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February 2006 Part B Medicare Bulletin

Posted February 3, 2006

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Ambulance Inflation Factor for CY 2006

Provider Types Affected
Providers and suppliers of ambulance services billing Medicare carriers and fiscal intermediaries (FIs) for those services

Provider Action Needed
None. This article is for your information only. It provides the Ambulance Inflation Factor (AIF) for Calendar Year (CY) 2006. The AIF for CY 2006 is 2.5%.

Background
Section 1834(l)(3)(B) of the Social Security Act (SSA) provides the basis for updating the payment limits that carriers and FIs use to determine how much to pay you for the claims that you submit for ambulance services. The national fee schedule for ambulance services has been phased in over a five - year transition period beginning April 1, 2002. The Ambulance Inflation Factor (AIF) updates payments annually and is equal to the percentage increase in the consumer price index for all urban consumers (CPI - U) for the 12 - month period ending with June of the previous year.

The AIF for calendar year (CY) 2006 will be 2.5 percent. This follows the CY 2005 AIF of 3.3 percent, the CY 2004 AIF of 2.1 percent, and the CY 2003 AIF of 1.1 percent.

Additionally, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) established that the ground ambulance base rate (for services furnished during the period July 1, 2004 through December 31, 2009) will have a baseline "floor" amount.

Payment will not be less than this "floor," which is determined by establishing nine fee schedules (one for each of the nine census divisions) and then using the same methodology that was used to establish the national fee schedule to calculate a regional conversion factor and a regional mileage payment.

Some key issues related to the AIF are discussed below:

Payments Based on Blended Methodology
During this five - year transition period, your payments are based on a blended methodology. Before January 1, 2006, for each ambulance provider or supplier, the AIF was applied to both the fee schedule portion of the blended payment amount (both national and regional) and to the reasonable cost/charge portion. Then, these two amounts were added together to determine each provider or supplier's total payment amount.

As of January 1, 2006, the total payment amount for ground ambulance providers and suppliers will be based on either 100% of the national ambulance fee schedule, or 60% of the national ambulance fee schedule added to 40% of the regional ambulance fee schedule. The total payment amount for air ambulance providers and suppliers will be based on 100% of the national ambulance fee schedule.

National or Regional Fee Schedules
Either the national fee schedule or regional fee schedule applies for all providers and suppliers in the census division, depending on the payment amount that the regional methodology yields. The national fee schedule amount applies when the regional fee schedule methodology results in an amount (for a given census division) that is lower than the national ground base rate.

Conversely, the regional fee schedule applies when its methodology results in an amount (for the census division) that is greater than the national ground base rate. When the regional fee schedule is used, that census division's fee schedule portion of the base rate is equal to a blend of the national rate and the regional rate. For CY 2006, this blend will be 40% regional ground base rate and 60% national ground base rate.

Part B Coinsurance and Deductible Requirements
Part B coinsurance and deductible requirements apply.

Additional Information
More information about the CY 2006 Ambulance Inflation Factor is available at http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS Web site. From that Web page, look for CR4061 in the CR NUM column on the right, and click on the file for that CR.

Also useful is the Medicare Claims Processing Manual, 100.04, Chapter 15, Section 20.6 (Update Charges), Subsection 20.6.1 (Ambulance Inflation Factor - AIF), which is included as an attachment to CR4061. 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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2006 HCPCS Revisions for Local Coverage Determinations

All Local Coverage Determinations affected by the 2006 Annual HCPCS Update have been completed. Changes are effective December 31, 2005. Please refer to the CIGNA Government Services Web site to view each policy in its entirety. Local Coverage Determinations may be found at www.cignagovernmentservices.com by clicking on Publications and then choosing TN, NC, or ID current policies.

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Ambulance Fee Schedule - Medical Conditions List: Manualization

Ambulance Fee Schedule - Medical Conditions List: Manualization Acrobat Document

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Annual Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement

Provider Types Affected
All Medicare providers billing carriers, including durable medical equipment regional carriers (DMERCs), regional home health intermediaries (RHHIs), or fiscal intermediaries (FIs), for medical supply or therapy services.

Provider Action Needed
The Centers for Medicare & Medicaid Services (CMS) periodically updates the lists of HCPCS codes subject to the consolidated billing provision of the Home Health Prospective Payment System (HH PPS). This article provides the annual HH consolidated billing update effective January 1, 2006. Affected providers should be aware of these changes.

Background
Section 1842(b)(6) of the Social Security Act (SSA) requires that payment for home health services provided under a home health plan of care be made to the home health agency (HHA.) As a result, billing for all such items and services is to be made by a single HHA overseeing that plan. This HHA is known as the primary agency for HH PPS for billing purposes.

Services appearing on this list that are submitted on claims to Medicare contractors will not be paid separately on dates when a beneficiary for whom such a service is being billed is in a home health episode (i.e., under a home health plan of care administered by an HHA). Exceptions include the following:

Medicare periodically publishes Routine Update Notifications, which contain updated lists of non - routine supply and therapy codes that must be included in HH consolidated billing. The lists are always updated annually, effective January 1, as a result of changes in HCPCS codes that Medicare also publishes annually. This list may also be updated as frequently as quarterly if required by the creation of new HCPCS codes during the year.

Additional Information
CR4114 provides the annual HH consolidated billing update effective January 1, 2006. The following table describes the HCPCS codes and the specific changes to each that this notification is implementing on January 3, 2006:

Code Description of Code: Type Change Replacement Code or Code Being Replaced
Non-Routine Suppies:
A4656 Needle, any size each Delete Replacement code: A4215 with revised definition (code A4215 is already on HH CB list)
A5119 Skin barrier wipes box pr Delete Replacement code: A5120
A6025 Gel sheet for dermal or epidermal application (e.g., silicone, hydrogel, other) Delete  
A6457 Tubular dressing with or without elastic, any width, per linear yard Add  
A4412 Ostomy pouch, drainable, high output, for use on a barrier with flange (two - piece system), without filter, each Add  
A5120 Skin barrier, wipes or swabs, each Add Replaces code A5119
A4363 Ostomy clamp, any type, replacement only, each Add  
A4411 Ostomy skin barrier, solid 4x4 or equivalent, extended wear, with built - in convexity, each Add  
Therapies - No Update

The last update to the HH consolidated billing was issued under Transmittal 340, CR3525. The related Medlearn Matters article, MM3525, may be found at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3525.pdf on the CMS Web site.

For complete details, please see the official instruction issued to your
carrier/DMERC/RHHI/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 CR4114 in the CR NUM column on the right, and click on the file for that CR.

A complete historical listing of codes subject to HH consolidated billing can be found at http://www.cms.hhs.gov/providers/hhapps/ on the CMS Web site. The last bullet on this page contains a link to download the list.

If you have any questions, please contact your carrier/DMERC/RHHI/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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Centers for Medicare & Medicaid Services (CMS) Seeks Provider Input on Satisfaction with Medicare Fee-for-Service Contractor Services

Note: This article was revised on January 13, 2006, to emphasize that the data collection period will run through January 25, 2006.

Provider Types Affected
Sample of 25,000 Medicare providers served by 42 Medicare Fee-for-Service FFS) Contractors, including fiscal intermediaries (FIs), carriers, durable medical equipment regional carriers (DMERCs), and rural home health intermediaries (RHHIs)

Provider Action Needed

STOP - Impact to You
The Centers for Medicare & Medicaid Services (CMS) would like to provide a channel for you to voice your opinions about the services you receive from your Fee-for-Service (FFS) Contractors. The Medicare Contractor Provider Satisfaction Survey (MCPSS) is designed to garner quantifiable data on provider satisfaction with the performance of FFS contractors. The MCPSS is one of the tools CMS will use to carry out the measurement of provider satisfaction levels, a requirement of the Medicare Modernization Act (MMA). Specifically, the survey will enable CMS to gauge provider satisfaction with key services performed by the 42 contractors that process and pay the more than $280 billion in Medicare claims each year. Those Medicare contractors will use the results to improve service. CMS will use the results to improve its oversight of and increase the efficiency of the administration of the Medicare program.

CAUTION - What You Need to Know
The first national implementation of the MCPSS will begin January 2006. If you have been selected, you will receive a notification packet in the mail with background information about the survey, as well as an instruction sheet with information on how to access and complete the survey instrument via a secure Internet Web site. The letter will also include a phone number that you can call to request a paper copy of the survey instrument to submit your responses by mail or fax, if you prefer to do so.

GO - What You Need to Do
Be alert for a notification packet in the mail. If you are selected and receive the notification packet, please take the time to complete and submit your survey responses as soon as possible. The data collection period for the pilot will continue through January 25, 2006.

Background
The 2006 survey will query approximately 25,000 randomly selected providers - those physicians, healthcare practitioners, and facilities that serve Medicare beneficiaries across the country - on the seven key areas of the providercontractor interface:

It contains a total of 76 questions and takes approximately 21 minutes to complete. The deadline for survey submission is January 25, 2006. CMS will analyze the data and release a summary report in July that will be made available on the Internet. Each contractor will also receive an individual report on their performance in June. The MCPSS will be conducted on an annual basis.

CMS has awarded a contract to Westat, a survey research firm, to administer the MCPSS.

Additional Information
For questions or additional information about the MCPSS, please visit http://www.cms.hhs.gov/MCPSS/ on the CMS Web site.

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Clinical Diagnostic Laboratory Date of Service (DOS) for Archived Specimens

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

Provider Action Needed
This article is based on Change Request (CR) 4156, which is being issued to define the DOS policy for laboratory tests on archived specimens, to clarify what is/or is not an archived specimen, and to revise the policy regarding a laboratory test that requires a specimen obtained from storage.

Background
The Centers for Medicare & Medicaid Services published a proposed rule on November 23, 2001 in the Federal Register (66 FR 58792, http://www.access.gpo.gov/su_docs/fedreg/a011123c.html) that clarified the date of service (DOS) for clinical diagnostic laboratory services, and CR 2383 (Transmittal AB - 02 - 134, dated October 4, 2002) was issued but did not define archived specimens.

Note: CR 2383 (Transmittal AB - 02 - 134, dated October 4, 2002, subject: Questions and Answers Related to Implementation of National Coverage Determinations (NCDs) for Clinical Diagnostic Laboratory Services) can be found at http://www.cms.hhs.gov/Transmittals/downloads/AB02134.pdf on the CMS Web site.

CMS has since developed a definition of an archived specimen through its rulemaking process and issued a revised DOS policy in the Federal Register notice dated February 25, 2005 (70 FR 9357, which can be viewed at http://www.access.gpo.gov/su_docs/fedreg/a050225c.html).

CR4156 implements this revised DOS policy for laboratory tests, and it clarifies what is/or is not an archived specimen. As a general rule, the DOS of a test is the date the specimen was collected, except as shown in the following table:

Specimen Description Date of Service (DOS)
Specimen Description Date of Service (DOS) Specimen collected over a period spanning two calendar days (unless collected from archive). Date the specimen collection ended.
Specimen stored for more than 30 calendar days before testing, (otherwise known as "an archived specimen"). Date the specimen was obtained from storage.

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/intermediary regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R800CP.pdf on the CMS Web site.

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/apps/contacts/ on the CMS Web site.

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CMS Launches First Survey of Provider Satisfaction with Medicare Fee - For - Service Contractors

The Centers for Medicare & Medicaid Services (CMS) today announced a new initiative designed to measure how satisfied providers in the fee - for - service (FFS) program are with the services of the contractors that are responsible for processing their claims, educating them about changes in Medicare policies, and responding to provider inquiries.

The initiative, the Medicare Contractor Provider Satisfaction Survey (MCPSS) will be administered on an annual basis. It is designed to garner quantifiable data on provider satisfaction levels with key services performed by the 42 FFS contractors that process and pay more than $280 billion in Medicare claims each year.

"The Medicare program depends on health care providers all over the country to serve our beneficiaries, and this new survey will help us work with the Medicare contractors to help us serve our providers as effectively as possible," said CMS Administrator Mark B. McClellan, M.D., Ph.D. "As we implement the most significant contractor reforms in the history of the Medicare program, provider satisfaction will be one of the key considerations."

The MCPSS is one of the tools CMS will use to measure provider satisfaction levels, as a result of the Medicare Modernization Act (MMA) of 2003. It was developed with extensive input from providers, and information about the survey has been disseminated to providers through a variety of channels, including Open Door Forum conference calls with providers, and Medlearn Matters articles posted on the CMS Web site. CMS will conduct ongoing outreach to providers throughout the survey process. "We are bringing satisfaction measures and other quality measures to many aspects of Medicare, to get the best possible performance for the dollars we spend," added Dr. McClellan. "This survey is very important provider feedback, and so we are identifying ways in which we can get the maximum provider participation."

The MCPSS will query 25,000 randomly selected providers (e.g., physicians, suppliers, healthcare practitioners, and institutional providers), a statistically valid and representative sample of the

1.2 million who serve Medicare beneficiaries. Those providers selected to participate in the survey will be notified by mail during the first week of January 2006. The survey is designed so that it can be completed in less than a half hour. Survey responses can be submitted via a secure Web site, mail, or fax and will be accepted through January 25, 2006.

The survey questions will focus on seven key areas of provider - contractor interactions, including:

CMS will use the MCPSS results for Medicare contractor oversight. Contractors will be able to use the survey results to improve the services they offer to providers. CMS plans to make the survey results available via an online reporting system in early July 2006.

Further information about the MCPSS is available at: http://www.cms.hhs.gov/MCPSS/

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Comprehensive Error Rate Testing (CERT) Call Center Problem Tickets

The CERT Documentation Contractor (CDC) Customer Service Representatives (CSRs) in the CERT call center contact hundreds of providers each day to verify provider addresses and phone numbers. These calls are also an opportunity to inform providers that CERT will be sending request letters for medical records on specific patients. A recent analysis by the CDC of these calls shows providers telling the CSRs "that is not our patient" or "wrong date of service" in 76% of the requests. In order to clarify the accuracy of this percentage, the CDC had one of their Problem Resolution Office (PRO) specialists do a little deeper research into sample calls of approximately 30 "problem" calls in the "not our patient" category and 20 calls from a related problem category - "wrong date of service." Each problem was examined by comparing information concerning the medical request in the database with information from each provider and with the original claim as filed with the Affiliated Contractor (AC). Of the samples examined, only one medical record request was inaccurate with an incorrect provider number.

Reasons for providers indicating "not our patient" and/or "wrong date of service" include the following:

This limited study of the problems will allow us all to better understand where and how mistakes and omissions occur.

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Documentation and Coding Guidelines for Medicare's 2006 Oncology Demonstration

Provider Types Affected
Hematologists and Oncologists participating in the 2006 demonstration.

Provider Action Needed
This Medlearn Matters Special Edition article should be viewed in conjunction with Medlearn Matters article SE0589, which relates to Change Request (CR) 4219. That CR, titled "2006 Oncology Demonstration," informs the Medicare carriers about the Medicare policy and claims processing procedures applicable to the 2006 Oncology Demonstration.

Medicare makes additional payments on claims submitted related to this demonstration when those claims contain the requisite information for making that additional payment, and the claims are submitted in conjunction with a qualifying visit. As noted in CR4219, a separate Medlearn Matters Special Edition article would be written to provide the oncology community with additional information on documentation and coding guidelines. This Special Edition article is for that specific purpose.

Background

Overview
The purpose of the 2006 oncology demonstration project is to capture the spectrum of services oncologists provide to Medicare beneficiaries with the listed cancers in SE0589 and CR 4219. Another purpose is to determine to what extent practice guidelines parallel care that hematologists/oncologists provide. To those ends, the demonstration project is asking what the primary focus is of each evaluation and management (E & M) visit (to capture the spectrum), and with respect to that primary focus, whether or not the care follows practice guidelines.

Participation
Participation in this project is voluntary and the physician participates by filing a claim for services (i.e. a level 2, 3, 4, or 5 established office visit with three separate G codes, one from each category) with the Medicare carrier. The demonstration only applies to E & M visits with patients who have a diagnosis in one of the 13 listed categories, and where the primary focus of the visit is management of that cancer, its complications, and the complications of its treatment. Eligible visits should include an ICD - 9 code on the claim for one of the included cancers, and that cancer should be the first listed cancer diagnosis on the claim form. The cancer does not need to be the first listed diagnosis of any kind on the claim form.

Medicare does make additional payment on claims containing the necessary information requested in this demonstration. Three separate G codes, one from each category, must be supplied for each submission to qualify for that payment - i.e., one code for disease status, one for the primary focus of the visit, and one for guideline adherence.

Documentation
Physicians must identify the appropriate G - code for:

  1. primary focus of visit;
  2. current disease state;
  3. adherence to guidelines

Physicians must also supply documentation in the patient chart in order to bill for the demonstration as described below. Local Medicare carriers have been advised that further documentation requirements are not to be imposed.

  1. One alternative, that fully satisfies the documentation requirements, is to identify the source of the guideline (the American Society of Clinical Oncology, National Comprehensive Cancer Network, both, or "no guideline available") consulted for reporting of guideline adherence and annotating the chart to reflect that source, using a phrase such as:
    1. Demonstration project - ASCO;
    2. Demonstration project - NCCN;
    3. Demonstration project - ASCO & NCCN, or BOTH;
    4. Demonstration project - No guideline available, or NONE or
    5. Demonstration project - Clinical Trial, or CT

Reporting the title of the specific guideline that was consulted is not required. "Demonstration Project - Clinical Trial" should be used when the patient is on an IRB - approved clinical trial relevant to the service
delivered during that visit.

Physicians do not have to provide additional documentation in the patient record beyond the elements listed above.

  1. An alternative approach to documentation would be to use a template (e.g. "a flowsheet"), which would also fulfill all requirements under the demonstration. An example of such a template is included at the end of this article. The use of a documentation template such as the example provided fulfills all documentation requirements under the demonstration.

If such a template is used, then physicians do not have to provide any additional documentation in the patient record. Local carriers are instructed to not impose additional documentation requirements.

Coding Guidance

Intent of the coding guidance
CMS is issuing this guidance to help ensure that reporting throughout the oncology community is consistent and data are meaningful. The guidance issued below is intended to clarify some of the distinctions between codes, and contextualize them within the general goals of the demonstration project.

Primary Focus of the Visit
The primary treating physician should determine the single code that best reflects the primary focus of that E & M visit on that particular day. It is assumed that many different issues are addressed in most E & M visits, and so physicians should make what to them seems the best choice. A narrative description of each code and a theoretical example follow.

G9050 Oncology Work - up Evaluation
This code should be used for visits where the patient is being evaluated or reevaluated prior to or after a treatment course or contemplated treatment course. It is assumed that such visits occur usually when there is insufficient information about extent of disease or other characteristics of disease to support informed treatment decision making.

G9051 Oncology Treatment Decision/Treatment Management
This code should be used for all visits in which cancer directed therapy is being offered, described or discussed, therapy is being provided by the coding physician or by another physician (for instance, radiation therapy delivered at another facility), or the effect of therapy is being evaluated. This code should also be used for visits in which the patient's treatment course is altered (such as when doses are reduced), during treatment "holidays," and visits where the focus is management of toxicities or complications of treatment. Cancer directed therapy includes hormonal therapies and other therapies given for extended periods of time to prevent disease recurrence or relapse.

G9052 Oncology Surveillance for Disease
This code should be used for visits for patients who:

G9053 Oncology Expectant Management of Patient
This code should be used for visits for patients who:

G9054 Oncology Supervision Palliative
This code should be used for visits for patients who meet the following criteria:

Cancer directed therapy aimed at palliation of symptoms might be provided or coordinated in these visits e.g., palliative radiation therapy for bone metastases or chemotherapy for symptom alleviation.

G9055 Oncology Visit Unspecified
This code should be used for visits in which the primary focus is other than any of the listed options.

A Theoretical Patient
THEORETICAL

Staging Stage established - treatment course recommended/accepted ( G9051)
Therapy  

Visit during/between cycles (G9051)

    Conclusion of treatment course - NED (G9051)
NED   Visit to discuss/plan/interpret surveillance (G9052)
    Another visist to discuss/plan/interpret surveillance (G9052)
EOD Eval   Urgent visit for back pain-high suspicion or dz recurrence/metastases Appropriate tests ordered (G9050)
    Definitive evidence of metastic disease...Treatment options discussed (G9051)
    Treatment course begun (G9051)
Therapy   Treatment stopped for toxicity (G9051)
    Dz progression - treatment changed (G9051)
    New treatment continued (G9051)
    Dz progression - pallative options (G9054)
Palliation   Coordination with palliative care (G9054)
     

Guideline Adherence
The treating physician should choose the single code that best reflects whether or not patient management adheres to practice guidelines, and if not, the best listed reason why not.

G9056 Oncology Practice Guidelines (Management adheres to guidelines)
Specifics about when to choose this code are discussed below in the section describing how guideline adherence should be evaluated with respect to the primary focus of the visit.

G9057 Oncology Practice Guidelines (Management differs from the guidelines as a result of enrollment in clinical trial)
This code is reserved for patients who are on an institutional review board approved clinical trial that dictates the care being provided in that visit. This will most often be relevant to visits in which the primary focus is on treatment, although some protocols may include experimental variation in evaluation, surveillance, expectant management, or palliation. If the primary focus of the visit (e.g. treatment) is the subject of the experiment, this code should be submitted. If the primary focus of the visit belongs to a category other than the one being evaluated in the clinical trial, then the treating physician should determine if that management adheres to guidelines.

Note: NCCN guidelines specify participation in a clinical trial as a recommended management strategy. For the purposes of this demonstration, if management differs from that specified in guidelines due to the patient's enrollment on an institutional review board approved clinical trial, G9057 should be reported as described above.

G9058 Oncology Practice Guidelines (Management differs from the guidelines because the physician disagrees with the guidelines)
This code is reserved for management that differs from guidelines because the treating physician disagrees with the recommendations included in the guideline.

G9059 Oncology Practice Guidelines (Management differs from the guidelines because the patient opts for different treatment)
This code is reserved for situations in which management differs from guidelines because the patient has chosen to receive alternative therapy or no therapy, despite the physician recommending management that parallels guidelines.

G9060 Oncology Practice Guidelines (Management differs from guidelines for reasons associated with patient illness)
This code is reserved for situations in which management differs from the guidelines because the patient's performance status, co - morbid illness, or other limitations preclude the management recommended in the guidelines.

G9061 Oncology Practice Guidelines (Patient's condition not addressed by guidelines)
This code is reserved for situations in which the recommended treatment or management for the patient's specific cancer and disease status is not addressed in the guidelines.

G9062 Oncology Practice Guidelines (Management differs from guidelines for other reasons)
This code is reserved for situations in which the management differs from the guidelines for a reason not listed above.

Disease Status
The physician providing the E&M service on that day should determine the single code that best represents the disease status of the patient's cancer. The disease status code should be relevant to the cancer that is the first listed cancer diagnosis on the claim form (not necessarily the first listed diagnosis). eligible diagnosis, a range of only 3 to 6 codes (depending on the specific diagnosis) needs to be considered.

Disease status should be based on the best available data at the time of the visit, unless otherwise specified. No additional diagnostic tests or evaluations should be performed for the purposes of further determining disease status for the purposes of this demonstration project.

Determining if Management is Adherent to Guidelines - Evaluating Guidelines based on the Primary Focus of Visit
The primary focus of the visit as documented should link to the guidelines that are to be evaluated. If the primary focus of the visit is work - up/evaluation, for instance, then the guidelines that should be referenced are those that describe the recommendations for work - up/evaluation. What follows is a simple table and accompanying list of items to consider in the guidelines when coding for guideline adherence for a particularly focus of a visit, followed by a narrative description.

Focus of the visit What to look for
G9050 Oncology work - up evaluation Compare tests obtained to those recommended in guidelines.
G9051 Oncology treatment decision/treatment management Compare chemotherapy, hormonal therapy, immunotherapy, and radiotherapy treatments offered or provided to those recommended in guidelines
G9052 Oncology surveillance for disease Compare surveillance approach, such as tests and frequency of tests, to that recommended in guidelines

G9053 Oncology expectant management of patient
Compare expectant management approach, such as tests and frequency of tests, to that recommended in guidelines

G9054 Oncology supervision of palliative
therapies Compare management of patient's primary symptom, complaint, or complication in that visit to that recommended in guidelines

G9055 Oncology visit unspecified Compare relevant management to relevant guidelines

G9050 Oncology work - up evaluation
When coding for guideline adherence, compare the tests listed in the guidelines for initial diagnosis or evaluation of recurrence to what is being ordered for the patient. If largely similar, with most or all recommended tests ordered/obtained and few or no tests ordered/obtained that are not recommended, code that management adheres to practice guidelines

G9051 Oncology treatment decision/treatment management
When coding for guideline adherence, compare the active cancer directed treatments (specifically chemotherapy, hormonal therapy, immunotherapy and/or radiotherapy) that are being discussed, considered, offered, or provided to those recommended in the guidelines. If treatment(s) that are recommended are being offered or provided, and treatment(s) that are not recommended are not being offered or provided, then code that management adheres to practice guidelines.

  1. Chemotherapy, hormonal therapy, and immunotherapy treatments that are offered or being provided should be considered to parallel guidelines if they are being provided as part of a recommended combination, at the doses and for the number of cycles or duration that is recommended (or at reduced doses or number of cycles for patient specific reasons), and as the "line" of therapy that is recommended.
  2. Radiotherapy should be coded as adherent to guidelines if the patient has been recommended to receive radiotherapy, been referred for radiotherapy, or is receiving/has received radiotherapy.
  3. If multi - modality therapy is recommended, treatment should be coded as adherent to guidelines if all modalities are offered or provided, meeting the criteria listed in a and b above.

Please note: Surgical therapy is not a focus of this demonstration project, so the treating physician is not expected to assess the appropriateness of surgical care in the context of guidelines for the purpose of identifying the appropriate G code.

G9052 Oncology surveillance for disease
When coding for guideline adherence, compare the tests and frequencies listed in the guidelines for disease surveillance with the tests and frequencies recommended in the guidelines. If largely similar, with most or all recommended tests ordered/obtained at approximately the recommended intervals, and few or no tests ordered/obtained that are not recommended, code that management adheres to practice guidelines

G9053 Oncology expectant management of patient
When coding for guideline adherence, compare the tests and frequencies listed in the guidelines for expectant management with the tests and frequencies recommended in the guidelines. If largely similar, with most or all recommended tests ordered/obtained at approximately the recommended intervals, and few or no tests ordered/obtained that are not recommended, code that management adheres to practice guidelines.

G9054 Oncology supervision of palliative therapies
When coding for guideline adherence in association with this code, the relevant guidelines on supportive care and palliation should be consulted. High quality palliative care is by its nature multi - dimensional in nature, making its delivery challenging, and making coding for guideline adherence burdensome. To simplify participation in the demonstration project, the coding physician should report whether the patient's primary symptom, complaint, or complication that is being managed in that visit is being managed according to practice guidelines, as judged by the treating physician.

G9055 Oncology visit unspecified
When coding for guideline adherence in association with this code, the guidelines covering the relevant service should be consulted, or if no guidelines exist, that should be reported.

Additional Information
For additional information, please see Medlearn Matters article SE0589, which can be viewed at
http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0589.pdf on the CMS Web site.

Example of a Documentation Flowsheet
On the following page, there is an example of a flowsheet that could be included in the chart of a patient with breast cancer. Hypothetical data have been entered for one visit, occurring on January 1st, 2006.

To use this flowsheet, the treating physician, for a visit on a particular day, checks one code from each of first two areas, and annotates the flowsheet to designate the guideline that was consulted for that visit next to the relevant code in the guideline adherence category.

Completed in this manner, this flowsheet would satisfy all documentation requirements.

The source of the guideline can be annotated as follows: American Society of Clinical Oncology (ASCO), National Comprehensive Cancer Network (NCCN), both guidelines consulted (BOTH), no guideline available (NONE), patient on Clinical Trial (CT).

Date 1/1/06 Primary Focus of Visit
  G9050 Work - up, evaluation, or staging at the time of cancer diagnosis or recurrence
X G9051 Treatment decision - making after disease is staged or restaged, Discussion of treatment options, supervising/coordinating active cancer directed therapy or managing consequences of cancer directed therapy
  G9052 Surveillance for disease recurrence for patient who has completed definitive cancerdirected therapy and currently lacks evidence of recurrent disease; cancer directed therapy might be considered in the future
  G9053 Expectant management of patient with evidence of cancer for whom no cancer directed therapy is being administered or arranged at present; cancer directed therapy might be considered in the future
  G9054 Supervising, coordinating or managing care of patient with terminal cancer or for whom other medical illness prevents further cancer treatment; includes symptom management, end - of - life care planning, management of palliative therapies
  G9055 Other, unspecified service not otherwise listed Disease State
  G9071 Invasive female breast cancer (does not include ductal carcinoma in situ); adenocarcinoma as predominant cell type; Stage I or Stage IIA - IIB; or T3, N1, M0; and ER and/or PR positive; with no evidence of disease progression, recurrence, or Metastases
X G9072 Invasive female breast cancer (does not include ductal carcinoma in situ); adenocarcinoma as predominant cell type; Stage I or Stage IIA - IIB; or T3, N1, M0; and ER and PR negative; with no evidence of disease progression, recurrence, or Metastases
  G9073 Invasive female breast cancer (does not include ductal carcinoma in situ); adenocarcinoma as predominant cell type; Stage IIIA - IIIB; and not T3, N1, M0; and ER and/or PR positive; with no evidence of disease progression, recurrence, or Metastases
  G9074 Invasive female breast cancer (does not include ductal carcinoma in situ); adenocarcinoma as predominant cell type; Stage IIIA - IIIB; and not T3, N1, M0; and ER and PR negative; with no evidence of disease progression, recurrence, or metastases
  G9075 Invasive female breast cancer (does not include ductal carcinoma in situ); adenocarcinoma as predominant cell type; M1 at diagnosis, metastatic, locally recurrent, or progressive
  G9076 Invasive female breast cancer (does not include ductal carcinoma in situ); adenocarcinoma as predominant cell type; extent of disease unknown, under evaluation, pre - surgical or not listed
Practice Guideline Use
ASCO G9056 Management adheres to guidelines
  G9057 Management differs from guidelines as a result of patient enrollment in an institutional review board approved clinical trial
  G9058 Management differs from guidelines because the treating physician disagrees with guideline recommendations
  G9059 Management differs from guidelines because the patient, after being offered treatment consistent with guidelines, has opted for alternative treatment or management, including no treatment
  G9060 Management differs from guidelines for reason(s) associated with patient comorbid illness or performance status not factored into guidelines
  G9061 Patient's condition not addressed by available guidelines
  G9062 Management differs from guidelines for other reason(s) not listed

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Expansion of Coverage for Percutaneous Transluminal Angioplasty (PTA)

Note: This article was revised on November 23, 2005, to add important information regarding diagnostic coding in the "Note" box at the top of page 5 of this article. All other information remains the same.

Provider Types Affected
Hospitals, physicians, and suppliers billing Medicare carriers or fiscal intermediaries (FIs) for Percutaneous Transluminal Angioplasty (PTA) services provided to Medicare beneficiaries

Provider Action Needed

STOP - Impact to You
MM3811 and related CR3811 announce the expansion of Medicare coverage for PTA of the carotid artery.

CAUTION - What You Need to Know
Effective March 17, 2005, Medicare revised its coverage of PTA of the carotid artery as detailed in this article and CR 3811.

GO - What You Need to Do
If you are a provider of PTA services, be aware of the coverage changes and make certain that your billing staff is aware of the expanded national coverage allowed to Medicare beneficiaries receiving PTA services

Background
Medicare covers PTA of the carotid artery concurrent with carotid stent placement when all the requirements stipulated by the Food and Drug Administration (FDA) - approved policies for Category B Investigational Device Exemption (IDE) clinical trials are met, effective for dates of service on or after July 1, 2001.

PTA of the carotid artery concurrent with the placement of an FDA - approved carotid stent for an FDA approved indication is covered, when all the requirements stipulated by the FDA - approved policies for post approval studies are met, for dates of service on or after October 12, 2004.

Expanded Coverage
Effective March 17, 2005, The Centers for Medicare & Medicaid Services (CMS) expanded the coverage of PTA of the carotid artery concurrent with placement of an FDA - approved carotid stent with embolic protection for the following:

CMS defines high risk patients as those having significant comorbidities and/or anatomic risk factors and are considered by a surgeon to be poor candidates for CEA. The significant comorbidities, include, but are not limited to, those listed in Section 20.7 of the Medicare NCD Manual as follows:

Symptoms of carotid artery stenosis include carotid transient ischemic attack (distinct focal neurologic dysfunction persisting less than 24 hours), focal cerebral ischemia producing a non - disabling stroke (modified Rankin scale < 3 with symptoms for 24 hours or more), and transient molecular blindness (amaurosis fugax). Patients who have had a disabling stroke (modified Rankin > 3) would be excluded from coverage.

The appropriate documentation confirming that a patient is at high risk for CEA and records of the patient's symptoms of carotid artery stenosis should be available in the patient medical records prior to performing any procedure.

The degree of carotid artery stenosis should be measured by duplex Doppler ultrasound or carotid artery angiography and recorded in the patient medical records. If the stenosis is measured by ultrasound prior to the procedure, then the degree of stenosis must be confirmed by angiography at the start of the procedure. If the stenosis is determined to be less than 70% by angiography, the CAS should not proceed.

All facilities must at least meet the minimum standards outlined in Pub 100 - 03, Section 20.7 of the NCD Manual in order to receive coverage for CAS for high - risk patients. Briefly, facilities must have high quality X - ray imaging equipment, device inventory, staffing, and infrastructure to support a dedicated CAS program.

For evaluation purposes, all facilities must provide written documentation to CMS indicating it meets one of the following criteria:

The affidavit must include the facility's name and complete address, Medicare provider number, point of - contact name and telephone number, CAS procedure data collection mechanism, and a senior facility administrative official's signature. (Note that a new affidavit is required every two years.) The affidavit should be sent to:
Director, Coverage and Analysis Group
7500 Security Boulevard, Mail - stop C1 - 09 - 06
Baltimore, MD 21244

Note: Performance of PTA to treat obstructive lesions of the vertebral and cerebral arteries remains noncovered.

All other indications of PTA for which CMS has not specifically indicated coverage remain noncovered.

Additional Information
All providers should note that the following relate to services on or after March 17, 2005:

Providers must also bill V70.7 (Exam - clinical trial) as a secondary diagnosis for claims with "From" dates before October 1, 2005. Providers must bill V70.7 in order to avoid unintentional Medicare Code Editor (MCE) editing. For claims that have "From" dates on or after October 1, 2005, hospitals are not required to bill V70.7 as the unintentional MCE editing will be corrected.

Coding for Carotid Artery Stents - IMPORTANT INFORMATION
In the American Hospital Association's (AHA's) publication Coding Clinic for ICD - 9 - CM, First Quarter 2002, page 10 (and corrected in Second Quarter 2002, page 19), there is a Q&A regarding coding of bilateral carotid artery stenosis. The answer said, "Assign only code 433.10, (Occlusion and stenosis of precerebral arteries, Carotid artery, without mention of cerebral infarction) as the principal diagnosis."

The correction notice changed that advice to use code 433.30 (Occlusion and stenosis of precerebral arteries, multiple and bilateral, without mention of cerebral infarction) instead of 433.10.

In an effort to reduce the confusion, CMS has decided to allow hospitals to be able to code both 433.30 and 433.10, in either principal diagnosis or secondary diagnosis positions, on the claim. Code 433.30 will identify the bilateral condition, while 433.10 will specifically identify the carotid vessel.

You may also want to review the following Medlearn Matters article MM3489 and CR3489 for additional information relating to Medicare coverage of PTA. They are available at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3489.pdf and
http://www.cms.hhs.gov/manuals/pm_trans/R314CP.pdf on the CMS Web site.

The official instruction issued to your carrier/FI 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 CR3811 in the CR NUM column on the right, and then click on the files for that CR. You will see two versions of CR3811. One version identified by transmittal number 33 contains the NCD Manual revision, and transmittal number 531 contains the revisions to the Medicare Claims Processing Manual.

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

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Faxing Documentation for Recoveries and Overpayments

Although faxing documents to CIGNA Government Services is acceptable, faxed work will not be prioritized over other work received by the Benefit Accounting Team through the normal mail process. The fax will be documented and placed in with other work received the same day and worked accordingly. Faxed correspondence sent in as the result of a demand or a request for additional information will not be included in this process. The fax number for the Benefit Accounting Team is 615.782.4623

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Fee Schedule Update for 2006 for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

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 services paid under the DMEPOS Fee Schedule

Provider Action Needed
This article is based on Change Request (CR) 4194, and it provides specific information regarding the annual update for the 2006 DMEPOS Fee Schedule.

Background
The DMEPOS fee schedules are updated on a quarterly basis in order to:

Payment on a fee schedule basis is required for:

Note: DMERCs will use the 2006 PEN fee schedule payment amounts to pay claims for items furnished from January 1, 2006 through December 31, 2006.

The 2006 DMEPOS Fee Schedule Update factors for Health Care Common Procedure Codes (HCPCS) items furnished from January 1, 2006, through December 31, 2006, and are as follows:

HCPCS Codes Notes
A5120 Modifier "AV" is added for billing items furnished for facial prosthetics.
Modifier "AU" is added for billing items furnished for urological supplies.
L2005 Is being revised effective January 1, 2006, to ensure that the code's allowable amount is representative of a full knee, ankle, foot orthosis (KAFO), including the joint component.
L8609 and
L8685 through
L8689

Describe items that are subject to the fee schedule for prosthetics and orthotics (PO) and are being added to the HCPCS effective January 1, 2006.

These codes fall under the jurisdiction of the local carriers rather than the DMERCs. The Centers for Medicare & Medicaid Services (CMS) will be calculating the fee schedule amounts for these items using the standard gapfilling process. The description for these codes can be obtained from the 2006 HCPCS file as soon as it becomes available at
http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp#TopOfPage on the CMS Web site.

The following codes are being deleted from the HCPCS, effective January 1, 2006, and are therefore being removed from the DMEPOS and PEN fee schedule files:

A4254
A4643 thru A4647
A5119
A5509
A5511
B4184
B4186
E0169
E0752
E0754 thru E0759
E0953
E0954
E0972		 E0996
E1000
E1001
E1019
E1021
E1025 thru E1027
E1210 thru E1213
E1239
K0064
K0066
K0067
K0068
K0074 		K0075
K0076
K0078
K0102
K0104
K0106
K0415
K0416
K0452
K0600
K0618 thru K0620
K0628 thru K0649		 K0670
K0671
K0731
K0732
L0860
L1750
L3963
L8100
L8110
L8120
L8130		 L8140
L8150
L8160
L8170
L8180
L8190
L8195
L8200
L8230
L8239
L8620

The HCPCS codes listed below are being added to the HCPCS on January 1, 2006:

A4218
A4233 thru A4236
A4363
A4411
A4412
A4604
A5120
A5512
A5513
A6457
A6513
A6530
A6531
A6532
A6533 thru A6544
A6549
A9275
A9281
A9282

B4185
E0170 thru E0172
E0485
E0486
E0641
E0642
E0705
E0762
E0764
E0911
E0912
E1392
E1812
E2207 thru E2210
E2211
E2212

 E2212 thru E2226
E2371
E2372
L0491
L0492
L0621 thru L0640
L0859
L2034
L2387
L3671 thru L3673
L3702
L3763 thru L3766
L3905
L3913
L3919
L3921
L3933
L3935		 L3961
L3967
L3971
L3973
L3975 thru L3978
L5703
L5858
L5971
L6621
L6677
L6883 thru L6885
L7400 thru L7405
L7600
L8609
L8623
L8624
L8680 thru L8689

The Medicare DMERCs will gap - fill base fee schedule amounts for each state in their region for the following new HCPCS codes that will be subject to the DMEPOS fee schedules in 2006:

HCPCS Codes Notes
A4363, A4411, A4412 Ostomy, Tracheostomy, or Urological Supplies (OS)
A4233, A4234,
A4235, A4236,
A4604, E0485,
E0486, E2216,
E2217, E2218,
E2222, E2223,
E2225, E2226,
E2371, E2372 		Inexpensive or Routinely Purchased DME (IN)
E0170, E0171,
E0911, E0912,
E1812		 Capped Rental DME (CR)
L0624, L0629,
L0632, L0634,
L2034, L2387,
L3671, L3672,
L3673, L3702,
L3763, L3764,
L3765, L3766,
L3905, L3913,
L3919, L3921,
L3933, L3935,
L3961, L3967,
L3971, L3973,
L3975, L3976,
L3977, L3978,
L5703, L5971,
L6621, L6677,
L6883, L6884,
L6885, L7400,
L7401, L7402,
L7403, L7404,
L7405 		Prosthetics and Orthotics (PO)
A6513 Surgical Dressings (SD)

Suppliers should remember to add HCPCS modifier AV when billing code A5120 for facial prosthetic items only when furnished in conjunction with a facial prosthesis. Also, add modifier AU when billing code A5120 for urological items only when furnished in conjunction with urological supplies.

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

Additional Information
The official instruction issued to your carrier, intermediary, or DMERC regarding this change, can be found at http://new.cms.hhs.gov/transmittals/downloads/R770CP.pdf on the CMS Web site.

If you have questions regarding this issue, you may also contact your carrier, FI, or 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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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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Home Care and Domiciliary Care Visits - Current Procedural Terminology (CPT) Codes 99324 - 99350

Provider Types Affected
Physicians and non - physician practitioners (NPPs) billing Medicare carriers for Part B services

Provider Action Needed

STOP - Impact to You
This article is based on Change Request (CR) 4212, which provides CPT coding updates to CR3922. CR3922 is being implemented on December 5, 2005. New code changes by the American Medical Association's (AMA) Current Procedural Terminology (CPT) 2006 identify the correct Evaluation and Management (E/M) visit codes to report beginning January 2006.

CAUTION - What You Need to Know
The AMA CPT 2006 has created new codes to be used beginning January 2006, for visits provided in a domiciliary, rest home (e.g., boarding home), or custodial care setting and new codes to be used for visits in the skilled nursing facility (SNF) or nursing facility (NF) settings. A new code for an annual NF assessment has been added. The new domiciliary codes have typical/average times associated with them and therefore, reasonable and medically necessary, face - to - face prolonged services may be reported with the appropriate companion E/M visit code.

Note: The CPT codes 99321 - 99333 for Domiciliary, Rest Home (e.g., boarding home), or Custodial Care Services are deleted after December 31, 2005. The CPT codes 99301 - 99303 for Initial Nursing Facility Care Services and codes 99311 - 99313 for Subsequent Nursing Facility Care Services are deleted after December 31, 2005.

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

Background
These revisions are included in the Medicare Claims Processing Manual, Pub. 100 - 04, Chapter 12, Section 30.6.14. Change Request (CR) 3922 (Transmittal 667, dated September 2, 2005, implementation date December 5, 2005) identifies the correct places of service and associated CPT codes to report for services through December 31, 2005, in the:

CR4212 updates the previous instruction with the new AMA CPT 2006 codes to use beginning January 2006.

Evaluation and Management (E/M) Services
Beginning January 2006, physicians and qualified NPPs are to report medically necessary E/M services to residents residing in a facility that provides room, board, and other personal assistance services, generally on a long - term basis using the following new CPT codes:

Description CPT Codes
Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services 99324 - 99328 (new patient visit) and 99334 - 99337 (established patient visit)

Private Residence
To report E/M services provided in a private residence of the patient, use the following CPT Codes:

Description CPT Codes
Home Services 99341 - 99350

Note: The Home Services codes will not be used for Place of Service (POS) code 13 (assisted living) and POS code 14 (group home).

Skilled Nursing Facility or Nursing Facility
Beginning January 2006, physicians and qualified NPPs will report covered, medically necessary E/M services to residents residing in a Skilled Nursing Facility (SNF) or a Nursing Facility (NF) using the following new CPT Initial Nursing Facility Care codes for the initial visit and Subsequent Nursing Facility Care codes for a subsequent visit:

Description CPT Codes
Initial Nursing Facility Care 99304 - 99306
Subsequent Nursing Facility Care 99307 - 99310

Annual Nursing Facility Assessment
Physicians and qualified NPPs will use the following CPT code to report an annual nursing facility assessment, beginning January 2006:

Description CPT Codes
Other Nursing Facility Services 99318

Note: The correct POS codes to use with the Nursing Facility Services CPT codes are POS 31 (SNF) and POS 32 (NF), POS 54 (Intermediate Care Facility/Mentallly Retarded) and POS 56 (Psychiatric Residential Treatment Center). See CR3922 (transmittal 667), http://new.cms.hhs.gov/transmittals/downloads/R667CP.pdf or its corresponding Medlearn Matters article at http://new.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3922.pdf on the CMS Web site.

Prolonged Services
Beginning January 2006, the new CPT codes for Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services have typical/average times associated with them. Therefore, beginning January 2006, physicians and qualified NPPs may report reasonable and medically necessary and direct (face - to - face) prolonged services represented by CPT codes 99354 - 99355 with the appropriate CPT Domiciliary companion E/M code. All the requirements for prolonged services must be met.

Description CPT Codes
Reasonable, Medically Necessary, and Direct (face - to - face) Prolonged Services 99354 - 99355

Note: Prolonged service performed and reported with the Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Service visit code must meet the requirements for a prolonged service as defined in the Medicare Claims Processing Manual (Pub. 100 - 04, Chapter 12, and Section 30.6.15.1).

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 regarding this change. That instruction may be viewed at http://new.cms.hhs.gov/transmittals/downloads/R775CP.pdf on the CMS Web site.

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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Key Medicare News for 2006 for Physicians and Other Health Care Professionals

Provider Types Affected
Physicians and health care professionals and their billing staffs billing Medicare carriers

Introduction
This Special Edition article is being provided to help you, the Medicare physician and health care professional, keep informed about important Medicare initiatives and additional new Medicare benefits available in Calendar Year (CY) 2006.

As you once again make your decision to enroll in or terminate enrollment in the Medicare participation program, the Centers for Medicare & Medicaid Services (CMS) would like to take this opportunity to review some important news, especially upcoming news for 2006.

CMS believes this information provides significant benefits to providers and their Medicare patients, and it will encourage providers to enroll in, or stay in, the Medicare participation program in order to take full
advantage of the upcoming changes.

Information You Need to Know

Ending the Medicare HIPAA Contingency Plan
Based on the progress made by the health care community in implementing the administrative simplification standards of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) since October 2003, CMS ended the Medicare HIPAA Contingency Plan for incoming claims as of October 1, 2005.

October 16, 2003, was the deadline for compliance with the electronic transaction and code set standards of HIPAA. While the vast majority of Medicare providers are in compliance with the HIPAA standards, more work remains to be done to get all electronic billing Medicare providers into compliance. To be in compliance with the law, every Medicare electronic billing provider must submit HIPAA - compliant claims.

To ensure that you stay informed about HIPAA issues, CMS encourages you to visit the following Web pages for the latest news affecting you. To access the national educational articles distributed as part of the Medlearn Matters process, visit http://www.cms.hhs.gov/medlearn/matters/ on the CMS Web site. Take special note of Medlearn Matters article MM3956. To access a variety of issues related to HIPAA policies affecting Medicare providers, visit http://www.cms.hhs.gov/providers/edi/ on the CMS Web site.

Release of HIPAA Security Rule
By April 21, 2005, all covered entities under HIPAA (except small health plans) were required to ensure the security of electronic protected health information. Small health plans have until April 21, 2006, to meet the HIPAA Security Compliance Deadline.

CMS has released the HIPAA Security Rule, which outlines the administrative, physical, and technical safeguards that a covered entity must implement to be in compliance with the HIPAA security standards. A copy of the rule may be downloaded from https://www.cms.hhs.gov/HIPAAGenInfo/ on the CMS Web site. CMS is eager to help you understand and implement the strategies for complying with the Security Rule and has developed educational materials that are available at http://www.cms.hhs.gov/HIPAAGenInfo/ on the CMS Web site. In addition, there are a number of professional and standards - setting organizations that offer listservs, white papers, and other helpful resources on security implementation.

National Provider Identifier
Health care providers who are covered entities under HIPAA are required by law to apply for a National Provider Identifier (NPI). The NPI will replace health care provider identifiers in use today in standard health care transactions. The health plans with which you do business will instruct you as to when you may begin using the NPI in standard transactions. All HIPAA - covered entities except small health plans must begin using their NPI in standard electronic transactions by May 23, 2007; small health plans have until May 23, 2008.

To apply online, visit https://nppes.cms.hhs.gov, or call 1.800.465.3203 to request a paper application. Also, visit http://www.cms.hhs.gov/HIPAAGenInfo/ for the latest information regarding the NPI, including a transcript from CMS's recent National Provider Identifier Roundtable conference call.

Therapy Services
Therapy Services are defined as outpatient physical therapy, occupational therapy, and speech - language pathology. These services were limited through the Balanced Budget Act of 1997. Limits have been imposed twice, once in 1999 and for a few months in 2003. These limits are scheduled to be implemented again on January 1, 2006. Therapy services will be limited for each beneficiary for the year.

The allowable amount is estimated to be $1,750, but this may change based on the Medicare Economic Index at the end of the year. The amount applies for physical therapy and speech - language pathology combined, and for occupational therapy alone.

Therapy services performed in a physician's office must follow the standards and conditions listed in the manuals and must be identified with a modifier for physical therapy, occupational therapy, or speech language pathology.

Those services identified as outpatient "therapy" are listed in the Medicare Claims Processing Manual (Pub 100 - 04), Chapter 5, Section 20. The benefit policies are in the Medicare Benefit Policy Manual (Pub 100 - 02), Chapter 15, Sections 220 and 230.

Medicare Contracting Reform
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA, Section 911) requires CMS to take the necessary steps between now and October 2011, to implement Medicare Contracting Reform. Although health care delivery in the United States has evolved through four decades of advances in medicine and technology, the contracting portion of Medicare's fee - for - service administrative structure has not.

Medicare Contracting Reform will bring standard contracting principles to Medicare, such as competition and performance incentives that the government has long applied to other federal programs under the Federal Acquisition Regulation.

Medicare Administrative Contractor (MAC) Authority
CMS is required to replace the current contracting authority with the new Medicare Administrative Contractor (MAC) authority. The law directs CMS to conduct full and open competitions for these new MACs. A/B MACs will administer both the Part A and Part B work currently being handled by Fiscal Intermediaries (FI) and carriers in 15 designated geographical jurisdictions.

Home health/hospice MACs will perform work currently performed by Regional Home Health Intermediaries (RHHIs) in four designated geographical jurisdictions, while Durable Medical Equipment (DME) MACs will perform the work of the current Durable Medical Equipment Regional Carriers (DMERCs) in four designated geographical jurisdictions that correspond to the jurisdictions of the home health/hospice MACs.

Start - Up Acquisition and Transition Cycles
CMS plans to begin to compete these workloads with a start - up acquisition and transition cycle. This startup cycle is the competition of the current DMERC workloads and the A/B workload for Jurisdiction 3, a first step that focuses on a small discrete workload. The start - up cycle is currently ongoing. The procurement schedule anticipates the DME workload will be awarded in December 2005 and the Part A/Part B workload for Jurisdiction 3 will be awarded in June 2006.

That start - up cycle will be followed by MAC acquisition and transition Cycles One and Two. CMS anticipates each of these acquisition cycles will take approximately 9 to 12 months, from solicitation to award. CMS expects to award the Cycle One procurement in September 2007 and Cycle Two in September 2008. The subsequent transition of workload from the existing contractors to the new MACs will last from approximately 7 to 13 months. Under this schedule, the full fee - for - service workload will be transitioned to MACs by October 2009.

For the most current information available, including the acquisition schedule for each MAC jurisdiction, visit the Medicare Contracting Reform Web site at http://www.cms.hhs.gov/medicarereform/contractingreform/ on the CMS Web site.

New Benefits for People with Medicare
The 2006 calendar year introduces new health benefits for people with Medicare, resulting from the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). The full text of this Act can be found at http://www.cms.hhs.gov/medicarereform/MMAactFullText.pdf on the CMS Web site.

Preventive Services Benefits
This MMA initiative was implemented in 2005. This is a reminder to you that newly covered preventive services include diabetes screening tests for seniors at risk for diabetes and blood tests to screen for cardiovascular disease. Also beginning in 2005, people enrolling in Medicare for the first time were eligible for an initial preventive physical exam, including an exam and an electrocardiogram, in addition to the other preventive and screening services that were already available: adult immunizations; electrocardiograms; pelvic exams; pap smears; mammograms; screenings for prostate and colorectal cancer, glaucoma, diabetes, and cardiovascular disease; and other preventive services.

Visit http://www.cms.hhs.gov/partnerships/tools/2005preventive/default.asp on the CMS Web site to access educational materials about these benefits for you, your staff, and Medicare patients.

Medicare Prescription Drug Coverage
Beginning January 1, 2006, Medicare Prescription Drug Coverage will be available to all people with Medicare. Insurance companies and other private companies will be working with Medicare to offer drug plans and negotiate discounts on drug prices. These plans are different from the Medicare - approved drug discount cards that phase out by May 15, 2006 (or when a beneficiary's enrollment in a Medicare prescription drug plan takes effect, if earlier). Where the cards offered discounts, the plans will offer insurance coverage for prescription drugs. Visit http://www.cms.hhs.gov/medlearn/drugcoverage.asp to access educational materials about this proposed benefit for you, your staff, and Medicare patients.

The Medicare Chronic Care Improvement Initiative ("Medicare Health Support")
This initiative, which currently consists of eight regional pilot programs, is the first large - scale chronic care improvement initiative for targeted groups of beneficiaries under the Medicare Fee - For - Service (FFS) program. CMS selected Medicare Health Support Organizations (MHSOs) that offer self - care guidance and support to chronically ill beneficiaries. MHSOs help beneficiaries manage their health, adhere to their physicians' plans of care, and ensure that they seek or obtain medical care that they need to reduce their health risks. The pilot programs all have the following features:

The new programs are not single - disease focused. They are to help participants manage all their health problems.

For an overview of the initiative, download the fact sheet that describes "Medicare Health Support" at http://www.cms.hhs.gov/medicarereform/ccip/ on the CMS Web site. Also, an informative Medlearn Matters article is available on this program at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3953.pdf, also on the CMS Web site.

Payment Information

Competitive Acquisition Program
The MMA requires the implementation of a Competitive Acquisition Program (CAP) for Medicare Part B drugs and biologicals not paid on a cost or prospective payment system basis. Under the new program, scheduled to be implemented by July 1, 2006, physicians will be given a choice between buying and billing these drugs under the Average Sales Price (ASP) system, or selecting a Medicare - approved CAP vendor that will supply these drugs.

If the physician elects to obtain drugs through the CAP, the vendor will bill Medicare for the drug. The vendor will also bill the beneficiary for any applicable coinsurance and deductible. Physician enrollment in the program is anticipated to begin in the spring of 2006 for July through December 2006, and will then be conducted annually, in the fall of each year, for the following calendar year.

To access MMA, Section 303(d), go to http://www.cms.hhs.gov/providers/drugs/compbid/303d.pdf on the CMS Web site. More information about the ASP system can be found at http://www.cms.hhs.gov/providers/drugs/asp.asp on the CMS Web site.

The following Web site is meant to keep physicians informed about enrollment procedures, approved drug vendors, and drugs that may be obtained through the program: http://www.cms.hhs.gov/providers/drugs/compbid. In addition, a full press release and fact sheet can be viewed at: http://www.cms.hhs.gov/media/press/release.asp?Counter=1490 on the CMS Web site.

Geographic Discrepancies and Scarcity Bonus Payments
Starting in 2004 and continuing through 2006, the MMA required that the geographic practice costs indices (GPCIs) applied to the physician work portion of the physician fee schedule may not be below 1.0. This provision increases payment rates in 57 of the country's 89 payment localities, and payments will go up for services provided up to the national average rate in areas that were previously below the national average.

Starting in 2005 and continuing through 2007, Scarcity Bonus Payments (a five percent (5%) bonus payment) will be paid to primary care physicians and specialists providing care to Medicare beneficiaries in newly defined shortage areas. The new shortage areas are those counties with the lowest ratio of primary care/specialist physicians to Medicare beneficiaries and which represent an aggregate total of twenty percent (20%) of the total Medicare beneficiaries in the county.

Within the official instructions issued by CMS are detailed instructions regarding services eligible for Health Professional Shortage Areas (HPSA) and Physician Scarcity Area (PSA) bonus payments, HPSA incentive payments for services rendered in a critical access hospital (CAH), as well as HPSA designations and information regarding zip codes.

The official instruction issued to your carrier and intermediary regarding this change in the HPSA modifier 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 CR3935 in the CR NUM column on the right, and click on the file for the desired CR. A Medlearn Matters article is also available related to this transmittal at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3935.pdf on the CMS Web site. Additional information on the PSA bonus can be found in The Guide for Using the HPSA/PSA Web Page, at http://www.cms.hhs.gov/providers/bonuspayment/guide.pdf on the CMS Web site.

Medicare Incentive Payment Program
Also beginning in 2005, the MMA modified the bonus payment program, which provides ten percent (10%) bonus payments to physicians in HPSAs. The bonus payments will be automatic for physicians practicing in counties that qualify as full HPSAs.

The PSA bonus payment was established in 2005 and per the MMA is currently scheduled to continue through 2007. This five percent (5%) bonus payment is paid to primary