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January 2006 Part B Medicare Bulletin

Posted January 3, 2006

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Coverage by Medicare Advantage (MA) Plans for Implantable Automatic Cardiac Defibrillator (ICD) Services Not Previously Included in MA Capitation Rates

Provider Types Affected
All Medicare providers billing either a Medicare carrier or fiscal intermediary (FI) for ICDs for Medicare beneficiaries who are also members of Medicare Advantage (MA) plans

Provider Action Needed

STOP - Impact to You
Be aware that, effective for services provided on and after January 1, 2006, your Medicare carrier or FI will no longer pay Fee-for-Service (FFS) claims for the expanded coverage of ICD services rendered to MA beneficiaries.

CAUTION - What You Need to Know
Related CR4133 instructs Medicare carriers and FIs to no longer pay FFS claims for the expanded coverage of ICD services (described in CR3604) that you provide to MA beneficiaries. These services are now part of the MA capitation rates.

GO - What You Need to Do
Make sure that your billing staffs are aware of these changes and also the basis for billing Medicare.

Background
In CR3604 (January 27, 2005), Medicare expanded ICD coverage for the following new indications:

See Medlearn Matters article MM3604 regarding this issue at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3604.pdf on the CMS Web site.

Adjustment in MA Rates
Beginning January 1, 2006, the MA rates are appropriately adjusted to account for the expanded coverage of ICD services, and MA plans are now liable for payment relating directly to providing these services. Thus CR4133:

Conditions for Denying Claims
CR4133 provides that Medicare systems will now deny, for beneficiaries in MA plans, claims that meet all of the conditions described in the following categories:

Outpatient Claims Processed by Your FI

Hospital Inpatient Claims

Professional Part B Claims

Finally, CR4133 instructs your carriers and FIs, when denying these services, to use:

Additional Information
You can find more information about billing for ICD services for MA Plan beneficiaries 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 "4133" in the CR NUM column on the right, and click on the file for that CR.

Indications and limitation of coverage for ICDs are located in the Medicare National Coverage Determinations Manual (Pub. 100-03), Chapter 1, Part 1, §20.4 (Implantable Automatic Defibrillators).

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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Appeals of Claims Decisions: Redeterminations and Reconsiderations and Appeals Rights for Dismissals

Effective Date: January 1, 2006, for appeals of initial determination of claims by Medicare carriers; May 1, 2005, for initial claim determinations by Medicare Fiscal Intermediaries (FIs)

Implementation Date: December 16, 2005, for FIs and January 1, 2006, for carriers

Provider Types Affected
Physicians, providers, and suppliers who appeal initial claims determinations by Medicare

Provider Action Needed
The purpose of CR3939 is to notify Medicare contractors (fiscal intermediaries (FIs) or carriers, including durable medical equipment regional carriers (DMERCs)) and Medicare providers about the upcoming transition to the new second level of the appeals process.

The Medicare claim appeals process was amended by the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA). Section 1869(c) of the Social Security Act (the Act), as amended by BIPA, requires a new second level in the administrative appeals process called a "reconsideration." This new "reconsideration" is different from the previous first level of appeal for Part A claims performed by FIs. Reconsiderations will be processed by Qualified Independent Contractors (QICs).

Rather than repeat the extensive details of CR3939 in this article, the Centers for Medicare & Medicaid Services (CMS) encourages physicians, providers, and suppliers who wish to appeal an initial determination of a Medicare claim made by a Medicare carrier or FI to review CR3939. The new/revised manual sections of Chapter 29 of the Medicare Claims Processing Manual that are attached to CR3939 contain many important details for those wishing to file claims determination appeals. You can find CR3939 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 CR3939 in the CR NUM column on the right, and click on the file for that CR.

The key new or revised sections contained in CR3939 include information on:

If you bill a Medicare FI, you may also wish to review Medlearn Matters article MM3530 and/or CR3530.

They are available as follows:
Medlearn Matters article MM3530 MMA - Revisions to Medicare Appeals Process for Fiscal Intermediaries (CR Title-"Appeals Transition - BIPA 521 Appeals") is available at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3530.pdf on the CMS Web site.

CR3530 Revisions to Medicare Appeals Process for Fiscal Intermediaries (CR Title-"Appeals Transition - BIPA 521 Appeals") is available at http://www.cms.hhs.gov/manuals/pm_trans/R146OTN.pdf on the CMS Web site.

Please refer to your local FI, carrier, or DMERC if you have questions on this issue. To find their toll free phone numbers go to http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.

free phone numbers go to http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.

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Appeals of Claims Decisions: Redeterminations and Reconsiderations

Effective Date: May 1, 2005, for appeals of claims submitted to Medicare intermediaries and January 1, 2006, for appeals of claims submitted to carriers

Implementation Date: December 16, 2005, for Medicare intermediaries and January 1, 2006, for Medicare carriers

Provider Types Affected
Physicians, providers, and suppliers who submit claims to Medicare for services

Provider Action Needed
Medicare providers who appeal claims decisions made by Medicare carriers and fiscal intermediaries (FIs), including durable medical equipment regional carriers (DMERCs) and regional home health intermediaries (RHHIs), need to be aware of the new appeals processes.

Background
The purpose of CR3944 is to notify Medicare contractors (FIs or carriers, including DMERCs) and Medicare providers about the upcoming transition to the new second level of the appeals process.

The "redetermination" is the first level of appeal. It is a second look at the Part A or B claim and supporting documentation by an employee of the contractor (Medicare carrier or intermediary) who was not involved in the initial claim determination. In performing a redetermination of the services requested by the appellant, Medicare contractor personnel must examine all issues in the claim.

The Medicare claims appeals process was amended by the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA). Section 1869(c) of the Social Security Act (the Act), as amended by BIPA, requires a new, second level in the administrative appeals process, called a "reconsideration." This new "reconsideration" is different from the previous first level of appeal for Part A claims performed by FIs. These appeals are processed by Qualified Independent Contractors (QICs).

Additional Information
Rather than repeat the extensive details of CR3944 in this article, the Centers for Medicare & Medicaid Services (CMS) encourages physicians, providers, and suppliers who wish to appeal an initial determination of a Medicare claim made by a Medicare carrier or FI to review CR3944. The new/revised manual sections of Chapter 29 of the Medicare Claims Processing Manual that are attached to CR3944 contain many important details for those wishing to file claims determination appeals. You can find CR3944 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 CR3944 in the CR NUM column on the right, and click on the file for that CR.

If you bill a Medicare FI, you may also wish to review Medlearn Matters article MM3530 and/or CR3530.

They are available as follows:
Med learn Matters article MM3530 MMA, "Revisions to Medicare Appeals Process for Fiscal Intermediaries" (CR Title-Appeals Transition - BIPA 521 Appeals), is available at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3530.pdf on the CMS Web site.

CR3530, "Revisions to Medicare Appeals Process for Fiscal Intermediaries" (CR Title-Appeals Transition - BIPA 521 Appeals), is available at http://www.cms.hhs.gov/manuals/pm_trans/R146OTN.pdf on the CMS Web site.

In addition, if your request for a redetermination is dismissed by the Medicare contractor, you may wish to understand your appeal rights with regard to that dismissal. These rights are discussed in CR3939, which can also be found at http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS Web site. Once at that page, look for CR3944 in the CR NUM column on the right and click on the file for that CR.

Please refer to your local FI, carrier, or DMERC if you have questions on this issue. To find their toll-free phone numbers, go to http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.

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CERT Documentation Contractor (CDC) Analysis of Tech Stops

Once a claim has been selected as part of the random sample, the CDC requests medical records for review. Upon receipt of the medical records the CERT Review Contractor (CRC) nurse reviewers check the documents to confirm that all of the correct documents have been sent in by the provider.

In order to help providers understand what information is missing or flawed and the frequency of that information, the CDC conducts a random review of approximately 80 tech stops for Part B (a tech stop is a request for additional documentation). The chart listed below was created by the CDC detailing the type of errors in document submission.

Description Total Number Observed
Hospital Notes 24
Office Notes 23
X-rays, EKG, Ultrasound 8
Physical Therapy 7
Lab Reports 5
Medications/injections 4
Ambulance 2
Medical Necessity 2
Chiropractor 1
Nail Debridement 1
Chemotherapy 1
Level Service 1
Total 79

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Auditory Osseointegrated and Auditory Brainstem Devices

Note: This article was revised on November 24, 2005, to show the correct codes for osseointegrated
implantation in the "Note" box (shaded box) on page 2. All other information remains the same.

Provider Types Affected
Physicians and providers billing Medicare carriers or fiscal intermediaries (FIs) for auditory osseointegrated and auditory brainstem devices.

Provider Action Needed

STOP - Impact to You
The definition of "hearing aids" in the Medicare Claims Processing Manual was modified to exclude certain implanted devices from the category of hearing aid.

CAUTION - What You Need to Know
Medicare contractors will not pay for any part A or part B expenses incurred for items or services related to "hearing aids or examination for the purpose of prescribing, fitting, or changing hearing aids." (42 CFR 411.15(d)) These items and services are excluded from coverage. However, the definition of hearing aids now indicates that auditory osseointegrated (code L8699) devices and auditory brainstem (code L8614) devices are prosthetic devices that are eligible for Medicare payment.

GO - What You Need to Do
Be aware that Medicare contractors will pay for osseointegrated auditory and brainstem auditory devices as prosthetic devices but only when indicated: where hearing aids are medically inappropriate or cannot be used due to congenital malformations, chronic disease, severe sensorineural hearing loss, or surgery.

Background
Medicare now defines hearing aids as follows: Hearing aids are amplifying devices that compensate for impaired hearing. Hearing aids include air conduction devices that provide acoustic energy to the cochlea via stimulation of the tympanic membrane with amplified sound. They also include bone conduction devices that provide mechanical energy to the cochlea via stimulation of the scalp with amplified mechanical vibration or by direct contact with the tympanic membrane or middle ear ossicles.

Certain devices that produce perception of sound by replacing the function of the middle ear, cochlea, or auditory nerve are payable by Medicare as prosthetic devices. These devices are indicated only when hearing aids are medically inappropriate or cannot be utilized due to congenital malformations, chronic disease, severe sensorineural hearing loss, or surgery. The following are prosthetic devices:

Hospital outpatient departments and physicians should bill related implantation services using the current codes for osseointegrated implantation (such as 69714, 69715, 69717, and 69718) for device code L8699. In addition, physicians should bill the appropriate services for implantation of the auditory brainstem device (code L8614), using the codes for tumor resection (61520, 61530, 61598), if indicated, and also a code for cranial neurostimulators (61875).

Additional Information
Additional information about coverage for cochlear implantation can be found in CR3796 and the accompanying Medlearn Matters article, MM3796. The Additional Information section of MM3796 also outlines the policy guidelines for cochlear implantation coverage, and a listing of Healthcare Common Procedural Coding System (HCPCS) codes associated with cochlear implantation.

To view CR3796, Transmittal #601: Cochlear Implantation, go to http://www.cms.hhs.gov/manuals/pm_trans/R601CP.pdf on the CMS Web site. To view the associated Medlearn Matters article, MM3796, on Cochlear Implantation, go to http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3796.pdf on the CMS Web site.

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 CR4038 in the CR NUM column on the right, and click on the file for that CR.

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

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Device Performance Advisory for Medtronic Sigma® Series Pacemakers

Medtronic, INC. recently released an advisory letter to physicians and CIGNA Government Services regarding a performance issue with a specific subset of Sigma® series pacemakers that may fail. Medtronic is reporting this information to the appropriate regulatory agencies and there have been no reported patient injuries or deaths due to this issue.

Under their Limited Warranty, Medtronic will provide a comparable replacement device at no charge and up to $800 for unreimbursed medical expenses. In accordance with the Medicare Benefit Policy online manual Pub 100-2, Chap. 16, Section 40.4 - Items Covered Under Warranty http://www.cms.hhs.gov/manuals/102_policy/bp102c16.pdf :

"When defective equipment or a defective medical device is replaced under a warranty, hospital or other provider services rendered by parties other than the warrantor are covered despite the warrantor's liability. However, see the Medicare MSP Manual (CMS Pub. 100-5) for requirements for recovery under the liability insurance provisions."

For detailed information on this performance issue, recommendations for possible replacement and how to obtain a replacement device contact Medtronic, Inc. Patient Services group at 1.800.551.5544 or visit their Web site at www.Medtronic.com and click on Product Advisories under the Information for Physicians section.

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Erroneous Guidance - Basis to Waive Penalty - MMA

Provider Types Affected
Physicians, suppliers, and providers who bill Medicare and who face penalties as a result of such billings

Provider Action Needed

STOP - Impact to You
Providers and suppliers may not be subject to a penalty if the basis for the penalty that would have otherwise been applicable was that the provider acted in accordance with erroneous guidance from the Medicare program.

CAUTION - What You Need to Know
Medicare can grant a waiver of a penalty when ALL of the following conditions are present:

GO - What You Need to Do
Review CR3898 if you feel you are being subjected to a penalty for acting in accordance with erroneous guidance from the Medicare program.

Background
Section 903© of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, referred to as MMA, establishes a basis for waiving penalties and interest charges levied on providers and suppliers who incurred such penalties and/or interest as a result of following Medicare guidance, which turned out to be erroneous. CR3898 details the conditions under which a provider or supplier may seek a waiver of a penalty due to such erroneous guidance. CR3898 does not address the waiver of interest charges.

Additional Information
Full details of the process for seeking and obtaining a waiver can be found in Chapter 33 (Miscellaneous Hold Harmless Provisions), Section 10 (Erroneous Program Guidance: Basis to Waive Penalty) of the Medicare Claims Processing Manual. That material is attached to CR3898, which can be found by going to: http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS Web site.

From that Web site, look for CR3898 in the CR NUM column on the right, and click on the file for that CR.

For additional information relating to this issue, please refer to your local carrier or intermediary at their 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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Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2006

Provider Types Affected
Physicians, suppliers, and providers billing Medicare carriers and/or fiscal intermediaries (FIs) for clinical diagnostic laboratory services.

Provider Action Needed

STOP - Impact to You
This article is based on Change Request (CR) 4161, which announces the implementation of changes to the list of codes associated with the 23 negotiated laboratory NCDs.

CAUTION - What You Need to Know
These changes to the list of codes are a result of revised NCD and coding analysis decisions developed under the procedures for maintenance of codes in the negotiated NCDs. They are necessary for the correct processing of claims using the most current negotiated lab NCDs and code lists.

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

Background
The National Coverage Determinations (NCDs) for clinical diagnostic laboratory services were developed by the laboratory negotiated rulemaking committee and published in the Federal Register as a final rule on November 23, 2001. (See below for links to the Final Rule.)

The Centers for Medicare & Medicaid Services (CMS) funded the development of software (laboratory edit module) to be incorporated in the shared systems so that laboratory claims subject to one of the 23 NCDs are processed uniformly throughout the nation effective January 1, 2003. (See below for more information contained in the Medicare Claims Processing Manual.)

Note: The laboratory edit module for the NCDs is updated quarterly as necessary to reflect coding updates and substantive changes to the NCDs developed through the NCD process.

Change Request (CR) 4161 announces the changes that will be included in the January 2006 release of the edit module for clinical diagnostic laboratory services. Changes are being made to the NCD code lists (as described below) to accommodate changes to the list of codes that have been made through the NCD and/or coding analysis process as explained in the final Federal Register notice. (See reference below.)

The Final Rule, Federal Register Volume 66, Number 226, can be found at http://www.access.gpo.gov/su_docs/fedreg/a011123c.html). The Medicare Claims Processing Manual (Pub. 100-04, Chapter 16, Section 120.2) is available at http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp on the CMS Web site. The final Federal Register notice, Volume 70, Number 37, dated February 25, 2005, can be found at
http://www.access.gpo.gov/su_docs/fedreg/a050225c.html.

Code Changes
CR4161 announces the following changes:

Decision memoranda explaining these changes can be found by going to http://cms.hhs.gov/coverage on the CMS Web site and clicking on the National Coverage Analysis in the Coverage Database section of the Web page. These changes become effective for services furnished on or after January 1, 2006.

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. 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 CR4161 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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Eliminate the Use of Surrogate Unique Physician Identification Numbers (UPINs) on Medicare Claims

Provider Types Affected
Physicians, suppliers, and providers billing Medicare carriers, including durable medical equipment regional carriers (DMERCs), using surrogate UPINs

Provider Action Needed
This article is based on Change Request (CR) 4177, which directs your carrier or DMERC to no longer accept the surrogate UPIN OTH000 to identify ordering or referring physicians on claims submitted by billers, suppliers, physicians, and nonphysician practitioners. (Beneficiary submitted claims and mass immunization claims are excluded.)

Background
The Social Security Act (Section 1833(q)) requires that all physicians who meet the definition of a physician (Section 1861(r)) must have a UPIN, and that all claims for services ordered or referred by one of these physicians include the name and UPIN of the ordering/referring physician.

Currently, suppliers, physicians, and non-physician practitioners are allowed to bill for diagnostic, radiology, consultation services, and equipment with the use of Surrogate UPIN OTH000. Surrogate UPINs were intended to be used during an interim period when a UPIN has been requested but has not yet been received.

CR4177 announces that CMS will no longer accept the Surrogate UPIN OTH000 to identify the ordering or referring physicians on claims submitted by billers, suppliers, physicians, and non-physician practitioners, effective for dates of service April 1, 2006, and later: (Beneficiary submitted claims and mass immunization claims are excluded.)

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

Additional Information
For complete details, please see the official instruction issued to your carrier/DMERC 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 CR 4177 in the CR NUM column on the right, and click on the file for that CR.

If you need to obtain another physician's UPIN for billing purposes, you may find that UPIN by going to http://www.upinregistry.com.

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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Enrolling Indian Health Service (IHS) Facilities as Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers - MMA

Provider Types Affected
Indian Health Services (IHS) facilities wishing to enroll as Medicare suppliers

Provider Action Needed

STOP - Impact to You
Section 630 of the Medicare Modernization Act (MMA) permits IHS facilities to directly bill for itemized DMEPOS as of January 1, 2005. Previously, IHS facilities could not directly bill Medicare for DMEPOS.

CAUTION - What You Need to Know
This article is based on information from Change Request (CR) 3845, which provides Medicare manual instructions describing how Indian Health Service (IHS) facilities enroll as DMEPOS suppliers.

GO - What You Need to Do
See the Background and Additional Information sections of this article to find out further details regarding these changes.

Background
The Medicare Modernization Act (MMA, Section 630) permits Indian Health Service (IHS) facilities to directly bill for itemized Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) as of January 1, 2005. Previously IHS facilities could not directly bill Medicare for DMEPOS. The MMA also provides for all Medicare Part B services to be billed including all preventive services.

To enable direct billing of DMEPOS, an IHS facility must enroll with the National Supplier Clearinghouse (NSC) and secure a Medicare supplier billing number. For enrollment purposes, Medicare recognizes two types of IHS facilities:

The Application
To enroll, the IHS facility must complete a Medicare Supplier Enrollment Application: CMS-855S Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers

CMS-855S must be completed in accordance with its associated instructions, except as follows:

Facility Requirements
IHS facility requirements include the following:

For example, if the DMEPOS supplier indicates on its application that it will be providing hospital beds and is located in a state that requires a bedding license, such licensure is not required for Medicare enrollment.

However, if they provide a DMEPOS item that requires a licensed professional in order to properly provide the item, the IHS facility must provide a copy of the professional license. The licensed professional can be licensed in any state or have a federal license. For example, a pharmacy does not need a pharmacy license, but must have a licensed pharmacist.

Assignment of Specialty Codes and Appropriate Billings
Upon successful enrollment, the NSC will provide identifiers identifying IHS enrollments and IHS hospitals in order to facilitate proper reimbursement by durable medical equipment regional carriers (DMERCs).

The NSC will enroll all Indian Health Service (IHS) facilities including all hospitals and clinics (free standing or hospital based). This includes all facilities whether wholly owned and operated by the IHS or tribally owned and/or operated. For any IHS facility that enrolls, the NSC will issue a supplier number with:

The specialty indicator will ensure that the claims are paid appropriately by either the FI or DMERC. IHS facilities with a specialty code of A9/A0 must submit claims for prosthetics, orthotics, and surgical dressings to their Medicare FI for payment and not to a DMERC.

Implementation
The implementation date for CR3845 is April 3, 2006.

Additional Information
IHS facilities that are tribally owned and/or operated are advised that their Medicare beneficiaries are not responsible for deductibles or coinsurance. However, Medicare still pays these IHS facilities a payment that is at 80 percent of the DMEPOS fee schedule. The remaining 20 percent will be shown as a CO denial on the remittance advice with an adjustment reason code of B6 indicating "This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty."

For further details, please see the official instruction issued to your DMERC/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 CR3845 in the CR NUM column on the right, and click on the file for that CR.

If you have any questions, please contact your DMERC/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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Full Replacement of and Rescinding Change Request (CR) 3504 - Modification to Online Medicare Secondary Payer Questionnaire

Provider Types Affected
Medicare providers who, upon inpatient or outpatient admissions of Medicare beneficiaries, use a questionnaire to determine other insurance coverage that may be primary to Medicare.

Provider Action Needed

STOP - Impact to You
CR4098 clarifies recent changes made to the "Medicare Secondary Payer Questionnaire."

CAUTION - What You Need to Know
This CR identifies all of the changes that were made to CR3504 and makes additional changes to the model questionnaire. These changes will assist providers in identifying other payers that may be primary to Medicare.

GO - What You Need to Do
Please refer to the Background and Additional Information sections of this article and make certain that, if there are other payers, these situations are identified.

Background
The Centers for Medicare & Medicaid Services (CMS) received information that a prior instruction (CR3504) did not specifically mention all of the changes that were made to the "Medicare Secondary Payer (MSP) Questionnaire." CR4098 identifies all of the changes made as part of CR3504 and makes additional changes to the model questionnaire.

The Medicare Secondary Payer Manual, Chapter 3, Section 20.2.1, available as an attachment to CR4098, provides a model: "Admission Questions to Ask Medicare Beneficiaries."

The model contains questions that may be printed out and used as a guide to help identify other payers. (The Web site for accessing CR4098 is provided in the Additional Information section of this article.)

The following bullets identify the changes within the model MSP Questionnaire:

Providers who use the model questionnaire to elicit MSP information from their Medicare patients should take special note of these changes.

Implementation
The implementation date for the instruction is January 21, 2006.

Additional Information
The official instructions issued to your Medicare carrier or intermediary regarding this change and the model questionnaire 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 the CR NUM column on the right to find the links for CR4098. Click on the links to open and view the files for this 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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Hurricanes Katrina and Rita - Transportation of Evacuees with Medical Needs

Provider Types Affected
Physicians, suppliers, and providers billing Medicare carriers, including durable medical equipment regional carriers (DMERCs), and/or fiscal intermediaries (FIs), including regional home health intermediaries (RHHIs), for transportation services provided to evacuees of Hurricanes Katrina and Rita

Provider Action Needed

STOP - Impact to You
This Special Edition article provides a summary of the Department of Health and Human Services (DHHS) Fact Sheet regarding the transportation of Hurricanes Katrina and Rita evacuees with medical needs.

CAUTION - What You Need to Know
If you made your own medical transportation arrangements, prior to or after the DHHS established the HHS Medical Travel Center services contract, then the
normal Medicare coverage rules apply

GO - What You Need to Do
As you receive inquiries from providers or beneficiaries seeking to discharge a patient (or to help those patients return home), you should provide them with the information contained in this special edition article. Please review the questions and answers at the end of this special edition article, and take appropriate action to use the instructions in your claims submissions.

Background
The Centers for Medicare & Medicaid Services (CMS) is providing this Special Edition article to give you important information regarding the transportation of Hurricanes Katrina and Rita evacuees with medical needs. This special edition article:

Hurricane Evacuation
Because of Hurricanes Katrina and Rita, many people were forced to evacuate their homes and healthcare facilities in Texas, Mississippi, and Louisiana.

Evacuees included many Medicare beneficiaries, including some with serious and/or ongoing medical needs, and assisting theses evacuees has included dealing with significant difficulties and has raised questions regarding:

In response to these and many more questions, DHHS created a Fact Sheet to provide information and answer frequently asked questions regarding certain issues resulting from Hurricanes Katrina and Rita.

The DHHS Fact Sheet provides instructions and answers questions pertaining to the provision of transportation for evacuees from Texas, Louisiana, and Mississippi who:

Note: The DHHS Fact Sheet may be viewed at http://www.hhs.gov/katrina/factsheet.html on the DHHS Web site.

In many counties and parishes in Texas, Mississippi, and Louisiana, the healthcare infrastructure will not support the return of evacuees with medical needs. Evacuees may need to continue to shelter in their host state, or travel to an interim location to be closer to friends and family until Texas, Mississippi, and Louisiana can support their return.

Texas is currently accepting the return of patients and those evacuees with ongoing medical needs to select counties in Texas.

Mississippi is currently accepting the return of patients and those evacuees with ongoing medical needs to select counties in Mississippi.

Louisiana is:

HHS Medical Travel Center
The DHHS established a transportation program to support the return of evacuees with medical needs from Texas, Mississippi and Louisiana. The HHS Medical Travel Center is under contract with HHS to arrange transportation for evacuees who require en-route medical care and/or medical transport to include a nonmedical attendant to an institution or to a private residence, as appropriate.

If the evacuee's originating medical facility is not available in their home state or if their residence and community medical infrastructure is not suitable, evacuees will be allowed to travel to an interim location in the continental United States.

The HHS Medical Travel Center will then return the evacuee to their home of record when a medical facility there is available, or they can return to a safe community/home environment.

The HHS Medical Travel Center provides transportation services without cost to providers. Providers (and patients) who use the HHS Medical Travel Center services will not incur any charge, and they should not bill Medicare. The HHS Medical Travel Center will be paid directly by HHS as per its contract.

The HHS Medical Travel Center can be reached at 1.866.753.9344. The phone lines are open everyday 7:00 a.m. to 5:00 p.m. Central Daylight Time (CDT). Before contacting the HHS Medical Travel Center or their home state, all medical evacuees must register with the Federal Emergency Management Agency (FEMA) and obtain a Disaster Registration Number from the FEMA Registration Center at 1.800.621.FEMA. This phone line is operational 24 hours a day, 7 days a week.

Important Information for Discharge Planners
For evacuees in health care facilities or special needs shelters with a discharge planner, the discharge planners are responsible for:

Facility to Facility Transfer
Once the discharge planner has completed these tasks, they may contact the HHS Medical Travel Center to arrange for medical transportation. In order to complete the transportation process, discharge planners must complete and submit a Documentation of Medical Necessity form provided by the HHS Medical Travel Center. This form will be provided planners when they call the HHS Medical Travel Center, and it is available at http://www.hhs.gov/katrina on the HHS Web site.

Facility to Non-Facility Transfer
If the discharge planner determines that the evacuee can be discharged to a residence, the discharge planner must call the evacuee's home state, which will be acting as a receiving point of contact. Please see below for information on how to contact the evacuee's home state.

Evacuees in a Shelter, Hotel, or Private Home
Evacuees should call their home state to access transportation if they:

Guidance from the Home State
The evacuee's home state will determine if the evacuee can ride commercial transportation and if their state medical system can support their ongoing medical needs. If the state medical system cannot support the evacuee's ongoing medical needs, the home state will help the evacuee find an interim location in another state, if appropriate.

Texas
Texas evacuees with medical needs may contact the 2-1-1 telephone service (if calling within Texas) or 1.888.312.4567 (if out-of-state) to initiate access to appropriate transportation and receive an evaluation of the community medical infrastructure to support the return. The Texas phone lines are open everyday 8:00 a.m. to 5 p.m., Central Daylight Time (CDT).

Mississippi Department of Health
Mississippi evacuees with medical needs may contact the Mississippi State Health Department at 601.576.7300 to initiate access to appropriate transportation. The Mississippi phone lines are open Monday to Friday 8:00 a.m. to 5 p.m., Central Daylight Time (CDT).

Louisiana Department of Health and Hospitals
Louisiana is not currently accepting the return of evacuees with out-patient and/or ongoing medical needs. Evacuees from Louisiana with medical needs sheltering in a hotel, residence or other facility that cannot provide discharge planning must have their current medical attendant or family member contact the HHS Medical Travel Center to initiate access to appropriate transportation.

The evacuee's medical attendant must complete and submit a Documentation of Medical Necessity form provided by the HHS Medical Travel Center to complete the transportation process. This form will be provided for the evacuee's medical attendant when they call the HHS Medical Travel Center or is available online at http://www.hhs.gov/katrina on the HHS Web site. If a family member is completing this form for the patient, it must be signed by the patient's current local healthcare provider.

Questions and Answers (Q&As)
Below are frequently asked questions about the transportation of Hurricane Katrina and Rita evacuees. CMS will be posting these Q & As at http://www.cms.hhs.gov/hki on the CMS Web site:

Q1. What is the first step in the process no matter what category of evacuee I am?
A1. Register for Disaster Assistance and obtain a FEMA Disaster Registration number via 1.800.621.FEMA.

Q2. What if the evacuee or patient I am arranging care for doesn't have a FEMA Disaster Registration number?
A2. Call the FEMA Registration Center at 1.800.621.FEMA to register for Disaster Assistance and obtain a FEMA Disaster Registration number.

Q3. Will this travel system arrange transportation for National Disaster Medical System (NDMS) patients as well as those persons who became patients in similar facilities after evacuating?
A3. Yes, the HHS Medical Travel Center will arrange transportation for all evacuees that currently require en-route medical care and/or medical transport, back to their home state or to an interim state. Discharge planners at medical facilities/shelters should contact the HHS Medical Travel Center to arrange for transportation of their evacuees.

Evacuees from Texas and Mississippi with medical needs who do not have a discharge planner should contact their home state. Evacuees from Louisiana with medical needs who do not have a discharge planner should contact the HHS Medical Travel Center and will need their healthcare provider to complete the forms.

Q4. Will evacuees or medical facilities incur any transportation costs using this travel system?
A4. The HHS Medical Travel Center covers all transportation costs; there will be neither bills nor co-pays and no insurance forms will be necessary.

Evacuees who can travel via commercial transportation must make their own arrangements to the airport or station.

Q5. Can a healthcare facility be reimbursed by the HHS Medical Travel Center for transportation arrangements already made? Can a healthcare facility make transportation arrangements for evacuees in the future and be reimbursed by the HHS Medical Travel Center?
A5. No. The HHS Medical Center will not reimburse facilities or states that have already made transportation arrangements for evacuees. All future transportation arrangements for evacuees should be made through the HHS Medical Travel Center or appropriate state system.

Q6. What are the criteria for deciding if an evacuee needs enroute medical care and/or medical transportation, and who makes this determination?
A6: If the evacuee is currently a patient at a medical facility and has a discharge planner coordinating their transportation, the healthcare facility discharge planner will determine if the evacuee requires medical transportation.

If the evacuee is not sheltering at a facility with discharge planning, the evacuee's home state or, in the case of Louisiana, the evacuee's medical attendant or accompanying family member, will determine if the evacuee is able to travel via commercial air or ground transportation.

Commercial airlines are very flexible in accepting people with such medical needs as oxygen and wheelchairs. If that is all that is required, a routine commercial flight will be arranged by FEMA for the evacuee and their family members if the evacuee meets the necessary qualifications.

Q7. Will the HHS Medical Travel Center perform discharge planning or provide clinical validation of evacuees?
A7. No. The discharge planners in the healthcare facilities and/or the evacuee's home state will provide that function PRIOR to movement. The HHS Medical Travel Center will provide safe, efficient, and effective medical transport en-route.

Q8. Who arranges for the discharge planning of evacuees, including destination, special medical equipment required, or other relevant transportation concerns?
A8. The discharge planners of the healthcare facility in which the evacuee resides should coordinate all
arrangements for the evacuee with the receiving
institution.

This includes working with the evacuee's home state, hospital, and/or nursing home to identify a receiving institution if the originating facility is not able to receive patients. Evacuees without discharge planners will need to contact their home state for assistance.

Q9. What if an evacuee requires en-route medical care and/or medical transport and has multiple accompanying family members (who are also evacuees) who must return with the evacuee?
A9. The HHS Medical Travel Center will provide a medical attendant to support en-route medical care if required. The HHS Medical Travel Center will make all reasonable efforts to accommodate at least one family member during medical transport. If the HHS Medical Travel Center is unable to do so, a separate transportation program will attempt to ensure family members will travel to the destination along a similar schedule. Both of these systems require all travelers to have a FEMA Disaster Registration Number.

Q10. If an evacuee is living in a hotel or a home (and therefore does not have a discharge planner) and has medical needs (e.g., requires oxygen or stabilized transport), how does the evacuee arrange for travel home?
A10. With the exception of Louisiana citizens, evacuees can call their home state to access travel arrangements. Their home state will act as their discharge planner and will determine if the evacuee can travel via commercial air or ground transportation and work with the evacuee to ensure that the medical infrastructure in their home community is ready to accept them. If the evacuee's home state determines that they can travel via commercial means, a separate transportation program will arrange their transportation. If the evacuee cannot travel by commercial means, the HHS Medical Travel Center will arrange for their transportation.

If the evacuee is a citizen of Louisiana and is living in a hotel or a home in a host state, he or she will not be able to return to Louisiana at this time. If their medical attendant or a family member determines that they can travel via commercial means, a separate transportation program will arrange their travel to an interim state. If the evacuee cannot travel by commercial means, the HHS Medical Travel Center will arrange for their transportation to an interim state and the evacuee's medical attendant should complete the necessary paperwork for the travel.

Q11. What if the evacuee wants to return to his or her original healthcare facility and that facility is not able to receive patients?
A11. There are three potential options if the originating facility is not able to receive patients:

Q12. As a discharge planner, do I have to arrange for transportation from my healthcare facility to the airfield (if aeromedical transportation is being used)?
A12. No, the HHS Medical Travel Center provides door-to-door service. See question Q4.

Q13. As a discharge planner, do I need to fill out and submit a particular discharge planning form when making travel arrangements for my patient evacuee?
A13. Yes. The HHS Medical Travel Center will fax or email you a Documentation of Medical Necessity form to complete. The information you provide on this form will help the HHS Medical Travel Center provide the necessary medical care enroute for your evacuee. This form is also available at http://www.hhs.gov/katrina on the HHS Web site.

Q14. What if a discharge planner needs to move an evacuee within the state? Do these travel systems arrange that transportation?
A14. Yes, all of these travel systems arrange for intra- and inter-state transportation.

Q15. How will hospitals and other providers be reimbursed for the medical care they provided to evacuees?
A15. Remember, with the use of the HHS Medical Travel System, there are no transportation costs associated with the return of evacuees to their home state or an interim state. However, there are many ways for providers to be reimbursed for services provided to evacuees:

Existing Health Care Insurance
Many evacuees have existing health insurance coverage. Providers should bill an evacuee's private health insurer, if one exists;

Medicare
Many evacuees are covered under the Medicare program. Providers should contact their local Medicare carrier or fiscal intermediary, if they have questions regarding Medicare reimbursement for evacuee health care.

On January 1, 2006, the Medicare prescription drug benefit begins. CMS will work closely with evacuees and those who provide insurance counseling to the elderly to ensure that those evacuees who want to enroll in a drug plan will be able to do so. We are also taking steps to let those elderly evacuees who qualify for extra help in paying for their drug costs know about the availability of this program.

National Disaster Medical System (NDMS)
Some evacuees received medical treatment via the NDMS. At the request of FEMA, CMS and DHHS is developing payment mechanisms for those patients who entered NDMS hospitals via the Federal Coordinating Centers as part of the NDMS evacuation. Specifics about how to submit claims for these patients will be made available on the CMS Web site (http://www.cms.gov).

Medicaid
Many evacuees will qualify for Medicaid, either because they were eligible in their home state, or because they are now eligible because of a loss of income and/or resources. CMS has approved Medicaid waivers for many states. Under these waivers, effective retroactively to August 24, 2005, evacuees who have been displaced from their home as a result of Hurricane Katrina will be provided the opportunity to enroll through a streamlined process to receive services under the Medicaid or SCHIP programs in whatever state they are now physically present.

Medicaid and SCHIP providers should work with their states to submit claims and receive payment. States are putting in place modifications to their current claims processing systems to accept such claims, and all payments for Medicaid and SCHIP eligible persons will be handled through the states.

Uncompensated Care
Through the waiver process mentioned above, CMS is working with states with large numbers of evacuees to put in place processes for handling those claims which would otherwise have been uncompensated. Providers should contact their state for information on how those claims will be submitted and how payments will be processed.

CMS will be providing information on these payment mechanisms on the CMS Web site (http://www.cms.hhs.gov/emergency/). CMS will also be sharing information with provider and patient-based national and state trade and professional associations, and the states via the state Emergency Operations Centers.

Note: All HHS press releases, fact sheets, and other press materials are available at http://www.hhs.gov/news on the HHS Web site.

Additional Information
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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Important Information about Medicare Coverage of Drugs Under Part B and the New Medicare Prescription Drug Coverage (Part D), and Vaccines Administered in a Physician's Office - The Ninth in the Medlearn Matters Series on the New Prescription Drug Plans

Provider Types Affected
Physicians, healthcare professionals, providers, suppliers, and their staff

Key Points to Remember

Highlights
This article highlights the differences in how drugs are covered and which drugs are covered by Medicare Part B and the new Medicare prescription drug coverage (Part D). It also offers additional guidance on the effect of Part D on vaccines given to Medicare patients in a physician's office. Those currently billing Medicare Part B for drugs or for vaccines may wish to pay particular attention to this article.

Drugs Covered Under Part B and Part D
Part A/B Covered Drugs Set by Statute
Traditional Part A/B Medicare does not cover most outpatient prescription drugs. Under Part A, Medicare bundled payments made to hospitals and skilled nursing facilities (SNFs) generally cover all drugs provided during a covered Part A stay. (An exception is clotting factor supplied during a stay, which is paid separately from the bundled payment.)

Medicare also makes payments under Part B to physicians for drugs or biologicals that are not usually self- administered.

Coverage is usually limited to drugs or biologicals administered by infusion or injection. If the injection is self-administered (e.g., Imitrex), it is not covered.

Physicians, healthcare professionals, providers, and suppliers may also bill Medicare Part B for other limited types of drugs as follows:

Durable Medical Equipment (DME) Supply Drugs
These are drugs that require administration by the use of a piece of covered DME (e.g., a nebulizer, or external or implantable pump). The statute does not explicitly cover DME drugs; they are covered as a supply necessary for the DME to perform its function.

The largest Medicare expenditures for drugs furnished as a DME supply are for inhalation drugs, (e.g., albuterol sulfate, ipratropium bromide) which are administered in the home through the use of a nebulizer.

The other category of drugs Medicare covers as a DME supply are drugs for which administration with an infusion pump in the home is medically necessary (e.g., some chemotherapeutic agents).

Immunosuppressive Drugs
These include drugs used in immunosuppressive therapy (such as cyclosporine) for a beneficiary who has received a Medicare covered organ transplant.

Hemophilia Clotting Factors
These include hemophilia clotting factors for hemophilia patients competent to use such factors to control bleeding without medical supervision, and items related to the administration of such factors.

Oral Anti-Cancer Drugs
These are drugs taken orally during cancer
chemotherapy, provided they have the same active ingredients and are used for the same indications as are chemotherapy drugs that would be covered if they were not self-administered but were administered instead as incident to a physician's professional service.

Oral Anti-emetic Drugs
These are oral anti-nausea drugs used as part of an anti-cancer chemotherapeutic regimen as a full therapeutic replacement for an intravenous anti-emetic drug within 24 or 48 hours of chemotherapy administration depending on the drug.

Pneumocococcal Vaccine
This refers to the vaccine and its administration to a beneficiary if ordered by a physician.

Hepatitis B Vaccine
This includes the vaccine and its administration to a beneficiary who is at high or intermediate risk of contracting Hepatitis B. High risk groups include the following:

Intermediate risk groups include staff in institutions for the mentally handicapped and workers in healthcare professions who have frequent contact with blood or blood-derived body fluids during routine work.

Influenza Vaccine
This refers to the vaccine and its administration when furnished in compliance with any applicable state law. The beneficiary may receive the vaccine upon request without a physician's order and without physician supervision.

Antigens
These are prepared by a physician (usually an allergist) for a specific patient. The physician or physician's nurse generally administers them in the physician's office. In some cases, the physician prepares antigens and furnishes them to a patient who has been taught to self-administer them at home.

Erythropoietin (EPO)
EPO is used for treating anemia in persons with chronic renal failure who are on dialysis.

Parenteral Nutrition
Parenteral nutrients are covered under the prosthetic benefit. They are available to beneficiaries who cannot absorb nutrition through their intestinal tract. Parenteral nutrition is administered intravenously and is regulated as a drug by the FDA.

Intravenous Immune Globulin Provided in the Home
The MMA created a benefit for the provision of intravenous immune globulin (IVIG) for beneficiaries with a diagnosis of primary immune deficiency disease. Coverage is provided if a physician determines that the administration of IVIG in the patient's home is medically appropriate. Payment is limited to that for the IVIG itself and does not cover items and services related to administration of the product.

Part B Covered Drugs in the Context of a Professional Service
Drugs Furnished "Incident to" a Physician's Service
These are injectable or intravenous drugs that are administered predominantly by a physician or under a physician's direct supervision as "incident to" a physician's professional service. The statute limits coverage to drugs that are not usually self-administered. (If a drug is not self-administered by more than 50 percent of Medicare beneficiaries, it is considered "not usually self-administered.")

Separately Billable ESRD Drugs
Most drugs furnished by dialysis facilities are separately billable. The largest Medicare expenditures for such drugs are for erythropoietin (EPO), which is covered for dialysis beneficiaries when it is furnished by independent and hospital-based ESRD facilities, as well as when it is furnished by physicians.

Separately Billable Drugs Provided in Hospital Outpatient Departments
For Calendar Year 2005, Medicare continues to pay separately for drugs, biologicals, and radiopharmaceuticals whose median cost per administration exceeds $50, while packaging the cost of drugs, biologicals, and radiopharmaceuticals whose median cost per administration is less than $50 into the procedures with which they are billed.

Drugs Covered as Supplies or - "Integral to a Procedure"
Some drugs are covered as supplies that are an integral part of a procedure that is a diagnostic or therapeutic service, including radiopharmaceuticals (both diagnostic and therapeutic) and low osmolar contrast media. Other examples of drugs covered under the "integral to a procedure" provision include eye drops administered before cataract surgery.

Blood
Medicare does make separate payment for blood and blood products and these products are regulated as biological agents by the Food and Drug Administration (FDA).

Drugs Furnished as a Part of a Service in Provider Settings
Also covered are drugs furnished as a part of a service in the following provider settings:

Part D Covered Drugs
Definition of a Part D Covered Drug
A Part D covered drug is a drug that is:

A covered Part D drug includes prescription drugs, biological products, insulin as described in specified paragraphs of Section 1927(k) of the Act, and vaccines licensed under Section 351 of the Public Health Service Act. The definition also includes "medical supplies associated with the injection of insulin (as defined in regulations of the Secretary)." CMS defines those medical supplies to include syringes, needles, alcohol swabs, and gauze.

Part D Excluded Drugs
The definition of a covered Part D drug excludes any drug for which, as prescribed and dispensed or
administered to an individual, payments would be available under Parts A or B of Medicare for that
individual, even though a deductible may apply.

In addition, the definition of a covered Part D drug specifically excludes drugs or classes of drugs, or their medical uses, which may be excluded from coverage or otherwise restricted under Medicaid under section 1927(d)(2) of the Act, with the exception of smoking cessation agents.

The drugs or classes of drugs that may currently be otherwise restricted under Medicaid include the following:

While these drugs or uses are excluded from basic Part D coverage, Medicare Part D drug plan sponsors can generally include them as part of supplemental benefits, provided they otherwise meet the definition of a Part D drug.

Because non-prescription drugs do not otherwise meet the definition of a Part D drug, the Part D drug plans may not include such drugs as part of supplemental benefits; however, under certain conditions as part of a plan utilization management program (including a step-therapy program), non-prescription drugs can be provided at no cost to enrollees. The cost of these drugs to the plan would be treated as administrative costs under such programs.

For more detailed information about Part B drugs and Part D coverage, please refer to the report at
http://www.cms.hhs.gov/pdps/PartBandPartDdoc-revised7-27-05.pdf on the CMS Web site. This report provides excellent detail on the overall issue of Part B and Part D drugs. For example, this report discusses the following:

Vaccines Administered in a Physician's Office
This section discusses the vaccines currently covered by Medicare Part B, and includes a few commonly asked questions regarding vaccine coverage under Medicare Part B and Part D. Basically, if a vaccine is currently covered under Part B, the vaccine will remain covered under Part B when the new Part D goes into effect on January 1, 2006.

Medicare Part B currently covers the following immunizations (as discussed earlier in this article):

Key Questions
Will All Vaccines be Covered under Part D, Effective January 1, 2006?
No. As just mentioned, if a vaccine was previously covered under Part B, it will continue to be covered under Part B. If it was previously not covered, then it will need to be covered under Part D.

Pneumococcal and influenza vaccines are not covered under Part D because of Part B coverage. Hepatitis B vaccine is covered under Part B for individuals at high or intermediate risk; for all other individuals, it would be covered under a Part D benefit. All other currently available vaccines and all future vaccines would be covered under Part D, but could be subject to plan prior authorization requirements to determine medical necessity.

If a Company That Offers Medicare Part D Drug Plans Determines, Through a Prior Authorization Program, that a Hepatitis B Vaccine is Going to be Administered by a Physician, Can This Company Deny the Claim Based on Part B Coverage in the Setting?
No. Since the Part B benefit for Hepatitis B vaccine is separate from the "incident to" benefit, the determination about whether it is a Part D drug depends solely on characteristics of the beneficiary. However, if the plan sponsor determines based on Medicare Part B guidelines that the individual is at high or medium risk for Hepatitis B, the company should deny the claim.

For all other individuals, the vaccine would be a "Part D drug," and would be covered unless the plan had otherwise established medical necessity criteria for the vaccine as part of its approved prior authorization program. In this case, only low risk individuals who meet the plan's criteria would be eligible to receive the vaccine.

Additional Information
Web sites for Part B and Part D Coverage Information
Medicare Claims Processing Manual http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp
Medicare Benefit Policy Manual http://www.cms.hhs.gov/manuals/102_policy/bp102index.asp
Medicare Coverage Database http://www.cms.hhs.gov/mcd/search.asp
Carrier, DMERC, and Fiscal Intermediary Contacts by Region http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf
Medicare Drug Information Resource http://www.cms.hhs.gov/providers/drugs/default.asp
Hospital Outpatient Prospective Payment System 2005 http://www.cms.hhs.gov/providers/hopps/fr2005.asp
Palmetto GBA http://www.palmettogba.com
AdminaStar http://www.adminastar.com
CIGNA http://www.cignamedicare.com
National/Local Coverage Determinations http://www.cms.hhs.gov/coverage
Medicare Part B versus Part D Coverage Issues
http://www.cms.hhs.gov/pdps/PartBandPartDdoc-revised7-27-05.pdf
Medicare Prescription Drug Coverage Information for Providers http://www.cms.hhs.gov/medlearn/drugcoverage.asp
Prescription Drug Plans http://www.cms.hhs.gov/pdps/

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Important Message to Nursing Home Administrators About Medicare Prescription Drug Coverage - The Tenth in the Medlearn Matters Series

Note: This article was revised on November 15, 2005, to provide a new Web address on page two for viewing a copy of the letter sent by CMS to nursing home residents who are Medicare beneficiaries who also have full Medicaid coverage.

Provider Types Affected
Skilled nursing facilities (SNFs) and nursing homes with Medicare residents

Impact on Providers
This article contains information on Medicare prescription drug coverage as it applies to nursing home residents. The Centers for Medicare & Medicaid Services (CMS) will continue to use Medlearn Matters articles, where appropriate, to supplement the Minimum Data Set (MDS) channel to communicate important information and recommended action steps.

The goal is to ensure that the long term care population has a seamless transition to Medicare prescription drug coverage beginning January 2006.

Important Points to Remember
Key points to remember about the new Medicare prescription drug coverage include the following:

If your Medicare residents ask you questions about the new coverage, you can refer them to http://www.medicare.gov and 1.800.MEDICARE for additional information and assistance.

Background
At the end of October 2005, CMS mailed a letter to nursing home residents with Medicare and full Medicaid coverage (full-benefit dually eligible beneficiaries). This letter explained that Medicare, instead of Medicaid, will start paying for their prescription drugs beginning January 1, 2006.

The letter explained that if they don't enroll in a plan by December 31, 2005, Medicare will enroll them in a plan to make sure they don't miss a day of coverage.

The letter provided the name and contact information for the plan in which Medicare would enroll them.

A sample copy of this letter can be found at:

http://www.cms.hhs.gov/medicarereform/Enrollment-Q&A-10-20-05-withcover-sheet.pdf on the CMS Web site.

Generally, residents with full Medicaid coverage who are enrolled in a Medicare Advantage plan or the Program of All-Inclusive Care for the Elderly (PACE) will receive their Medicare drug coverage through that plan.

CMS is establishing a Web-based system through which nursing homes can access residents' plan enrollment information. This will enable the nursing facility, with the resident's permission, to identify the Medicare drug plan in which the resident is enrolled.

Everyone with Medicare is eligible to join a Medicare drug plan in their area. Many of your residents may want to join a plan to help with the high costs of medications. Your residents can first enroll in a Medicare prescription drug plan from November 15, 2005 - May 15, 2006.

Action Item
Residents with limited income and resources can apply for extra help paying for their prescription drugs. They can apply for this extra help through the Social Security Administration or their State Medical Assistance Office.

For more information on who can get extra help with prescription drug costs and how your residents can apply for that help, call the Social Security Administration at 1.800.772.1213. TTY users should call 1.800.325.0778. You may also find this information at http://www.socialsecurity.gov/ on the Web.

Remember, your facility may request applications for the extra help and help residents who may qualify apply. It is important to submit applications for the extra help for new residents who are "Medicaid pending." Residents who have Medicare and full Medicaid coverage, get help from Medicaid paying their Medicare premiums, or receive Supplemental Security Income (SSI) benefits, automatically qualify for extra help and do not need to apply for it.

Additional Information
More information concerning Medicare prescription drug coverage and the nursing home population will continue to be supplied through articles such as these and through the MDS channel. Additional information and resources are available at http://www.cms.hhs.gov/medicarereform/pdbma/ on the CMS Web site.

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Influenza/Flu Season and Available Resources for Providers

Provider Types Affected
Physicians, non-physician practitioners, providers and other health care professionals who bill Medicare carriers or fiscal intermediaries (FIs) for flu vaccines and vaccine administration.

Provider Action Needed
Special Edition 0580 is published by the Centers for Medicare & Medicaid Services (CMS) to alert providers to influenza resources that are available to them and their patients. While some of these resources are not CMS-sponsored Web sites or products, they are respected informational sites and products sponsored by health care professionals.

CMS Resources
The following are CMS Web-based resources.

Immunization Educational Resource Web Guide
The Immunization Educational Resource Web Guide is one-stop shopping for informational and educational resources related to CMS immunization initiatives and is available at http://www.cms.hhs.gov/medlearn/refimmu.asp on the CMS Web site. Available resources include the following (click on each title to access the Web site address):

Medlearn Articles

Brochures
Adult Immunizations and Hepatitis Vaccine Benefits. This is a two-sided brochure that can be downloaded and printed.

Provider Education
The following publications address Medicare preventative services:

Other CMS Resources
Other helpful CMS resources include the following:

Other Resources
The following are resources that are not CMS Web sites but providers may find them useful.

American Lung Association (ALA) Flu Center
The ALA flu center site is located at http://www.flucliniclocator.org/. This site enables individuals to input their zip code and find a flu clinic location in their area. Providers are able to add their flu clinic to this site by visiting http://lungusa2.org/embargo/flucliniclocator05/ on the Internet.

2-1-1 Information and Referral Service
The Consumer Education Working Group would like health care providers to know about another new resource to help citizens find a flu shot this fall. It is anticipated that this service will go hand-in-hand with the ALA's Flu Locator site. Those who do not have Internet access can call the 2-1-1 information and referral service and the operator can then use the Flu Locator site to help the person find a nearby
influenza clinic.

2-1-1 is an easily remembered telephone number that helps callers find critical health and human services available in their community. Callers can get answers to questions such as shelter locations after a natural disaster, traveler aid, emergency funding, or flu vaccination clinic locations.

2-1-1 serves approximately 139 million Americans - over 46% of the US population. One hundred and seventy-one (171) active 2-1-1 systems cover all or part of 32 states (including 14 states with 100% coverage) plus Washington, DC and Puerto Rico.

When this system is connected nationwide, it will provide easy access to social service resources for everyone. The technology ensures that a real person will answer every time - no recorded messages. Anyone with flu vaccine can register with a local 2-1-1 call center. The call center will include that information in their database and make it available to the community.

For more information about 2-1-1, go to http://www.211.org or http://www.airs.org on the Internet.

Influenza Pocket Guides/Information about Vaccines
Although hard copy versions of the Influenza Pocket Guides are no longer available, electronic and camera ready versions are available, copyright free and can be found at http://www.immunize.org/influenza/pocketguide.htm on the Internet.

Comprehensive information about vaccines and vaccine-preventable diseases can be found at
http://www.vaccineinformation.org on the Internet.

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Local Carrier Revision to Diagnosis Requirement for the Drug Vidaza (Azacitidine)

***UPDATE***

Effective for claims with dates of service February 1st, 2005, and forward, it has been determined that the ICD-9 diagnosis code 205.10 (Myeloid Leukemia Chronic Without Mention of Remission) may now be accepted, in addition to the already established 238.7 (Myelodysplastic Syndrome), as support of medical necessity.

For further details, please see the appropriate Local Coverage Determination document for your state/region:

Tennessee - LCD #L18069

North Carolina - LCD #L18986

Idaho - LCD #L18715