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September 2005 Part B Medicare Bulletin

Posted September 2, 2005

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Abarelix for the Treatment of Prostate Cancer

Note: This article was revised on July 26, 2005, to reflect changes made to CR 3775, which was revised and reissued by the Centers for Medicare & Medicaid Services on July 22, 2005. The changes made as a result of the revised CR 3775 are to clarify that GnRH therapy is GnRH agonist therapy. Also, providers billing Medicare intermediaries for the use of abarelix should note that revenue code 0250 should be used on inpatient claims.

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

Provider Action Needed

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

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

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

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

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

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

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

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

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

The physician must attest willingness and ability to:

Finally, be aware that CMS has also determined that the evidence is not adequate to conclude that abarelix
(PlenaxisTM) is reasonable and necessary for indications other than those specified above.

Therefore, all other uses of abarelix (PlenaxisTM) are not covered. Further, in light of the concern regarding safety risks of abarelix (PlenaxisTM), off-label uses that may appear in listed statutory drug compendia on which Medicare and its contractors rely to make coverage determinations will remain non-covered until CMS completes a reconsideration of this National Coverage Determination.

Additional Information
The following claims processing points should be noted:

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

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

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

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

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CERT Provider Address Web Site Now Available

On July 18, 2005, the following Web site became available for providers to review address information CERT currently has in the CMS database: http://www.certprovider.org/. This is a “read only” Web site with an e-mail link: byron@certcdc.com to send updates to the CERT Documentation Contractor (CDC). Verification of the information will be done via a return phone call to the provider’s office to ensure authenticity.

Listed below is the information the CDC needs from the providers:

Name or Number of Affiliated Contractor
Provider Identification Number (all provider ID numbers affiliated with provider’s office)
Provider Name
Business Name
Address (where the medical records are stored)
Point of Contact (POC-the person who handles requests for medical records)
Direct Phone Number for the POC
Fax Number (direct Fax number where requests for medical records can be faxed)
E-mail address of the POC.

There are a number of ways in which this information can be provided to the CDC.

  1. Providers can send the information to the CDC directly by logging on to the provider’s public Web site at http://www.certprovider.org/ and sending an e-mail with the new address or contact information through the link posted on the site.
  2. The provider can also call the CDC Call Center to speak with a Customer Service Representative at 301.957.2380 who will update the information.
  3. For those providers with large group practices, it would be extremely helpful if this information is provided electronically in a Microsoft Excel spreadsheet or Access database format.

Remember you must also submit your updated office address, phone number, and fax numbers to CIGNA Government Services. CMS allows 90 days for you to submit these types of changes to us, your Medicare carrier/contractor.

These changes must be done by completing the CMS 855I application (Individual) or CMS 855B application (Group or Organization) application to change your information. These forms and instructions can be found on our Web site at http://www.cignagovernmentservices.com under Provider Enrollment or on the CMS Web site at www.cms.hhs.gov. If you have additional questions after reviewing these resources, please call our Provider Enrollment department at 866.520.4007 hours 9:00 a.m. - 3:00 p.m. (CST).

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Comprehensive Error Rate Testing (CERT) Program Bar Coded Cover Sheets

When the medical record request letters are sent the request includes a bar coded cover sheet. Please use the cover sheet as the first page of the records being faxed back to the CERT Documentation Contractor (CDC). The bar code on the sheet provides identifying information to the CDC and the scanners cannot read cover sheets if their print quality, especially the print quality of the bar code, is poor.

To help the scanning process run smoothly and efficiently, and to avoid having to refax records, please make sure the bar code cover sheet is clean and distinct.

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Claim Status Code/Claim Status Category Code Update Provider Types Affected

All providers submitting Health Care Claim Status Transactions to Medicare carriers, including Durable Medical Equipment Carriers (DMERCs), and Fiscal Intermediaries (FIs), including Regional Home Health Intermediaries (RHHIs)

Provider Action Needed
This is a reminder item regarding the periodic update of certain code sets used as a result of the Health Insurance Portability and Accountability Act (HIPAA). Effective January 1, 2006, the Medicare Claims processing system will update its lists of Health Care Claims Status Codes and Health Care Claims Status Category Codes with all applicable code changes posted online with the “new as of 10/05” and prior date designations.

Background
Under HIPAA, code sets that characterize a general administrative situation, rather than a medical condition or service, are referred to as non-clinical or non-medical code sets.

Claim Status Category Codes and Claim Status Codes are used in the Health Care Claim Status Inquiry and Response (276/277) transactions:

These codes are available online at: http://www.wpc-edi.com/codes/Codes.asp

Additional Information
For complete details, please see the official instruction issued to your carrier/DMERC/FI/RHHI 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 3960 in the CR NUM column on the right, and click on the file for that CR.

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

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Clarification for Carrriers and Durable Medical Equipment Regional Carriers (DMERCs) About Correction and Recoupment of Payments for Previously Processed Claims Provider Types Affected

Providers and suppliers who bill Medicare Carriers, including Durable Medical Equipment Regional Carriers
(DMERCs)


Provider Action Needed

STOP – Impact to You
This is a one-time notice that provides clarification about correction and recoupment of payments for previously processed Medicare claims.

CAUTION – What You Need to Know
Be aware of actions that could impact your payments.

GO – What You Need to Do
When a previously processed claim needs to be adjusted, a full claim adjustment must be done. This will happen regardless of whether Medicare is primary or secondary.

Background
Previously, Medicare’s CR 1523 required that carriers and DMERCs make a full claim adjustment whenever an adjustment was processed for a claim that was previously adjudicated. CR 3772 reiterates CR 1523 by requiring a full claim adjustment when money is recouped from providers whether the claim is a Medicare Secondary Payer (MSP) claim or non-MSP.

If money needs to be recouped, the previous payment is negated, and a new payment is recognized if payment is being reduced, and Medicare creates an account receivable in the amount that was overpaid. If there is no payment due, the previous payment is reversed, and an account receivable is created in the same amount as that previously paid.

Should you receive a demand letter from Medicare as a result of such an adjustment and overpayment, the
letter will identify:

If payment is made timely, Medicare will adjust its system to reflect the overpayment was made. However, if payment is not received timely, Medicare will adjust payments on future claims to obtain repayment.

Implementation
The implementation date for this instruction is January 3, 2006.

Related Instructions
Complete details of CR 1523, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Administrative Simplification - Implementation of Version 4010 of the Accredited Standards Committee X12 835 (Payment/Remittance Advice) Transaction Standard Format, may be viewed at: http://www.cms.hhs.gov/manuals/pm_trans/B0135.pdf

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

From that Web page, look for CR 3772 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 contact your carrier/DMERC via their toll free number. That number may be found at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

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Cochlear Implantation

Note: This article was revised on August 1, 2005, to correct the statement in item 3 at the top of page 3 to reflect the correct usage of the QV modifier.

Provider Types Affected
Physicians and providers billing Medicare carriers and Fiscal Intermediaries (FIs) for cochlear implantation services to Medicare patients

Provider Action Needed

STOP – Impact to You
The coverage for cochlear implantation has expanded and is effective for services performed on or after April 4, 2005.

CAUTION – What You Need to Know
CMS will cover treatment of bilateral pre- or post-linguistic, sensorineural, moderate-to-profound hearing loss for individuals with hearing test scores equal to or less than 40% correct in the best aided listening condition on tape-recorded tests of open-set sentence recognition. More detailed coverage requirements are further listed in this article.

Additionally, CMS will cover cochlear implants of individuals with open-set sentence recognition test scores of greater than 40% to less than or equal to 60% correct, where the device was implanted in an acceptable clinical trial/study. See further details listed below.

GO – What You Need to Do
This revision is a binding national coverage determination (NCD) made under section 1862(a)(1) of the Social Security Act. The remainder of this article provides more detailed billing instructions for these services.

Background
A cochlear implant device is an electronic instrument, part of which is implanted surgically to stimulate auditory nerve fibers, and part of which is worn or carried by the individual to capture, analyze, and code sound. The purpose of implanting the device is to provide awareness and identification of sounds and to facilitate communication for persons who are moderately to profoundly hearing impaired. Cochlear implant devices are available in single-channel and multi-channel models.

Additional Information
The information in this section outlines the policy guidelines for cochlear implantation coverage, the coverage criteria for an acceptable clinical trial/study, billing requirements for cochlear implantation, and a listing of Healthcare Common Procedural Coding System (HCPCS) associated with cochlear implantation.

Nationally Covered Indications
Medicare coverage is provided only for those patients who meet all of the following selection guidelines.

Criteria for Acceptable Clinical Trials and Studies
The coverage criteria that allows for services for individuals meeting the above guidelines and with hearing test scores greater than 40% and less than or equal to 60% requires the provider to participate in and the patient to enroll in an acceptable clinical trial/study, which includes the following:

Billing Requirements for Cochlear Implantation When Billing FIs and Carriers
These services should be billed on an approved electronic claim form or a paper CMS form 1500. For services performed on and after April 4, 2005:

Medicare Contractors (FIs and Carriers) pay for:

  1. Cochlear implant devices and services for moderate-to-profound hearing loss in patients with hearing test scores equal to or less than 40%.
  2. Cochlear implant devices for patients with hearing test scores of greater than 40% to less than or equal to 60% hearing provided in a clinical trial setting that is billed with the QR modifier.
  3. Other services related to cochlear implantation, but not the device itself, for patients with hearing test scores of greater than 60% hearing who are in a clinical trial. (These services must be identified with a QV modifier.)
  4. Services for patients with hearing test scores of greater than 40% to less than or equal to 60% hearing who are in a prospective, controlled comparative trial approved by CMS. (These services must be billed with the QR modifier.)
  5. Any covered diagnostic audiology or therapy services related to the cochlear implant. (The QR or QV does not need to be applied to HCPCS 92601- 92604 and 92506 and 92507.)

Also, when billing FIs for cochlear implantations, follow these additional instructions:

  1. Submit claims on the following bill types (TOB):
    1. 11x
    2. 12x
    3. 13x
    4. 83x (for non-OPPS providers)
    5. 85x
  2. Report diagnosis code V70.7 (Examination of participant in clinical trial) as the second or subsequent diagnosis code, along with the appropriate principal diagnosis code, for patients in a clinical trial.

HCPCS Associated with Cochlear Implantation
Some of the Healthcare Common Procedural Coding System (HCPCS) codes used when billing for cochlear implant services and devices provided by audiologists or physicians, and for the services of 92506 and 92507, by speech language pathologists include:

  1. 69930 – Cochlear device implantation, with or without mastoidectomy.
  2. L8614 – Cochlear Device/System
  3. L8619 – Cochlear implant external speech processor, replacement.
  4. L7500 – Repair of prosthetic device, hourly rate (excludes V5335 repair of oral laryngeal prosthesis or artificial larynx).
  5. L7510 – Repair of prosthetic device, repair or replace minor parts.
  6. 92506 – Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status.
  7. 92507 – Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation); individual.
  8. 92601 – Diagnostic analysis of cochlear implant, patient under 7 years of age; with programming.
  9. 92602 – Diagnostic analysis of cochlear implant, patient under 7 years of age; subsequent programming. (Do not report 92602 in addition to 92601).
  10. 92603 – Diagnostic analysis of cochlear implant, age 7 years or older; with programming.

Note: Codes 92601 and 92603 describe post-operative analysis and fitting of previously placed external devices, connection to the cochlear implant, and programming of the stimulator.

Codes 92602 and 92604 describe subsequent sessions for measurements and adjustment of the external transmitter and re-programming of the internal stimulator.

Medicare beneficiaries not meeting all of the coverage criteria for cochlear implantation specified above, or the specific coverage criteria for cochlear implantation in the context of a clinical trial/study, also specified above, are deemed not eligible for Medicare coverage under section 1862(a)(1)(A) of the Social Security Act.

A National Coverage Determination revision is binding on all carriers, FIs, quality improvement organizations, health maintenance organizations, competitive medical plans, health care prepayment plans, The Medicare Appeals Council, and administrative law judges (see 42 CFR section 405.732, 405.860).

Because it expands coverage, the NCD is also binding on a Medicare advantage organization. In addition, an administrative law judge may not review an NCD. (See section 1869(f)(1)(A)(i) of the Social Security Act.)

The official instruction issued to your FI or 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 3796 in the CR NUM column on the right, and click on the file(s) for that CR. You will note two files for CR3796. The file with transmittal number 42 is the NCD itself and the file with transmittal number 601 contains the claims processing instructions.

For additional information relating to this issue, please refer to your local carrier or FI. To find the toll free
phone number for your local carrier, go to: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

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Coverage and Billing for Ultrasonic Stimulators for Nonunion Fracture Healing

Note: This article was revised on July 15, 2005, to show that, effective for services performed on or after April 27, 2005, that meet the coverage criteria for CPT code 20979, payment will be made by Medicare carriers and RHHIs. Originally, the article incorrectly said carriers and FIs.

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 & RHHIs 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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CY2006 Part B Fee Schedule and Participation Enrollment Material

Each year CIGNA Government Services conducts an open enrollment period in order to provide eligible physicians with the opportunity to make their calendar year Medicare participation decision by December 31. In order to facilitate enrollment each year, CIGNA Government Services delivers this information, along with the Part B fee schedule, to all Medicare providers in Idaho, North Carolina, and Tennessee.

The Centers for Medicare & Medicaid Services (CMS) has asked CIGNA Government Services, along with all ther Part B carriers, to once again furnish the Part B fee schedule and participation enrollment information for CY2006 on CD-ROM rather than printed format. CMS continues to see a cost savings associated with producing this information on CD-ROM and very positive feedback from the provider community.

The CD-ROM is less expensive to produce and mail than the printed format, and it also has the ability to furnish providers with supplemental information that would not be mailed otherwise, including archived issues of the Part B Medicare Bulletin, HIPAA information, and general Provider Enrollment information. All of the items on the CD-ROM, including the fee schedules, can also be easily printed and distributed throughout a provider’s office.

The CD-ROM, which is expected to be delivered to all providers by mid-November, will include an order form in the envelope for those providers unable to use the CD-ROM on their computer system. No pre-orders will be accepted. Additional information will be made available in future editions of the Medicare Bulletin, through the CIGNA Government Services Web site (www.cignagovernmentservices.com), and through CIGNA Medicare ListServ announcements.

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Medicare Announces End of HIPAA Contingency Plan for Claims Submissions

Provider Types Affected
All Medicare physicians, providers, and suppliers who continue to submit electronic claims in non-compliant HIPAA formats

Impact on Providers

STOP – Impact to You
The Centers for Medicare & Medicaid Services (CMS) is ending its contingency plan that allowed providers to submit claims formats electronically that were not in the format required by the Health Insurance Portability and Accountability Act (HIPAA). As of October 1, 2005, all providers must use the HIPAA compliant format for claims submitted to Medicare. In June, 2005, over 99% of claims submitted to Medicare were in HIPAA compliant formats.

CAUTION – What You Need to Know
Non-compliant claims submitted to Medicare on or after October 1, 2005, will be rejected and returned to the provider.

GO – What You Need to Do
To assure that your claims are processed timely and that your cash flow is not interrupted, be sure to submit HIPAA compliant claims as of October 1, 2005.

Background
The Health Insurance Portability and Accountability Act (HIPAA) regulation required claims be submitted electronically effective October 16, 2003, in a format adopted for national use. To allow additional time for entities to become compliant, CMS established a contingency plan to continue Medicare fee-for-service (FFS) payments beyond October 16, 2003, based on non-compliant formats.

In a measured step toward full compliance, CMS announced that effective July 1, 2004, non-compliant electronic claims would be paid after 27 days (the same as paper claims). Further information on the contingency plan may be found in Medlearn Matters articles MM2981 and SE0414 at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM2981.pdf and http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0414.pdf respectively. These articles also provided important information to assist those few remaining providers who need to begin sending HIPAA compliant claims.

Through provider outreach activities, CMS has seen a steady decrease in the number of non-HIPAA compliant providers. In June 2005, fewer than 4% of Medicare FFS billing providers submitted electronic non-HIPAA compliant claims.

Considering the number of all active Medicare providers, it is clear that the Medicare provider community at large has done an outstanding job of adopting the HIPAA claims formats.

CMS believes that the industry has surpassed critical mass in both the total number of compliant claims and number of providers capable of sending compliant claims. Therefore, Medicare will end its HIPAA contingency Plan for claims submission on October 1, 2005.

Claims that are not compliant as of October 1, 2005 will be returned to the provider for submission as a compliant claim. But, prior to October 1, if you are not submitting HIPAA compliant claims your Medicare carrier, Durable Medical Equipment Regional Carrier (DMERC), or intermediary will contact you directly regarding the need to become compliant to offer further assistance.

CMS expects to end the contingency plan for other transactions in the near future. The remittance advice (835) is our next target to end the full contingency. We will continue to monitor progress toward use of the HIPAA standards to guide in that decision.

Additional Information
As previously mentioned, further information on the contingency plan and on help in becoming compliant may be found in Medlearn Matters articles MM2981 and SE0414 at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM2981.pdf and
http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0414.pdf respectively.

As Medlearn Matters article MM2981 indicates Medicare carriers and intermediaries can provide free/low cost software that will enable submission of HIPAA compliant claims electronically. If you need such software, contact your carrier or intermediary at their special EDI telephone number. Your carrier/intermediary will also have a list of vendors who may assist you in submitting compliant claims.

For those billing Medicare Part A (including hospital outpatient services), a list of these carrier/intermediary
numbers by State is available at: http://www.cms.hhs.gov/providers/edi/anum.asp

For those billing Medicare Part B, you may find those numbers listed by State at: http://www.cms.hhs.gov/providers/edi/bnum.asp

For additional information on HIPAA, visit the CMS Web site at: http://www.cms.hhs.gov/HIPAAGenInfo/default.asp

To view the revised manual chapter for the claims receipt rules, see Chapter 1, Section 80.2.1.2, which can be found in Pub 100-04, the Medicare Claims Processing Manual. This can be found at:
http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp

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Enforcement of Hospital Inpatient Bundling: Carrier Denial of Ambulance Claims During an Inpatient Stay

Provider Types Affected
Independent ambulance services suppliers billing Medicare carriers

Provider Action Needed

STOP – Impact to You
Independent ambulance services suppliers cannot bill Medicare carriers for ambulance services that they provide to hospital inpatients (on or after 12/31/04), unless the services are provided either:

If services other than these two scenarios are billed separately as Part B, the bills will be rejected. (There are exceptions for patients of long-term care hospitals, inpatient psychiatric facilities, or inpatient rehabilitation facilities as discussed later in this article.)

CAUTION – What You Need to Know
If an ambulance supplier bills Medicare and is paid prior to Medicare’s receipt of the hospital inpatient claim, Medicare will recover the improper payment from the ambulance supplier.

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

Background
The Centers for Medicare & Medicaid Services (CMS) is strengthening its claims processing edits to detect incorrect payments to detect and prevent (or correct) improper payments to ambulance suppliers for transporting hospital inpatients. In CR 3933 (on which this article is based), CMS wants to make you aware of the rules that govern payment for the ambulance services that such suppliers provide to hospital inpatients.

Sections 1882(a)(14), 1886(d) and (g) of the Social Security Act, and Code of Federal Regulations (CFR) 411.15(m) disallow payment for ambulance services furnished to hospital inpatients on dates that fall between the patients’ admission and discharge dates, unless the hospitals bills for services directly or makes special arrangements for the services with the independent ambulance supplier.

As a result, the independent supplier of ambulance services must look to the hospital for payment for these services, rather than to the Medicare beneficiary or carrier. More specifically, with the exception of services on the admission and discharge dates, all ambulance transportation provided to hospital inpatients must be bundled into the hospital bill. Medicare carriers will reject any bill for ambulance services that are provided to a hospital inpatient on a date that falls between their admission and discharge dates.

In summary, here is how this process works. Effective for dates of service on or after December 31, 2004, Medicare’s systems search the paid claim histories of independent suppliers of ambulance services and compares the line item service dates (line items with specialty codes of “59”) on the ambulance claims to the admission and discharge dates on hospital inpatient stays. Medicare then rejects the line items when an ambulance line item service date falls between the admission and discharge dates on a hospital inpatient bill.

And, if Medicare receives the ambulance claim prior to receiving the hospital inpatient bill, it performs the same search and if the ambulance claim falls within the admission and discharge dates, the ambulance claim is adjusted and the incorrect payment for the ambulance service will be recovered from the ambulance supplier.

Note: There is a special group of ambulance transportation payment situations that are permitted for inpatients of certain facilities. Specifically, these payments are permitted when the beneficiary is an inpatient of a long term care facility (LTCH), inpatient psychiatric facility (IPF), or inpatient rehabilitation facility (IRF), and is transported by ambulance to an acute care hospital to receive specialized services and the service date falls within the occurrence span code 74 (non-covered level of care) from and through dates, plus one day, on a LTCH, IPF, or IRF bill.

Finally, when Medicare rejects/adjusts an ambulance claim, the carrier will indicate, by using Remittance Advice Remark Code M2: “Not paid separately when the patient is an inpatient;” that:

  1. The ambulance transportation occurred during a hospital inpatient stay (on a date that falls within the admission and discharge dates of a covered hospital inpatient stay), and is not separately payable, or
  2. The service date falls outside the occurrence span code 74 (non-covered level of care) from and through dates plus one day on a LTCH, IPF or IRF, and is not separately payable.

In addition, the carrier will also indicate the adjustment using Remittance Advice (RA) Adjustment Reason Code 97 “Payment is included in the allowance for another service/procedure.”

Additional Information
You can find more information about the payment of ambulance claims during an inpatient stay by going to:
http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

From that Web page, look for CR 3933 in the CR NUM column on the right, and click on the file for that CR.

You might also want to look at the Medicare Claims Processing Manual, Chapter 3 (Inpatient Part A Hospital) Section 10.5 (Hospital Inpatient Bundling). You can find this manual chapter as an attachment to CR3933.

Finally, 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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Comprehensive Error Rate Testing (CERT) Program Explanation of Differences in Contractors

CERT Documentation Contractor (CDC): The CDC is responsible for the request and receipt of medical record documentation from providers (hospitals, doctors, and durable medical equipment suppliers) to support the claims being reviewed by the CRC. The CDC also operates a call center, scans all medical record documentation received, verifies that the correct documentation has been sent by providers, and has a problem resolution department that handles problem cases.

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Medical Review Frequently Asked Questions

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

  1. Low Osmolar Contrast

Q: How are providers supposed to bill with the new low osmolar contrast codes?

A: Previously, there were local coverage decisions on low osmolar contrast for Tennessee and North Carolina but these have since been retired (see attached).

http://www.cignagovernmentservices.com/partb/lmrp_lcd/tn/archive/96-03-04.html

http://www.cignagovernmentservices.com/partb/lmrp_lcd/nc/archive/92-02.html

CIGNA Government Services published an article 041505 reflecting the change in the codes as directed by CMS. Attached is that article we published in addition to the CMS Medlearn Matters article explaining the change: http://www.cignagovernmentservices.com/articles/April05/cope2347.html

http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3748.pdf

These articles direct:
Effective with April 1, 2005 (date of service):
HCPCS codes Q9945 – Q9951 will replace codes A4644–A4646; except that Hospital outpatient departments shall continue to bill codes A4644–A4646 (Change Request 3748: http://www.cms.hhs.gov/manuals/pm_trans/R502CP.pdf).

As there are specific codes with corresponding prices, providers do not need to submit invoice information. We do suggest providers include in the notepad of their claim the total dosage given to the patient. Pricing per number of service for each code is available on the CIGNA Government services Web site via the following link:
http://www.cignagovernmentservices.com/partb/fsch/2005/Q2/ASP.html

All of the new codes pay per milliliter (except for Q9954 which is per 100 ml of oral magnetic resonance contrast agent). The number of services you should bill is equal to the number of milliliters given to the patient of the specific low osmolar contrast concentration/preparation you gave the patient (except for Q9954 as explained above). For example, Q9945 is for products with a concentration of iodine up to 149mg/ml whereas Q9946 is for products containing an iodine concentration of 150-199mg per milliliter (150-199mg/ml). So, you have to know which product/preparation/concentration of drug you are using and how many milliliters were given to the patient in order to bill the right number of services and get the right payment.

  1. Nursing Home Visits

Q: How often can a nursing home patient be seen if the physician is just managing the care. I know that the patient can be seen at any time if there is a new problem for the physician to address but for managing the care does it have to be every 30 days?

A: Attached is a link to CMS Publication 100-4, the Medicare Claims Processing Manual, Chapter 12, Section 30.6.13, Subsection A and B: http://www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf

It addresses coverage and frequency of visits. Please note it says:

Payment is made for visits required to monitor and evaluate residents at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. These visits and all other medically necessary visits for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member are covered under Medicare Part B.

Please note this section is in reference to visits required by “Federal Regulations.” Please note these are not state regulations.

Additionally, please see CMS Publication 100-4, the Medicare Claims Processing Manual, Chapter 12, Section 30.6.13 via the following link: http://www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf

It states:
The required initial comprehensive visit in a skilled nursing facility (SNF) and nursing facility (NF) is the initial visit during which the physician completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the resident. This must take place no later than 30 days after admission.

 

  1. Nursing Home Visits

Q: Can a nursing home code and a hospital discharge code be billed the same date if the physician only sees the patient in the hospital and does not go to the nursing home?

A: The physician cannot bill for both codes unless the physician has a face-to-face visit with the patient at both places of service. If a physician prepares nursing home admit orders as part of the discharge from the hospital but does not see the patient at the nursing home that date, then the nursing home orders would be considered part of the discharge services. Furthermore, the discharge visit requires a final examination of the patient at the hospital, but the nursing home codes specifically require all three key components be performed (at the nursing facility place of service) and billed at the level medically necessary for that patient and as supported (met/exceeded) by the documentation in the medical record.

  1. Internal Medicine and Family Practice Visits Same Date of Service

Q: If an internist and a family practitioner of the same group saw the same patient on the same date of service, would both be reimbursed?

A: This is addressed in CMS Publication 100-4, the Medicare Claims Processing Manual, Chapter 12, section 30.6.5 via the following link: http://www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf

Please note it states:

Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group.

Please note it should be medically necessary for the patient to have both a family practitioner and internist seeing the same patient. Each doctor would need to be managing different aspects of the patient’s care.

Please also see CMS Publication 100-4, Chapter 12, Section 30.6.9, Subsections B and C via the following link: http://www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf

It says:

B - Two Hospital Visits Same Day

Carriers pay a physician for only one hospital visit per day for the same patient, whether the problems seen during the encounters are related or not. The inpatient hospital visit descriptors contain the phrase “per day” which means that the code and the payment established for the code represent all services provided on that date. The physician should select a code that reflects all services provided during the date of the service.

C - Hospital Visits Same Day But by Different Physicians

In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, carriers do not pay physician B for the second visit. The hospital visit descriptors include the phrase “per day” meaning care for the day.

If the physicians are each responsible for a different aspect of the patient’s care, pay both visits if the physicians are in different specialties and the visits are billed with different diagnoses. There are circumstances where concurrent care may be billed by physicians of the same specialty.

  1. “Incident To”

Q: When a patient is being seen incident to the physician by a non-physician practitioner, is there a requirement the physician sees the patient every 3rd visit?

A: There is guidance in the CMS Manuals stating the physician should see the patient receiving “incident to” services at a frequency to stay current of the patient’s status: “where the physician performs an initial service and subsequent services of a frequency which reflect his/her active participation in and management of the course of treatment. (However, the direct supervision requirement must still be met with respect to every nonphysician service).”

See CMS Publication 100-2, the Medicare Benefits Policy Manual, Chapter 15, Section 50.1 for the above.

Previously, an article published in the July-August 2001 issue of the Medicare Bulletin advised that if the qualified employee performing “incident to” services is “not a nurse practitioner, a physician assistant, a clinical nurse specialist, a certified nurse midwife, or a certified registered nurse anesthetist, the physician/practitioner must perform the initial service and they should perform subsequent services at a frequency of one out of every three.”
http://www.cignagovernmentservices.com/partb/bltin/all/01bltin/01_4/forall/b0104b07b.html

This “one in three” rule is no longer required by CIGNA Government Services, but the ancillary personnel referred to in this excerpt (i.e. those that do not have a benefit category under the Medicare program such as nurses, medical assistants, etc.) cannot bill “incident to” at anything other than the 99211 CPT code level.

  1. Drug Adminstration Codes

Q: With the new drug administration codes, how do you bill if more than one infusion is performed?

A: If a combination of chemotherapy drugs, nonchemotherapy drugs, and/or hydration is administered by infusion, the initial code that best describes the primary or major service at that encounter should always be billed irrespective of the order in which the infusions occur. The initial code is the code that best describes the primary or major service the patient is receiving and the additional codes are secondary to the initial code. Only one initial drug administration service code should be reported per patient per day, unless protocol requires that two separate IV sites must be utilized. The initial infusion codes for chemotherapy, nonchemotherapy and hydration are G0359, G0347 and G0345 respectively.

Providers can view the following resource on the CMS Web site regarding the 2005 drug administration coding revisions and the chemotherapy demonstration project: http://www.cms.hhs.gov/medlearn/cmsinit.asp Medlearn Matters article MM3818 can be viewed using the link below. This article advises on other important revisions to the 2005 Drug Administration codes effective 051605. http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3818.pdf

  1. New Patient Visits

Q: Regarding a patient seen in a multispecialty practice, if a patient is seen by a specialist such as a neurologist for the first time at this group, then the same patient is seen by an internist at the same group several days later, can each physician bill a new patient visit?

A: Historically, CMS has defined a new patient as one not having received services from a physician or another physician of the same specialty within the same group practice in the past three years; and CIGNA Government Services would observe the same on claim reviews.

Therefore, in your example, both physicians could bill a new patient visit.

  1. Radiologists

Q: Can a radiologist order additional tests if medically necessary as long as they document the medical necessity and write an order?

A: It is our interpretation that an order for additional tests can be given only by the treating physician. NOTE: A radiologist performing a therapeutic interventional procedure is considered a treating physician. A radiologist performing a diagnostic interventional or diagnostic procedure is not considered a treating physician.)

The specific regulatory language from the Code of Federal Regulations (42 CFR 410.32(a)) states as follows: All diagnostic X-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.

CMS does allow for the following exception for screening mammograms (see CMS Publication100-4, the Medicare Claims Processing Manual, Chapter 18, Section 20.6B: http://www.cms.hhs.gov/manuals/104_claims/clm104c18.pdf

It states:
A radiologist who interprets a screening mammography is allowed to order and interpret additional films based on the results of the screening mammogram while a beneficiary is still at the facility for the screening exam. When a radiologist’s interpretation results in additional films, Medicare will pay for both the screening and diagnostic mammogram.

Carrier Claims
For carrier claims, providers submitting a claim for a screening mammography and a diagnostic mammography for the same patient on the same day, attach modifier “-GG” to the diagnostic mammography. A modifier “-GG” is appended to the claim for the diagnostic mammogram for tracking and data collection purposes. Medicare will reimburse both the screening mammography and the diagnostic mammography.

See also CIGNA Government Services Web site for the Radiology Provider Specialty Manual:
http://www.cignagovernmentservices.com/partb/specman/pdf/Radiology.pdf

  1. Corrections in the Medical Record

Q: What is acceptable for correcting medical records/documentation and what is the time period allowed?

A: See via the attached link a previously published article regarding delayed entries and (from the July/August 2001 issue of the Medicare Bulletin):
http://www.cignagovernmentservices.com/partb/bltin/all/01bltin/01_4/forall/b0104b08b.html

These are not Medicare regulations but would be our expectations on claim reviews.

Please note these references state:

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Information and Education Resources for Medicare Providers, Suppliers, and Physicians

Provider Types Affected
All Medicare physicians, providers, and suppliers

Provider Action Needed
This article is informational only and is intended to notify Medicare physicians and other providers about the information and education resources that the Centers for Medicare & Medicaid Services (CMS) have developed to help meet their Medicare business needs.

Background
One of the goals of CMS is to give Medicare’s 1.2 million physicians and other providers the information they need to understand the program, be aware of changes, and bill correctly. By making information and education resources easily accessible, understandable, and as timely as possible, physicians and other providers will be better able to submit bills correctly the first time, receive reimbursements more quickly, and spend less time dealing with paperwork. All of this can result in more time to spend on patient care. We are committed to accomplishing this goal by offering Medicare physicians and other providers a variety of educational products and services and using various information delivery systems to reach the broadest and most appropriate audiences possible.

Three-Pronged Provider Information and Outreach Approach
CMS relies on the cooperative efforts of its Medicare contractors, Regional Offices, and Central Office provider communications staff to deliver a seamless information and outreach approach to Medicare physicians and other providers.

1) Medicare Contractors
Medicare contractors, also called Fiscal Intermediaries and Carriers, serve as the primary point of contact for most Medicare physicians and other providers. These contractors provide toll-free telephone lines for inquiries, conduct outreach and education, and often interact with local professional associations. Their outreach and education activities include in-person seminars, bulletins and newsletters, speaker appearances, and quick dissemination of timely information via Web sites and provider-specific electronic listservs (mailing lists).

If you have questions about the Medicare Program, you should first get in touch with your Fiscal Intermediary or Carrier. To find Fiscal Intermediary and Carrier contact information, please visit:
http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

2) CMS Regional Offices
Staff at CMS’ Regional Offices are active with the physician and other provider communities at State and local levels through their relationships with State and local associations and big billers, and through outreach activities such as hosting provider-oriented meetings and furnishing speakers at professional conferences. CMS’ Regional Offices also provide oversight of Medicare contractors and play a key role in resolving issues that physicians and other providers cannot get resolved.

CMS Regional Offices are located at various locations around the country. You can find their contact information at: http://www.cms.hhs.gov/about/regions/professionals.asp

3) CMS Central Office in Baltimore, Maryland
The provider communications staff at the CMS Central Office work closely with both Medicare contractor and Regional Office staff to ensure that consistent and coordinated Medicare information and resources are available to all physicians and other providers. Education and outreach activities from the CMS Central Office focus on accuracy, consistency, and timeliness. Given the hectic schedules of today’s health care professionals, most of our current initiatives are aimed at fostering a “self-service” environment so that physicians and other providers can access information and education 24 hours a day, 7 days a week. As a result, we have significantly increased the use of the Internet as a key tool for continuous-improvement customer service.

Our efforts have resulted in a variety of products and services, such as:

From the CMS Home Page at http://www.cms.hhs.gov, you can access select physician and other provider pages from the “Professionals” drop-down menu. You can also see a complete listing of available provider and supplier Web pages by clicking on http://www.cms.hhs.gov/providers or http://www.cms.hhs.gov/suppliers.

Physician and Other Provider Feedback
Although we try our best to be responsive to the Medicare physician and other provider community’s education and information needs, we cannot do it alone. Your feedback on the effectiveness and usefulness of our educational resources is very important to us as it helps ensure that we are “getting it right.” Please submit your comments or suggestions at http://www.cms.hhs.gov/providers by selecting “Feedback” from the blue template located at the top of the page. There is also a feedback link on the Medlearn Web pages for your suggestions on new educational products at: http://www.cms.hhs.gov/medlearn/suggestform.asp. We look forward to hearing from you!

CMS receives in excess of 2 billion claims per year from Medicare Fee-for-Service physicians, providers, and suppliers. CMS implemented the CERT program as part of its efforts to comply with the Improper Payment Information Act (IPIA). The CERT program calculates the error rate for Medicare claims submitted to Carriers, Durable Medical Equipment Regional Carriers (DMERCs), and Fiscal Intermediaries (FIs) to improve the quality and accuracy of Medicare Claims submission, processing, and payments. The CERT Documentation Contractor is responsible to CMS and the CERT program for the request, receipt, imaging and storage of medical records. As part of the Medicare program, it is of the utmost importance that providers assist CMS in its error rate reduction efforts by complying with requests for medical records made by the CERT Documentation Contractor. If a provider fails to submit the documentation requested by the CERT Documentation Contractor, the claim is scored as an error and an overpayment letter requesting refund of payment received for the “erroneous” claim.

The CERT Documentation Contractor Call Center may be reached at:
Phone: 301.957.2380 Fax: 240.568.6222

Service Representatives are available between the hours of 8:00 a.m. to 8:00 p.m. Eastern Time. Fax is the preferred method for delivery of requested medical records. Lengthy medical record documentation may be sent via mail to their office address at:
CERT Documentation Office
9090 Junction Drive Suite 9
Annapolis Junction, Maryland 20701.

A provider who wishes to update or change contact information for the CERT program should contact their Carrier/DMERC/FI as well as the CERT Documentation Contractor. In the future providers will be able to update or make changes to their information on the CERT provider’s Web site at: www.certprovider.org.

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Information Regarding Article SE0516

Article SE0516 has been removed from the Medlearn Matters Web site. This article was also published in the June 2005 Medicare Bulletin. The information in that article is no longer valid and should be disregarded.

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Low Osmolar Contrast Media (LOCM): Payment Criteria and Payment Level

Provider Types Affected
Physicians, suppliers, and providers who bill Medicare carriers for LOCM

Provider Action Needed

STOP – Impact to You
CMS has eliminated the restrictive criteria (see Background section) for the payment of LOCM for nonhospital patients, effective January 1, 2005. CMS has additionally established new codes and a new payment methodology for LOCM. The payment methodology is effective as of April 4, 2005.

CAUTION – What You Need to Know
HCPCS code replacement

GO – What You Need to Do
Be sure billing staff are aware of these changes to ensure prompt and accurate payment of your claims for LOCM.

Background
Effective January 1, 2005, payment for LOCM furnished as part of medically necessary imaging procedures for intrathecal procedures and in intraarterial and intravenous injections will be made regardless of whether any of the five medical conditions listed in previous instructions are present. These previously restrictive criteria included:

Medicare carriers will use status indicator “E” for HCPCS codes Q9945-Q9951 and these codes are being updated on the Medicare Physician Fee Schedule effective for services on or after April 1, 2005.

Effective April 4, 2005, payment by carriers for LOCM is based on the average sales price (ASP) plus six percent, in accordance with the standard method for drug pricing established by the Medicare Modernization Act (MMA) for other than hospital outpatient claims. For services during the period of January 1, 2005 to April 3, 2005, inclusive, payment is made in accordance with the established payment for calendar year 2004.

Additional Information
Medicare Part B drug pricing files are available at:
http://www.cms.hhs.gov/providers/drugs/default.asp on the CMS Web site.

Medlearn Matters article MM3748 is available at:
http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3748.pdf

The official instruction (CR3902) issued to your carrier regarding this change can be found by going to:
http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

From that Web site, look for CR3902 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 at their toll-free number,
which may be found at: http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf

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

Note: This article was revised on July 1, 2005. The original article indicated that Chapter 23, Section 10.2 of the Medicare Claims Processing Manual was revised as a result of CR3888. In fact, the manual was not revised, but was only referenced by CR3888.

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, non-physician 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

The update should be available at this site in June.

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

Related Instructions
The ICD-9-CM codes are updated annually as stated in 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). That manual may be accessed at: http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp on the CMS Web site.

The official instruction issued to your carrier 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 Preventive Services Resources CD ROM Now Available

The Division of Provider Information Planning & Development (DPIPD) staff of CMS’ Provider Communication Group is pleased to announce the availability of the following new educational product for providers:

The Medicare Preventive Services Resources for Physicians, Providers, Suppliers, and Other Health Care Providers CD ROM contains:

  1. The Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Health Care Providers,
  2. five brochures (Expanded Benefits, Glaucoma Screenings, Cancer Screenings, Bone Mass Measurements, and Adult Immunizations), and
  3. Quick Reference Information: Medicare Preventive Services chart. These resources are useful for Medicare fee-for-service (FFS) physicians, providers, suppliers, and other health care professionals that bill Medicare FFS contractors (Fiscal Intermediaries and Carriers). This new product can be ordered, free of charge, from the Medicare Learning Network’s Medlearn product ordering system at www.cms.hhs.gov/medlearn which is located on the CMS Web site.

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Medicare Provider Feedback Town Hall Meeting

September 12, 2005
2:00 p.m. - 4:00 p.m. EST

The Centers for Medicare & Medicaid Services (CMS) would like to request your participation in a Town Hall meeting on September 12, 2005, from 2:00 p.m. to 4:00 p.m. (Eastern Standard Time). The meeting will be held in the auditorium at the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244 and by teleconference. The purpose of the meeting is to solicit the opinions of individual Medicare FFS physicians, providers and suppliers. The meeting will provide the Agency with an open and public venue to interact with individual Medicare providers and suppliers and obtain their feedback on a variety of Medicare policy and operational issues. All providers and suppliers that participate in the Medicare program, including physicians, hospitals, home health agencies, and other third-party billers, are invited to attend this meeting.

The agenda items for the meeting will be available in the August 26, 2005, Federal Register Notice announcing the meeting. CMS will also hold a question and answer session that offers meeting participants an opportunity to provide feedback, as well as make suggestions regarding how this process can be improved.

Meeting Registration Details
Registration for the meeting will open on August 19, 2005. Individuals interested in attending the meeting and providing feedback, either in person or by teleconference, must complete the on-line registration located at http://registration.mshow.com/cms2/. The on-line registration system will capture contact information and practice characteristics, such as names, email addresses, and provider/supplier types. Registered participants may be contacted for follow-up meetings to solicit additional opinions and clarify any issues that may arise during the September 12 Town Hall meeting.

The on-line registration system will generate a confirmation page to indicate the completion of your registration. Please print this page as your registration receipt. We encourage you to complete your registration as soon as possible. Registration after 12 p.m. on September 9, 2005, will delay confirmation and you may not be permitted entrance to the building. However, registrations received after September 9, 2005 will enable individuals to listen to a digital audio recording of the meeting. The digital audio recording will be available hours after the meeting and can be accessed through midnight on September 14, 2005, by dialing 1.800.642.1687 and entering the Conference ID 7970566.

Meeting Participation Details
The meeting will be held in a Federal Government building; therefore all persons attending the meeting in person will be required to show a photographic identification, preferably a valid driver’s license, and be listed on an approved security list before entering.

Those participating by teleconference should dial: 1.877.357.7851 and enter the Conference ID: 7970566.

Note: TTY Communications Relay Services are available for the Hearing Impaired. For TTY services dial 7.1.1 or 1.800.855.2880, and for Internet Relay services visit http://www.consumer.att.com/relay/which/index.html. A Relay Communications Assistant will be available to assist you.

Additional Questions/Information
For questions or additional information about the Medicare Provider Feedback Town Hall Meeting, please send an email to MFG@cms.hhs.gov.

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Medicare’s Common Working File (CWF) Expansion of Duplicate Claim Edit for Clinical Diagnostic Services

Note: This article was revised on August 4, 2005, to reflect that the correct Web address for CR3551 is
http://www.cms.hhs.gov/manuals/pm_trans/R124OTN.pdf

Provider Types Affected
Clinical laboratories billing Medicare carriers for laboratory services

Provider Action Needed

STOP – Impact to You
Effective January 1, 2006, the Medicare system’s edit to check for duplicate claims for referred clinical diagnostic laboratory services to more than one carrier will be modified to include all claims, with or without the “90” modifier.

CAUTION – What You Need to Know
Claims submitted, with or without the “90” modifier, for referred clinical diagnostic laboratory services will be identified as “duplicate claims” when the involved claims contain different carrier numbers and all of the following data matches in the claim fields: (a) Beneficiary Name; (b) Beneficiary Health Insurance Claim Number (HICN); (c) Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code; and (d) Date of Service

GO – What You Need to Do
Affected providers should be aware of this change.

Background
The Centers for Medicare & Medicaid Services (CMS) issued CR 3551, Transmittal 124, on October 29, 2004, to implement a new edit in Medicare’s systems, effective April 1, 2005, to check for duplicate claims for referred clinical diagnostic laboratory services and purchased diagnostic services submitted by physicians/suppliers to more than one carrier.

This edit for clinical diagnostic laboratory services and purchased diagnostic claims, which was implemented on April 4, 2005, did not edit line items that contained the “90” modifier. When performing the data matching, the Medicare duplicate claim edit for referred clinical diagnostic laboratory performed the matching on the claim fields: (a) Beneficiary Name; (b) Beneficiary Health Insurance Claim Number (HICN); (c) Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code; (d) Date of Service; and (e) CPT/HCPCS Code Modifier. That edit was not applied to claims with a “90” modifier.

Medicare will modify the duplicate claim edit to reject all clinical laboratory services submitted to carriers when it has been determined that another carrier has already paid for the same service on the same date of service, with the exception of those claims containing the “91” modifier. This modified edit will apply to all laboratory claims with dates of service on or after January 1, 2006.

When claims are denied as a result of this edit, Medicare carriers will use remark code N347 on the remittance advice to show “Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer.”

Note: Repeat clinical laboratory services for the same beneficiary on the same date of service are identified by the “91” modifier. When performing the data matching, the CWF duplicate claim edit for referred clinical diagnostic laboratory service will not include the “91” modifier on referred laboratory claims in the matching criteria, but will perform matching on all others as specified above.

The CWF duplicate claim edit will only apply to claims containing a CPT code that is included on the clinical laboratory fee schedule (available on the CMS clinical laboratory Web site at: http://www.cms.hhs.gov/suppliers/clinlab/default.asp), or a HCPCS code that is included on the Abstract File for Purchased Diagnostic Tests/Interpretations implemented in April 2005.

Implementation Date
The implementation date for this instruction is January 3, 2006.

Additional Information
CR 3551, Transmittal 124, Common Working File (CWF) Duplicate Claim Edit for Referred Clinical Diagnostic/Purchased Service may be viewed at http://www.cms.hhs.gov/manuals/pm_trans/R124OTN.pdf on the CMS Web site.

The related Medlearn Matters article may be viewed at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3551.pdf on the CMS Web site.

For complete details on this change, please see the official instruction issued to your carrier. 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 3946 in the CR NUM column on the right, and click on the file for that CR.

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

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More Web-Based Educational Products Available on Medicare Prescription Drug Coverage – The Fifth in the Medlearn Matters Series

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

Important Points to Remember