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August 2005 Part B Medicare Bulletin

Posted August 4, 2005

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Anti-Cancer Chemotherapy for Colorectal Cancer

Note: This article was revised on June 21, 2005, to reflect a revision to CR3742. The CR was revised to show that Medicare fiscal intermediaries (FIs) will implement the change on or before July 5, 2005, instead of April 18, 2005. The effective date of CR3742 and all other information remains the same, but providers should take note that their Medicare FI may not be ready to process claims in accordance with CR3742 until July 5, 2005.

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 ob this Web site. The version of CR 3742 with a transmittal number of R38NCD will contain the NCD information and the version with a transmittal number of R588CP 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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Coverage and Billing for Ultrasonic Stimulators for Nonunion Fracture Healing

Provider Types Affected
Physicians, providers, and suppliers billing Medicare carriers and intermediaries, including regional home health intermediaries (RHHIs) and durable medical equipment regional carriers (DMERCs), for ultrasonic osteogenic stimulators.

Provider Action Needed

STOP – Impact to You
This article is based on Change Request (CR) 3836 which informs physicians, providers, and suppliers that the Centers for Medicare & Medicaid Services (CMS) announced a reconsideration of the National Coverage Determination (NCD) covering the use of Ultrasonic Osteogenic Stimulators, effective April 27, 2005.

CAUTION – What You Need to Know
Upon reconsideration of the existing policy, CMS determined that Ultrasound Stimulation for Nonunion Fracture Healing will remain covered with an additional expansion of coverage to patients without prior surgeries to the non-healing fracture.

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

Background
The Centers for Medicare & Medicaid Services (CMS) announced a Reconsideration of the National Coverage Determination (NCD) covering the use of Ultrasonic Osteogenic Stimulators, effective April 27, 2005.

An ultrasonic osteogenic stimulator is a non-invasive device that emits low intensity, pulsed ultrasound signal to stimulate fracture healing. The device is applied to the surface of the skin at the fracture site and ultrasound waves are emitted via a conductive coupling gel to stimulate fracture healing. An ultrasonic osteogenic stimulator:

Nationally Covered Indications
Ultrasonic osteogenic stimulators are covered as medically reasonable and necessary for the treatment of non-union fractures when the following is demonstrated:

The national noncoverage policy relating to ultrasonic osteogenic stimulators for fresh fractures and delayed unions remains in place. In addition, nonunion fractures of the skull, vertebrae, and tumor-related fractures are excluded from coverage.

Effective for services performed on or after April 27, 2005, Medicare will cover an osteogenic stimulator for beneficiaries who meet the criteria described above. Carriers & Fiscal Intermediaries (FIs) will allow payment for an osteogenic stimulator with the following CPT Code:

Implementation
The implementation date for this change is August 1, 2005.

Additional Information
See the Medicare National Determinations Manual (Pub. 100-03), Section 160.11 (Osteogenic Stimulators) at the following CMS Web site:
http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103c1_Part2.pdf.

For more information about the medical coverage of clinical trials, see the following CMS Web site:
http://www.cms.hhs.gov/coverage/8d.asp.

For complete details on this change, 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 CR3836 in the CR NUM column on the right, and click on the files for that CR. You will note two files for CR3836. The file with transmittal number 41 is the NCD itself and the file with transmittal number 597 contains the billing requirements.

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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Fee for Service Medicare’s Transition to the National Provider Identifier (NPI)

Medicare has the following announcements on plans for transitioning to the National Provider Identifier (NPI) in the Fee-for-Service Medicare Program:

Between May 23, 2005, and January 2, 2006, our claims processing systems will accept an existing legacy Medicare number and reject as unprocessible any claim that includes only an NPI.

Beginning January 3, 2006, and through October 1, 2006, our systems will accept an existing legacy Medicare number or an NPI as long as it is accompanied by an existing legacy Medicare number.

Beginning October 2, 2006, and through May 22, 2007, our systems will accept an existing legacy Medicare number and/or an NPI. This will allow for 6-7 months of provider testing before only an NPI will be accepted by the Medicare Program on May 23, 2007.

Beginning May 23, 2007, our systems will only accept an NPI.

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

Note: This article was revised on June 6, 2005, to show that the correct effective date (as shown above) was December 17, 2004.

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 250.00-250.93 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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Instructions for Provider Notification – Quarterly Reminder to Apply for a National Provider Identifier (NPI)

Reminder - Health care providers are required by law to apply for a National Provider Identifier (NPI). To apply online, visit https://nppes.cms.hhs.gov, or call 1.800.465.3203 to request a paper application.

Visit www.cms.hhs.gov/HIPAAGenInfo/ for the latest information regarding the NPI, including a transcript from CMS’ recent NPI Roundtable conference call.

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

Between May 23, 2005, and January 2, 2006, CMS claims processing systems will accept an existing legacy Medicare number and reject, as unprocessable, any claim that includes only an NPI.

Beginning January 3, 2006, and through October 1, 2006, CMS systems will accept an existing legacy Medicare number or an NPI as long as it is accompanied by an existing legacy Medicare number.

Beginning October 2, 2006, and through May 22, 2007, CMS systems will accept an existing legacy Medicare number and/or an NPI. This will allow for 6-7 months of provider testing before only an NPI will be accepted by the Medicare Program on May 23, 2007.

Beginning May 23, 2007, CMS systems will only accept an NPI.
To apply for an NPI, visit https://nppes.cms.hhs.gov on the CMS Web site. To request a paper application, call 1.800.465.3203.

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Important Notice Regarding the Part B Provider Contact Center

CIGNA Government Services is taking action to respond to an increase in busy signals encountered when calling our Customer Service department’s current toll-free number. To address this issue, CIGNA Government Services will divide our existing toll-free number into two lines; one to reach the Interactive Voice Response Unit (IVR) and one to speak directly with a Customer Service Representative.

Beginning July 1, 2005, the existing toll-free line/number will be dedicated exclusively to the Interactive Voice Response Unit (IVR). Accessing this toll-free number will offer providers a host of self-service options, including eligibility verification, claim status, check status, entitlement dates, etc. Remember, the Centers for Medicare & Medicaid Services (CMS) requires providers to utilize the IVR for these inquiries. The IVR-only line will enable you to reach the IVR with significantly fewer busy signals. In addition, the IVR will continue to be available extended hours for your convenience.

Providers who need to speak with a Customer Service Representative about issues that cannot be handled via the IVR will be required to call the new toll-free number directly. Likewise, providers who call the Customer Service Representative line with inquiries that can be handled by use of the IVR will be asked to hang up and call the toll-free IVR-only line. Calls can not be transferred from or to these lines.

As a reminder, our Customer Service department is open Monday through Friday from 8:00 a.m. to 5:00 p.m. CST. Also note that this change does not affect beneficiary callers. All beneficiary calls should continue to be directed to 1.800.Medicare (1.800.633.4227) for assistance. Providers calling the beneficiary toll-free line will be instructed to call the IVR-only line directly.

We trust that this change will be of benefit to you in gaining the answers needed to your inquiries in the most efficient and expedient manner. CIGNA Government Services appreciates your continued support of our efforts to provide you with the best service possible.

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Medicare Contractor Annual Update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)

Provider Types Affected
Physicians, suppliers, hospitals and other providers billing Medicare contractors (carriers, Durable Medical Equipment Regional Carriers (DMERCs), and Fiscal Intermediaries (FIs)

Provider Action Needed

STOP – Impact to You
Medicare will soon issue the annual update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to Medicare contractors.

This update will apply for claims with service dates on or after October 1, 2005, and discharges and through dates on or after October 1, 2005, for institutional providers.

CAUTION – What You Need to Know
An ICD-9-CM code is required for all professional claims, e.g., physicians, nonphysician practitioners, independent clinical diagnostic laboratories, occupational and physical therapists, independent diagnostic testing facilities, audiologist, ambulatory surgical centers (ASCs), and for all institutional claims, but not for ambulance supplier claims. Remember that as of October 1, 2004, Medicare no longer provides a 90-day grace period for physicians, practitioners and suppliers to use in billing discontinued ICD-9-CM diagnosis codes.

GO – What You Need to Do
Be ready to use the updated codes on October 1, 2005. Please refer to the Background and Additional Information sections of this article for further details regarding this instruction.

Background
This instruction is a reminder that Medicare carriers, DMERCS, and Fiscal Intermediaries will use the annual International classification of diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding update effective for:

The use of ICD-9-CM codes at The Centers for Medicare & Medicaid Services (CMS) has evolved as
follows:

Important Note: Effective for dates of service on and after October 1, 2004, CMS no longer provided a 90- day grace period for physicians, practitioners, and suppliers to use in billing discontinued ICD-9-CM diagnosis codes on Medicare claims. The Health Insurance Portability and Accountability Act (HIPAA) requires that medical code sets be date-of-service compliant, and ICD-9-CM diagnosis codes are a medical code set (see CR 3094, dated February 6, 2004 at: http://www.cms.hhs.gov/manuals/pm_trans/R95CP.pdf)

Additional Information

Publication of ICD-9-CM Codes

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

Related Instructions
The Medicare Claims Processing Manual, Pub. 100-04, Chapter 23 (Fee Schedule Administration and Coding Requirements), Section 10.2 (Relationship of ICD-9-CM Codes and Date of Service) has been revised. The updated manual instructions are included in the official instruction issued to your carrier, and it can be found by going to: http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

From that Web site, look for CR3888 in the CR NUM column on the right, and click on the file for that CR. For additional information relating to this issue, please refer to your local carrier or intermediary at their tollfree number which may be found at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

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Medicare Electronic Remittance Advice RA Initiative

CIGNA Government Services (CGS) would like to make you aware of two valuable tools available to you and encourage you to take advantage of them.

ERA
Medicare Summary Notice (MSN) is a notice of payments and adjustments sent to providers, billers, and suppliers. The MSN also contains detailed and specific claim decision information. A convenient way for you to receive the MSN from CIGNA Government Services is to be transmitted in an electronic format called the Electronic Remittance Advice (ERA). This is used to post payments and to review claim adjustments.

The ERA is not simply an electronic text version of the MSN currently sent with your check or EFT information. In order to make use of the ANSI 4010A1 835 ERA, you must have a system capable of reading and processing this information—normally as payment posting module for a practice management system. If you are unaware as to what your practice management system’s capabilities are in this regard, or if your system is capable of doing these types of functions but you do not know how to use them, please contact your software vendor for further information.

Several advantages to receiving the ERA:

To enroll for ERA’s, complete the Medicare Part B EDI Customer Profile form. To obtain this form, visit CIGNA Government Services Web site at: www.cignagovernmentservices.com/partb - under the EDI menu click on forms.

Once you decide to receive ERA’s, you may find that the paper remittance is no longer needed. If you would like to stop receiving paper remittances contact Provider Enrollment at 1.866.520.4007 or if you have questions related to ERA’s, please contact the EDI Department at 1.866.520.4022 for Tennessee and Idaho customers and 1.866.352.1608 for North Carolina customers.

EFT
The second tool available to you is Electronic Funds Transfer.

No longer do you have to wait on your check to arrive in the mail. Your claims payment can be deposited electronically. The enrollment is free and there is no risk of your check being lost in the mail.

To enroll, simply complete an EFT Enrollment Form with the original signature of your authorized representative (an Owner, Officer, CEO, or someone with the authority to hire and fire) and attach a voided check containing your account and routing information.
Download the EFT Form (14K)

Mail the form with original signature to:
EFT Enrollment
Part B: P.O. Box 25226
Nashville, TN 37202

Questions regarding EFT enrollment should be directed to Provider Enrollment at 866.520.4007. Enjoy using your new features. If any assistance is needed please feel free to call.

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The Fourth in the Medlearn Matters Series of Articles on the Medicare Prescription Drug Coverage

New Educational Products Available

Provider Types Affected
Physicians, providers, suppliers, and their staff providing service to people with Medicare

Important Points to Remember

Release of Notices to Medicare Beneficiaries Who Automatically Qualify for Extra Help Starting at the end of May through June, the Centers for Medicare & Medicaid Services (CMS) is mailing notices to people who are automatically eligible for extra help paying for a Medicare prescription drug plan, including people with Medicare and Medicaid, Supplemental Security Income, and Medicare Savings Program coverage.

The notices will let these people know that Medicare prescription drug coverage is coming and that they will get extra help without needing to apply for it. The notices can be viewed at http://www.cms.hhs.gov/medicarereform/lir.asp on the CMS Web site.

This summer, the Social Security Administration (SSA) will mail a different letter to other people who do not automatically qualify for the extra help but may be potentially eligible for it. The letter will include an application that people can fill out and return to find out if they qualify for extra help paying for a Medicare prescription drug plan. This letter can viewed at http://www.ssa.gov/organizations/medicareoutreach2/ on the Social Security Administration Web site. Select “Application for Help with Medicare Prescription Drug Plan Costs.”

Posters - Now Available for Display
Posters titled “Have Limited Income? Social Security Can Help with Prescription Costs” can be ordered free of charge on the CMS Web site. The posters are suitable for display in a physician’s, providers, or supplier’s office; a pharmacy; or other health care setting where Medicare beneficiaries will see this information. The posters direct Medicare beneficiaries with limited income and resources to a toll free number where they can find out if they are eligible for help with prescription drug costs.

To view and order the posters, go to the Medlearn Prescription Drug Coverage Web page located at http://www.cms.hhs.gov/medlearn/drugcoverage.asp on the CMS Web site. We need your help in getting this information out to Medicare beneficiaries with limited income and resources. We encourage you to order and display the posters where Medicare beneficiaries will see them.

Information Tool Available on Web
The new prescription drug coverage informational tool, “Learn About Your Medicare Prescription Coverage Options” was recently released on http://www.medicare.gov. This awareness tool for people with Medicare rovides information about what is coming and what actions they will need to take with regard to the new prescription drug coverage. By answering 2-3 questions, the individual will be provided with information such as: eligibility for extra help for people with limited income and resources, customized information based on the individual’s current coverage, as well as educational resources and links to publications about the new drug coverage.

Summary
CMS understands the pressure on your clinical time with patients, which is why we ask that you inform your Medicare patients that this new prescription drug coverage could be valuable to them and worth exploring.

In addition to the products discussed in this article, CMS plans to provide you with access to information you could make available to your patients in your offices.

Additional Information
More information on provider education and outreach regarding drug coverage can be found at:
http://www.cms.hhs.gov/medlearn/drugcoverage.asp on the CMS Web site.

Detailed drug coverage information for CMS partners and beneficiary advocates can be found at:
http://www.cms.hhs.gov/partnerships/news/mma/default.asp on the CMS Web site.

You can also find additional information regarding prescription drug plans at http://www.cms.hhs.gov/pdps/ on the CMS Web site.

Further information on CMS implementation of the MMA can be found at the following CMS Web site:
http://www.cms.hhs.gov/medicarereform/

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Non-Physician Practitioner Questions and Answers

Note: This article was revised on July 6, 2005. The only change was the answer (A10) to question 10 (Q10) on page 3. All other information remains the same.

Provider Types Affected
Non-Physician Practitioners (NPPs), physicians, suppliers, and providers

Provider Action Needed
Be sure to understand the policies related to services for Skilled Nursing Facilities (SNF) and Nursing Facilities (NF) as they relate to Non-Physician Practitioners.

Background
The Balanced Budget Act of 1997 modified the way the Medicare program pays for Non-Physician Practitioner (NPP) services. Prior to January 1, 1998, these services were reimbursed by Medicare Part B only in certain geographical areas and health care settings. The Balanced Budget Act removed the restrictions on settings and effective January 1998, payment is allowed for non-physician practitioner services in all geographic areas and health care settings permitted under State licensing laws.

On November 13, 2003, CMS issued the Survey & Certification letter (S&C-04-08), which addresses the differences in requirements concerning the delegation of physician tasks in Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs) from a survey and certification perspective. Please note that reimbursement requirements for NPPs may differ from the survey and certification requirements. The following questions (Q1 through Q17) have been asked by NPPs, and each question has been answered (A1 through A17) by the Centers for Medicare & Medicaid Services (CMS).

Q1. Why do new regulations from CMS governing physician delegation of services differ between Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs)?
A1. The requirements addressing physician delegation of services are not new. The distinction made between the delegation of physician visits and tasks between SNFs and NFs is mandated by Congress in the law.

The original authority for 42 Code of Federal Regulations (CFR) § 483.40 was the sentence in section 1819(b)(6)(A) of the Social Security Act requiring that every SNF resident’s medical care be under the supervision of a physician (the same sentence appeared in section 1919(b)(6)(A) of the Social Security Act for NFs). The requirements contained in 42 CFR, § 483.40, include a prescribed visit schedule and the requirement for the physician to perform the initial visit personally.

Section 483.40 of the CFR originally applied these same standards uniformly in both SNFs and NFs. However, in section 4801(d) of the Omnibus Budget Reconciliation Act of 1990 (OBRA ’90), Congress subsequently amended the Medicaid provisions of the law (section 1919(b)(6)(A) of the Social Security Act) to allow, at the option of the State, all physician tasks (including the initial visit) to be delegated to physician extenders who are not employed by the facility but who are working in collaboration with the physician. In response, CMS amended the regulations to reflect this broader authority for delegating physician tasks in NFs (see § 483.40(f)). Since Congress declined to make a similar change in the statutory requirements for SNFs at section 1819(b)(6)(A) of the Social Security Act, the corresponding SNF requirements in § 483.40(c) and (e) remain unchanged.

Q2. When may non-physician practitioners (NPPs) begin to bill for medically necessary visits that
occur prior to the initial comprehensive visit in a SNF and in a NF?
A2. CMS defined “initial comprehensive visit” in the November 13, 2003, S&C-04-08 and stated that NPPs may perform any medically necessary visits even if they occur prior to the initial comprehensive visits in both SNFs and NFs. Medically necessary visits that NPPs perform on or after November 13, 2003, may be billed to the carrier when collaboration and billing requirements are met in the SNF and NF setting. The Survey & Certification letter S&C-04-08, may be found at: http://www.cms.hhs.gov/medicaid/survey-cert/letters.asp

Q3. If State regulations require a physician co-signature for orders and/or notes written by an NPP, may the physician bill for this action?
A3. No. CMS only pays for medically necessary face-to-face visits by the physician or NPP with the resident. Since the NPP is performing the medically necessary visit, the NPP would bill for the visit.

Q4. If State regulations require more frequent visits than those that are federally mandated, are
NPPs able to bill for those visits?
A4. CMS only reimburses physicians and NPPs for medically necessary visits and federally prescribed visits. Visits required to fulfill or meet State requirements are considered administrative requirements and are not medically necessary for the resident. Medicare pays for services that are reasonable and medically necessary for the treatment of illness or injury only, as stated in the Social Security Act, section 1862(a)(1)(A).

Q5. May NPPs who are employed by the facility bill for medically necessary visits?
A5. Payment may be made for the services of Nurse Practitioners (NPs) and Clinical Nurse Specialists (CNSs) who are employed by a SNF or NF when their services are rendered to facility residents. If NPs and CNSs employed by a facility opt to reassign payment for their professional services to the facility, the facility can bill the appropriate Medicare Part B carrier under the NPs’ or CNSs’ UPINs for their professional services. Otherwise, the NPs or CNSs who are employed by a SNF or NF bill the carrier directly for their services to facility residents.

On the other hand, Physician Assistants (PAs) who are employed by a SNF or NF cannot reassign payment for their professional services to the facility because Medicare law requires the employer of a PA to bill for the PA’s services. Hence, the facility must always bill the Part B carrier under the PA’s UPIN for the PA’s professional services to facility residents.

Q6. May NPPs employed by the NF perform the initial comprehensive visit, sign initial orders, or perform other federally required visits in NFs?
A6. No. The statute specifies that the NPPs are prohibited from providing these services when employed by the facility. The Social Security Act states at section 1919(b)(6)(A) that the health care of every resident must be provided under the supervision of a physician or under the supervision of an NPP not employed by the facility who is working in collaboration with a physician.

Q7. May NPPs perform the initial comprehensive visit in SNFs?
A7. No. The Social Security Act states at Section 1819(b)(6)(A) “that the medical care of every resident must be provided under the supervision of a physician.” Congress did not extend this benefit to NPPs in an SNF as was done under 1919(b)(6)(A).

Q8. When may NPPs sign the initial orders for a SNF resident?
A8. NPPs may not sign initial orders for an SNF resident. However, they may write initial orders for a resident (only) when they review those orders with the attending physician in person or via telephone conversation and have the orders signed by the physician.

Q9 Must a physician verify and sign orders written by an NPP who is employed by the NF?
A9. Yes. The regulation at 42 CFR, § 483.40(b)(3) states, the physician must “Sign and date all orders with the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.”

In accordance with 42 CFR, Section 483.40(f), required physician tasks, such as verifying and signing orders in an NF, can be delegated under certain circumstances to a physician assistant, nurse practitioner, or clinical nurse specialist who is not an employee of the facility but who is working in collaboration with a physician. Therefore, in order to comply with survey and certification requirements, the physician must sign all orders written by an NPP who is employed by the NF.

Q10. Why must a physician verify and sign orders written by an NPP in the SNF?
A10. In SNFs, depending on State law and the facility’s policy, physicians do NOT have to verify and sign orders written by an NPP after the initial comprehensive visit. Nonetheless, the ultimate responsibility for delegated tasks remains with the physician, as indicated in § 483.40(e)(1)(iii). For a NF, depending upon State law, NPPs not employed by the facility but who are working in collaboration with a physician are not required to have their orders (initial or ongoing) cosigned by a physician.

Q11. Referring to S&C –04-08 issued on November 13, 2003, the chart under the “Other Medically Necessary Visits and Orders” column, it specifies the ability of the NPP to perform AND sign but in the column for “Other Required Visits” it does not address signing. Does CMS require a physician’s signature in such cases?
A11. Other Required Visits refers to the federally required visits. During these required visits, it is not
always necessary to write orders. However, during a “Medically Necessary Visit,” which is when the resident’s condition may have changed, thus, warranting a visit outside the federally required schedule, the resident is exhibiting signs and/or symptoms that require medical attention. In these cases, CMS believes orders will often be required and, thus, expect orders to address the resident’s change in condition. Therefore, an NPP may sign the medically required orders. Please remain mindful that the survey and certification requirement that the physician must sign and date all orders remains in effect. (See Q&As 9 & 10.)

Q12. Why can’t a PA, regardless of employment, sign certifications/re-certifications for SNF residents?
A12. Congress amended section 1814(a)(2) of the Social Security Act in 1989. The Social Security Act specifies that NPs and CNSs who are not employed by the facility may certify (and recertify) that the services the beneficiary requires may only be performed in the SNF. They did not extend this benefit to PAs. Therefore, by statute, PAs may not sign SNF certifications/re-certifications.

Q13. If a physician extender is not employed by the NF but is employed by an organization related to the NF, may he/she still provide services in the nursing home?
A13. The requirement in 42 CFR, § 483.40(f), is specific in that the physician tasks may be performed by a NP, PA, or CNS “who is not an employee of the facility.” In this case, the NPP is not an employee of the NF and, thus, can perform physician tasks as long as they work in collaboration with the physician.

Q14. If an NP or CNS is not employed by the SNF but is employed by an organization related to the SNF, may he/she sign the certification and re-certifications?
A14. The requirement in 42 CFR § 424.20(e) is specific in that an NP or CNS “neither of whom has a direct or indirect employment relationship with the facility” may sign the certifications and re-certifications.

In this case, the NP or CNS is not an employee, but has an indirect employment relationship and, thus, are not permitted to sign the certifications and re-certifications. (Social Security Act section 1814(a)(2))

Q15. If physician delegation responsibilities are based on payment source, what are the physician delegation responsibilities for private pay resident, VA contracts or managed care?
A15. If the resident’s stay is being paid for by a source other than Medicare or Medicaid AND the resident is residing in a Medicare/Medicaid dually-certified facility, follow the most stringent requirement. If the resident is residing in a Medicare only or a Medicaid only certified facility, then follow the requirements for that specific certified facility.

Q16. Are NPPs allowed to certify/recertify therapy plans of care under Medicare Part B?
A16. 42 CFR § 424.24(c)(3) states that if a physician or NPP establishes the plan of care, he/she must also certify the plan of care. If the plan of care is established by a physical or occupational therapist or speech language pathologist, a physician or NPP who has knowledge of the case must sign the plan of care. (This Q&A was not addressed in the November 13, 2003, Survey & Certification letter, S&C-04-08.)
Should you have any questions concerning this article, please submit your inquiry via the CMS Web site as follows:

  1. Click on Feedback in top tool bar of http://www.cms.hhs.gov (from Home page or any page on cms.hhs.gov).
  2. Select and click “Site Feedback” in last paragraph.
  3. User should:
    1. Enter his/her email address;
    2. At Category, select “Providers” from the drop down menu;
    3. At the sub-category, select Nursing Home Quality Initiative;
    4. Enter feedback in space provided; and
    5. Submit feedback.

Related Instructions
The CMS Web site contains considerable information regarding SNF billing procedures and NPP billing processes. Some of the specific sites are as follows:
The Medicare Claims Processing Manual, Pub. 100-04, Chapter 7 (SNF Part B Billing (Including Inpatient Part B and Outpatient Fee Schedule)) can be found at the following CMS Web site: http://www.cms.hhs.gov/manuals/104_claims/clm104c07.pdf

The Skilled Nursing Facility Manual, Chapter V (Billing Procedures) is located at the following CMS Web site: http://www.cms.hhs.gov/manuals/12_snf/sn500.asp

The Home Health Agency Manual, Chapter IV (Billing Procedures) Web site is located at:
http://www.cms.hhs.gov/manuals/11_hha/hh400.asp.

Additional Information
The CMS Quarterly Provider Update Web sites for Non-Physician Practitioners (NPPs) for 2004 can be
found at: http://www.cms.hhs.gov/providerupdate/january2004/nonphys.asp

http://www.cms.hhs.gov/providerupdate/april2004/nonphys.asp
http://www.cms.hhs.gov/providerupdate/July2004/nonphys.asp
http://www.cms.hhs.gov/providerupdate/october2004/nonphys.asp

In addition, the CMS Quarterly Provider Update Web sites for NPPs for 2003 can be found at:
http://www.cms.hhs.gov/providerupdate/january2003/nonphys.asp
http://www.cms.hhs.gov/providerupdate/april2003/nonphys.asp
http://www.cms.hhs.gov/providerupdate/july2003/nonphys.asp
http://www.cms.hhs.gov/providerupdate/october2003/nonphys.asp

Acronyms
CFR = Code of Federal Regulations
OBRA ’90 – Omnibus Budget Reconcilliation Act of 1990
CMS – Centers for Medicare & Medicaid Services PA = Physician Assistant
CNS = Clinical Nurse Specialist S&C = Survey & Certification
NF = Nursing Facility
SNF – Skilled Nursing Facility
NP – Nurse Practitioner
VA = Veterans Adminsitration
NPP = Non-Physician Practitioner )NPs, CNSs, & PAs are considered NPPs)

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Reminder Regarding Medicare Billing Rules for Ambulance Services Rendered to Medicare Patients During an Inpatient Hospital Stay

Provider Types Affected
Suppliers of ambulance services billing Medicare carriers for services provided to Medicare patients during an inpatient hospital stay.

Provider Action Needed

STOP – Impact to You
The purpose of this Special Edition is to remind ambulance service suppliers of the rules regarding payment for certain services provided to Medicare patients in an inpatient hospital stay.

CAUTION – What You Need to Know
The Centers for Medicare & Medicaid Services (CMS) will add an edit in the Medicare’s claims processing systems to prevent payment by carriers for services that are bundled in the hospital’s payment under the applicable inpatient Prospective Payment System (PPS).

GO – What You Need to Do
Please see the Background and Additional Information Sections of this article for further details.

Background
The Social Security Act (Section 1886(d) and (g)) established several Prospective Payment Systems (PPS) for inpatient services furnished to Medicare beneficiaries, and under the inpatient PPSs, Medicare Fiscal Intermediaries (FIs) reimburse hospitals a predetermined amount for services furnished to Medicare beneficiaries based on the beneficiary’s condition and severity of treatment modalities. All services received by hospital inpatients must be supplied by the hospital either directly or under arrangements. With the exception of the days of admission and discharge, costs for transportation of a hospital inpatient by ambulance (to and from another hospital, freestanding facility, or physician’s office) to receive specialized services, and costs for radiology services (including computed tomography scans) furnished to inpatients by a physician’s office, another hospital or a radiology, clinic are not payable by Medicare.

CMS will add an edit in its claims processing systems to prevent payment by carriers for services that are bundled to the hospital. As an initial implementation of this policy, Medicare will cease making payments to independent suppliers of ambulance services for beneficiaries in an inpatient hospital stay.

Additional Information
As a reminder, all Medicare claims processing information is in the Medicare Claims Processing Manual.

This manual may be viewed at http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp on the CMS Web site.

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

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Revisions to the Medicare Benefit Policy Manual (Pub. 100-02), Chapter 15, Section 220 and 230 Therapy Services

Note: This article was revised on July 7, 2005, to reflect a delay in implementation of portions of CR3648 relating to the qualifications required for staff providing services billed as physical therapy and occupational therapy services incident to the services of a physician or nonphysician practitioner. All other information in the article is unchanged. This article also replaces Medlearn Matters article SE0533.

Provider Types Affected
Physicians and other providers who bill Fiscal Intermediaries (FIs) and carriers for therapy services

Provider Action Needed

STOP – Impact to You
This manual revision reorganizes sections 220 and 230 in Chapter 15 of the Medicare Benefit Policy Manual; it adds reference information and clarifies current policy concerning physician visits and certification. Portions of this article and article SE0533 did not reflect a June 1, 2005, agreement to delay the implementation of requirements for qualifications for staff who provide services billed as physical therapy and occupational therapy services incident to the services of a physician or nonphysician practitioner. This agreement was made with National Athletic Trainers’ Association (NATA) and is contained in a June 3, 2005, order issued by the United States District Court for the Northern District of Texas. (See attached court order.).

CAUTION – What You Need to Know
Please note that to ensure payments for therapy services you must meet the conditions and standards for therapy services described in the manuals. In addition, the qualified therapy service must be furnished by qualified professionals/personnel as defined in the Medicare Benefit Policy Manual. Note that the requirements for qualifications for staff providing services billed as physical and occupational therapy services incident to a physician or non-physician practitioner have been delayed pursuant to the June 3, 2005, court order and agreement with NATA. All other requirements remain unchanged.

GO – What You Need to Do
To ensure accurate and timely processing of therapy claims, be familiar with instructions and requirements described in the CMS Manual System related to such claims. Read the detailed policies in the manuals and contact your intermediary or carrier if you have any questions about these changes.

Background
In summary, this revision to the Medicare Benefit Policy Manual (Pub 100-02), Chapter 15, Sections 220 and 230, clarifies policies concerning orders, visits, plans of care, delayed certification, and private practice.

Some key points in this modification include:

Additional Information
This manual change does not require a change in the way therapy services are currently provided. You may continue to obtain an order, send the plan of care promptly to the physician, obtain certification as soon as you can and recommend a visit to the physician when needed. However, in the case where a physician does not promptly return a certification of the plan of care for a patient under his/her care, this change provides some flexibility in obtaining the certification.

Also, a physician retains the authority to require that a patient under his/her care must return for a visit prior to certification, and the physician may limit the length of time for which the plan is certified, or may chose to certify an interval in advance if it is medically appropriate.

The revised manual sections are attached to the official instruction issued to your carrier/FI regarding this change. That instruction, CR 3648, can be found at: http://www.cms.hhs.gov/manuals/transmittals/ comm_date_dsc.asp link to open and view the file for the CR.


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

Attached are the following:

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Temporary Change in Carrier Jurisdictional Pricing Rules for Purchased Diagnostic Services

Note: This article was revised on May 26, 2005, to include this reference to related Change Requests CR3481 (Implementation of the Medicare Physician Fee Schedule (MPFS) National Abstract File for Purchased Diagnostic Tests and Interpretations), and CR3694 (Implementation of the Abstract File for Purchased Diagnostic Tests/Interpretations (Supplemental to CR 3481)).

To see the Medlearn Matters article related to CR3481, go to the following CMS Web site:
http://www.cms. hhs.gov/medlearn/matters/mmarticles/2005/MM3481.pdf.

To see the Medlearn Matters article related to CR3694, go to the following CMS Web site:
http://www.cms. hhs.gov/medlearn/matters/mmarticles/2005/MM3694.pdf.

Provider Types Affected
Physicians, laboratories, and Independent Diagnostic Testing Facilities (IDTFs)

Provider Action Needed
This instruction implements a temporary change in carrier jurisdictional pricing rules for purchased diagnostic services to allow physicians/suppliers purchasing out-of-jurisdiction diagnostic tests/interpretations to bill their local carrier for these services.

It also instructs carriers to revoke any previously issued provider identification numbers (PINs) used to allow IDTFs physically located outside of the carrier’s jurisdiction to bill and be paid for purchased diagnostic tests/interpretations payable under the Medicare Physician Fee Schedule (MPFS).

Effective January 25, 2005, and until further notice, physicians/suppliers must bill their local carrier for all purchased diagnostic tests and interpretations, regardless of the location where the service was actually furnished.

Background
Effective for claims with dates of service on or after April 1, 2004, Medicare carriers must use the zip code of the location where the service was rendered to determine both the carrier jurisdiction for processing the claim and the correct payment locality for any service paid under the MPFS (see the Medicare Claims Processing Manual (Pub.100-04), Chapter 1, Section 10.1.1). Diagnostic tests and their interpretations are paid under the MPFS, and are therefore subject to the same payment rules as all other services paid under the MPFS.

Laboratories, physicians, and IDTFs may bill for purchased tests and interpretations, but under the current carrier jurisdictional pricing rules, these suppliers must bill the purchased test or interpretation to the carrier that has jurisdiction over the geographic location where the test or service is performed.

Since the implementation of carrier jurisdictional pricing edits on April 1, 2004, the Centers for Medicare & Medicaid Services (CMS) has received reports that, due to current enrollment restrictions, some physicians/suppliers purchasing diagnostic tests/interpretations are unable to receive reimbursement for these services when the services are performed outside of their local carrier’s jurisdiction.

This article and related CR3630 address these reported problems by temporarily changing the carrier jurisdictional pricing rules that apply when billing for an out-of-jurisdiction area purchased diagnostic service. Carrier jurisdictional pricing rules for all other services payable under the MPFS remain in effect.

Until further notice:

Note: The Office of Inspector General (OIG) maintains a database of information concerning parties that are excluded from participation in the Medicare, Medicaid, or other Federal health programs. The OIG exclusions database is available to the public on the OIG Web site at the following address: www.oig.hhs.gov/fraud/exclusions.html. Physicians/suppliers may access this database, or use another available source, to determine whether another supplier is eligible to participate with Medicare prior to billing for a purchased diagnostic test or interpretation.

When billing for an out-of-jurisdiction purchased diagnostic service, physicians/suppliers must use their own PIN to bill for the service and must report their local facility address in the service facility location area of the claim. (For these services only, the place of service is deemed to be the billing physician’s/supplier’s location, rather than the location where the service was actually performed. The billing physician/supplier should use the same address reported for the portion of the service that the physician/supplier performed when reporting the address for the purchased portion of the test.)

When submitting paper claims (form CMS-1500), physicians/suppliers billing their local carrier for a purchased test/interpretation performed outside of the carrier’s jurisdiction must report their name and use their own PIN to bill both the purchased portion of the test and the portion of the test that they performed.


When billing for a purchased interpretation, the billing physician/supplier should not report the PIN of the physician who performed the interpretation in item 19 of the claim. Instead, the billing physician/supplier must maintain a record of the name and address of the physician performing the purchased interpretation and supply it to the Medicare carrier upon request. In addition, when billing for the test/interpretation, the purchasing physician/supplier must enter the address of that portion of the service they actually performed as the address where the purchased service was preformed in block 32 of the CMS-1500 claim form.

When submitting a claim for a purchased service on the form CMS-1500, remember that the billing physician/supplier must check box 20 “Yes” or continue to bill for the technical and professional components on separate claim forms.

When using electronic claims submissions (ANSI X12 837, version 4010A) physicians/suppliers billing for the purchased test/interpretation performed outside their carrier’s jurisdiction must report their name and their PIN to bill for the purchased diagnostic service. The billing physician/supplier should continue to report the 1C qualifier (Medicare Provider Number) in the reference identification segment of the 2310C (Purchased Service Provider Secondary ID) loop.

When reporting the 2400 PS1 segment (Purchased Service Information) of the 837 format, billing physicians/suppliers must report their own PIN. The reference identifier entered in the REF02 segment of the 2310C loop must also be the PIN of the billing physician/supplier, not the PIN of the physician/supplier who actually performed the service.

In addition, the billing physician/supplier must enter as the service facility location the same address as the location where they performed the non-purchased portion of the test. Enter this address in the appropriate service facility location (Service Facility Location Loop 2310D for claim level or 2420C for the line level on the claim).

Also, a physician/supplier billing a carrier for a purchased diagnostic test must continue to report on the claim the amount that the physician/supplier charged, net of any discounts. (Independent laboratories are exempt from reporting the amount charged for purchased tests.)

When billing for a diagnostic service purchased within the local carrier’s geographical service area, the physician/supplier must continue to follow existing guidelines for reporting the location where the service was furnished.

Physicians/suppliers are advised that:

Medicare carriers will accept and process claims billed by suppliers (including radiologists, physicians, and
IDTFs) enrolled in the carrier’s jurisdiction based on the zip code entered on the claim, regardless of where
the service was actually furnished. Suppliers billing for purchased diagnostic tests/interpretations must meet all other enrollment criteria, and must be eligible to bill for the purchased component of the test.

If your carrier determines (during the claims review process) that the service was performed at a location
other than the service facility address entered on the claim, the carrier must hold the physician/supplier
harmless for this discrepancy, and may not deny the claim on this basis.

NOTE: For audit purposes, physicians/suppliers must maintain, and provide upon request, supporting documentation demonstrating that the test/interpretation was purchased, and documenting the location where the service was performed.

Finally, carriers will not reopen claims, but will allow physicians/suppliers to resubmit claims under this revised policy, where such claims were denied due to problems with billing out-of-jurisdiction purchased services. Such claims may be resubmitted to the local carrier for processing, but they must be filed within the time limits established for timely filing of claims.

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/pm_trans/R415CP.pdf

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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The Comprehensive Error Rates Testing (CERT) Program CERT Documentation Contractor Transition Medical Record Request and Receipt Functions.

The CERT program calculates the error rate for Medicare claims submitted to Carriers, Durable Medical Equipment Regional Carriers (DMERCs), and Fiscal Intermediaries (FIs). The Centers for Medicare and Medicaid Services (CMS) receives in excess of 2 billion claims per year of which CERT randomly selects a statistical sample for review to ensure the claims were paid properly. Beginning July 1, 2005, the CERT Program will begin using two contractors to accomplish this work - the CERT Documentation Contractor (CDC) and the CERT Review Contractor (CRC).

Failure to receive requested medical records remains one of the highest causes of Medicare errors in the CERT program. The CDC will be responsible for requesting and receiving medical record documentation in support of the provider’s claim. Their call center operation attempts to make telephone contact with the provider’s office to explain the program and to explain that the request is in accordance with the Health Insurance Portability and Accountability Act (HIPAA) followed by a faxed or mailed medical request letter to the provider’s office. The request letters are specifically tailored to the medical functions and services performed by the provider. The CDC call center operates between the hours of 8:00 am to 8:00 pm Eastern Standard Time, and their phone number is (301) 957.2380. The call center customer service representatives are available to take incoming phone calls and answer your questions. The CDC will forward the requested documentation to the CRC. The CRC, staffed by specially trained nurses and physicians, will review the claim to ensure it was paid correctly.

Requests for medical records received prior to July 1, 2005 may be faxed to (804) 264.3268. Requests received after June 30, 2005 may be faxed to (240) 568.6222. Fax is the preferred method of delivery.

Voluminous pages of medical record documentation may be sent via mail to:

Prior to July 1st:
CERT Operations Center
Attn: Disposition Department – Distribution
1530 E. Parham Road
Richmond, VA 23228

After June 30th:
CERT Documentation Office
9090 Junction Drive, Suite 9
Annapolis Junction, Maryland 20701

Every effort is made to secure the medical record documentation from providers in a timely manner. Failure to provide the necessary documentation will result in a denial of the provider’s claim.

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Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers, and Billers

“A reference document titled Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers, and Billers is now available on the Medicare Learning Network’s (Medlearn) Web page located at http://www.cms.hhs.gov/medlearn/RA_Guide_05-27-05.pdf on the CMS Web site. Chapters 1 and 2 describe a Remittance Advice (RA) and the components of an RA. For institutional providers, Chapter 3 includes a sample Electronic Remittance Advice (ERA) and Standard Paper Remittance Advice (SPR) with field descriptions. Chapter 4 includes a crosswalk between ERA and SPR fields and a sample SPR with field descriptions, specifically for professional providers. At the end of Chapters 3 and 4, providers can find information on remittance balancing. Print the chapter that fits your needs! The guide also includes informative resources such as an acronym list, a glossary, and important Web sites and phone numbers. Finally, the guide has three comprehensive indexes: 1) for key terms and concepts; 2) for institutional ERA and SPR field descriptions; 3) professional SPR field descriptions. Check it out today!”

“If you are currently receiving the Standard Paper Remittance Advice (SPR), consider utilizing the technology available to increase productivity by switching to the Electronic Remittance Advice (ERA). Take advantage of faster communication, payment information, and reduction of paperwork by receiving the ERA. If you are receiving both an SPR and ERA, consider canceling the SPR. Please contact our EDI department at 1.866.352.1608 for North Carolina customers and 1.866.520.4022 for Tennessee/Idaho customers and ask to receive the ERA and/or cancel the SPR today!”

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

Note: This article was revised on June 13, 2005, to reflect a change to CR 3679, which was reissued on June 10, 2005. The article was revised to reflect the new transmittal number of the CR, but no other changes were made.

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 or purchased service cannot be paid because payment has already been made for this service to another provider by a payment contractor representing the payer.” The new remark code is N347.

GO – What You Need to Do
Be ready to accept this new remark code (N347) 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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Reminder for Anesthesia Billing

Anesthesia services should be billed as the actual number of minutes. When billing for anesthesia use the MJ (minutes) qualifier in the SV103 (units or basis for Measurement code) element of the ANSI 4010A1 format. For National Standard Format (NSF) billers, the field for anesthesia minutes is located in the FA0 record, field 19 positions 86-89. When field 19 is populated then field 18, units of service, must be zero filled.

Please contact your vendor if you need assistance with these fields in your software.

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Access Process for Beneficiary Eligibility Inquiries/Replies (HIPAA 270/271 Transations) (Extranet Only)

Note: This article was revised on June 17, 2005, because related CR 3883 was re-issued on June 15, 2005. The CR release date and transmittal number (above) have been revised, but no other changes were made to the article.

Provider Types Affected
All physicians, providers, and suppliers billing Medicare

Provider Action Needed

STOP – Impact to You
This article is based on information from Change Request (CR) 3883, which states that the Centers for Medicare & Medicaid Services (CMS) is making changes to its Information Technology (IT) infrastructure. The goal is to address standards for Medicare beneficiary eligibility inquiries to create the necessary database and infrastructure to provide a centralized Health Insurance Portability and Accountability Act (HIPAA) compliant 270/271 health care eligibility inquiry and response on a real-time transaction.

CAUTION – What You Need to Know
In June 2005, only clearinghouses, certain providers, and trading partners will be permitted to send 270 transactions via the Extranet, a secure, closed, and private network used to transmit data between Medicare carriers and intermediaries and CMS. CMS expects to provide limited access via the Internet for 270/271 transactions later this year.

GO – What You Need to Do
See the Background and Additional Information sections of this article for further details regarding these changes and manual revisions that explain how this access will work.

Background
Change Request (CR) 3883 states that CMS is making changes to its IT infrastructure to address standards for Medicare beneficiary eligibility inquiries. This IT change will create the necessary database and infrastructure to provide a centralized HIPAA- compliant 270/271 beneficiary health care eligibility inquiry and response in real-time.

Not only will these changes satisfy the current demand for a fully functioning HIPAA-compliant 270/271 eligibility transaction for FFS providers/submitters, they will also support (over time) a national provider telephone interactive voice response (IVR) as well as Internet eligibility queries.

The new infrastructure will support the 270/271 for Medicare and will use a central national Medicare eligibility database in processing these queries bypassing the current:

However, Medicare plans to continue to use the provider newsletters and Web sites of the carriers, DMERCs, and FIs to share information on availability, enrollment, Internet use, and other pertinent information about the 270/271 as developments warrant.

The 270/271 implementation guide adopted for national use under HIPAA can be obtained at the Washington Publishing Co. Web site at: http://www.wpc-edi.com/HIPAA

A provider that prefers to obtain eligibility data in an electronic data interchange (EDI) format, but does not want to use the 270/271 Version 4010, may contract with a clearinghouse to translate the information on its behalf; however, that provider would be liable for those clearinghouse costs.

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 at http://www.cms.hhs.gov/it on the CMS Web site. 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). The 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.

Note: 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 are:

• IVANS: http://www.ivans.com
• McKesson: http://www.mckesson.com

Future Requirement
CMS is developing an Attestation that all Clearinghouses and Providers will be required to agree to provisions concerning adherence of the HIPAA Privacy and Security Rule. This Attestation will be available for review through the Paperwork Reduction Act Process and will be available for public comment in the near future.

Implementation
The implementation date for this instruction is August 22, 2005.

Additional Information
For complete details, including a list of data elements that will be provided in response to the 270 transaction, please see the official instruction issued to your Medicare carrier, including DMERCs, or FI regarding this change. That instruction may be viewed by going to http://www.mckesson.com

From that Web page, look for CR 3883 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/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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Access Process for HIPAA 270/271 (Extranet Only)

I. SUMMARY OF CHANGES: The Centers for Medicare and 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

Disclaimer for manual changes only: The revision date and transmittal number apply to the red italicized material only. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.

II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual not updated.)
(R = REVISED, N = NEW, D = DELETED) – (Only One Per Row.)

R/N/D Chapter / Section / SubSection / Title
Table of Contents
R 31/10/X12N Health Care Eligibility Benefit Inquiry and Response 270/271 Implementation
R 31/10.1/Background
R 31/10.2/Eligibility Workflow
R 31/20.7/Health Care Claim Status Category Codes and Health Care Codes for Use with the Health Care Claim Status Request and Response ASC X12N 276/277
D 31/10/10.3/Eligibility Query Types
D 31/10/10.4/Intermediary and Carrier Responsibilities
D 31/10/10.5/Data Center Responsibilities
D 31/10/10.6/Provider/Network Service Vendor’s Responsibilities
D 31/10/10.7/Supplemental CWF Module Information
D 31/10/10.8/Eligibility Queries Options and Work Flows
D 31/1/Purpose of chapter
D 31/30/Furnishing Claims Information to Complementary Insurers
D 31/40/ANSI X12N 278 - Electronic Referral Certification and Authorization
D 31/50/Related Internet Files Routinely Updated by CMS


III. FUNDING: No additional funding will be provided by CMS; contractor activities are to be carried out within their FY 2005 operating budgets.

IV. ATTACHMENTS:

X Business Requirements
X Manual Instruction
Confidential Requirements
One-Time Notification
Recurring Update Notification

*Unless otherwise specified, the effective date is the date of service.

Attachment - Business Requirements

I. GENERAL INFORMATION
A. Background:
The Centers for Medicare and 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 Health Insurance Portability and Accountability Act (HIPAA) compliant 270/271 health care eligibility inquiry and response in real-time.

B. Policy:
This CR will support the Health Insurance Portability and Accountability Act (HIPAA) Health Care Eligibility Benefit Inquiry and Response transaction (270/271).

II. BUSINESS REQUIREMENTS
“Shall” denotes a mandatory requirement
“Should” denotes an optional requirement

Requirement Requirements Responsibility (“X” indicates the columns that
Number apply)

Requirement Number Requirements Responsibility ("X" indicates the columns that apply)
    F
I		 R
H
H
I

C
a
r
r
i
e
r

D
M
E
R
C		 Shared System Maintainers Other
F
I
S
S		 M
C
S		 V
M
S		 C
W
F
  NA X X X X          

III. PROVIDER EDUCATION

Requirement Number Requirements Responsibility ("X" indicates the columns that apply)
    F
I		 R
H
H
I

C
a
r
r
i
e
r

D
M