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December 2005 Part B Medicare Bulletin

Posted December 5, 2005

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Requirements for Voided, Canceled, and Deleted Claims

Note: This article was revised on October 4, 2005, to correct errors on page 2. Specifically, references to form HCFA 1500 were corrected to state form CMS 1500.

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

Provider Action Needed
This Medlearn Matters article is based on information contained in Change Request (CR) 3627, which describes new CMS procedures and specific instructions to Medicare Contractors (Medicare carriers, intermediaries, and DMERCs) for voiding, canceling, and deleting claims.

As a result of these changes, providers should note that some claims they were able to delete in the past will no longer be deleted from Medicare’s systems, but will instead become denied claims.

Background
The Department of Health and Human Services (DHHS) Office of the Inspector General (OIG) has verified instances in which Medicare claims have been voided, cancelled, or deleted by Medicare carriers, DMERCs, and FIs. Further, the Medicare contractors have not traditionally maintained an audit trail for the voided, cancelled, or deleted claims. The OIG has indicated that Medicare must maintain an audit trail for voided, cancelled, and deleted claims.

The Centers for Medicare & Medicaid Services (CMS) is therefore implementing requirements for Medicare contractors (carriers/FIs, including DMERCs and Regional Home Health Intermediaries (RHHIs)) to:

Note: CR3627 requires that Medicare carriers, intermediaries, and DMERCs keep an audit trail on these claims once a CCN or DCN has been assigned to the claim.

Acceptable Claims Deletions
Below is a list of acceptable reasons a Medicare contractor may cancel, delete, or void a claim:

  1. The current CMS 1500 form or the current CMS 1450 form is not used.
  2. The front and back of the CMS 1500 (12/90) claim form are required on the same sheet and are not submitted that way (claims submitted to carriers only).
  3. A breakdown of charges is not provided, i.e., an itemized receipt is missing.
  4. Only six line items have been submitted on each CMS 1500 claim form (Part B only).
  5. The patient’s address is missing.
  6. An internal clerical error was made.
  7. The Certificate of Medical Necessity (CMN) was not with the claim (Part B only).
  8. The CMN form is incomplete or invalid (Part B only).
  9. The name of the store is not on the receipt that includes the price of the item (Part B only).

Note: The Medicare contractor must keep an audit trail for all claims in the above “Acceptable Claims Deletions” category if a CCN or a DCN was assigned to the claim.

Unacceptable Claims Deletions
The following are unacceptable reasons for Medicare contractors to void, cancel, or delete claims:

  1. A provider notifies the Medicare contractor that claim(s) were billed in error and requests the claim be deleted (carrier claims only).
  2. The provider goes into the claims processing system and deletes a claim via any mechanism other than submission of a cancel claim (Type of Bill xx8). Providers may only cancel claims that are not suspended for medical review or have not been subject to previous medical review. (FI claims only)
  3. The patient’s name does not match any Health Insurance Claim Number (HICN).
  4. A claim meets the criteria to be returned as un processable under the incomplete or invalid claims instructions in the Medicare Claims Processing Manual, Chapter 1, Section 80.3.2.ff, which is available at http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp on the CMS Web site.

Medicare contractors must deny or reject claims in the above “Unacceptable Claims Deletions”category.

Medlearn Matters articles are prepared as a service to the public and are not intended to grant rights or impose obligations. Medlearn Matters articles may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.

Return as Unprocessable Claims
Medicare contractors may return a claim as unprocessable for the following reasons:

  1. Valid procedure codes were not used and/or services are not described (e.g., block 24D of the CMS 1500) (Part B only).
  2. The patient’s HICN is missing, incomplete, or invalid (e.g., block 1A of the CMS 1500).
  3. The provider number is missing or in complete.
  4. No services are identified on the claim.
  5. Block 11 (insured policy group or FECA Number) of the CMS 1500 is not completed to indicate whether an insurer primary to Medicare exists (Part B only).
  6. The beneficiary’s signature information is missing (Part B only).
  7. The ordering physician’s name and/or UPIN are missing/invalid (blocks 17 and 17A of the CMS 1500).
  8. The place of service code is missing or invalid (block 24B of the CMS 1500 – Part B only).
  9. A charge for each listed service is missing (e.g., block 24F of the CMS 1500).
  10. The days or units are missing (e.g., block 24G of the CMS 1500).
  11. The signature is missing from block 31 of the CMS 1500 (Part B only).
  12. Dates of service are missing or incomplete (block 24A of the CMS 1500).
  13. A valid HICN is on the claim, but the patient’s name does not match the name of the person assigned that HICN.

Summary
In summary, CMS believes the following:

If a Medicare contractor determines that a claim is unprocessable before the claim enters that contractor’s claims processing system (i.e., the claim processing system did not assign a CCN or DCN to the claim):

If a Medicare contractor determines that a claim is unprocessable after the claim enters their claims processing system (i.e., the claim processing system did assign a CCN or DCN to the claim):

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

Additional Information
For complete details, please see the official instruction issued to your carrier/intermediary regarding this change. That instruction may be viewed by going to http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS Web site. From that Web page, look for CR3627 in the CR NUM column on the right, and click on the file for that CR.

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

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Hurricanes Katrina and Rita – Frequently Asked Questions – Medicare Issues

Provider Types Affected
All providers who are affected by Hurricanes Katrina and Rita or serving Medicare patients affected by those hurricanes

Key Points
This article contains important information about Medicare issues resulting from Hurricanes Katrina and Rita. The Centers for Medicare & Medicaid Services (CMS) has posted pertinent information on its Web site at http://www.cms.hhs.gov/hki. This Web site is updated on a daily basis.

The information on this site includes the following:

A Question and Answer Document
This document was created to answer frequently asked questions about Medicare issues resulting from Hurricanes Katrina and Rita. Please review each question and answer and take appropriate action to implement them into your claims process. Account and document all activities associated with implementing these instructions. (To view this information, scroll down to the Question and Answer section on the page (http://www.cms.hhs.gov/hki) and select the category desired (e.g., Section 1135, General, Ambulance, etc.).

Hurricane Katrina Electronic Mailing List
This is an electronic mailing list service for those interested in receiving news automatically via e-mail from the CMS.

Hurricane Katrina: What Government Is Doing
This Department of Homeland Security Web site focuses on the government’s response to Hurricane Katrina - including links to:

Fact Sheet: CMS Actions to Help Beneficiaries, Providers in Katrina Stricken Areas
This link leads to specific Medicare-related hurricane relief information for healthcare providers who furnish medical services related to Hurricane Katrina.

Phone Numbers for State Medical Assistance Offices
This Web page contains contact information for all states; related Web sites; and resources (a download of the Helpful Contacts tool).

State Health Officials Letter and 1115 Model Waiver Template
This links to state Medicaid directors’ information, including:

Approved Katrina 1115 Waiver Information
This Web page contains approved Katrina 1115 Waiver documents for the states of Alabama, Arkansas, District of Columbia, Florida, Georgia, Idaho, Mississippi, and Texas, including an Approval Letter, the Terms and Conditions, and the Attachments for each of the states.

Hurricane Information from the Department of Health and Human Services
Topics on this page include:

Hurricane Katrina Medicare Contractor and CMS Regional Office Contacts
This Web page informs Medicare providers about relevant contact points for those in the affected areas; and notifies providers about a list of Questions and Answers available online at http://www.cms.gov in the “Spotlight” section.

Signed Waiver Under Section 1135 of the Social Security Act 9/4/2005
Section 1135 of the Social Security Act allows the Secretary of Health and Human Services to waive or modify certain Medicare, Medicaid, or State Children’s Health Insurance Program requirements in order to protect the public health and welfare in times of national crisis. On Wednesday August 31, 2005, Secretary Michael Leavitt notified the Congress that he was invoking this authority, as a consequence of Hurricane Katrina, in order to protect the health and welfare of the public in areas impacted by this crisis. CMS is taking action consistent with this authority to ensure that the people in these areas receive all necessary health care services.

Hurricane Katrina Recovery Information from FirstGov.gov
Links on this page include:

Katrina Information Resources
Links on this page include:

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CMD Announcement

CIGNA Government Services is pleased to announce a new addition to our staff. Dr. Gary Oakes will serve as our new Carrier Medical Director for Part B Tennessee.

Dr. Oakes comes to us with a resonant background in health care. He formerly occupied the position of HMO Medical Director for CIGNA HealthCare and most recently BlueCross BlueShield of Tennessee. In addition to serving as the CMD, Dr. Oakes will continue to work in the areas of family practice and emergency medicine.

An alumnus of Tennessee Technological University, Dr. Oakes pursued graduate studies at the University of Tennessee (Memphis) and later went on to engage in post-graduate training in the United States Navy. During the Gulf War, he was awarded the Navy Commendation Medal for Service. Dr. Oakes is Board Certified by the American Board of Family Medicine and is a Fellow with the American Academy of Family Practice.

Dr. Oakes will be located in our Franklin, Tennessee office.

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CIGNA Government Services NetCourses Reminder

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

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

General Courses

Part B Courses

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

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Removal of Electronic File Version of the Provider/Supplier Enrollment Applications

Effective September 16, 2005, the Centers for Medicare & Medicaid Services (CMS) discontinued supporting the electronic versions of the CMS 855 Provider/Supplier Enrollment Applications. Additionally the applications were removed from the CIGNA Government Services Web site. However, the applications remain available in PDF format and can be obtained by accessing the CMS Web site at http://www.cms.hhs.gov/providers/enrollment/forms/.

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Medicare Guide to Rural Health Services Information for Providers, Suppliers, and Physicians Now Available

The Division of Provider Information Planning & Development at the Centers for Medicare & Medicaid Services (CMS) recently developed the “Medicare Guide to Rural Health Services Information for Providers, Suppliers and Physicians” which offers rural health information and resources in a single source. The guide is available in electronic downloadable format at http://www.cms.hhs.gov/medlearn/MedRuralGuide.pdf on the CMS Web site. Print and CD-Rom versions of the guide will be available in late November free of charge from the Medicare Learning Network’s Web page at http://www.cms.hhs.gov/medlearn/default.asp?link=products on the CMS Web site.

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

NOTE: This article was revised on October 11, 2005, to further clarify the language on how this issue affects services from independent ambulance suppliers and how it affects services to inpatients of acute care hospitals, Long Term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), and Inpatient Psychiatric Facilities (IPFs).

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 an inpatient of an acute care hospital, LTCH, IRF, or IPF (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.

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 and to prevent (or correct) improper payments to ambulance suppliers for transporting hospital inpatients. In CR3933 (on which this article is based), CMS explains 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 by independent ambulance services suppliers on dates that fall between the patients’ admission and discharge dates.

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 or ambulance services that fall within the occurrence span code 74 from and through dates plus one day, 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 unless they are within occurrence span code 74 from and through dates plus one day.

How the Process Works
In summary, here is how this process works:

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 on the CMS Web site.

From that Web page, look for CR3933 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 on the CMS Web site.

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National Modifier and Condition Code To Be Used To Identify Disaster-Related Claims

Note: This article was revised on October 14, 2005, to clarify that CR4106 related to Medicare beneficiaries and it also relates to Hurricane Rita. In addition, the CR release date and transmittal number (see above) were modified.

Provider Types Affected
Physicians, suppliers, and providers billing Medicare contractors (carriers, including Durable Medical Equipment Regional Carriers (DMERCs) and/or Fiscal Intermediaries (FIs), including Regional Home Health Intermediaries (RHHIs)) for services rendered to beneficiaries affected by Hurricane Katrina.

Provider Action Needed

STOP – Impact to You
This article is based on Change Request (CR) 4106, which establishes a new condition code and modifier for providers to use to indicate claims for victims of Hurricanes Katrina and Rita and other disasters.

CAUTION – What You Need to Know
To accommodate the emergency health care needs of Medicare beneficiaries and providers affected by Hurricanes Katrina and Rita and any future disasters, the Centers for Medicare & Medicaid Services (CMS) has created the following new condition code and modifier, effective for dates of service on and after August 21, 2005. The new condition code is “DR (Disaster Related)” and the new modifier is “CR (Catastrophe/Disaster Related).”

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

Background
CMS has acted to ensure that the Medicare program will be flexible enough to accommodate the emergency health care needs of beneficiaries and medical providers in the states devastated by Hurricanes

Katrina and Rita. Many of the programs’ normal operating procedures have been relaxed to speed the provision of health care services to the elderly and persons with disabilities who depend on Medicare services.

Because of hurricane damage to local health care facilities, many Medicare beneficiaries have been evacuated to neighboring states where receiving hospitals and nursing homes have no access to patients’:

Note: CMS is assuring facilities and medical providers receiving Medicare beneficiaries affected by Hurricanes Katrina and Rita that the normal requirements for documentation will be waived and the presumption of eligibility should be made.

Health care providers that furnish medical services in good faith, but who cannot comply with normal program requirements because of Hurricanes Katrina and Rita, will be:

New Condition Code and Modifier
To facilitate Medicare claims processing and track services and items provided to victims of Hurricanes Katrina and Rita and any future disasters, CMS has established a new condition code and modifier for providers to use on disaster-related claims. The new condition code and modifier are for use by providers submitting claims for Medicare beneficiaries who are Katrina disaster patients in any part of the country and are effective for dates of service on and after August 21, 2005. The new codes are the following:


For physicians or suppliers billing their local carrier or DMERC, only the modifier (CR) should be reported and not the condition code. A condition code is used in FI billing.

For institutional billing, either the condition code or modifier may be reported. The condition code would identify claims that are impacted or may be impacted by specific payor policies related to a national or regional disaster. The modifier would indicate a specific Part B service that may be impacted by policy related to the disaster.

CR4106 instructs Medicare contractors to recognize the new condition code and modifier on October 3, 2005, if possible, but no later than October 31, 2005.

In addition to this Medlearn Matters Article, CMS regional offices will help facilitate contractor outreach regarding provider education on the use of the new modifier and condition code.

Implementation
The targeted implementation date is October 3, 2005, but no later than October 31, 2005.

Additional Information
For complete details, please see the official instruction issued to your carrier/DMERC/FI regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS Web site. From that Web page, look for CR4106 in the CR NUM column on the right, and click on the file for that CR.

If you have any questions, please contact your carrier/DMERC/FI 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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2006 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB)

Provider Types Affected
Physicians, suppliers, and providers billing Medicare carriers and Fiscal Intermediaries (FIs) for services supplied to Medicare patients in SNFs

Provider Action Needed

STOP – Impact to You
This article is based on Change Request (CR) 4086 regarding the annual update of HCPCS codes for SNF Consolidated Billing and how the updates affect edits in Medicare claims processing systems, especially the Common Working File (CWF).

CAUTION – What You Need to Know
CR4086 provides updates to HCPCS codes that will be used to revise CWF edits to allow carriers and FIs to make appropriate payments in accordance with the policy for SNF consolidated billing that is detailed in Chapter 6 (Section 110.4.1) for carriers, and Chapter 6 (Section 20.6) for FIs.

GO – What You Need to Do
Physicians, suppliers, and providers should review the new coding files that will be posted on the CMS Web site.

Background

The Common Working File (CWF)
Medicare’s claims processing systems currently have edits in place for claims received for beneficiaries in a Part A covered Skilled Nursing Facility (SNF) stay as well as for beneficiaries in a non-covered stay. These edits allow only those services excluded from consolidated billing to be separately paid by the carrier and\or FI.

For physicians and providers billing carriers: By the first week of December 2005, new code files will be posted to http://www.cms.hhs.gov/medlearn/snfcode.asp on the CMS Web site.

For those providers billing FIs: By the first week of December 2005, new Excel and PDF files will be posted to http://www.cms.hhs.gov/providers/snfpps/snffi/ on the CMS Web site, under the “2006 Annual and Quarterly Updates” section.

Note: It is important and necessary for the provider community billing the FIs to view the “General Explanation of the Major Categories” bullet located under each Annual update bullet, at the http://www.cms.hhs.gov/providers/snfpps/snffi/ link, to understand the Major Categories, including additional exclusions not driven by HCPCS codes.

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

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

From that Web page, look for CR4086 in the CR NUM column on the right, and click on the file for that CR.

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

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Modification to Reporting of Diagnosis Codes for Screening Mammography Claims

Note: This article was revised on October 11, 2005, to reflect changes made to CR3562 on October 7, 2005. The CR release date and transmittal date (see above) were revised and the effective date was changed from July 1, 2005, to January 1, 1998. All other information remains the same.

Provider Types Affected
All providers billing Medicare carriers or Fiscal Intermediaries (FIs) for screening mammography claims

Provider Action Needed
This article modifies instructions to allow reporting of either diagnosis code V76.11 or V76.12. Providers should note that to ensure proper coding, one of the following diagnosis codes should be reported on screening mammography claims:

Background
Effective January 1, 1998, providers only reported diagnosis code V76.12 on screening mammography claims. Effective July 1, 2005, the Centers for Medicare & Medicaid Services (CMS) will allow reporting of either V76.11 or V76.12, as appropriate.

Implementation
Implementation date is July 5, 2005.

Additional Information
The official instruction issued to your carrier/intermediary regarding this change may be found at:
http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS Web site. From that Web page, look for CR3562 in the CR NUM column on the right and click on the file for that CR.

If you have any questions, please contact your carrier/intermediary at their toll-free number, which may be found at http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf 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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New Educational Products Available on Medicare Prescription Drug Coverage – The Eighth in the Medlearn Matters Series

Provider Types Affected
Physicians, health care professionals, providers, suppliers, and staff who provide service to people with Medicare.

Important Points to Remember

New Products Available on http://www.cms.hhs.gov/medlearn/drugcoverage.asp New products are available to download at the Medicare Prescription Drug Coverage Information for Providers Web page. This page is dedicated to providing the latest drug coverage information for Fee-For-Service (FFS) Medicare providers. The new products include the following:

Medicare Rx Training Course: Important Information for Health Care Professionals – Earn CME Credit

This training course covers important information about Medicare prescription drug coverage,including the fundamental components of the program, types of drug plans available, resources for people with Medicare and health care professionals, and important dates in 2005 and 2006.

The University of Kansas Medical Center (KUMC) is offering Continuing Education Credit for this course in coordination with the Centers for Medicare & Medicaid Services (CMS):

Once you complete the course and receive a passing score on the post-assessment, you will be provided with a link to KUMC. KUMC will charge a nominal fee for credit courses.

Physician Brochure
This publication explains the new Medicare prescription drug coverage for physicians and their staff.

Physician Tear-off Sheet
This resource is appropriate for distribution in physicians’ offices and other clinical settings. It contains basic information on the new coverage, as well as contact numbers for each state’s State Health Insurance Assistance Program (SHIP). The SHIPs will direct people with Medicare to resources for individual counseling.

“Have Limited Income? SSA Can Help” - Posters for Your Office or Clinic
These posters direct people with Medicare who have limited income and resources to sources for help with prescription drug costs. The posters are suitable for display in healthcare settings where people with Medicare and their caregivers will see the information. To view and order the posters, go to http://www.cms.hhs.gov/medlearn/drugcoverage.asp on the CMS Web site.

New Beneficiary Publications Available
New publications for people with Medicare that explain various aspects of the new coverage are available at http://www.cms.hhs.gov/medlearn/drugcoveragepubs.asp on the CMS Web site.

Additional Information
To find Medicare Prescription Drug Plans available in each state, visit the Landscape of Local Plans on the Medicare Web site for a complete listing.

You can use the new Medicare Prescription Drug Plan Finder to help people with Medicare learn about the new Medicare prescription drug coverage, find and compare prescription drug plans that meet personal needs, and enroll in the prescription drug plan that is right for him/her.

The new Formulary Finder on the Medicare Web site will help people with Medicare find plans in each state that match their required drug lists.

Bookmark the Medicare Prescription Drug Coverage Information for Providers page, http://www.cms.hhs.gov/medlearn/drugcoverage.asp, for the latest information and educational resources.

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The New CMS National Provider Identifier (NPI) Web Page

The Centers for Medicare & Medicaid Services is pleased to announce the new CMS Web page dedicated to providing all the latest National Provider Identifier (NPI) news for Fee-For-Service (FFS) Medicare providers. Visit http://www.cms.hhs.gov/providers/npi/default.asp on the Web. As a reminder, all health care providers are required by law to apply for an NPI. To apply online, visit https://nppes.cms.hhs.gov.

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2006 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments

Provider Types Affected
Physicians who provide services in designated HPSAs

Provider Action Needed

STOP – Impact to You
New information on the new automated HPSA bonus payments for 2006 is posted on the Centers for Medicare & Medicaid Services (CMS) Web site.

CAUTION – What You Need to Know
Section 413(b) of the Medicare Prescription Drug Improvement and Modernization Act of 2003 mandated an annual update to the automated HPSA bonus payment files. This CR provides those files for claims with dates of service on or after January 1, 2006, through December 31, 2006.

GO – What You Need to Do
You should review the information on the CMS Web site to determine if you qualify for the HPSA bonus payment for 2006.

Background
Section 1833(m) of the Social Security Act provides a 10 percent bonus payment for physicians who furnish medical care services in geographic areas that the Health Resources and Services Administration (HRSA) designates as primary medical care Health Professional Shortage Areas (HPSAs).

MMA Section 413(b) required CMS to annually update the bonus payment files, and CR4113 provides the names of those updated files for 2006. To find details regarding the HPSA bonus payments, please visit http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0449.pdf on the CMS Web site.

The updated list of HPSA zip codes for calendar year (CY) 2006 can be found at http://www.cms.hhs.gov/providers/bonuspayment on the CMS Web site.

Additional Information
You can find more information about the HPSA bonus payment 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 CR4113 in the CR NUM column on the right, and click on the file for that CR.

You can also go to the Medlearn Matters Provider Education Web page at http://www.cms.hhs.gov/medlearn/matters/ to find other Medlearn Matters articles that address the bonus payments.

Special Edition articles SE0449, SE0453, and SE0450 and Medlearn Matters articles MM3108, MM3827, MM3822, MM3336, and MM3800 all address HPSA issues. From this Web site, you can also look at the CRs from which the articles were derived by clicking on the respective CR number.

You might also want to look at the Medicare Claims Processing Manual (Publication 100.04), Chapter 12 (Physician/Practitioner Billing), Section 90.4 (Billing and Payment in Health Professional Shortage Areas (HPSAs).

You can find this manual at http://www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf on the CMS Web site.

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 on the CMS Web site.

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Instructions for Provider Notification Regarding Provider Drug Coverage Medlearn Web Page and Posting of Public Service Announcements

Coming in 2006! Beginning January 1, 2006, Medicare prescription drug coverage will be available to people with Medicare. Health care professionals can find information about this new coverage at www.cms.hhs.gov/medlearn/drugcoverage.asp, on the CMS Web site.

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Smoking and Tobacco-Use Cessation Counseling Services: Common Working File (CWF) Inquiry for Providers

Provider Affected
Providers billing Medicare carriers or fiscal intermediaries (FIs) for smoking and tobacco-use cessation counseling

Provider Action Needed
CR4104 announces the implementation of the capability for providers to access the CWF (part of Medicare’s claims processing systems) for viewing the number of smoking and tobacco-use cessation counseling sessions a beneficiary has received.

Background
CR3929, issued July 15, 2005, implements a frequency of service limitations edit in the CWF for smoking and tobacco-use cessation counseling, for dates of service on or after October 1, 2005. The implementation date for this CWF edit is October 3, 2005.

Effective April, 1, 2006, Medicare providers will be given the capability to view the number of smoking and tobacco-use cessation counseling sessions provided to a beneficiary. Providers will be able to access this file through the CWF, by entering the beneficiary’s health insurance claim number (HICN).

Ultimately, the capability to view the number of smoking and tobacco-use cessation counseling sessions provided to a beneficiary gives providers the ability to determine a beneficiary’s available coverage for this service.

Additional Information
For complete details, please see the official instruction issued to your carrier/intermediary regarding this change. That instruction 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 4104 in the CR NUM column on the right, and click on the file for that CR.

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

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Medicare Provider Satisfaction Survey

Beginning in January 2006, the Centers for Medicare & Medicaid Services (CMS) will begin conducting the Contractor Provider Satisfaction Survey (MCPSS) to measure provider satisfaction of the key services provided by the 42 Medicare contractors, including CIGNA Government Services. This survey is just one of the tools CMS will use to carry out the measurement of satisfaction levels among providers, a requirement of the Medicare Modernization Act. The end goal is to influence the efficient administration of the Medicare program.

Only about 400 randomly selected Part B providers per state will be selected to participate in the survey. The survey will take approximately 20 minutes to complete and will focus on six key areas of the provider-contractor interface, including provider communications, provider inquiries, claims processing, appeals, provider enrollment, and medical review.

If a provider is asked to participate, they will receive a packet of information that will include a letter from CIGNA Government Services, a letter from Westat, the company performing the survey, and instructions on how to access and complete the survey via a secure Internet Web site. It will also include contact information to request a paper copy of the survey instrument to submit responses by mail or fax. All responses will be due back by January 25, 2006.

Although CIGNA Government Services has conducted provider satisfaction surveys in the past, this is the first time that CMS has conducted a uniform, national mechanism for measuring provider satisfaction. We urge all providers chosen to participate in the survey to proactively respond to the survey request to not only help CIGNA Government Services improve the services we provide to the medical community.

If you have any questions regarding the survey, please contact Westat at 1.800.863.3561 or mcpss@westat.com.

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Posters Now Available!

Posters titled “Have Limited Income? Social Security Can Help with Prescription Costs” can be ordered free of charge on the Centers for Medicare and Medicaid Services’ (CMS) Web site.

The posters are suitable for display in a physician’s, provider’s, or supplier’s office, a pharmacy, or other health care setting where Medicare beneficiaries will see this information. The posters direct Medicare beneficiaries with limited income to a toll free number where they can find out if they are eligible for help with prescription drug costs. Flat posters are suitable for wall display. Easel posters are suitable for counter display. Order the size and style appropriate for your use. Artwork cannot be specified as posters will be sent based on availability at the time the order is received. To view and order the posters, go to the Medlearn Prescription Drug Coverage Web page located at: http://www.cms.hhs.gov/medlearn/drugcoverage.asp on the CMS Web site. We need your help in getting this information out to Medicare beneficiaries with limited income and resources. We encourage you to order and display the posters where Medicare beneficiairies will see them.

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Announcement of New NPI Web Page

Announcing the new Centers for Medicare & Medicaid Services (CMS) Web page dedicated to providing all the latest NPI news for Fee-For-Service (FFS) Medicare providers! Visit http://www.cms.hhs.gov/providers/npi/default.asp on the Web! While this page is dedicated to the Medicare FFS community, it contains helpful information and links that may benefit all health care providers. Reminder–Health care providers are required by law to apply for a National Provider Identifier (NPI). To apply online, visit: https://nppes.cms.hhs.gov.

For technical questions about the NPI, the application process, and to receive a paper application, call the NPI Enumerator Helpline at 1.800.465.3203.

Also please post a link to the enumerator Web site (https://nppes.cms.hhs.gov) on the Part B Web site.

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Update to the Healthcare Provider Taxonomy Codes (HPTC) Version 5.1

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

Provider Action Needed

STOP – Impact to You
This article is based on Change Request (CR) 4072, which includes details regarding the Version 5.1 HPTC update.

CAUTION – What You Need to Know
CR4072 advises your carrier and/or DMERC to obtain the Healthcare Provider Taxonomy Code list Version 5.1 and use it to update their internal HPTC tables to process your claim(s) correctly.

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

Background
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that submitted data, which is part of a named code set, be valid data from that code set. Claims with invalid data are noncompliant.

Because healthcare provider taxonomy is a named code set in the American National Standards Institute (ANSI) X12N 837 Professional Implementation Guide, Medicare carriers, including DMERCs, must validate the inbound taxonomy codes against their internal HPTC tables. The HPTC is an external non-medical data code set designed for use in classifying healthcare providers in an electronic environment according to provider type, or practitioner specialty. HPTCs are scheduled to be updated twice per year (April and October).

The updated code list is available from the Washington Publishing Company at http://www.wpcedi.com/codes/taxonomy in two forms:

CR4072 advises your carrier and/or DMERC to use the most cost effective means to obtain the Version 5.1 HPTC list and update their HPTC tables as necessary.

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

Additional Information
To summarize the changes in Version 5.1, the following taxonomy codes are added:

For complete details, please see the official instruction issued to your carrier/DMERC regarding this change at http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS Web site.

From that Web page, look for CR 4072 in the CR NUM column on the right, and click on the file for that CR.

If you have any questions, please contact your carrier/DMERC 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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CLIA Waived Test (Modifier QW)

The Centers for Medicare and Medicaid Services (CMS) has identified a number of simple laboratory procedures that can be performed in physicians’ offices after obtaining a Certificate of Waiver. Waived tests are subject to change at any time, so check the CMS Web site for changes to the waived tests.

Waived tests submitted to Medicare should be reported exactly as they appear on the Medicare list of waived procedures. Those identified with HCPCS Level II modifier QW on the list, should be submitted with the QW modifier appended to the code. If the code is not identified with a QW on the list, do not append the modifier.

The following link will take you directly to the CMS Web page dedicated to the CLIA Program. Scroll down to the heading titled “Categorization of Tests under CLIA,” and click on the first bullet titled “List of Waived Tests” in order to access a complete listing of waived tests. http://www.cms.hhs.gov/clia/

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

Provider Types Affected
All Medicare providers who bill Medicare for Part B drugs

Provider Action Needed

STOP – Impact to You
CR4160 revises the payment allowance limits in the October 2005 Medicare Part B drug pricing files.

CAUTION – What You Need to Know
The revised October 2005 payment allowance limits apply to dates of service October 1, 2005, through December 31, 2005.

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

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

The ASP file, used in the ASP methodology, is based on data CMS receives quarterly from manufacturers.

Each quarter, the Centers for Medicare & Medicaid Services (CMS) will update your carrier and fiscal intermediary (FI) payment allowance limits with the ASP drug pricing files based on these manufacturers’ data. Beginning January 1, 2005, the payment allowance limits for Medicare Part B drugs and biologicals that are not paid on a cost or prospective payment basis are 106 percent of the ASP, and CMS will update the payment allowance limits quarterly.

Exceptions to General Rule
However, there are exceptions to this general rule as summarized below:

The payment allowance limits will not be updated in 2005.
The payment allowance limits for infusion drugs furnished through a covered item of durable medical equipment that were not listed in the published compendia as of October 1, 2003, (i.e., new drugs) are 95 percent of the first published AWP.

In determining the payment limit based on WAC, carriers/FIs will follow the methodology specified in Chapter 17 of the Medicare Claims Processing Manual for calculating the AWP, but substitute WAC for AWP. Chapter 17 (Drugs and Biologicals) is available at http://www.cms.hhs.gov/manuals/104_claims/clm104c17.pdf on the CMS Web site:

The payment limit is 100 percent of the WAC for the lesser of the lowest brand or median generic. Your carrier or FI may, at their discretion, contact CMS to obtain payment limits for drugs not included in the quarterly ASP or NOC files. If available, CMS will provide the payment limits either directly to the requesting carrier/FI or by posting an MS Excel file on the CMS Web site. If the payment limit is available from CMS, carriers/FIs will substitute CMS-provided payment limits for pricing based on WAC or invoice pricing.

Your carrier/FI will not search and adjust claims that are processed prior to implementation of this change unless you bring such claims to their attention. The payment limits included in the revised ASP and NOC payment files supersede the payment limits for these codes in any publication published prior to this document.

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

Implementation
The implementation date for the instruction is November 28 2005

Additional Information
The official instructions issued to the intermediary regarding this change can be found at http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS Web site. On the above page, scroll down while referring to the CR NUM column on the right to find the link for CR4160. Click on the link to open and view the CR.

If you have 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 on the CMS Web site.

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Calendar Year 2005 Payment for Medicare Part B Radiopharmaceuticals Not Paid on a Cost or Prospective Payment Basis

Provider Types Affected
All providers billing carriers, fiscal intermediaries (FIs), or regional home health intermediaries (RHHIs), for Medicare Part B radiopharmaceuticals

Provider Action Needed

STOP – Impact to You
Medicare Part B radiopharmaceuticals payment allowance limits are not subject to the Average Sales Price (ASP), effective January 1, 2005.

CAUTION – What You Need to Know
Effective January 1, 2005, the payment allowance limits for radiopharmaceuticals are determined by the payment methodology in place under Part B as of November 2003.

GO – What You Need to Do
If you require adjustments on radiopharmaceuticals claims processed prior to January 1, 2005, contact your carrier, FI, or RHHI.

Background
In accordance with section 303(c) of the Medicare Modernization Act (MMA) of 2003, effective January 1, 2005, drugs and biologicals not paid on a cost or prospective basis are paid based on the Average Sales Price (ASP).

However, section 303(h) of the MMA of 2003 provided for the continuation of the payment methodology under Medicare Part B, prior to the MMA for radiopharmaceuticals, effective January 1, 2005. Therefore, the payment allowance limits for radiopharmaceuticals are based on the payment methodology under Part B, as of November 2003.

This article and related CR4053 supersede instructions provided in CR3783, transmittal 528, dated April 22, 2005, which stated that Medicare carriers, FIs, and RHHIs will determine payment allowance limits for radiopharmaceuticals based on the ASP. The payment allowance limits for radiopharmaceuticals are not subject to the ASP.

Additional Information
Medlearn Matters article MM3783, titled “MMA - July 2005 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing File, Effective July 1, 2005,” can be viewed at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3783.pdf on the CMS Web site.

The official instruction issued to your carrier/FI/RHHI regarding this change 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 CR4053 in the CR NUM column on the right and click on the file for that CR.

If you have any questions, please contact your Medicare carrier/FI/RHHI 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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Alert Regarding End of Eligibility-File Based Crossover Processes

The Centers for Medicare & Medicaid Services (CMS) decided that it will not continue to maintain both an eligibility file-based crossover process at all Medicare contractors and the consolidated COBA process at the COBC. Therefore, Medicare contractors shall no longer cross claims over to trading partners pursuant to signed crossover agreements and the submission of eligibility files beyond December 31, 2005. As of that date, the COBC will exclusively cross over all claims to trading partners in the HIPAA ANSI X12-N 837 COB formats via the eligibility file-based COBA process, unless Medicare contractors request specific waivers on behalf of current trading partners. Waivers will be granted on a case-by-case basis and must include a justification for not testing the COBA process with the COBC.

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Free Medicare Remit Easy Print Software

Are you still using the Standard Paper Remittance (SPR)? Save TIME and MONEY by taking advantage of FREE Medicare Remit Easy Print (MREP) software now available for viewing and printing the HIPAA compliant Electronic Remittance Advice (ERA)! The MREP software gives providers and suppliers the following abilities:

Providers and suppliers can view and print as many or as few claims as needed. This will be especially helpful when you need to print only one claim from the remittance advice when forwarding the claim to a secondary payer. This FREE software can save you time resolving Medicare claim issues. Take advantage of the MREP features unavailable with the SPR.

In order to utilize the MREP software, you will need to receive a HIPAA compliant ERA. Contact the EDI Help Desk at 866.352.1608 for NC and 866.520.4022 for TN and ID to find out more about MREP and/or for information on how to receive a HIPAA compliant ERA. Take advantage of this new software. Begin using MREP today!

The link to the Medicare Remit Easy Print (MREP) on the CMS Web site is http://www.cms.hhs.gov/IT

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Medical Review Additional Documentation Requests (ADRs)

Provider Types Affected
All Medicare providers and suppliers

Provider Action Needed

STOP – Impact to You
Through the use of the Additional Documentation Request (ADR), your carrier, including Durable Medical Equipment Regional Carriers (DMERCs), or intermediary may ask you for additional documentation regarding a particular Medicare claim.

CAUTION – What You Need to Know
To get a more complete picture of a patient’s clinical condition, CR4022 allows carriers, DMERCs, and intermediaries to request additional documentation about the patient’s condition before and after a specific service to gain a more complete picture of the patient’s clinical condition.

GO – What You Need to Do
Your staffs should be aware of ADRs and should be prepared to respond to them within 30 days.

Background
When a carrier, DMERC, or intermediary (also referred to as Medicare contractor(s)), cannot make a coverage or coding determination from the information that has been provided on a claim and its attachments, they may ask for additional documentation by issuing an Additional Documentation Request (ADR). The Medicare contractor must request records related to the claim(s) being reviewed. The Medicare contractor may collect documentation related to the patient’s condition before and after a service in order to get a more complete picture of the patient’s clinical condition. Your Medicare contractor will not deny other claims related to the documentation of the patient’s condition before and after the claim in question unless they review and give appropriate consideration to the actual additional claims and associated documentation.

For more information about ADRs during prepayment or postpayment medical review, go to
http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS Web site. From that Web page, look for CR4022 in the CR NUM column on the right and click on the file for that CR.

Also useful is the Medicare Program Integrity Manual, Chapter 3 (Verifying Potential Errors and Taking Corrective Actions), Section 3.4.1.2 (Additional Documentation Requests (ADR) During Prepayment or Postpayment MR), which is an attachment to CR4022.

Finally, 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 on the CMS Web site.

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Tennessee, North Carolina, and Idaho Revised LCDs

The following Local Coverage Determinations (LCDs) have been revised for Tennessee, Idaho, and North Carolina:

Please follow the attached link to access the LCD’s. http://www.cignagovernmentservices.com. Click on “Part B” and use the “Medical Review” tab to locate the policies for your state.

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Informational and Educational Materials for the New Preventive Services

Revised: This article was revised on October 12, 2005, to provide clarifying language regarding nonphysician practitioners and to provide definitions related to diabetes.

Provider Types Affected
Physicians, suppliers, and providers billing Medicare carriers and Fiscal Intermediaries (FIs)

Introduction
This Special Edition article provides an overview of the many informational and educational products developed by the Centers for Medicare & Medicaid Services (CMS) to inform and educate physicians, providers, suppliers, and other health care professionals, including non-physician practitioners, about the array of Medicare-covered preventive services and screenings available. These include the following three new services that became effective January 1, 2005:

(For the purpose of this article, non-physician practitioners are physician assistants, nurse practitioners, or clinical nurse specialists.)

Note: It is important to emphasize that the diabetes screening tests and cardiovascular screening blood tests are each stand alone billable services separate from the Initial Preventive Physical Examination (IPPE) or “Welcome to Medicare” Physical Exam. The IPPE is a unique benefit for beneficiaries new to the Medicare program. This benefit must be received in the first six months after the effective date of the beneficiary’s first Part B coverage period, which must begin on or after January 1, 2005.

To ensure that your Medicare patients receive the best possible health care, it is important to be aware of the preventive benefits available for these patients.

Diabetes Screening Tests
Section 613 of the MMA provides for coverage, under Medicare Part B, of diabetes screening tests, effective for services furnished on or after January 1, 2005, for beneficiaries at risk for diabetes (see eligibility below) or those diagnosed with pre-diabetes.

Medicare provides coverage for the following diabetes screening blood tests:

Who Is Eligible?
To be eligible for the diabetes screening tests, beneficiaries must have any of the risk factors or at least two of the characteristics discussed below.

Risk Factors
Individuals who have any of the following risk factors are eligible for diabetes screening:

Characteristics
Alternatively, individuals who have a risk factor consisting of at least two of the following characteristics are eligible for diabetes screening:

Frequency of Screening Tests
Effective for services performed on or after January 1, 2005, Medicare provides coverage for diabetes screening tests with the following frequency:

Nationally Non-Covered Indications

CMS provides the following definitions for the purpose of this article:

Diabetes: diabetes mellitus, a condition of abnormal glucose metabolism diagnosed from a fasting blood sugar > 126 mg/dL on two different occasions; a 2-hour post-glucose challenge > 200 mg/dL on two different occasions; or a random glucose test > 200 mg/dL for an individual with symptoms of uncontrolled diabetes.

Pre-diabetes: abnormal glucose metabolism diagnosed from a previous fasting glucose level of 100 to125 mg/dL, or a 2-hour post-glucose challenge of 140 to 199 mg/dL. The term “pre-diabetes” includes impaired fasting glucose and impaired glucose tolerance.

Post-glucose challenge test: an oral glucose tolerance test with a glucose challenge of 75 gms of glucose for non-pregnant adults, or a 2-hour post-glucose challenge test alone.

Reimbursement
Reimbursement for the diabetes screening tests is made under the Medicare Clinical Laboratory Fee Schedule. There is no deductible or co-payment for this benefit.

For detailed instructions regarding Type of Bills (TOBs) to use, including special instructions for Maryland Hospitals and Critical Access Hospitals (CAHs), see CR3637 (Transmittal 446, Re-issued on January 21, 2005, “MMA – Diabetes Screening Tests”) at http://www.cms.hhs.gov/manuals/pm_trans/R446CP.pdf on the CMS Web site. There is a related Medlearn Matters article (MM3637) at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3637.pdf on the CMS Web site.

Cardiovascular Screening Blood Tests
Section 612 of the MMA provides for coverage, under Medicare Part B, of cardiovascular screening blood tests (tests for the early detection of cardiovascular disease or abnormalities associated with an elevated risk for that disease) effective for services performed on or after January 1, 2005. The MMA permits coverage of tests for cholesterol and other lipid or triglycerides levels for this purpose.

Therefore, effective January 1, 2005, coverage is provided for the following three screening blood tests:

Other cardiovascular screening tests for which CMS has not specifically indicated national coverage continue to be non-covered.

The implementation of this new benefit permits Medicare beneficiaries who have not been previously diagnosed with cardiovascular disease to receive cardiovascular screening blood tests for risk factors associated with cardiovascular disease. This includes individuals who have no prior knowledge of heart problems but recognize that their behavior or lifestyle may put them at risk because of diet or lack of exercise.

Under Part B, Medicare provides coverage for each of these three cardiovascular screening blood tests once every five years (i.e., 59 months after the last covered screening tests). These tests must be ordered by the physician who is treating the beneficiary for the purpose of early detection of cardiovascular disease in individuals without apparent signs or symptoms.

Reimbursement
Reimbursement for the cardiovascular screening blood tests is made under the Medicare Clinical Laboratory Fee Schedule. There is no deductible or co-payment for this benefit.

Details regarding HCPCS/CPT codes and diagnosis codes, and how carriers and intermediaries will treat claims, are described in CR3411 (Transmittal 408, dated December 17, 2004, “MMA – Cardiovascular Screening Blood Tests,” which can be found at http://www.cms.hhs.gov/manuals/pm_trans/R408CP.pdf on the CMS Web site. In addition, there is a related Medlearn Matters article (MM3411) at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3411.pdf on the CMS Web site.

The Initial Preventive Physical Examination (IPPE) Section 611 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), provides for coverage, under Medicare Part B, of an Initial Preventive Physical Examination (IPPE), including a screening electrocardiogram (EKG) for new beneficiaries, effective for services furnished on or after January 1, 2005 (subject to certain eligibility and other limitations).

Once in a Lifetime Benefit
The IPPE is a once-in-a-lifetime benefit that must be performed within six months after the effective date of the beneficiary’s first Part B coverage, but only if such Part B coverage begins on or after January 1, 2005.

An IPPE furnished on January 10, 2005, for example, to a beneficiary whose Medicare Part B coverage was effective initially on December 1, 2004, would not be covered under this benefit. If a beneficiary is first covered by Part B on January 1, 2005, however, then a physical provided on January 10, 2005 would be
covered by this new benefit.

This service provides for payment for an IPPE to be performed in various provider settings by physicians, or qualified non-physician practitioners (NPPs). However, coverage is provided for only one IPPE per beneficiary lifetime.

Services Included in the IPPE Visit
The complete IPPE visit consists of all of the following services furnished to a beneficiary with the goal of health promotion and disease detection:

1) Review of an individual’s medical and social history, with attention to modifiable risk factors for disease detection
This review includes, at a minimum, past medical and surgical history, such as experience with illnesses, hospital stays, operations, allergies, injuries and treatments, current medication and supplements (including calcium and vitamins), family history (including diseases that may be hereditary or place the individual at risk), and social history of alcohol, tobacco, and illicit drug use, diet, and physical activities.

2) Review of an individual’s potential (risk factors) for depression
This review includes current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression. The physician or other qualified NPP may select a screening instrument from various available standardized screening tests designed for this purpose and recognized by national professional medical organizations.

3) Review of the individual’s functional ability and level of safety
This review is based on the use of appropriate screening questions or a screening questionnaire, which the physician or other qualified NPP may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations. The review must include, at a minimum, a review of hearing impairment, activities of daily living, risk of falls, and home safety.

4) An examination
This examination includes measurement of the individual’s height, weight, blood pressure, a visual acuity screen, and other factors as deemed appropriate by the physician or qualified NPP, based on the individual’s medical and social history (refer to service element 1) and current clinical standards.

5) Performance and interpretation of an EKG
As required by statute, the IPPE benefit always includes a screening EKG. If the primary physician or qualified NPP is not able to perform the EKG during the IPPE visit, arrangements should be made for the beneficiary to be referred to another physician or entity to perform and interpret the EKG. The primary physician or qualified NPP must document the results of the screening EKG in the beneficiary’s medical record to complete and bill for the IPPE benefit. Both the IPPE and the screening EKG must be performed and interpreted before the physician, qualified NPP, and/or entity can submit the claims.

6) Education, counseling, and referral
These will be conducted, as deemed appropriate, by the physician or qualified NPP, based on the results of the review and evaluation services described in the previous five elements.

7) Education, counseling, and referral for other preventive services
Education, counseling, and referral including a brief written plan (e.g., a checklist or alternative) provided to the individual for obtaining the appropriate screening and other preventive services, which are covered separately under Medicare Part B. These services include the following:

Note: The MMA did not make any provision for the waiver of Medicare coinsurance and Part B deductible for the IPPE. Payment for this service would be subject to the required deductible, which is $110 for Calendar Year 2005, if the deductible has not been met, with
the exception of Federally Qualified Health Centers (FQHCs). In addition, the usual coinsurance provisions would apply.

For more detailed instructions regarding HCPCS codes to use, including special instructions for Rural Health Clinics/Federally Qualified Health Centers (RHCs)/FQHCs, Maryland Hospitals, Critical Access Hospitals (CAHs), and Indian Health Service (IHS) Hospitals, review Change Request (CR) 3638 (Transmittal 417, dated December 22, 2004, “MMA – Initial Preventive Physical Examination”) at http://www.cms.hhs.gov/manuals/pm_trans/R417CP.pdf on the CMS Web site.


You can also view the related Medlearn Matters article (MM3638) at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3638.pdf on the CMS Web site.

Preventive Services Informational and Educational Products
CMS has developed a variety of informational and educational products for health care professionals to:

The Additional Information section of this Special Edition article will tell you where you can find
informational/educational products specifically for Medicare beneficiaries.

The following informational and educational products have been developed especially for you, the Medicare fee-for-service physician, provider, supplier, and health care professional.

The Preventive Services Educational Resource Web Guide
CMS has developed a Medlearn Web page where Medicare fee-for-service providers can find links to all provider/supplier specific informational and educational related preventive services products and resources.

The Web page is located at http://www.cms.hhs.gov/medlearn/preventiveservices.asp on the CMS Web site. Access to products discussed in this Special Edition article can be found on that Web page.

The Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Health Care Professionals
This comprehensive guidebook to Medicare-covered preventive services and screenings is intended to provide physicians, providers, suppliers, and other health care professionals that bill Medicare fee-forservice contractors with information on coverage, coding, billing, and reimbursement to help them file claims effectively.

It also gives providers information that will enable them to encourage utilization of these benefits as appropriate. You may order a print copy of The Guide or download, view, and print a copy by going to http://www.cms.hhs.gov/medlearn/preventive/psguide.asp on the CMS Web site.

Brochures
Five two-sided, tri-fold brochures provide an overview of the coverage information for each preventive service covered by Medicare. These brochures may be ordered through the Medlearn product ordering system, or they may be downloaded, viewed, and printed at http://www.cms.hhs.gov/medlearn/preventiveservices.asp on the CMS Web site.

Expanded Benefits
The Expanded Benefits brochure provides Medicare fee-for-service physicians, providers, suppliers, and other health care professionals with an overview of Medicare’s coverage for the three new preventive services and screenings (the IPPE, cardiovascular screening blood tests, and diabetes screening tests), as well as other covered diabetes benefits. This brochure can be found at http://www.cms.hhs.gov/medlearn/expanded_benefits_06-08-05.pdf on the CMS Web site.

Cancer Screenings
The Cancer Screenings brochure provides Medicare fee-for-service physicians, providers, suppliers, and other health care professionals with an overview of Medicare’s coverage for screening mammography, screening Pap test, pelvic examination, colorectal cancer screening, and prostate cancer screening benefits. This brochure can be found at http://www.cms.hhs.gov/medlearn/cancer_screening_06-08-05.pdf on the CMS Web site.

Adult Immunizations
The Adult Immunizations brochure provides Medicare fee-for-service physicians, providers, suppliers, and other health care professionals with an overview of Medicare’s coverage for influenza, hepatitis B, and pneumococcal polysaccharide vaccines and their administration. This brochure can be found at http://www.cms.hhs.gov/medlearn/adult_immunization_06-08-05.pdf on the CMS Web site.

Glaucoma Screening
The Glaucoma Screening brochure provides Medicare fee-for-service physicians, providers, suppliers, and other health care professionals with an overview of Medicare’s coverage for the glaucoma screening benefit. This brochure can be found at http://www.cms.hhs.gov/medlearn/glaucoma_06-08-05.pdf on the CMS Web site.

Bone Mass Measurements
The Bone Mass Measurements brochure provides Medicare fee-for-service physicians, providers, suppliers, and other health care professionals with an overview of Medicare’s coverage for the bone mass measurements (bone density studies) benefit. The Bone Mass Measurements brochure is available at http://www.cms.hhs.gov/medlearn/bone_mass_06-08-05.pdf on the CMS Web site.

The above brochures can be ordered or downloaded, viewed, and printed by going to http://www.cms.hhs.gov/medlearn/preventiveservices.asp on the CMS Web site.

Quick Reference Information: Medicare Preventive Services
This two-sided laminated chart gives Medicare fee for-service physicians, providers, suppliers, and other health care professionals a quick reference to Medicare’s preventive services and screenings. It identifies coding requirements, eligibility, frequency parameters, and co-payment/coinsurance and deductible information for each benefit. You may order copies of the Quick Reference Chart or download, view, and print a copy by going to http://www.cms.hhs.gov/medlearn/preventiveservices.asp on the CMS Web site.

Medicare Preventive Services Resources for Physicians, Providers, Suppliers, and Other Health Care Professionals (CD ROM)
CMS has created a special CD ROM titled Medicare Preventive Services Resources for Physicians, Providers, Suppliers, and Other Health Care Professionals that contains useful preventive services resources for Medicare fee-for-service physicians, providers, suppliers, and other health care professionals who bill Medicare fee-for-service contractors (FIs and carriers). These resources include:

To order the Medicare Preventive Services Resources for Physicians, Providers, Suppliers, and Other
Health Care Professionals CD ROM, go to http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=5 on the CMS Web site.

Preventive Services Web-Based Training (WBT) Courses
The current WBT course, Medicare Preventive Services: Osteoporosis, Diabetes, and Prostate Cancer, is being expanded to include the new MMA benefits, and will be renamed Medicare Preventive Services Series: Part 3 Expanded Benefits. The Medicare Preventive Services Series: Part 1 Adult Immunizations WBT is being updated to include hepatitis B, and the Medicare Preventive Services Series: Part 2 Women’s Health WBT is also being updated.

These updated products will be available later in 2005. To access the preventive services Web-based training courses, see the Provider Education section of the Preventive Services Educations Resource Web Guide at http://www.cms.hhs.gov/medlearn/preventiveservices.asp on the CMS Web site.

Preventive Services Medlearn Matters Articles
CMS issued the following Medlearn Matters articles in January 2005 for each new preventive service as corresponding implementing instructions were released:

Coming Soon! An Overview of Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Health Care Professionals (Video and Audio programs)