medicare claims with the dates of service on or after July 1, 2005.
The following codes are being added to the HCPCS effective for dates of service on or after July 1, 2005:

These codes are to be used to bill for replacement batteries previously coded under L8620 that are
furnished on or after July 1, 2005. Also, please note that codes L8110 and L8120 do not meet the Medicare definition of prosthetic devices.

Controlled Dose Inhalation Drug Delivery System
The following code is also added to the HCPCS on July 1, 2005 and is effective for claims with service dates on or after April 1, 2005: K0730-Controlled Dose Inhalation Drug Delivery System.

Note: The allowed rental payment amount for this device is based on your Medicare contractor’s individual consideration of each claim until fee schedule amounts can be established for this new code.

Code K0670 was added to the HCPCS effective on April 1, 2005, but the fee schedule amount for K0670 was based on incorrect information and the amount is revised with this change. Your DMERC or FI will adjust previously processed claims for code K0670 with dates of service on or after April 1, 2005, but only if you resubmit the claim for adjustment.

Parenteral and Enteral Nutrition (PEN) Equipment and Supplies
There are no changes to the PEN fee schedule file for July 2005.

Implementation
The implementation date for this instruction is July 5, 2005.

Additional Information
The quarterly updates process for the DMEPOS fee schedule is located in the Medicare Claims Processing Manual, Pub. 100-04, Chapter 23 (Fee Schedule Administration and Coding Requirements), Section 60 (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule), which can be reviewed at the following CMS Web site: http://www.cms.hhs.gov/manuals/104_claims/clm104c23.pdf

The official instruction issued to your carrier/DMERC/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 3779 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 carrier/DMERC/intermediary. To find their toll free phone numbers go to: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

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Correction of 2005 Payment Fees for Clinical Laboratory Travel – Codes P9603 and P9604

Provider Types Affected
Clinical laboratories and providers billing Medicare carriers or Fiscal Intermediaries for travel to perform a specimen collection

Provider Action Needed

STOP – Impact to You
This instruction relates corrections to the 2005 payment fees provided in CR 3526 for P9603 and P9604, which relate to transportation to a nursing home or homebound patient to perform a specimen collection.

CAUTION – What You Need to Know
Article MM 3526 and related CR 3526 incorrectly stated the standard mileage rate for transportation to a nursing home or homebound patient to perform a specimen collection as $.385 per mile. Effective for dates of service January 1, 2005 through December 31, 2005, the correct standard mileage rate for transportation is $.405 per mile. Effective for dates of service January 1, 2005 through December 31, 2005, the personnel payment is $.45 per mile. Accordingly, the corrected 2005 payment fees for code P9603 is $.855 and for code P9604 is $8.55.

GO – What You Need to Do
To ensure accurate claims processing, please review the information included in this instruction and stay current with updates for clinical laboratory fee schedule and laboratory services.

Additional Information
Please note that Medicare carriers and intermediaries will not automatically adjust any claims paid prior to the implementation of this correction. However, they will make corrections if the provider brings such claims to their attention.

For complete details, please see the official instruction issued to your carrier/intermediary 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 3785 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/intermediary on their toll free number, which is available at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf


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CMS Announces the National Provider Identifier (NPI) Enumerator Contractor and Information on Obtaining NPIs

Provider Types Affected
All health care providers - Medicare and non-Medicare

Provider Action Needed
Learn about the NPI and how and when to apply for one.

Background
The Centers for Medicare & Medicaid Services (CMS) is pleased to announce the availability of a new health care identifier for use in the HIPAA standard transactions.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated that the Secretary of Health and Human Services adopt a standard unique health identifier for health care providers. On January 23, 2004, the Secretary published a Final Rule that adopted the National Provider Identifier (NPI) as this identifier.

The NPI must be used by covered entities under HIPAA (generally, health plans, health care
clearinghouses, and health care providers that conduct standard transactions). The NPI will identify health care providers in the electronic transactions for which the Secretary has adopted standards (the standard transactions) after the compliance dates. These transactions include claims, eligibility inquiries and responses, claim status inquiries and responses, referrals, and remittance advices.

The NPI will replace health care provider identifiers that are in use today in standard transactions.
Implementation of the NPI will eliminate the need for health care providers to use different identification numbers to identify themselves when conducting HIPAA standard transactions with multiple health plans.

All health plans (including Medicare, Medicaid, and private health plans) and all health care clearinghouses must accept and use NPIs in standard transactions by May 23, 2007 (small health plans have until May 23, 2008). After those compliance dates, health care providers will use only their NPIs to identify themselves in standard transactions, where the NPI is required.

Important Note: While you are urged to apply for an NPI beginning May 23, 2005, the Medicare program is not accepting the NPI in standard transactions yet. Explicit instructions on time frames and implementation of the NPI for Medicare billing will be issued later in 2006.

NPI Enumerator Contract Awarded
Recently, the CMS announced the selection of Fox Systems, Inc. as the contractor, to be called the Enumerator, to perform the support operations for the NPI project. Fox Systems, Inc. will process NPI applications from health care providers and operate a help desk to assist health care providers in obtaining their NPIs.

Who may apply for the NPI?
All health care providers including individuals, such as physicians, dentists, and pharmacists, and organizations, such as hospitals, nursing homes, pharmacies, and group practices are eligible to apply for and receive an NPI. Note: All health care providers who transmit health information electronically in connection with any of the HIPAA standard transactions are required by the NPI Final Rule to obtain NPIs. This is true even if they use business associates such as billing agencies to prepare the transactions.

The NPI Application Process
Health care providers may begin applying for an NPI on May 23, 2005. Once the process begins, it will be important to apply for your NPI before the compliance date of May 2007 because health plans could require you to use your NPI before that date.

You will be able to apply for your NPI in one of three ways:

  1. You may apply through an easy-to-use Web-based application process, beginning May 23, 2005.
    The Web address will be https://nppes.cms.hhs.gov, but please note — the Web site is not available until May 23, 2005.
  2. Beginning July 1, 2005, you may complete a paper application and send it to the Enumerator. A copy of the application, including the Enumerator’s mailing address (where you will send it) will be available on https://nppes.cms.hhs.gov or you can call the Enumerator to receive a copy. The phone number is 1.800.465.3203 or TTY 1.800.692.2326. But remember, paper applications may not be submitted until July 1, 2005.
  3. With your permission, an organization may submit your application in an electronic file. This could mean that a professional association, or perhaps a health care provider who is your employer, could submit an electronic file containing your information and the information of other health care providers. This process will be available in the fall of 2005.

You may apply for an NPI using only one of these methods. When gathering information for your application, be sure that all of your information, such as your social security number and the Federal Employer Identification Number, are correct. Once you receive your NPI, safeguard its use.

If all information is complete and accurate, the Web-based process could result in you being issued a number within minutes. If there are problems with the information received, it could take longer. The paper application processing time is more difficult to estimate, depending on the information supplied in the application, the workload, and other factors.

The transition from existing health care provider identifiers to NPIs will occur over the next couple of years.

Each health plan with which you conduct business, including Medicare, will notify you when it will be ready to accept NPIs in standard transactions like claims. You can expect to hear about the importance of applying for an NPI from a variety of sources. Be clear that you only have to apply for, and acquire, one NPI. Your unique NPI will be used for all standard transactions, Medicare and non-Medicare.

Please be particularly aware that applying for an NPI does not replace any enrollment or credentialing processes with any health plans, including Medicare.

Additional Information
For additional information on NPIs:

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Instructions for Provider Notification Regarding National Provider Identifier NPI Letter from CMS Administrator

Just released!! The CMS Administrator has announced a May 23, 2005 start of enumeration for the National Provider Identifier (NPI). The NPI is the standard unique health identifier for health care providers that was adopted by the Secretary of Health and Human Services under the Health Insurance Portability and Accountability Act of 1996. The Administrator’s announcement letter informs health care providers about the NPI, describes three ways to obtain an NPI, and gives them guidance as to what they should do once they have obtained their NPI. The letter, which also provides contacts and resources should health care providers have questions about the NPI, can be viewed at http://www.cms.hhs.gov/HIPAAGenInfo/npi_provider.asp on the CMS Web site.

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Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA)

Provider Types Affected
Physicians, providers, and suppliers billing Medicare carriers, including Durable Medical Equipment Regional Carriers (DMERCs) and Fiscal Intermediaries (FIs) for OSA-related claims

Provider Action Needed
Providers need to be aware that on April 4, 2005, the Centers for Medicare & Medicaid Services (CMS) declared that the national coverage policy for CPAP therapy for OSA will remain unchanged. Unattended home sleep testing for the diagnosis of OSA is not considered reasonable and necessary.

Polysomnography must be performed in a facility-based sleep study laboratory, not in the home or a mobile facility.

Background
CR3843 is updating and confirming the National Coverage Determination (NCD) policy section 240.4 of the Medicare NCD Manual (Pub. 100-03), which states that polysomnography must be performed in a facility based sleep study laboratory, not in the home or a mobile facility.

The use of CPAP is covered under Medicare when used in adult patients with moderate or severe OSA for whom surgery is a likely alternative to CPAP. The use of CPAP devices must be ordered and prescribed by the licensed treating physician to be used in adult patients with moderate to severe OSA if either of the following criteria using the Apnea-Hyopopnea Index (AHI) is met:

The AHI is equal to the average number of episodes of apnea and hypopnea per hour and must be based on a minimum of 2 hours of sleep recorded by polysomnography using actual recorded hours of sleep (i.e., the AHI may not be extrapolated or projected). Apnea is defined as a cessation of airflow for at least 10 seconds.

Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30 percent reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4 percent oxygen desaturation.

Initial claims must be supported by medical documentation (separate documentation where electronic billing is used), such as a prescription written by the patient’s attending physician that specifies:

The claim must also certify that the documentation supporting a diagnosis of OSA (described above) is available.

Implementation
The implementation date of CR3843 is June 6, 2005.

Additional Information
The HCPCS codes that can be used for billing covered Medicare CPAP devices and various accessories are E0601, A7030-A7039, A7044-A7046, and E0561-E0562.

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

From that Web page, look for CR3843 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 carrier/DMERC/intermediary. To find their toll free phone numbers go to: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

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CMS National Provider Identifier NPI Job Aid

CMS is pleased to announce the addition of a new job aid to the Job Aids Web page. Job aids are information tools to assist Customer Service Representatives (CSRs) to answer inquiries. The site displays a variety of topics and its content will be especially useful to call center management including supervisors, trainers, quality assurance staff, and CSRs who handle matters related to Medicare providers. In addition, each job aid contains a reference to the relevant Change Request (CR), if applicable. The Job Aids Web page can be viewed at: http://www.cms.hhs.gov/contractors/customerserv/jobaids/default.asp

Instructions are included at the top of the Web page to assist with navigation of this site. Based on your feedback, we have added an indicator for the listserv messages that are new, and now a notation of the date they were posted. For your convenience, these indicators will remain until we add more listserv messages.

The new message announces that the Centers for Medicare and Medicaid Services (CMS) Administrator has announced a May 23, 2005 start of enumeration for the National Provider Identifier (NPI). The NPI is the standard unique health identifier for health care providers that was adopted by the Secretary of Health and Human Services under the Health Insurance Portability and Accountability Act of 1996. The Administrator’s announcement letter informs health care providers about the NPI, describes three ways to obtain an NPI, and gives them guidance as to what they should do once they have obtained their NPI. The letter, which also provides contacts and resources should health care providers have questions about the NPI, can be viewed at http://www.cms.hhs.gov/HIPAAGenInfo/npi_provider.asp on the CMS Web site.

Additionally, a new Medlearn Matters article regarding the NPI is also available at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0528.pdf on the Web.

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Quarterly Provider Update

The Quarterly Provider Update is a comprehensive resource published by the Centers for Medicare & Medicaid Services (CMS) on the first business day of each quarter. It is a listing of all non-regulatory changes to Medicare including Program Memoranda, manual changes, and any other instructions that could affect providers. Regulations and instructions published in the previous quarter are also included in the Update. The purpose of the Quarterly Provider Update is to:

To receive notification when regulations and program instructions are added throughout the quarter, sign up for the Quarterly Provider Update listserv (electronic mailing list) at:
http://list.nih.gov/cgi-in/wa?SUBED1=cms-qpu&A=1.

The Quarterly Provider Update can be accessed at http://www.cms.gov/providerupdate. We encourage you to bookmark this Web site and visit it often for this valuable information.

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Payments to Ambulatory Surgery Centers (ASCs) for New CPT Code 66711

Provider Types Affected
Physicians and providers billing carriers for services involving ciliary body destruction

Provider Action Needed

STOP – Impact to You
The Centers for Medicare & Medicaid Services (CMS) inadvertently failed to include the new CPT code 66711 (ciliary body destruction, cyclophotocoagulation, endoscopic) in the ASC list on January 1, 2005. CPT 66711 should have been added to the list effective January 1, 2005.

CAUTION – What You Need to Know
This article and related CR 3817 provide information on the appropriate CPT code for endoscopic treatment involving ciliary body destruction.

GO – What You Need to Do
Awareness of and implementation of these revised coding guidelines will help Medicare make prompt and correct payments for this procedure.

Background
On an annual basis the American Medical Association Current Procedural Terminology (CPT) Editorial Panel revises and updates the CPT codes. The Centers for Medicare & Medicaid Services (CMS) found that CPT code 66711, Ciliary body destruction, cyclo-photocoagulation, endoscopic, inadvertently was not added to the Ambulatory Surgery Center (ASC) list. CMS will add CPT code 66711, Ciliary body destruction, cyclophotocoagulation, endoscopic, to the ASC list of covered procedures in the July 2005 update, with an effective date of January 1, 2005.

Prior to January 1, 2005, the procedure was included in the 2004 CPT code 66710, Ciliary body destruction, cyclophotocoagulation that was included in the ASC list. The existing code a 66710 was revised to read Ciliary body destruction; cyclophotocoagulation, transscleral and 66711 was created, effective January 1, 2005.

Note: You may bill procedures performed between January 1, 2005, and July 1, 2005, retroactively
using the new code 6671, and payment may be made at the group 2 level.

To see the official instruction regarding this update to the 2005 ASC list, go to:
http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

From that Web page, look for CR 3817 in the CR NUM column on the right, and click on the file for that CR.

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

 

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Revision to Health Professional Shortage Area (HPSA) and Physician Scarcity Area (PSA) Payment Rules

Provider Types Affected
Physicians billing carriers for services provided in designated HPSAs or in PSAs

Provider Action Needed

STOP – Impact to You
This article includes information from Change Request (CR) 3822, which instructs Medicare carriers to allow payment of the bonus on just the professional component of services that have a Professional Component (PC)/Technical Component (TC) indicator of 1 (even when a global service code is submitted).

CAUTION – What You Need to Know
Effective for claims received on or after October 1, 2005, when carriers will accept claims for a service with a PC/TC of 1 and the service is provided in a HPSA or PSA and consider those claims for the bonus payment. For claims received prior to October 1, 2005, please refer to CR 3827 and the Medlearn Matters article MM3827, which is located at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3827.pdf

GO – What You Need to Do
See the Background section of this article to find out further details regarding this change.

Background
Currently, physicians may not receive the HPSA or Physician Scarcity Area PSA bonus payments on globally billed services.

CR 3822 revises this policy and allows the payment of the bonus on just the professional component of services that have a Professional Component (PC)/Technical Component (TC) indicator of 1 even when a global service code is submitted. Effective for claims received on or after October 1, 2005, when carriers receive a claim for a service with a PC/TC of 1 and the service is provided in a HPSA or PSA bonus payment area, they shall accept the claim and pay the bonus on the professional component of the service.
CR3822 instructs your carrier(s) to:

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

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

From that Web page, look for CR 3822 in the CR NUM column on the right, and click on the file for that CR.

On that same Web page, you may also want to look for CR3827 and review the related material in that CR on claims received prior to October 1, 2005. (CR 3822 relates to claims received on or after October 1, 2005.)

You may also want to review the Medlearn Matters article MM3827, which is at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3827.pdf on the CMS Web site.

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

From that Web page, look for CR 3822 in the CR NUM column on the right, and click on the file for that CR.

On that same Web page, you may also want to look for CR3827 and review the related material in that CR on claims received prior to October 1, 2005. (CR 3822 relates to claims received on or after October 1, 2005.)

You may also want to review the Medlearn Matters article MM3827, which is at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3827.pdf on the CMS Web site.

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

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Updated Requirements for Autologous Stem Cell Transplantation (AuSCT) for Amyloidosis

Provider Types Affected
Physicians and providers billing Medicare carriers and intermediaries for AuSCT

Provider Action Needed
This article is based on information contained in Change Request (CR) 3797, which informs physicians and providers that, effective for services on or after March 15, 2005, High Dose Mephalan (HDM) and Autologous Stem Cell Transplantation (AuSCT) is reasonable and necessary for all Medicare beneficiaries with primary Amyloid Light chain (AL) amyloidosis who meet the following criteria:

  1. Amyloid deposition in two or fewer organs; and
  2. Cardiac left ventricular ejection fraction (EF) greater than 45 percent.

Primary AL amyloidosis is covered for all beneficiaries who meet the above criteria regardless of age.

All forms of non-primary (AL) amyloidosis remain non-covered.

Background
Stem cell transplantation is a process by which stem cells are harvested from either a patient’s or a donor’s bone marrow (or peripheral blood) for intravenous infusion. Autologous Stem Cell Transplantation (AuSCT) is a technique for restoring a patient’s stem cells using the patient’s own previously stored cells (ICD-9-CM procedure code 41.01, 41.04, 41.07, and 41.09 and CPT-4 code 38241).

AuSCT must be used to effect hematopoietic reconstitution following severely myelotoxic doses of
chemotherapy (High Dose Chemotherapy (HDCT)) and/or radiotherapy used to treat various malignancies.

Allogeneic stem cell transplant may also be used to restore function in recipients who have an inherited or acquired deficiency or defect.

Coverage Policy Changes
For Medicare beneficiaries age 64 years or older who have primary Amyloid Light chain (AL) amyloidosis (ICD-9-CM 277.3), the Centers for Medicare & Medicaid Services (CMS) previously had a national non –coverage policy for High-Dose Melphalan (HDM), together with Autologous Stem Cell Transplantation (AuSCT). This non-coverage policy was based on the lack of sufficient data to establish definitive conclusions regarding the efficacy of AuSCT, and for those beneficiaries age 63 years or younger, coverage of HDM/AuSCT was left to the local Medicare carrier’s/intermediary’s discretion.

However, CR3797 informs physicians, providers, and suppliers that (effective for services on or after March 15, 2005) when recognized clinical risk factors are employed to select patients for transplantation, HDM together with AuSCT is reasonable and necessary for Medicare beneficiaries of any age group with primary AL amyloidosis who meet the following criteria:

Primary AL amyloidosis is covered for all beneficiaries who meet the above criteria regardless of age, and all forms of non-primary (AL) amyloidosis remain noncovered.

To clarify existing coverage, AuSCT must be used to effect hematopoietic reconstitution following severely myelotoxic doses of chemotherapy (high dose chemotherapy (HDCT)) and/or radiotherapy used to treat various malignancies.

Please refer to the National Coverage Determinations Manual (Pub. 100-03), Section 110.8.1 for complete coverage guidelines; and the Medicare Claims Processing Manual (Pub. 100-04), Chapter 3, Section 90.3.2 (FI), plus Chapter 32, Section 90-90.6 (Carrier) for complete claims processing guidance.

Updates to Medicare Claims Processing Manual
CR3797 updates the Medicare Claims Processing Manual (Pub.100-04), Chapter 3, Section 90.3.2 (FI claims) and Chapter 32, Section 90.3 (carrier claims) with the new coverage guidelines for primary amyloid light chain (AL) amyloidosis for high-dose melphalan together with autologous stem cell transplantation (HDM/AuSCT).

The criteria for multiple myeloma (Durie-Salmon) within the Fiscal Intermediary (FI) section is also revised to coincide with the Nation Coverage Determination Manual (NCD) (Pub. 100-03), Section 110.8.1 and the non-coverage guidelines have been updated to remove the age requirement language to in Chapter 32, Section 90.3.2.

In addition, CMS removed reference to revenue code 0891 in the Medicare Claims Processing Manual (Pub. 100-04, Chapter 3, Section 90.3.3), since that revenue code no longer exists. CMS also removed the reference to physicians that does not belong in the hospital chapter. All other information within the claims processing manual remains the same.

Implementation
The implementation date for this instruction is May 16, 2005.

Additional Information
For complete details (including the manual updates listed in the previous section), please see the official instruction issued to your carrier/intermediary regarding this change. That instruction may be viewed by going to: http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp.

From that Web page, look for CR3797 in the CR NUM column on the right, and click on the files for that CR.
Please note that there will be two files representing CR3797 on this Web page. One file will contain the National Coverage Determination manual changes and the other will contain the changes to the Medicare Claims Processing Manual.

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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CMS’ Implementation of Section 1011 of the Medicare Modernization Act - Federal Funding of Emergency Health Services Furnished to Undocumented Aliens

Provider Types Affected
Hospitals, physicians and ambulance providers

Provider Action Needed

STOP – Impact to You
This special edition article summarizes the Centers for Medicare & Medicaid Services (CMS) policy regarding section 1011 of the Medicare Prescription Drug, Improvement and Modernization Act (MMA) regarding the Federal Funding of Emergency Health Services furnished to undocumented aliens.

CAUTION – What You Need to Know
On May 9, 2005, CMS announced its policy regarding section 1011, Federal Funding of Emergency Health Services Furnished to Undocumented Aliens, of the MMA. This new program will provide $1 billion over four years to help hospitals, certain physicians, and ambulance providers recoup the costs of providing needed emergency medical care to undocumented aliens and certain other aliens. Since this provision of the MMA is not part of the Medicare program, CMS will designate a single contractor for the purposes of enrolling providers, receiving claims, calculating provider payment amounts, and effectuating payments. As soon as CMS awards a contract to perform this workload, you will be notified. CMS’ policy notice and related documents can be found be viewed at: http://www.cms.hhs.gov/providers/section1011 on the CMS Web site.

GO – What You Need to Do
See the Background and Additional Information sections of this special edition article to find out further details regarding the CMS policy for Section 1011 of the MMA.

Background
Section 1011 provides $250 million per year for the fiscal years (FY) 2005 – 2008 for payments to eligible providers for emergency health services provided to undocumented and other specified aliens. Two-thirds of the funds will be divided among all 50 states and the District of Columbia based on their relative percentages of undocumented aliens. One-third will be divided among the six states with the largest number of undocumented alien apprehensions.

From the respective state allotments, payments will be made directly to hospitals, certain physicians, and ambulance providers for some or all of the costs of providing emergency health care required under section 1867 and related hospital inpatient, outpatient, and ambulance services to eligible individuals. Eligible providers may include an Indian Health Service facility, whether operated by the Indian Health Service or by an Indian tribe or tribal organization. A Medicare critical access hospital (CAH) is also a hospital under the statutory definition. Payments under section 1011 may only be made to the extent that care was not otherwise reimbursed (through insurance or otherwise) for such services during that fiscal year.

Payments may be made only for services furnished to certain individuals described in the statute as:

  1. Undocumented aliens;
  2. Aliens who have been paroled into the United States at a United States port of entry for the purpose of receiving eligible services; and
  3. Mexican citizens permitted to enter the United States for not more than 72 hours under the authority of a biometric machine-readable border crossing identification card (also referred to as a “laser visa”) issued in accordance with the requirements of regulations prescribed under a specific section of the Immigration and Nationality Act.

Additional Information
Additional information can be found be viewed at: http://www.cms.hhs.gov/providers/section1011 on the CMS Web site.

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List of Medicare Telehealth Services

Note: This article was revised on May 17, 2005, to correct the code in the example on page 3 to read G0318 GT, instead of G3018 GT.

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 & Medicare 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 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 service 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. G0318 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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Anti-Cancer Chemotherapy for Colorectal Cancer

Note: This article was revised on May 23, 2005, to reflect the revision of the original CR3742. The CR was revised to show that revenue code 0636 is used when billing Medicare fiscal intermediaries for anti-cancer drugs furnished during a clinical trial on outpatient claims, but revenue code 0250 should be used when billing for anti-cancer drugs furnished during a clinical trial on inpatient claims.

Provider Types Affected
Providers and suppliers billing Medicare carriers, including Durable Medical Equipment Regional Carriers (DMERCs), and fiscal intermediaries (FIs) for anti-cancer chemotherapy.

Provider Action Needed
This article is based on information contained in Change Request (CR) 3742, which states that the Centers for Medicare & Medicaid Services (CMS) will cover the off-label use of Oxaliplatin (Eloxatin™), Irinotecan (Camptosar®), Cetuximab (Erbitux™), or Bevacizumab (Avastin™) in clinical trials identified by CMS and sponsored by the National Cancer Institute (NCI).

This national coverage decision does not:

Medicare carriers, DMERCs, and intermediaries will continue to make local coverage determinations for medically accepted uses of off-label indications based on guidance provided by the Secretary of the Department of Health and Human Services (DHHS).

Background
On January 28, 2005, CMS announced a National Coverage Determination (NCD) covering the off-label use of certain colorectal anti-cancer drugs in identified clinical trials of colorectal cancer and other cancer types. These clinical trials study the use of one or more off-label uses of these four drugs in colorectal and other cancer types.

Note: The clinical trials for which these drugs and other items and services are covered appear in
Appendix A in the NCD at: http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=90 on the CMS Web site.

Anti-cancer chemotherapeutic agents are eligible for coverage in a clinical trial setting when the following occurs:

Effective for services provided on or after January 28, 2005, CMS covers the following anti-cancer
chemotherapeutic agents, which have been approved by the FDA for the treatment of colorectal cancer, when used in clinical trials identified by CMS and sponsored by the National Cancer Institute:

Under the concept of linking Medicare coverage determinations to clinical studies, the investigational items and services provided in qualified scientific studies are covered (including clinical trials, practical trials, and systematic data collection systems) when:

Note: The list of identified clinical trials for which the routine costs of the items and services are covered appears in the Clinical Trials section, at: http://www.cms.hhs.gov/coverage on the CMS Web site.

Non-routine clinical costs include items and services that are provided in either the investigational or the control arms of a clinical trial specified by CMS for coverage. The following non-routine items and services are not covered and include items and services:

This NCD, issued on January 28, 2005, does not withdraw Medicare coverage for items and services that may be covered according to the existing national coverage policy for Routine Costs in a Clinical Trial (See National Coverage Determination Manual, Section 310.1 at: http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp on the CMS Web site.

Note: The existing requirements for coverage of oxaliplatin, irinotecan, cetuximab, bevacizumab, or other anticancer chemotherapeutic agents for FDA-approved indications or for indications listed in an approved compendium are not modified.

Medicare contractors will continue to make reasonable and necessary coverage determinations under the Social Security Act (Section 1861(t)(2)(B)(ii)(II)) based on guidance provided by CMS for medically accepted uses of off-label indications of Oxaliplatin, Irinotecan, Cetuximab, Bevacizumab, or other anticancer chemotherapeutic agents provided outside of the identified clinical trials appearing on the CMS Web site noted previously.

Some important points to remember when billing Medicare for these anti-cancer drugs are as follows:

Note: While this NCD is effective as of January 28, 2005, Medicare systems will be unable to process claims containing the QR modifier received before April 1, 2005. For that reason, do not send in claims for drugs or other nonroutine services covered under this NCD until April 1, 2005. Do not hold claims for nonroutine services containing the QV modifier associated with this NCD.

Additional Information
For complete details, please see the official instruction issued to your carrier/DMERC/intermediary regarding this change. That instruction includes the NCD section 110.17 and it may be viewed by going to:
http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

From that Web page, look for CR 3742 in the CR NUM column on the right, and click on the file for that CR.

You should see two versions of CR 3742 on this Web site. The version of CR 3742 with a transmittal
number of R30NCD will contain the NCD information and the version with a transmittal number of R512CP will contain the Medicare claims processing instructions.

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

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Quarterly Update to Correct Coding Initiative (CCI) Edits, Version 11.2, Effective July 1, 2005

Provider Types Affected
Physicians billing Medicare carriers

Provider Action Needed
This is a reminder for physicians to take note of the quarterly updates to the coding initiatives. The next round of CCI edits will be effective on July 1, 2005. Physicians may view the current CCI edits and the current Mutually Exclusive Code (MEC) edits on the Centers for Medicare & Medicaid (CMS) Web site at: http://www.cms.hhs.gov/physicians/cciedits

The Web site will be updated with the Version 11.2 edits as soon as they are effective.

Background
The National Correct Coding Initiative developed by CMS helps promote national correct coding methodologies and controls improper coding. The coding policies developed are based on coding conventions defined in the American Medical Association’s Current Procedural Terminology (CPT) manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practice, and review of current coding practice.


The latest package of CCI edits, Version 11.2, is effective on July 1, 2005. This version will include all previous versions and updates from January 1, 1996 to the present and will be organized in two tables: Column 1/Column 2 Correct Coding Edits and MEC Edits.

Additional Information
The CCI and MEC files will be maintained in the Medicare Claims Processing Manual (Publication 100-04), Chapter 23, Section, 20.9, which can be found at: http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp

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New Stratus Error Message

Effective July 05, 2005, you may receive a new error message when you login to the Stratus Network.

The message is:
USER ALREADY LOGGED ON; MULTIPLE LOGINS NOT ALLOWED

This new message will appear if you are logging into Stratus and someone is already logged in using the same Stratus login number (PB number). This change limits the amount of logins to one session per Stratus login number.

If you have multiple units within your organization which must use the same Stratus login (such as Billing and Accounts Receivable or multiple locations), they will need to coordinate to ensure that they are not trying to login at the same time, as this will no longer be possible. Organizations which have automated processes to dial into Stratus to send and pull down files (such as clearinghouses and billing services) will also need to ensure that those automated processes do not attempt to generate multiple concurrent logins, as any process other than the first will fail. Attention will also need to be given to scripts to recognize this new error message as well.
If you have any questions regarding this change, please contact the appropriate EDI Helpdesk for your state:

North Carolina 866.352.1608
Tennessee/Idaho 866.520.4022

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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

Note: This article was revised on May 2, 2005, to show the 2004 national gross paid claims error rate in the “STOP” section and to correct the phone number provided in the “Additional Information” section.

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

Provider Action Needed

STOP – Impact to You
The 2004 national gross paid claims error rate was 10.1 percent. 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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Access Process for HIPAA 270/271 (Extranet Only)

  1. SUMMARY OF CHANGES: The Centers for Medicare & Medicaid Services (CMS) is making changes to its Information Technology infrastructure to address standards for Medicare beneficiary eligibility inquiries. This approach will create the necessary database and infrastructure to provide a centralized HIPAA compliant 270/271 health care eligibility inquiry and response in real-time.
    NEW/REVISED MATERIAL - EFFECTIVE DATE: May 20, 2005

IMPLEMENTATION DATE: August 22, 2005

10.2 - Eligibility Extranet Workflow
(Rev. 565, Issued: 05-20-05, Effective: 05-20-05, Implementation: 08-22-05)
The Centers for Medicare & Medicaid Services (CMS) is making changes to its Information Technology infrastructure to address standards for Medicare beneficiary eligibility inquiries. This approach will create the necessary database and infrastructure to provide a centralized HIPAA compliant 270/271 health care eligibility inquiry and response in real-time. The CMS is using a phased approach for providing this eligibility transaction on a real-time basis:

  1. Extranet: In June of 2005, Clearinghouses, certain providers and trading partners (as described below) will be permitted to submit 270s via the CMS AT&T communication Extranet (the Medicare Data Communication Network or MDCN). This Extranet is a secure closed private network currently used to transmit data between Medicare Fee-for-Service (FFS) contractors and CMS.
  2. Internet: We expect to provide limited internet access to the 270/271 transaction later this year. Instructions on accessing eligibility data via this method will be provided prior to the time internet access becomes available.

All electronic 270 files will be processed at the CMS data center. The CMS data center will use a single consolidated national eligibility database to respond to the eligibility inquiries.

Access Process for Clearinghouses/Provider
To obtain access to the MDCN via the extranet, Clearinghouses and Providers must complete the 270/271 Access Form that can be found on the CMS Web site at WWW.CMS.HHS.GOV/IT. The 270/271 Access Form should be completed in full and submitted electronically. The electronic submitted form will be directed to both CMS staff and the CMS’ Medicare Eligibility Integration Contractor (MEIC).

CMS staff will ensure that all of the necessary information is provided on the form, as well as ensure the complete connectivity to the 270/271 application. The MEIC will be responsible for contacting the Clearinghouses, providers, and trading partners to authenticate the accessing entity’s identity. Once authentication has been completed, the MEIC will provide the Clearinghouses, Providers, and Trading Partners with a submitter ID that is required to be used on all 270/271 transactions. Testing will be coordinated by the MEIC. After successful testing, 270 production inquiries may be sent real-time.

Please note that in order to access the MDCN, an entity must on its own obtain the necessary telecommunication software from the AT&T reseller. The current AT&T resellers and contact numbers are listed below: IVANS: www.ivans.com1.800.548.2675
McKesson: www.infosolutions.mckesson.com 1.800.782.7426, option 5, key option 8

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Override of Automated Health Professional Shortage Area (HPSA) and/or Physician Scarcity (PSA) Bonus Payments for Globally Billed Services

Provider Types Affected
Physicians billing services to Medicare carriers

Provider Action Needed

STOP – Impact to You
This article is based on information from Change Request (CR) 3827, which relates to physicians who do not want to receive the HPSA/PSA bonus payment. Currently, those physicians cannot get their claims paid without having to resubmit the services as separate components.

CAUTION – What You Need to Know
CR3827 directs Medicare carriers to bypass certain edits when notified by a physician that they do not want to receive the physician bonus payment.

GO – What You Need to Do
Please see the Background section of this article for further details regarding these changes.

Background
The Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA, Sections 413(a) and (b)) required the Centers for Medicare & Medicaid Services (CMS) to revise some of the policy for the current Health Profession Shortage Area (HPSA) bonus payment and to develop a new Physician Scarcity Area (PSA) bonus. Medicare automatically pays HPSA/PSA bonuses on a quarterly basis without the need for a modifier on claims for services provided in zip code areas that fully fall within a county designated as a HPSA or PSA. CMS policy did not address providers who wish not to receive the HPSA/PSA bonus payment.

As of 2005, CMS has a new HPSA/PSA automated payment file that lists zip codes that will receive the bonus payment. Currently, carriers are returning the services as unprocessable if:

Carriers are then notifying the physician that the professional and technical components must be rebilled separately if performed in a qualifying bonus area. Subsequently, some providers wish to forgo the HPSA/PSA incentive rather than have to bill the components separately.

As of June 13, 2005, effective for claims with dates of services on or after January 1, 2005, Medicare carriers will accept claims from physicians who are eligible to receive automated HPSA/PSA bonus payments but have billed services globally. If approved, the services will be paid, but no bonus payment will be made. These procedures will change for claims received on or after October 1, 2005. See the reference under “Additional Information”

In addition, Medicare carriers will re-open and re-process claims brought to their attention should
physicians indicate they wish to have the global services paid without the bonus payment. Physicians
choosing not to receive the HPSA and/or PSA bonus payment must notify their carrier.

Implementation
The implementation date for this instruction is June 13, 2005.

Additional Information
The Medicare Information for Health Professional Shortage Areas (HPSAs) and PSAs can be found at the following CMS Web site: http://www.cms.hhs.gov/providers/hpsa/
For complete details, please see the official instruction issued to your carrier regarding this change.

That instruction may be viewed by going to: http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

Once at that page, scroll down the CR NUM column on the right looking for CR3827 and click on the link for that file.

For information on claims received by Medicare on or after October 1, 2005, use this same link and view CR3822. You may also want to view the Medlearn Matters article for CR3822, which can be found at: http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3822.pdf

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

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MA27 Billing Reminder

MA27 denials identify unprocessable claims returned for “Missing/incomplete/invalid entitlement number or name shown on the claim”. These claims cannot be processed as submitted. They must be corrected by reporting the Medicare patient’s name and Health Insurance Claim Number as it appear on the red, white and blue Medicare identification card. Submit these claims as new claims. Do not resubmit Medicare claims that were returned as unprocessable as “corrected claims”. This will only increase processing time. “Unprocessable claims” are identified by the MA130 message (“Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is uprocessable. Please submit the correct information to the appropriate fiscal intermediary or carrier.)

Electronic Billers: Correct your claims and retransmit them electronically. Do not submit a paper claim.

Paper Billers: Correct your claims. Do not annotate them as corrected on refiled claims. Include them in the same batch as claims being submitted for the first time.

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New April 2005 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing File and Revisions to January 2005 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing File

Provider Types Affected
All Medicare providers billing Medicare carriers, including Durable Medical Equipment Regional Carriers (DMERCs) and Fiscal Intermediaries (FIs)

Provider Action Needed

STOP – Impact to You
CR 3846 revises payment allowance limits in the January 2005 and the April 2005 drug pricing files. For the codes listed below, the revised payment limits supersede the payment limits cited in any previously published document.

CAUTION – What You Need to Know
Effective 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 Average Sales Price (ASP).

GO – What You Need to Do
Make sure that your billing staffs are aware of these changes.

Background
The Medicare Modernization Act of 2003 (MMA), Section 303, revises the payment methodology for Part B covered drugs and biologicals that are not paid on a cost or prospective payment basis. Effective January 1, 2005, these drugs and biologicals are paid based on the new Average Sales Price (ASP) drug payment methodology.

The ASP file, used in the ASP methodology, is based on data that CMS receives quarterly from manufacturers. Each quarter, CMS will update your carrier and Fiscal Intermediary (FI) payment allowance limits with the ASP drug pricing files based on these manufacturers’ data.

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. However, you should be aware that there are exceptions to this general rule as summarized below:

Note: For infusion drugs (furnished through a covered item of durable medical equipment) that were not listed in the published compendia as of October 1, 2003 (i.e., new drugs), the payment allowance limits are 95 percent of the first published AWP.

Table 1 below displays the revised 1st Quarter 05 payment allowance limits for the indicated codes,
effective for services provided on or after January 1, 2005.

Table 1

HCPCS Short Description HCPCS Code Dosage 1Q05 Payment Limit 1Q05 Independent ESRD Limit
90371 Hep B ig, im 1 ML $115.878 $115.878
J2790

Rho d immune
globulin, inj

300 MCG $101.733 $101.733
J2792 Rho (D)
immune globulin		 100IU $13.101 $13.101
Q0187 NovoSeven Per 1.2 MG $1,211.050 $1,211.050
HCPCS Short Description HCPCS Code Dosage 2Q05 Payment ESRD 2Q05 Independent Limit 2Q05 Vaccine Limit 2Q05 Blood Limit
90747 Hep B vacc, ill
pat 4 does im		 40 MCG $133.915 $113.915 $113.915  
J0135 Adalimumab injection 20MG $294.632
$294.632 		   
J0287 Amphotericin b
lipid complex		 10MG $11.724 $11.724    
J0725 Chorionic
gonadotropin		 1000 UNITS $2.976 $2.976    
J2597 Inj desmopressin
acetate		 1 MCG $2.493 $2.493    
J7190 Factor viii 1 IU $0.641 $0.641    
J7192 Factor viii recombinant 1 IU $1.063 $1.063    
J7193 Factor IX
Non-recombinant		 1 IU $0.882 $0.882    
J7194 Factor ix complex 1 IU $0.650 $0.650    
J7195 Factor IX recominant 1 IU $0.982 $0.982    
J7197 Antithrombin iii
injection		 1 IU $1.542 $1.543    
J7198 Anti-inhibitor 1 IU $1.241 $1.241    
J7344 Nonmetabolic active 1 SQ CM
tissue 		$52.777 $52.777    
J9098 Cytarabine Liposome 10 MG $359.359 $359.359    
J9245 Inj melphalan hydrochl 50 MG $513.694 $513.694    
J9266 Pegasphargase
single dose vial		 1 EA $1,499.306 $1,499.306    
P9041 Albumin (human), 5% 50 ML $14.545 $14.545   $14.545
P9043 Plasma protein
fraction, 5%		 50 ML $14.545 $14.545   $14.545
P9046 Albumin (human), 25% 20 ML $14.545 $14.545   $14.545
P9048 Plasma protein fraction, 5% 250 ML $29.099 $29.099   $29.099
Q0187 NovoSeven Per 1.2 MG $1,228.438 $1,228.438    
Q2002 Elliottts b solution per ml 1 ML $3.350 $3.350    
Q2005 Corticorelin ovine triflutat 1 EA $349.067 $379.067    
Q2012 Pegademase bovine 25 IU $158.048 $158.048    
Q2018 Urofolitropin, 75 iu 75 IU $43.865 $43.865    
Q9941 IVIG lyophil 1G $38.735 $38.735    
Q9942 IVIG lyophil 10 MG $0.387 $0.387    
Q9943 IVIG non-lyophil 1G $56.221 $56.221    
Q9944 IVIG non-lyophil 10 MG $0.562 $0.562    
Q9954 Oral MR contrast 100 ML $8.844 $8.844    

Notice that J2910 is no longer included in the April 2005 pricing file.

You should note that the new April 2005 ASP drug pricing files will contain three decimal places in the currency fields. You can find more information on the April 2005 ASP data format in CR 3436, which instructs the carriers/DMERCs/FIs to accommodate 3 places after the decimal point, and to follow standard rounding procedure, round to 2 decimal places after multiplying the number in the “units” field of the line item by the payment allowance applicable to the HCPCS code.

You should also note that the absence or presence of a HCPCS code and its associated payment limit in the payment files do not indicate Medicare coverage of the drug or biological. Nor does inclusion of a payment limit within a specific column indicate Medicare coverage of the drug in that specific category. The carrier/DMERC/FI processing your claim will make these determinations.

To comply with these requirements, your carrier, DMERC, or FI will:

Additional Information
The new April 2005 and revisions to the January ASP Pricing Files