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October 2005 Part B Medicare Bulletin

Posted October 4, 2005

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Clarification on Part D and Fee–For–Service (FFS) Providers, New Web–based Educational Products, and the Latest Information on Medicare Prescription Drug Coverage – The Seventh in the Medlearn Matters Series

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

Important Points to Remember

Clarifying Information for Fee–For–Service (FFS) Medicare Providers
Billing for Drugs Covered Under Part D
There has been some confusion among FFS providers regarding their ability to bill drugs covered under Part D, commonly referred to as “Medicare Prescription Drug Coverage.” In short, being an enrolled provider in the FFS program does not impart Part D–related billing privileges. Medicare Part B covers a limited number of prescription drugs and biologicals. Currently, covered Medicare drugs generally fall into three categories:

• Drugs furnished incident to a physician’s service;
• Drugs furnished through a Medicare Part B covered item of durable medical equipment (DME); and
• Drugs specifically covered by statute (for example, oral immunosuppressive drugs).

These drugs continue to be covered and paid for under the FFS Medicare program (i.e., Part B) and FFS providers (e.g., physicians, hospitals, and pharmacies) will continue to bill their Carriers, Fiscal Intermediaries, and Durable Medical Equipment Regional Carriers (DMERCs) for these drugs. This coverage under Part B continues after the January 1, 2006, effective date for Part D. (For a more detailed discussion of Medicare Part B covered drugs, see http://www.cms.hhs.gov/providers/drugs/ on the CMS Web site.)

How Medicare Prescription Drug Coverage Will be Administered
Medicare prescription drug coverage under Part D will be administered through Medicare Advantage Prescription Drug Plans (MA–PDs) and Prescription Drug Plans (PDPs). For a person with Medicare who joins an MA or a PDP, their provider must have a contractual relationship with that MA–PD or PDP to bill and receive payment from the MA–PDP or PDP for that individual’s covered prescription drugs. This is true regardless of whether or not the provider is enrolled in the FFS Medicare program and billing FFS Medicare for Medicare Part B covered drugs.

Example: Suppose a pharmacy is currently receiving payment under Medicare Part B for an individual’s Medicare Part B covered drug, albuterol, delivered through a nebulizer, which is considered to be DME. The pharmacy would, as they do today, bill the local DMERC for this drug. The same individual has joined a PDP and has coverage of albuterol delivered through a metered dose inhaler (which is not considered DME under Part B). The pharmacy can only bill the MA–PD or PDP for covered albuterol delivered through a metered dose inhaler if the pharmacy has a contractual relationship with that MA–PD or PDP.

New Information on the Medicare Prescription Drug Coverage Information for Providers Web page
The following new information can be found on the Medicare Prescription Drug Coverage Information for Providers Web page at http://www.cms.hhs.gov/medlearn/drugcoverage.asp on the CMS Web site.

Toolkit for Health Professionals: Medicare Prescription Drug Coverage
The Centers for Medicare & Medicaid Services (CMS) has released the Toolkit for Health Care Professionals: Medicare Prescription Drug Coverage, available as an Adobe PDF file (860Kb) at http://www.cms.hhs.gov/medlearn/provtoolkit.pdf on the CMS Web site. This toolkit includes downloadable educational materials specifically for physicians and other health care professionals and their staff to learn the basics about Medicare Prescription Drug Coverage. It also includes materials that can be distributed to Medicare patients. The kit contains reproducible artwork, a letter from the CMS Administrator, a fact sheet (English and Spanish), a brochure, an article, and a list of other resources. You may add your logo and business information to these materials and copy freely.

Limited Income? SSA Can Help – Posters to Display in Health Care Settings
Flat wall posters directing people with Medicare who have limited income to a number they can call to find out if they are eligible for help with prescription drug costs are available now. Posters are suitable for display in a physician’s, provider’s or supplier’s office, a pharmacy, or other health care setting where people with Medicare will see this information. Easel posters are no longer available.

To order, visit the Medlearn Product Ordering Page at http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=5 on the CMS Web site.

New Fact Sheets Available On the Medicare Web site
The following Fact Sheets are now available at http://www.medicare.gov. These can help your patients better understand Medicare’s new prescription drug coverage:

Quick Facts about Medicare’s New Coverage for Prescription Drugs for People Who Have Coverage from an Employer or Union (Publication Number 11107)
Basic information about Medicare’s new prescription drug coverage for people who have prescription coverage from an employer or union. (2 pages) http://www.medicare.gov/Publications/Pubs/pdf/11107.pdf

Quick Facts about Medicare’s New Coverage for Prescription Drugs for People with a Medicare approved Drug Discount Card (Publication Number 11104)
Basic information about Medicare’s new prescription drug coverage for a person with a Medicare–approved drug discount card. (2 pages) http://www.medicare.gov/Publications/Pubs/pdf/11104.pdf

New Medicare Prescription Drug Coverage—Who Can Help Me Apply and Enroll? (Publication Number 11125)
Explains who can help people with Medicare apply for extra help in paying for prescription drug costs and join a Medicare prescription drug plan. (2 pages) http://www.medicare.gov/Publications/Pubs/pdf/11125.pdf

Quick Facts about Medicare’s New Coverage for Prescription Drugs for People in a Medicare Health Plan with Drug Coverage (Publication Number 11135)
Basic information about Medicare’s new prescription drug coverage for people with a Medicare health plan with prescription drug coverage. (2 pages) http://www.medicare.gov/Publications/Pubs/pdf/11135.pdf

New Medicare Prescription Drug Coverage: A Message for People Who Care for Someone with Medicare (Publication Number 11126)
Explains Medicare’s new prescription drug coverage to those who make health care decisions for people with Medicare. (4 pages) http://www.medicare.gov/Publications/Pubs/pdf/11126.pdf

Quick Facts about Medicare’s New Coverage for Prescription Drugs for Alaskans with Limited Income and Resources (Publication Number 11105_AK)
Basic information about Medicare’s new prescription drug coverage for a person with limited income and resources in Alaska. (2 pages) http://www.medicare.gov/Publications/Pubs/pdf/11105_AK.pdf

Quick Facts about Medicare’s New Coverage for Prescription Drugs for Hawaiians with Limited Income and Resources (Publication Number 11105_HI)
Basic information about Medicare’s new prescription drug coverage for a person with limited income and resources in Hawaii. (2 pages) http://www.medicare.gov/Publications/Pubs/pdf/11105_HI.pdf

Quick Facts About Medicare Prescription Drug Coverage and Protecting Your Personal Information (Publication Number 11147)
Information about how people with Medicare can protect their personal information when dealing with plans and others about Medicare prescription drug coverage. (2 pages) http://www.medicare.gov/Publications/Pubs/pdf/11147.pdf

New Publications Available on the CMS Web site
The following new publications are available by going to http://www.cms.hhs.gov/medicarereform/factsheets.asp on the CMS Web site and clicking on the appropriate links described below:

Basic Questions and Answers About Prescription Drug Coverage
We encourage you to use these basic questions and answers to respond to inquiries from people with Medicare: http://www.cms.hhs.gov/partnerships/news/mma/qsandas.pdf

What Medicare Prescription Drug Coverage Means to You: A Guide to Getting Started
A new brochure available to explain the basics of prescription drug coverage: http://www.cms.hhs.gov/medicarereform/91007_MedicareBrochure.pdf

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 advocates for people with Medicare 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 Medicare Modernization Act MMA can be found at http://www.cms.hhs.gov/medicarereform/ on the CMS Web site.

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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 provide 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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Comprehensive Error Rate Testing Program (CERT) Helpful Hints for Faxing Documentation

Most documents received via fax are in black or dark letters on white background paper. These documents are normally legible when received by the CERT Documentation Contractor’s (CDC) fax system from senders with fax machines that use one of the commonly available fax resolution modes, such as “normal” or “fine.” However, especially for documents containing small fonts, the recommended mode of resolution for faxing should be “fine.”

The resolution modes on most fax machines can easily be changed at the time of faxing by a button usually labeled “resolution” that is easily accessible near the other buttons at the top of the machine. Note that on most fax machines, the button will not function or change resolutions unless the document to be faxed has first been inserted. Should you not see this at the top of your machine, check your fax machine’s instruction manual for the location of the “resolution” button.

Documents containing either light–colored or light grey text or text embedded within background in shades of gray or color should be faxed using a resolution mode of “photo,” alternatively referred to as “gray scale.” This mode is available via the same “resolution” button mentioned above. This mode may not be available on all fax machines. Check your fax machine’s instruction manual for availability of this mode.


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Billing Guidelines for HCPCS Code Q0112

Clarification has been requested regarding the correct billing of HCPCS code Q0112–All potassium hydroxide (KOH) preparations. This code should be billed once per patient per day regardless of the number of different sites/slides prepared.

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Non–Physician Practitioner Questions and Answers

Note: This article was revised on August 16, 2005. The only change was the answer (A14) to question 14 (Q14) on page 4. 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’ PINs 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 PIN 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. Under 42 CFR 424.20(e)(2)(ii), when an NP or CNS has a direct employment relationship (as defined under common law) with an entity other than the SNF itself, he or she is also considered to have an indirect employment relationship with the SNF in any instance where the employing entity has an agreement with the SNF for the provision of general nursing services. For further explanation of this provision, please refer to the FY 2006 SNF prospective payment system final rule, 70 FR 45035 – 36, August 4, 2005. (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 Reconciliation 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 Administration
NPP=Non-physician practitioner (NPs CNSs, & Pas are considered NPPs)  

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October 2005 Quarterly Update to Skilled Nursing Facility (SNF) Consolidated Billing (CB)

Note: This article was revised on August 15, 2005, to add language that was inadvertently deleted from the original article and to clarify the timeframes during which claims affected by the issue were processed incorrectly.

Provider Types Affected
Physicians providing Positron Emission Tomography (PET) scan professional component services to SNF patients affected by SNF CB.

Provider Action Needed

STOP – Impact to You
Medicare established HCPCS codes, 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815, and 78816 for Positron Emission Tomography (PET) scans effective for dates of service on or after January 28, 2005. The physician professional component of these services may be paid separately outside of SNF CB. These codes will be added to editing on October 3, 2005.

CAUTION – What You Need to Know
Since April 18, 2005, your Medicare carrier may not have paid you correctly for these services, but the carrier will adjust the claims on or after October 3, 2005 if you bring such claim(s) to your carrier’s attention.

GO – What You Need to Do
Should you have received a denial for these services after April 18, 2005, for claims with dates of service on after January 28, 2005, through October 2, 2005, contact your carrier to have those claims adjusted.

Background
The affected HCPCS codes are as follows:

Implementation Date
This change will be made to Medicare systems on October 3, 2005.

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

From that Web page, look for CR 4010 in the CR NUM column on the right, and click on the file for that CR.

For more information on SNF CB, see Medlearn Matter Special Edition SE0431, Skilled Nursing Consolidated Billing, available at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0431.pdf on the CMS Web site.

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 on the CMS Web site.

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CMS Releases New Educational Guide on Remittance Advice (RA) Notices

Provider Types Affected
All Medicare physicians, providers, suppliers, and their billing staff who submit claims to Medicare Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs), Carriers, and Durable Medical Equipment Regional Carriers (DMERCs)

Provider Action Needed
This special edition article describes the release of a national educational guide for Medicare–Fee–For–Service (FFS) providers, physicians, suppliers and their billing staff who may wish to use the guide to help increase their understanding of the Remittance Advice (RA). The Guide is available at http://www.cms.hhs.gov/medlearn/RA_Guide_05–27–05.pdf on the CMS Web site.

Background
The Medicare FFS program serves many of the more than 40 million Medicare beneficiaries enrolled in the Medicare Program. Under this program, more than 1 billion claims are submitted annually for reimbursement of health care services. The claims are processed by Medicare contractors, FIs, RHHIs, Carriers, and DMERCs. These Medicare contractors use the standard Remittance Advice (RA) as their means to communicate to providers claim processing decisions regarding payments, adjustments, and denials, as well as data that was missing or incorrect on the incoming claims which need to be submitted or corrected before a payment decision can be made on a claim.

Every day Medicare FFS contractors send thousands of RAs to providers. Each of these RAs conveys information that may impact the provider’s Medicare business. CMS wants to be certain that providers understand how to read and interpret the RA; therefore, CMS has developed and is pleased to announce the release of Understanding the Remittance Advice: A Guide for Medicare Providers, Physician, Suppliers and Billers. This educational guide has useful information that is designed to be used as a self–help tool.

The Guide offers the user the following benefits:

The Guide is comprised of four chapters each highlighting a specific aspect of the RA, an acronym list, a glossary, important Web sites and phone numbers, and three comprehensive indices: 1) for key terms and concepts; 2) for institutional ERA and SPR field descriptions; 3) professional SPR field descriptions. Each chapter and/or section of the Guide can be printed according to the provider’s specific needs.

Print What Fits Your Needs

Additional Information
Print Copies of the Guide will be available late summer of 2005. Until print copies are available Understanding the Remittance Advice: A Guide for Medicare Providers, Physician, Suppliers and Billers can be accessed electronically at http://www.cms.hhs.gov/medlearn/RA_Guide_05–27–05.pdf on the CMS Web site.

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October Update to the 2005 Medicare Physician Fee Schedule Database

Provider Types Affected
Physicians and providers billing Medicare carriers or intermediaries for services paid under the Medicare Physician Fee Schedule

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

Background
CR4031 amends payment files issued to Medicare carriers and intermediaries based upon the November 15, 2004, Final Rules for the 2005 Medicare Physician Fee Schedule Database.

Additional Information
The changes to the fee schedule involve numerous CPT/HCPCS codes. While many of these changes are effective retroactive to January 1, 2005, please note that your carrier/FI will not reprocess claims already processed, unless you request them to do so.

The complete details of these changes to the October update to the 2005 Medicare Fee Schedule Database are described in an attachment to CR 4031, which is the official instruction issued to your carrier/intermediary. That instruction may be viewed by going to http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS Web site. From that Web page, look for CR 4031 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/intermediary at their toll–free number, which may be found at http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.

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Quarterly Provider Update

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

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

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

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Preventive Services Guide Now Available

CMS is pleased to announce that the “Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Health Care Professionals” is now available to order. This comprehensive guide to Medicare–covered preventive services and screenings is intended to give physicians, providers, suppliers, and other health care professionals that bill Medicare fee–for–service contractors information on coverage, coding, billing, and reimbursement to help them file claims effectively, while also giving providers information that will enable them to encourage utilization of these benefits as appropriate. A downloadable PDF version of the guide is available at http://www.cms.hhs.gov/medlearn/preventiveservices.asp on the CMS Web site. The Guide is also one of the resources included in the Medicare Preventive Services Resources CD ROM for health care professionals. Copies of both the Guide and the CD ROM may be ordered, free of charge, through the Medicare Learning Network’s Medlearn home page at www.cms.hhs.gov/medlearn on the Web. Order your copies today!

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Implementation of Carrier Guidelines for End Stage Renal Disease (ESRD) Reimbursement for Automated Multi–Channel Chemistry (AMCC) Tests (Supplemental to Change Request 2813)

Provider Types Affected
Physicians, providers, and suppliers billing automated multi–channel chemistry tests to Medicare carriers

Provider Action Needed

STOP – Impact to You
This article is based on information from Change Request (CR) 3890, which supplements CR2813 by implementing Carrier procedures for enforcing compliance with the payment policy for End Stage Renal Disease (ESRD)–related laboratory services (i.e., the ESRD 50/50 rule).

CAUTION – What You Need to Know
The ESRD 50/50 rule requires the billing laboratory to identify AMCC tests ordered and to classify them according to the following categories:

  1. AMCC test ordered by an ESRD facility (or MCP physician) that is part of the composite rate and is not separately billable;
  2. AMCC test ordered by an ESRD facility (or MCP physician) that is a composite rate test but is beyond the normal frequency covered under the rate and is separately reimbursable based on medical necessity; and
  3. AMCC test ordered by an ESRD facility (or MCP physician) that is not part of the composite rate and is separately billable.

This proportion (or percentage) of composite tests to non–composite tests is used to determine whether
separate payment may be made for all tests performed on the same day for the same beneficiary.

GO – What You Need to Do
When billing Medicare for ESRD–related AMCC tests, laboratories must identify which tests, if any, are not included within the ESRD facility composite rate payment. Ensure the tests are properly identified. When billing for AMCC tests, the laboratory must identify the appropriate modifier for each test, as follows:

Background
This instruction supplements Change Request (CR) 2813 (Transmittal 198, dated June 4, 2004, subject: End Stage Renal Disease (ESRD) Reimbursement for Automated Multi–Channel Chemistry (AMCC) Tests) by implementing Medicare carrier procedures to enforce compliance with the payment policy for End Stage Renal Disease (ESRD)–related laboratory services. The Centers for Medicare & Medicaid Services (CMS) is implementing these new procedures in response to payment vulnerabilities identified by the Office of the Inspector General (OIG) in the Department of Health and Human Services.

The ESRD 50/50 Rule
The ESRD 50/50 rule requires the billing laboratory to determine (for the same beneficiary on the same date–of–service):

The proportion of composite versus non–composite tests calculated by the billing laboratory is then used to determine whether separate payment may be made for all tests performed on that day.

Medicare’s composite rate payment to an ESRD facility (or Monthly Capitation Payment (MCP) to a physician) includes reimbursement for certain routine clinical laboratory tests furnished to an ESRD beneficiary. However, separate payment for such clinical laboratory tests may be made when more than 50 percent of all Medicare–covered laboratory services (furnished to the same beneficiary on the same date of service) are AMCC tests that are not included in the composite payment rate.

In other words (for the same beneficiary on the same date of service):

When

 Then
The 50 percent threshold is met [i.e. more than 50 percent of the covered tests are non-composite payment rate tests] All laboratory tests (composite payment rate and non-composite payment rate tests) furnished on that date are separately payable.
The 50 percent threshold is not met [i.e., 50 percent or more of the covered tests are incuded under the composite payment rate] No laboratory tests (including non-composite payment rate tests) furnished on that date are separately payable.

Note: A non–composite payment rate test is defined as any test separately reimbursable outside of the composite payment rate or beyond the normal frequency covered under the composite payment rate that is reasonable and necessary.

Laboratory Tests Subject to ESRD 50/50 Rule
The laboratory tests subject to the ESRD 50/50 rule are those tests:

Note: Tests ordered by the MCP physician outside of the dialysis clinic are not subject to the ESRD 50/50 rule.

Payment Policy for AMCC Tests for ESRD Beneficiaries

With respect to the application of the payment policy for AMCC tests for ESRD beneficiaries, the following applies:

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

Provider Types Affected
Laboratories billing Medicare carriers or intermediaries for clinical diagnostic laboratory services

Provider Action Needed
CR4005 announces changes to the list of codes included in the October 2005 release of the Medicare Laboratory National Coverage Determination (NCD) edit module for clinical diagnostic laboratory services. These changes are a result of new ICD–9–CM code changes that become effective October 1, 2005.

Background
The NCDs for clinical diagnostic laboratory services were developed by the laboratory negotiated rulemaking committee and published as final rule, 66 FR, 58788, on November 23, 2001. Nationally uniform software was developed by Computer Sciences Corporation and incorporated into the Medicare claim processing systems so that laboratory claims subject to any of the 23 NCDs are processed uniformly throughout the nation, effective January 1, 2003.

In addition, the laboratory edit module for the NCDs is updated quarterly as necessary to reflect ministerial coding updates and substantive changes to the NCDs developed through the NCDs process. (See the Medicare Claims Processing Manual, Pub. 100–4, Chapter 16, Section, 120.2. This manual may be found at
http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp on the CMS Web site.) CR4005 announces the changes that will be included in the October 2005 release of the edit module for clinical diagnostic laboratory services. Those changes, which become effective October 1, 2005, include the following:

Urine Culture
In accordance with the coding analysis, CMS is adding new ICD–9–CM code 585.6, End Stage Renal
Disease, to the list of ICD–9–CM Codes Covered by Medicare for Urine Culture. CMS is deleting ICD–9–CM code 585, Chronic Renal Failure, from the same list for this NCD.

Immunodeficiency Virus (HIV) Testing (Diagnosis)
CMS is adding new ICD–9–CM codes to the list of ICD–9–CM Codes Covered by Medicare for Human Immunodeficiency Virus (HIV) Testing (Diagnosis).

Those codes are as follows:

287.30 - Primary thrombocytopenia, unspecified 287.33 - Congenital and herediatary thrombocytopenic purpura
287.31 - Immune thrombocytopenic purpura 287.39 - Other primary thrombocytopenia
287.32 - Evans’ syndrome  

CMS is deleting ICD–9–CM code 287.3, Primary Thrombocytopenia, from the same list for this NCD.

Blood Counts CMS is adding new ICD–9–CM codes to the list of ICD–9–CM Codes That Do Not Support Medical Necessity for Medicare for Blood Counts. Those codes are as follows:

443.82 - Erthromelalgia V26.31 - Testing for genetic disease carrier status
525.40 - Complete edentulism, unspecified V26.32 - Other genetic testing
525.41 - Complete edentulism, class I V26.33 Genetic counseling
525.42 - Complete edentulism class II V49.84 - Bed confinement status
525.43 - Complete edentulism, class III V59.70 - Egg (oocyte) (ovum) donor, unspecified
525.44 - Complete edentulism, class IV V59.71 - Egg (oocyte) (ovum) donor, under age 35, anonymous recipient
525.50 - Partial edentulism, unspecified V59.72 - Egg (oocyte) (ovum) donor, under age 35, designated recipient
525.51 - Partial edentulism, class I V59.73 - Egg (oocyte) (ovum) donor, age 35 and over, anonymous recipient
525.52 - Partial edentulism, class II V59.74 - Egg (oocyte) (ovum) donor, age 35 and over, designated recipient
525.53 - Partial edentulism, class III V62.84 - Suicidal ideation
525.54 - Partial edentulism, class IV  

CMS is deleting ICD–9–CM code V26.3, Genetic Counseling and Testing, from the same list for this NCD.

Partial Thromboplastin Time (PTT)

CMS is adding new ICD–9–CM codes to the list of ICD–9–CM Codes Covered by Medicare for Partial Thromboplastin Time (PTT). Those codes are as follows:

287.30 – Primary thrombocytopenia, unspecified 585.4 Chronic kidney disease, Stage IV (severe)
287.31 – Immune thrombocytopenic purpura
287.32 – Evans’ syndrome 		585.5 Chronic kidney disease, Stage V
585.6 – End stage renal disease
287.33 – Congenital and hereditary thrombocytopenic purpura 585.9 Chronic kidney disease, unspecified
287.39 – Other primary thrombocytopenia  

CMS is deleting ICD–9–CM codes, 287.3, Primary Thrombocytopenia, and 585, Chronic Renal Failure, from the same list for this NCD.

Prothrombin Time (PT)
CMS is adding new ICD–9–CM codes to the list of ICD–9–CM Codes Covered by Medicare for Prothrombin Time (PT). Those codes are as follows:

287.30 – 287.39 as defined in the section on Partial

Thromboplastin Time (PTT) above
585.4 – 585.9 as defined in the section on Partial

Thromboplastin Time (PTT) above.
443.82 Erythromelalgia

CMS is deleting ICD–9–CM code, 287.3, Primary Thrombocytopenia, and 585, Chronic Renal Failure, from the same list for this NCD.

Serum Iron Studies
CMS is adding new ICD–9–CM codes to the list of ICD–9–CM Codes Covered by Medicare for Serum Iron Studies. Those codes are as follows:

287.30 – 287.39 as defined in the section on Partial
Thromboplastin Time (PTT) above.

585.4 – 585.9 as defined in the section on Partial
Thromboplastin Time (PTT) above.

CMS is deleting ICD–9–CM codes 287.3, Primary Thrombocytopenia, and 585, Chronic Renal Failure, from the same list for this NCD.

Blood Glucose Testing
CMS is adding new ICD–9–CM codes to the list of ICD–9–CM Codes Covered by Medicare for Blood Glucose Testing. Those codes as follows:

276.50 Volume depletion, unspecified
276.52 Hypovolemia
276.51 Dehydration

CMS is deleting ICD–9–CM code 276.5, Volume Depletion, from the same list for this NCD.

Thyroid Testing
CMS is adding new ICD–9–CM codes to the list of ICD–9–CM Codes Covered by Medicare for Thyroid Testing. Those codes are as follows:

327.00 – Organic
insomnia, unspecified 		327.29 – Other organic sleep apnea
327.01 – Insomnia due to medical condition classified elsewhere 327.52 – Sleep related leg cramp
327.09 – Other organic insomnia 327.8 – Other organic sleep disorders

Lipid Testing
CMS is adding new ICD–9–CM codes to the list of ICD–9–CM Codes Covered by Medicare for Lipid Testing.

Those codes are as follows:
278.02 – Overweight
585.4 – 585.9 as defined in Partial Thromboplastin Time (PTT) above.

CMS is deleting ICD–9–CM code 585, Chronic Renal Failure, from the same list for this NCD.

Digoxin Therapeutic Drug Assay
CMS is adding new ICD–9–CM codes to the list of ICD–9–CM Codes Covered by Medicare for Digoxin Therapeutic Drug Assay. Those codes are as follows:

276.50 – Volume depletion, unspecified 585.3 – Chronic kidney disease, Stage III
(moderate)
276.51 – Dehydration 585.4 – Chronic kidney disease, Stage IV (severe)
276.52 – Hypovolemia 585.5 – Chronic kidney disease, Stage V
426.82 – Long QT syndrome 585.6 – End stage renal disease
585.1 – Chronic kidney disease, Stage I 585.9 – Chronic kidney disease, unspecified
585.2 – Chronic kidney disease, Stage II (mild)  

CMS is deleting ICD–9–CM codes 276.5, Volume Depletion, and 585, Chronic Renal Failure, from the same list for this NCD.

Prostate Specific Antigen Testing
CMS is adding new ICD–9–CM codes to the list of ICD–9–CM Codes Covered by Medicare for Prostate Specific Antigen Testing. Those codes are as follows:

599.60 – Urinary obstruction, unspecified
599.69 – Urinary obstruction, not elsewhere classified

CMS is deleting ICD–9–CM codes, 599.6, Urinary Obstruction, from the same list for this NCD.

Gamma Glutamyl Transferase Testing
CMS is adding new ICD–9–CM codes to the list of ICD–9–CM Codes Covered by Medicare for Gamma Glutamyl Transferase Testing. Those codes are as follows:

291.82 – Alcohol induced sleep disorders 567.39 – Other retroperitoneal infections
567.21 – Peritonitis (acute) generalized 567.81 – Choleperitonitis
567.22 – Peritoneal abscess 567.82 – Sclerosing mesenteritis
567.23 – Spontaneous bacterial peritonitis 567.89 – Other specified peritonitis
567.29 – Other suppurative peritonitis 585.6 – End Stage Renal Disease
567.38 – Other retroperitoneal abscess  

CMS is deleting ICD–9–CM codes, 567.2, Suppurat Peritonitis NEC, 567.8, Peritonitis NEC, and 585, Chronic Renal Failure, from the same list for this NCD.

Fecal Occult Blood Testing
CMS is adding ICD–9–CM codes 287.30 – 287.39 (as defined in Partial Thromboplastin Time (PTT) above) to the list of ICD–9–CM Codes Covered by Medicare for Fecal Occult Blood Testing. CMS is deleting ICD–9–CM code, 287.3, PrimaryThrombocytopenia, from the same list for this NCD.

Negotiated Laboratory NCDs
In accordance with the coding analysis, CMS is adding new ICD–9–CM codes to the list of ICD–9–CM Codes Not Covered by Medicare for the Negotiated Laboratory NCDs. Those codes are as follows:

V17.81 – Family history, Osteoporosis
V18.9 – Family history, Genetic disease carrier
V17.89 – Family history, Other musculoskeletal diseases

CMS is deleting ICD–9–CM code, V17.8, Family history of certain chronic disabling diseases, from the same list.

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

Additional Information
To see the official instruction issued to your carrier/intermediary regarding this change may be found by going to http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS Web site. From that Web page, look for CR 4005 in the CR NUM column on the right, and then click on the file for that CR.

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

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New Waived Tests Approved by the Food and Drug Administration (FDA) Under Clinical Laboratory Improvement Amendments (CLIA) of 1988

Note: This article was revised on August 23, 2005, to correct the date as of when the new waived code 83721QW has been assigned for LDL cholesterol testing, from March 21, 2005 to March 25, 2005.

Provider Types Affected
Providers/suppliers billing services to Medicare carriers

Provider Action Needed

STOP – Impact to You
This article includes information from Change Request (CR) 3984 which informs Medicare carriers of new tests granted waived status under CLIA by the FDA.

CAUTION – What You Need to Know
Since these tests are marketed immediately after their approval, Medicare carriers need to be aware of these new tests and update their files so your claims can be accurately processed.

GO – What You Need to Do
See the Background Section of this article for more details regarding these new waived tests.

Background
The Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations require a facility to be appropriately certified for each test performed. To ensure that Medicare & Medicaid pay only for laboratory tests categorized as waived complexity under CLIA in facilities with a CLIA certificate of waiver, laboratory claims are currently edited at the CLIA certificate level.

Change Request (CR) 3984 notifies Medicare carriers of the new waived CLIA covered tests which were approved by the FDA. Medicare carriers will update their files to include the new tests granted waived status under CLIA, and CR3984 includes the complete list of these tests as an attachment.

To review the attachment to CR3984, please see the official instruction issued to your carrier by going to: http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp. From that Web page, look for CR 3984 in the CR column on the right, and click on the file for that CR.

The latest tests approved by the FDA as waived tests under the CLIA are listed below. The Current Procedural Terminology (CPT) codes for the new tests in the following table must have the modifier QW to be recognized as a waived test.

CPT Code/Modifier Effective Date Description

CPT Code/Modifier Effective Date Description
86318QW December 9, 2004 Germaine Laboratories, Aimstep H. pylori {whole blood}
87807QW January 28, 2005 Binax Now RSV Test (K032166/A005)
81003QW February 18, 2005 Physician Sales & Service, Inc. PSS Select Urine Analyzer
87880QW March 8, 2005 McKesson Medi–Lab Performance Strep A Test Dipstick
86308QW March 8, 2005 Clearview Mono–Plus II

86318QW		 March 8, 2005 Wampole Laboratories Clearview H. pylori II (finger stick or whole blood)
87899QW March 16, 2005 Genzyme OSOM Trichomonas Rapid Test
86308 March 16, 2005 McKesson Medi-lab Perfrmance infectious Mononucleosos Test
83721 March 25, 2005 Polymer Technology Systems Cardiochek PA Analyzer
86308QW March 16, 2005 McKesson Medi–lab Performance Infectious Mononucleosis Test
83721QW March 25, 2005 Polymer Technology Systems Cardiochek PA Analyzer
87880QW April 21, 2005 Biotechnostix Rapid Response Strep A Rapid Test Strip
87880QW April 21, 2005 Biotechnostix Rapid Response Strep A Rapid Test Device
87880QW April 21, 2005 RAC Medical Clarity Strep A Rapid Test Strips
80101QW June 3, 2005 Acon One Step Multi–Drug, Multi–Line Screen Test Device (Professional Use)

Note: The tests mentioned on the first page of the Attachment included with CR3984 (i.e., CPT codes: 81002, 81025, 82270, G0107, 82962, 83026, 84830, 85013, and 85651) do not require a QW modifier to be recognized as a waived test.

Also note the following:

For these two tests, your carrier will not search their files to 1) either retract payment or 2) retroactively pay claims. However, your carriers should adjust claims if you bring the claims to their attention.

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

Additional Information
For complete details, please see the official instruction issued by going to http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS Web site.

From that Web page look for CR 3984 in the CR column on the right, then click on the file for that CR.

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

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Correct Coding Initiative (CCI) Edits to Apply to ALL Therapy Providers

Note: This article was revised on August 8, 2005, to clarify that the CCI edits will apply to all services furnished by the affected provider types and also to clarify that the CCI edits have been applied since 2000 to Outpatient Prospective Payment System (OPPS) hospital services, including therapy services.

Provider Types Affected
Skilled Nursing Facilities (SNFs), Comprehensive Outpatient Rehabilitation Facilities (CORFs), Outpatient Physical Therapy and Speech–Language Pathology Providers (OPTs), and Home Health Agencies (HHAs)

Provider Action Needed

STOP – Impact to You
Effective January 1, 2006, the Medicare CCI edits will be applied to ALL outpatient services furnished by the above mentioned providers.

CAUTION – What You Need to Know
Be aware that application of CCI edits under the Physician Fee Schedule (PFS) will make uniform the manner in which all outpatient rehabilitation therapy services ─ including physical therapy, occupational therapy, and speech - language pathology services ─ are paid. To review the CCI edits that apply to Medicare Part B services paid by Medicare fiscal intermediaries (FIs) see http://www.cms.hhs.gov/providers/hopps/cciedits/ on the CMS Web site.

GO – What You Need to Do
Affected providers should begin immediately to prepare their systems with any necessary software, educate their staff and management about the 2006 CCI application to their claims, and watch for forthcoming information from CMS and their local contractor (carrier or fiscal intermediary), after October 1, 2005, although the CCI concept should not be unfamiliar just its application.

Background
This Special Edition, SE0545, is published by the Centers for Medicare & Medicaid Services (CMS) as a ‘heads–up’ to institutional therapy providers to make certain that they are aware of the changes in Medicare’s payment processes that are to begin January 1, 2006. It is important to note that the CCI edits are applied to services billed by the same provider for the same beneficiary on the same date of service.

Medicare’s National Correct Coding Initiative (NCCI) is an edit system that was developed to promote national correct coding methodologies and eliminate improper coding. These edits are developed based on coding conventions defined in the American Medical Association’s Current Procedural Terminology (CPT) manual, current standards of medical and surgical coding practice, input from specialty societies, and analysis of current coding practices.

Carriers currently apply the CCI edits to all practitioners filing claims for rehabilitation therapy services, including the services of physicians (and their incident–to services) and the services provided by physical therapists and occupational therapists in private practices. Additionally, CCI edits are applied in the outpatient hospital setting by the intermediaries, including rehabilitation therapy services. However, until now, CCI edits have not been applied to other institutional therapy providers of outpatient rehabilitation therapy services, including physical therapy (PT), occupational therapy (OT), and speech–language pathology (SLP) services. These institutional therapy providers include:

In January 1999, the institutional therapy providers were changed, via the 1997 Balanced Budget Act (BBA) requirements, from cost–based reimbursement to payment under the Medicare physician fee schedule (MPFS). At that time, these entities were granted a temporary postponement from the CCI edits because there was no Outpatient Code Editor (OCE) CCI mechanism in place.

Congressional concerns about rising utilization of therapy services and the fact that these facilities have had 5–plus years to adjust to the billing requirements of the MPFS, CMS has determined that this is the appropriate time to apply the CCI edits in these settings. Application of the CCI edits ensures that all therapy providers are subject to the same billing and coding rules and requirements. It is believed that these changes will have a positive budgetary effect as it incorporates safeguards against improper coding and over–payment of therapy services.

Billing Instructions
Skilled Nursing Facilities (SNFs), comprehensive outpatient rehabilitation facilities (CORFs), outpatient physical therapy and speech–language pathology providers (OPTs) (sometimes referred to as rehabilitation agencies), and HHAs (home health services not under a home health plan of treatment) will see the CCI edits applied to types of bills (TOB) as follows:

Skilled Nursing Facilities (SNFs):

  • Skilled Nursing Facility Inpatient
    Part B TOB 22X
  • Skilled Nursing Facility Outpatient
    TOB 23X

TOB 22X


TOB 23X

Comprehensive Outpatient Rehabilitation Facilities (CORFs)

 TOB 75X

Rehabilitation Agencies/Outpatient Physical Therapy and Speech–Language Pathology Providers (OPTs)

 TOB 74X

Home Health Agency (HHAs) (home health services not under a home health plan of treatment.

 TOB 34X

The CCI edits will be applied to the above bill types as of January 1, 2006. Since calendar year 2000, the edits have been applied to all services, including outpatient therapy services, provided by OPPS hospitals.

Please also note the following billing pointers:

Additional Information
There is Medlearn information on the Web written about the CCI edits. The Medlearn Matters article numbers are: MM3244, MM3995, MM3823, MM3349, and MM3688 and can be viewed by going to: http://www.cms.hhs.gov/medlearn/matters/ then clicking on the appropriate number.

Another Medlearn product is a CCI Reference Guide published in 2002. The Guide is comprehensive and helpful in terms of acquainting the reader with the entire CCI edit process. Keep in mind that the latest edits will always be available on the Web—this Guide is excellent background information and available at http://www.cms.hhs.gov/contractors/customerserv/ccirefgde.pdf on the CMS Web site.

Another version of this guide focused on the viewpoint of interest to hospitals may be found at http://www.cms.hhs.gov/providers/hopps/cciedits/ on the CMS Web site. A version of the CCI guide for physicians may be found at http://www.cms.hhs.gov/physicians/cciedits/ on the CMS Web site.

The following site describes eleven therapy billing scenarios and scenario number six explains CCI edits with modifier 59, an excellent reference for all types of billing: http://www.cms.hhs.gov/providers/therapy/billing.asp

The following AMA site is a primer on CCI edits and presents a history of the CCI initiative, column one and two codes and the rationale behind modifier–59: http://www.ama–assn.org/ama/pub/category/3233.html

Further information on these CCI edit applications will be made available via future Medlearn Matters articles as well. Watch the Medlearn Matters site and information made available from your carrier/intermediary for further developments. As always, if you have questions, please contact your carrier or intermediary at their toll free number available at http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.

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The Comprehensive Error Rate Testing (CERT) Process for Handling a Provider’s Allegation of Medical Record Destruction

Provider Types Affected
All Medicare providers

Provider Action Needed

STOP – Impact to You
SE0547 outlines the process Medicare providers should follow when medical records requested by Medicare’s Comprehensive Error Rate Testing (CERT) Documentation Contractor (CDC) and/or Medicare’s CERT Review Contractor (CRC) are destroyed by disaster.

CAUTION – What You Need to Know
For CERT purposes, a “disaster” is defined as any natural or man–made catastrophe which causes damages of sufficient severity and magnitude to partially or completely destroy or delay access to medical records and associated documentation.

GO – What You Need to Do
If you cannot submit the requested medical records because they were destroyed by a disaster, the CDC/CRC will ask you to attest, under penalty of perjury, to the destruction of the medical records. The Attestation Form is available to providers at http://www.certprovider.org.

Providers who need to use this form can print and fax the form to the CDC who will either retain the form or send it to the CRC depending on which contractor sent the initial request letter for medical record documentation to the provider.

Background
The Centers for Medicare & Medicaid Services (CMS) recognizes that there are circumstances in which destruction of medical record documentation because of unforeseen events should not count as a “no documentation error.” Therefore, CMS has established the following process and procedures to corroborate allegations that CERT–requested medical records were destroyed by a disaster.

The corroboration process is comprised of two steps: 1) qualification and 2) accuracy. In the first step, the CDC/CRC will review the attestation statement to determine if the event qualifies as a disaster.

Provider induced disasters and disasters caused by negligence on the part of providers will be counted as “no documentation errors.”

The following are examples of provider induced disasters and disasters caused by negligence on the part of providers that would NOT qualify as a natural or man–made disaster:

If the event does not qualify as a natural or man–made disaster defined in the Provider Action Needed section of this article, the claim associated with that medical record is documented as a “no documentation error.”

The following are examples of events that WOULD qualify as a natural or man–made disaster:

If the event does qualify as a natural or man–made disaster, the CDC/CRC will move to the second step in the corroboration process: confirming the accuracy of the attestation. The CDC will confirm the attestation statement through any or all of the following means:

The CDC checks the following database records for evidence of natural, man–made, and/or provider induced disasters: Pacer (Civil and Criminal Searches,) Crimetime.com, News Searches, Internet Search, HHS OIG Sanctioned Providers, Merlin, State Record Searches (Courthouse Records, Insurance Carriers or http://www.insurancefraud.org/Choicepoint/Autotrak, Argyli, Tracer, and the National Crime Insurance Bureau).

The CDC interviews the provider who reported the destruction of medical records. The CDC determines the events leading up to the destruction of medical records, such as: what caused the destruction (weather, fire, etc.), were back–up records maintained (electronic or otherwise), what else might have been destroyed, were fire, police, insurance adjusters called to review the damage? The CDC will identify the magnitude of the destruction to medical records, determine if the Medicare Carrier/DMERC/FI has copies, interview other third parties as necessary, and determine if medical records were retained elsewhere and how were they maintained.

The CDC validates additional supporting evidence for the event, which may include but not be limited to the following sources: