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March 2006 Part B Medicare Bulletin

Posted March 3, 2006

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Announcement of Redesigned National Provider Identifier Web Page

Announcing the redesigned CMS Web page dedicated to providing all the latest NPI news for health care providers! Visit http://www.cms.hhs.gov/NationalProvIdentStand/ on the Web. This page also contains a section for Medicare Fee-For-Service (FFS) providers with helpful information on the Medicare NPI implementation. A new fact sheet with answers to questions that health care providers may have regarding the NPI is now available on the Web page; bookmark this page as new information and resources will continue to be posted.

For more information on private industry NPI outreach, visit the Workgroup for Electronic Data Interchange (WEDI) NPI Outreach Initiative Web site at http://www.wedi.org/npioi/index.shtml on the Web.

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Attestation Form for Conducting Real Time Eligibility Inquiries with Medicare - Revision to Chapter 31

Note: This article was revised on January 31, 2006, to change the effective date (shown above) from October 1, 2006, to October 1, 2005. All other information remains the same.

Provider Types Affected
Providers who access the 270/271 health care eligibility inquiry and response application in real time

Provider Action Needed

STOP - Impact to You
Beginning September 1, 2005, an on-line attestation form (Trading Partner Agreement for Submission of 270s to Medicare on a Real-Time Basis) must be completed by submitters authenticated by the Centers for Medicare & Medicaid Services (CMS) to conduct 270/271 transactions with CMS before providers may access the real-time 270/271 health care eligibility inquiry and response application.

CAUTION - What You Need to Know
Submitters requesting access to the Medicare beneficiary database must follow the procedure outlined in the Additional Information section below.

GO - What You Need to Do
Please be sure to fill out this new agreement form located at http://www.cms.hhs.gov/it so you can conduct 270/271 transactions with Medicare.

Background
The purpose of Change Request (CR) 4093 is to alert Medicare providers to the revision in the Medicare Claims Processing Manual, Chapter 31 (ANSI X12N Formats Other than Claims or Remittance).

This revision addresses the standards for Medicare beneficiary eligibility inquiries, and creates the database and infrastructure needed to provide a real-time, centralized Health Insurance Portability and Accountability Act (HIPAA) compliant Health Care Eligibility Benefit Inquiry and Response transaction (270/271).

Additional Information

Access Process for Clearinghouses/Provider
Beginning September 1, 2005:

Beginning October 1, 2005:

A CMS contractor known as the Medicare Eligibility Integration Contractor (MEIC) will contact the submitter in order to authenticate the accessing entity's identity.

Once authentication has been completed, the MEIC will provide the Clearinghouses, Providers, and Trading Partners with a submitter identification (ID) that must be used on all 270/271 transactions.

The MDCN extranet application is suitable for many providers that can create, send, and receive complete X12 eligibility transactions. CMS will soon offer a second solution for providers that desire to conduct the transaction using the Direct Data Entry (DDE) version. The DDE version will allow all approved providers to conduct eligibility transactions over the public internet at no cost to the provider.

Please note that in order to access the MDCN, an entity must obtain the necessary telecommunication software from the AT&T reseller on its own. AT&T Resellers and contact cumbers include the following:

Helpdesk Support
You may also contact the MEIC help desk for connectivity issues on Monday through Friday, 7:00 a.m.-9:00 p.m. EST; Telephone: 1.866.324.7315; E-mail address: MCARE@cms.hhs.gov.

Related Links
The official instruction issued to your fiscal intermediary (FI), regional home health intermediary (RHHI), carrier, or durable medical equipment regional carrier (DMERC) regarding this change may be found by going to http://www.cms.hhs.gov/Transmittals/downloads/R700CP.pdf on the CMS Web site.

Please refer to your local FI, RHHI, Carrier or DMERC for more information about this issue. To find the toll free phone number, go to http://www.cms.hhs.gov/apps/contacts/ on the CMS Web site.

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Cardiac Catheterization In Other Than A Hospital Setting

Provider Types Affected
Physicians and/or providers who bill Medicare carriers for cardiac catheterizations performed in freestanding facilities

Important Points to Remember

Background
The original language from section 20.25 of publication 100-03 required that Medicare carriers, in consultation with the Peer Review Organizations (PROs), renamed Quality Improvement Organizations (QIOs), review freestanding cardiac catheterizations facilities to determine that procedures can be performed safely. This function of the QIOs is no longer in their scope of work as their focus has shifted to include other functions. It will now be at the carrier's discretion through local medical review policies to make decisions regarding the coverage of cardiac catheterization in freestanding facilities.

Implementation
The implementation date for this instruction is February 27, 2006.

Additional Information
The official instructions issued to your carrier regarding this change can be found at http://www.cms.hhs.gov/Transmittals/downloads/R46NCD.pdf on the CMS Web site.

If you have questions, please contact your Medicare carrier 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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CIGNA Government Services NetCourses Reminder

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

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

General Courses

Part B Courses

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

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Claim Status Category Code and Claim Status Code Update

Provider Types Affected
All providers submitting Health Care Claim Status Transactions to Medicare contractors (carriers, durable medical equipment regional carriers (DMERCs), fiscal intermediaries (FIs), and regional home health intermediaries (RHHIs))

Provider Action Needed

STOP - Impact to You
This article is based on Change Request (CR) 4256, which provides the April 2006 updates of the Claim Status Codes and Claim Status Category Codes for use by Medicare contractors (carriers, DMERCs, FIs, and RHHIs).

CAUTION - What You Need to Know
Medicare contractors are to use codes with the "new as of 4/06" designation and prior dates and inform affected providers of the new codes. CR 4256 applies to Chapter 31, Section 20.7, Health Care Claim Status Category Codes and Health Care Claims Status Codes for Use with the Health Care Claim Status Request and Response ASC X12N 276/277.

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

Background
Claim Status Category codes indicate the general category of a claim's status (accepted, rejected, additional information requested, etc.), which is then further detailed by the Claim Status Code(s). Under the Health Insurance Portability and Accountability Act (HIPAA), all payers (including Medicare) must use Claim Status Category and Claim Status codes approved by a recognized code set maintainer (instead of proprietary codes) to explain any status of a claim(s) sent in the Version 004010X093A1 Health Care Claim Status Request and Response transaction.

The Health Care Code Maintenance Committee maintains the Claim Status Category and Claim Status codes, and as previously mentioned, the Committee meets at the beginning of each X12 trimester meeting and makes decisions about additions, modifications, and retirement of existing codes.

Note: The updated list is posted three times a year (after each X12 trimester meeting) at the Washington Publishing Company Web site at http://www.wpc-edi.com/codes. Once at the Washington Publishing Company Web site, select "Claim Status Codes" or "Claim Status Category Codes" to access the updated code list. Included in the code lists are specific details, including the date when a code was added, changed or deleted. All code changes approved in February 2006 are to be listed at this above Web site approximately thirty (30) days after the meeting concludes. For this update, Medicare will begin using the codes in place as of 4/06.

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/intermediary regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R814CP.pdf on the CMS Web site.

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/apps/contacts/ on the CMS Web site.

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CMS Makes First Awards To Medicare Administrative Contractors Contracting Reform Will Lower Administrative Costs, Improve Quality And Service For Durable Medical Equipment Benefits

The Centers for Medicare & Medicaid Services (CMS) announced today that it has awarded contracts for four specialty contractors who will be responsible for handling the administration of Medicare claims from suppliers of durable medical equipment, prosthetics and orthotics. The new contracts awarded represent a first step in CMS' initiatives designed to improve service to beneficiaries and providers, support the delivery of coordinated and quality care, and provide greater administrative efficiency and effectiveness for fee-for-service Medicare.

To view the entire press release, please visit http://www.cms.hhs.gov/apps/media/press/release.asp?counter=1749

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CMS Posts NPI Information for Medicare Organization Provider Subparts

The National Provider Identifier (NPI) Final Rule requires health care providers who are organizations and who are covered entities under HIPAA to determine if they have "subparts" that should be assigned NPIs. The NPI Final Rule provides guidance to those health care providers in making those determinations.

The Centers for Medicare and Medicaid Services (CMS) has communicated to the Provider Enrollment staff at the carriers and fiscal intermediaries the Medicare program's expectations concerning the determination of subparts for NPI assignment purposes. CMS has posted a document describing the subpart concept and its relationship to the way in which Medicare enrolls its organization providers at http://www.cms.hhs.gov/NationalProvIdentStand/06_implementation.asp#TopOfPage.
This document will be helpful to providers in understanding the issue of subparts and how subpart determination could be done in a way that helps to promote smoother and more efficient Medicare claims processing during the implementation of the NPI in the Medicare program.

The health care industry in general has expressed an interest in being informed of this type of information. CMS is making this information available on the CMS Web site so that it is easily available to interested parties.

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CPT 76937, Ultrasound Guidance For Vascular Access…

Recently we have clarified with AMA/CPT Services that this procedure code applies only to venous access procedures. The imaging includes preaccess assessment of venous patency and actual real time visualization of needle passage to the venous lumen. The descriptor for code 76937 includes all phases of actual guidance, documentation, and reporting required to perform this procedure. Use of code 76937 requires a permanent recorded image(s) of the vascular access site to be included in the patient record, as well as a documented description of the process either separately or within the procedure report. Therefore, for those instances when ultrasound is utilized only to identify a vein, mark a skin entry point, and proceed with non-guided puncture, it would not be appropriate to report code 76937 for ultrasound guidance. (Note: CPT 76942 chould not be reported with 76937.) Several of the base or primary codes for this add-on code have been applied incorrectly, as some arterial procedures have been included in the past, and more have been requested for coverage by the provider community.

Effective immediately, the base codes for this ultrasound guidance procedure will be payable only for certain venous access procedures. These are:
36555 - 36585
36481
36000
36012
36005
36011
36010
36500
36145
36581

The key to appropriate code selection is documentation. Some key elements to include in the documentation for this procedure are:

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Emergency Update to the 2006 Medicare Physician Fee Schedule (MPFS)

Provider Types Affected
Physicians, suppliers, and providers billing Medicare carriers and/or fiscal intermediaries (FIs) for services paid under the MPFS and provided to Medicare beneficiaries

Provider Action Needed

STOP - Impact to You
This article is based on Change Request (CR) 4268, which amends payment files issued to Medicare carriers based upon the November 21, 2005, MPFS Final Rule.

CAUTION - What You Need to Know
CR4268 includes a new G-code for intravenous infusion of immunoglobulin (G0332), new G-codes for the 2006 Oncology Demonstration Project, and changes to CPT code status indicators, global periods, and relative value units.

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

Background
The Centers for Medicare & Medicaid Services (CMS) issued payment files to carriers based upon the MPFS Final Rule published in the November 21, 2005, Federal Register (http://www.access.gpo.gov/su_docs/fedreg/a051121c.html), and the Social Security Act (Section 1848(c)(4) (http://www.ssa.gov/OP_Home/ssact/title18/1848.htm) authorizes CMS to establish ancillary policies necessary to implement relative values for physicians' services.

CR4268 amends the November 21, 2005, MPFS Final Rule payment files and includes a new G-code (G0332-Intravenous Infusion of Immunoglobulin) and additional new G-codes for the 2006 Oncology Demonstration Project. There are corrected descriptors for codes G0332, G9050-G9130, 0137T, 0001F, 0005F, and J7640. The coverage indicator on the HCPCS files should be a "C" for Category III codes 0144T-0154T. In addition, CR4268 includes changes to several Current Procedural Terminology (CPT) codes with respect to:

See Attachment 1 of CR4268 for the complete list of changes to G-codes and CPT codes included in this Emergency Update to the 2006 MPFS Database.

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

Additional Information
For complete details, please see CR4268, the official instruction issued to your carrier/intermediary regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R798CP.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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Essential Information and Resources for Prescribing Health Care Professionals - The Eleventh in the Medlearn Matters Series on the New Prescription Drug Plans-Medicare Prescription Drug Coverage

Note: This article was revised on February 6, 2006, to reflect revised CMS policy that now provides for a 90 day supply of transitional prescription medicine. (See page 4.)

Provider Types Affected
All health care professionals who prescribe prescription medications for Medicare beneficiaries

Impact on Providers
The new Medicare prescription drug coverage began on January 1st. Already, pharmacists have filled millions of prescriptions for people with Medicare. During this important transition period to the new prescription drug coverage, the Centers for Medicare & Medicaid Services (CMS) understands that there is much that prescribing health care professionals need to know about this new coverage in order to help their Medicare patients.

Essential Information for Prescribing Health Care Professionals
CMS has compiled a list of information, resources, and tools that will allow health care professionals and their support staff to help their Medicare patients during this transition period.

Finding Formulary Information
CMS has a formulary finder that provides direct access to all plan Web sites at http://formularyfinder.medicare.gov/formularyfinder/selectstate.asp on the Web. In addition, we have worked with Epocrates to provide free software which makes the formulary selection process very simple. You can load this program into your PDA or run the software on a desktop. This tool is available at http://www.epocrates.com/ on the Web.

Coverage Determination
CMS defines a coverage determination as the first decision made by a plan regarding the prescription drug benefits an enrollee is entitled to receive under the plan, including a decision not to provide or pay for a Part D drug, a decision concerning an exception request, and a decision on the amount of cost sharing for a drug.

An exception request is a type of coverage determination request. Through the exceptions process, an enrollee can request an off-formulary drug, an exception to the plan's tiered cost sharing structure, and an exception to the application of a cost utilization management tool (e.g., step therapy requirement, dose restriction, or prior authorization requirement).

CMS does not have the authority to mandate a standard exception process for each Medicare drug plan or MA-PD; however, the Agency is working to simplify the exceptions process. Like typical commercial payers, health care professionals may occasionally need to help a patient file a prior authorization for a medication or appeal a medication's tier. CMS is working with medical specialty societies to address these issues.

A form has been created by a coalition of medical societies and advocacy groups that can be faxed to your office by a pharmacist when he or she is given a prescription that is either not on the formulary or on a higher tier.

This form streamlines communication between the pharmacist and the physician and reduces the need for time consuming telephone calls to the doctor's office.

The form is located at http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/Downloads/PartDPharmacyFaxForm.pdf on the CMS Web site, as well as at several medical society Web sites.

Expedited Review Process
There is an expedited review process that CMS has outlined to ensure that drug plans can move an appeal quickly, i.e., within a 24-hour turnaround time, to provide medicines to patients with an immediate need. Beyond this expedited review process, the standard appeals process to challenge a plan's coverage determination has five levels:

Visit http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/04_Formulary.asp for a list of plan contacts you can use to query your patient's plan should you need to pursue an appeal or require clarification on an issue.

Part B Drugs vs. Drugs Covered under Medicare Prescription Drug Coverage (Part D)
A previous Medlearn Matters article explains the difference between drugs covered under Part B versus those covered under Part D.

This article can be found at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0570.pdf on the CMS Web site. Additionally, a chart explaining specific drugs can be found at http://www.cms.hhs.gov/pharmacy/downloads/partsbdcoverageissues.pdf on the CMS Web site.

Verifying Beneficiary Enrollment in a Medicare Drug Plan
Office staff can use the Medicare Prescription Drug Plan Finder, located at http://www.medicare.gov, to verify a beneficiary's enrollment in a Medicare drug plan. By entering all information provided on a beneficiary's Medicare card, the Plan Finder will identify the plan in which the beneficiary is enrolled.

Pharmacists have access to a new computer tool called "E1" that provides real time enrollment and eligibility information. This tool provides both eligibility and billing information at the point of sale and is constantly updated by CMS.

Obtaining Prior Authorizations
A prior authorization can only be obtained by calling the drug plan directly. 1.800.MEDICARE cannot process a prior authorization.

Ensuring Coverage for a Dual Eligible Beneficiary Who Needs to be Enrolled in a Plan CMS has ensured that people with Medicare and full Medicaid benefits (full dual) will have drug coverage by enabling customer service representatives at 1.800.MEDICARE to enroll these beneficiaries in WellPoint, a national plan.

If these beneficiaries have immediate prescription needs, they should visit their local pharmacies. The pharmacist can enroll them in WellPoint at the pharmacy. To find out more about what happens with Medicare prescription drug coverage in certain situations, visit http://www.cms.hhs.gov/Pharmacy/Downloads/whatif.pdf on the CMS Web site.

Providing a 90-day Supply of Transitional Prescription Medication
CMS has instructed all Medicare-approved plans to extend the original 30-day transitional coverage period by an additional 60 days. This means that a Part D beneficiary will be able to get a 90 day supply of all of his or her medications when they enroll in Part D, even if some of the medications are not on formulary. This 90 day period will give the patient's doctor and pharmacist time to adjust the patient's drug regimen, or request exceptions to the plan's formulary, so that the next refill of medications will be consistent with the plan's coverage rules. Beneficiaries who enroll after March 31st will get a 30 day transitional fill so that they have time to adjust their medication regimen to the plan formulary.

Important Contact Information to Report Problems with Medicare Prescription Drug Coverage
Health Care Professionals: E-mail prit@cms.hhs.gov with problems and issues encountered. Please take advantage of CMS' regular conference call at 2PM EST every Tuesday. This call gives health care professionals an opportunity to ask questions of CMS staff. Call 1.800.619.2457; Passcode: RBDML.
Pharmacists: Call 1.866.835.7595, a CMS dedicated line designed to help answer questions regarding billing and beneficiary enrollment information.

Additional Information
Health care professionals can visit
http://www.cms.hhs.gov/MedlearnProducts/23_DrugCoverage.asp#TopOfPage on the CMS Web site. The redesigned Web page contains all the latest information on Medicare prescription drug coverage.

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Instructions for Reporting New HCPCS Code V2788 for Presbyopia-Correcting Intraocular Lenses (PC-IOLs)

Provider Types Affected
Physicians, providers, and suppliers billing Medicare carriers or fiscal intermediaries (FIs) for Intraocular Lenses (IOLs)

Provider Action Needed
This instruction provides guidance regarding the new Healthcare Common Procedure Coding System (HCPCS) code, V2788 (Presbyopia-correcting function of an intraocular lens). It is being established as a code for reporting non-covered charges associated with the insertion of a presbyopia-correcting lens.

Providers may report this code on claims to reflect the PC-IOL when inserted in lieu of the conventional IOL in conjunction with correcting cataract surgery. The new HCPCS code will be part of the annual HCPCs update and is not a payable service for Medicare on the HCPCS file for 2006.

Background
The Centers for Medicare & Medicaid Services (CMS) announce that Section 120 has been added to Publication 100-04, Chapter 32, which outlines general policy, payment, and billing procedures for PC-IOLs. Much of this information was previously released in Change Request 3927 in August, 2005.

A Medlearn Matters article (MM3927) on the subject can be viewed at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3927.pdf on the CMS Web site. As stated in CR3927, the new coverage policy was effective for dates of service on and after May 3, 2005.

CR4184 provides a new HCPCS code, effective January 1, 2006, for reporting non-covered charges associated with the insertion of a presbyopia-correcting lens. That code is V2788. Medicare carriers and intermediaries will use an appropriate claim adjustment reason code such as 96 (non-covered charges) when denying non-covered PC-IOL charges. The carrier or intermediary will also send an appropriate message to the beneficiary via a Medicare Summary Notice to inform the beneficiary of the denial.

CPT Codes
Physicians and hospitals are to report one of the following Current Procedure Terminology (CPT) codes on these claims:

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

Additional Information
For complete details, please see CR4184, the official instruction issued to your carrier or intermediary regarding this change, which may be found at http://www.cms.hhs.gov/Transmittals/downloads/R801CP.pdf on the CMS Web site.

If you have any questions, please contact your Medicare carrier or 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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List of Medicare Telehealth Services

Provider Types Affected
Registered dietitians, nutrition professionals, and other providers of Medicare telehealth services billing Medicare carriers or fiscal intermediaries (FIs) for such services

Provider Action Needed

STOP - Impact to You
The Centers for Medicare & Medicaid Services (CMS) has added individual medical nutrition therapy (MNT) to the list of Medicare telehealth services.

CAUTION - What You Need to Know
CR4204, from which this article is taken, expands the list of Medicare telehealth services to include individual MNT (as represented by HCPCS codes G0270, 97802 and 97803); and adds registered dietitians and nutrition professionals to the list of practitioners eligible to furnish, and receive payment, for telehealth.

GO - What You Need to Do
Make sure that your billing staffs are aware of these changes in telehealth services.

Background
The use of a telecommunications system may substitute for a face-to-face, "hands on" encounter for consultation, office visits, individual psychotherapy, pharmacologic management, psychiatric diagnostic interview examination, and end-stage renal disease related services included in the monthly capitation
payment (except for one visit per month to examine the access site). In the calendar year 2006 Physician Fee Schedule-Final Rule (CMS-1502-FC), CMS expanded the list of Medicare telehealth services to include individual MNT as described by HCPCS codes G0270, 97802, and 97803. Therefore, effective January 1, 2006, the telehealth modifiers "GT" (via interactive audio and video telecommunications system) and modifier "GQ" (via asynchronous telecommunications system) are valid when billed with these HCPCS codes.

Additionally, since certified registered dietitians and nutrition professionals (as defined in 42 CFR, Section 410.134) are the only practitioners permitted by law to furnish MNT, registered dietitians and nutrition professionals have been added to the list of practitioners who may furnish and receive payment for a telehealth service.

Publication 100-02 (Medicare Benefit Policy Manual), Chapter 15, Sections 270.2 and 270.4, and Publication 100-04 (Medicare Claims Processing Manual), Chapter 12, Section 190, have been revised to implement this addition to the list of Medicare telehealth services.

Be aware, nonetheless, that this expansion to the list of Medicare telehealth services does not change the eligibility criteria, conditions of payment, payment or billing methodology applicable to Medicare telehealth services as set forth in these manuals. For example, originating sites must be located in either a non-MSA county or rural health professional shortage area, and can only include a physician's or practitioner's office, hospital, critical access hospital (CAH), rural health clinic, or federally qualified health center.

Further, you must use an interactive audio and video telecommunications system that permits real-time communication between the distant site physician, or practitioner, and the Medicare beneficiary, and as a condition of payment, the patient must be present and participating in the telehealth visit.

The only exception to this interactive telecommunications requirement is in the case of Federal telemedicine demonstration programs conducted in Alaska or Hawaii. In these circumstances, Medicare payment is permitted for telehealth services when asynchronous store-and-forward technology is used.

Finally, you should remember that if the distant site is a CAH that has elected Method II, and the physician or practitioner has reassigned his/her benefits to this CAH, it should bill its regular fiscal intermediary for the professional telehealth services provided, using any of the revenue codes 096x, 097x or 098x. All requirements for billing distant site telehealth services apply.

Additional Information
You can find more information about telehealth services by going to http://www.cms.hhs.gov/Transmittals/downloads/R790CP.pdf and http://www.cms.hhs.gov/Transmittals/downloads/R43BP.pdf on the CMS Web site. These Web addresses contain CR4204.

You might also want to look at the following manuals:

You can find these revised manual sections as attachments to CR4204. 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/apps/contacts/ on the CMS Web site.

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MREP Brochures Are Now Available

The Medicare Remit Easy Print (MREP) brochures are now available from the Medlearn Product Ordering Page which is available at http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=5. The MREP brochure is available in the Office Management Information section and reads as follows: Medicare Remit Easy Print (ICN #006740) (October 2005) (Brochure)

The brochure is also available for download from the Medlearn Web page through the Medlearn Products-Medlearn Publications list or it can be downloaded directly at http://www.cms.hhs.gov/MedlearnProducts/downloads/remit_easy_print.pdf. Please use these brochures when conducting provider training or other provider outreach opportunities, per JSM-05522. As a reminder, MREP version 1.6 will be available for download beginning January 17, 2006.

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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. In addition, the article was revised again on January 18, 2006, to reflect correct Web addresses to conform to the new CMS Web site. 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:

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/Transmittals/downloads/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/Medlearn MattersArticles/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//Transmittals/downloads/R39BP.pdf 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/apps/contacts/ on the CMS Web site.

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Non-Biodegradable Drug Delivery Implant Services

We have learned of some apparent confusion as to how to code and bill for these services, CPT codes

These procedures appear straightforward. If an implant is only inserted, bill the 11981 code. If an implant is only removed, with no new implant inserted, bill the 11982 code. If the old implant is not removed, but a new implant is inserted, do not bill the 11983 code, as this service was not done. To correctly bill the 11983 code, both the removal of the expended implant and the insertion of a new implant must be done.

The package inserts for these drug delivery devices state that the old, expended implant must be removed, and coverage is dependent on the instructions in the manufacturer's insert being followed.

Each of the CIGNA states - Idaho, North Carolina and Tennessee - have a Local Coverage Determination covering use of LH/RH Analogues for treatment of prostate cancer. Please refer to the particular policy applicable to your location for more information.. These can be accessed at http://www.cignagovernmentservices.com, click on Part B, then on Medical Review, then find the state where you practice, and scroll to the LH/RH Analogue policy.

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Nursing Facility Services (Codes 99304-99318)

Provider Types Affected
Physicians and non-physician practitioners (NPPs) and physicians

Provider Action Needed

STOP - Impact to You
In both the skilled nursing facility (SNF) and nursing facility (NF) settings, qualified non-physician practitioners (NPP), i.e., a nurse practitioner (NP), physician assistant (PA), or a clinical nurse specialist (CNS), may provide certain defined beneficiary visits prior to, and after, the physician performs the initial visit. In addition, in the NF setting, when certain requirements are met, an NPP not employed by the NF may also perform the initial visit itself.

In addition, effective January 1, 2006, Current Procedural Terminology (CPT) codes (99301-99303) for reporting the initial nursing facility care and subsequent nursing facility care (99311-99313) are deleted, and are replaced by new codes (see below).

CAUTION - What You Need to Know
CR4246, from which this article is taken, conveys that, in both the SNF and NF settings, a qualified NPP may provide covered medically necessary visits prior to and after the physician performs the initial visit. Qualified NPPs may provide federally mandated visits (after the initial visit by the physician and as permitted under the Long Term Care Regulations). Further, it provides that, when specific requirements are met in the NF setting, an NPP who is not employed by the NF and who is permitted by State law may perform the beneficiary's initial visit.

It also clarifies the distinction between required (i.e., federally mandated) and medically necessary visits, "incident to" services, prolonged services, split/shared E/M services, gang visits, and the SNF/NF discharge day management services.

The CR revises the Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.13, with new CPT codes for reporting visits in the skilled nursing facility (SNF) or nursing facility (NF)settings: Initial Nursing Facility Care (codes 99304-99306); Subsequent Nursing Facility Care (codes 99307-99310) and Other Nursing Facility Services (CPT code 99318 for an annual assessment).

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

Background
To begin this discussion, remember that the Medicare Statute is the basis for distinguishing between delegation of physician visits and tasks in skilled nursing facilities (SNF - Place of Service Code 31, for patients in a Part A SNF stay), and nursing facilities (NF - Place of Service Code 32, for patients who do not have Part A SNF benefits, patients who are in a Nursing Facility or in a non-covered SNF stay).

To the point, Section 1819 (b) (6) (A) of the Social Security Act (the Act) governs SNFs while section 1919 (b) (6) (A) of the Act governs NFs. (For further information, refer to Medlearn Matters article number SE0418 at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0418.pdf on the CMS Web site.

Payment Policy for E/M Visits
CR4246 clarifies payment policy (effective January 1, 2006) for evaluation and management (E/M) visits by physicians and qualified NPPs (i.e., nurse practitioners [NP], physician assistants [PA], or clinical nurse specialists [CNS]) in SNF and NF settings:

Delegation of the Initial Visit
First, CR4246 clarifies the policy for the delegation of the initial visit in the NF setting. Remember that the initial visit in both SNFs and NFs is defined (per the Survey and Certification memorandum (S&C-04-08), dated November 13, 2003) as the initial comprehensive assessment visit during which the physician completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the nursing facility resident.

It must occur no later than 30 days after admission. In the SNF setting, the physician must perform this initial visit. In the NF setting, a qualified NPP, not employed by the NF, may perform the initial visit when permitted by state law, and when (as in all Evaluation & Management visits) the NPP meets all Medicare and physician collaboration and supervision requirements, and the service falls within the scope of practice and licensure for the state where the service occurs. (Physician assistants, additionally, must meet the general physician supervision requirement as well as employer billing requirements.)

After the Initial Visit
In the SNF setting, after the initial visit by the physician, physicians may delegate alternating federally mandated physician visits to qualified NPPs (whether they are employed or not by the SNF).

Qualified NPPs in the NF setting, who are not employed by the NF, may, at the option of the state, perform federally mandated physician visits including the initial visit.

Physician Delegation of Medically Necessary Visits to Qualified NPPs
Also, CR4246 clarifies physician delegation of medically necessary visits to qualified NPPs in the SNF and NF settings. In both of these settings, if all the requirements for collaboration, physician supervision, licensure, and billing are met, qualified NPPs may perform medically necessary E/M visits (those visits necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member) prior to, and after, the physician's initial visit.

General physician supervision and employer billing requirements shall be met for PA services. The PA must also meet the state scope of practice and licensure requirements where the E/M visit is performed.

Medically Necessary E/M Visits
Medically necessary E/M visits are payable under the physician fee schedule under Medicare Part B.

Note: The federally mandated E/M visit may serve also as a medically necessary E/M visit if the situation arises (i.e., the patient has health problems that need attention on the day the scheduled mandated physician E/M visit occurs). The physician or qualified NPP shall report only one E/M visit.

New Code Changes to Medicare Claims Processing Manual
CR4246 also revises the Medicare Claims Processing Manual, Pub.100-04, Chapter 12, Section 30.6.13, with new code changes made by the American Medical Association (AMA) Current Procedural Terminology (CPT) 2006 for services reported in a nursing facility.

Beginning January 1, 2006, CPT codes for reporting the initial nursing facility care and subsequent nursing facility care are deleted and replaced by new ones. The new codes that physicians and qualified NPPs should use for SNF and NF visits are as follows:

CPT Codes 99304-99306 - Initial Nursing Facility Care
As of January 1, 2006, CPT codes 99304-99306 (Initial Nursing Facility Care, per day) shall be used to report the initial visit. CPT codes 99301-99303 are deleted after 12/31/05.

Only a physician may report 99304-99306 for an initial visit performed in an SNF or NF except for (as explained above) those performed by a qualified NPP in the NF setting who is not employed by the facility and when state law permits.

A readmission to a SNF or NF has the same payment policy requirements as an initial admission in both settings.

Codes 99307-99310 - Subsequent Nursing Facility Care
Codes 99307-99310 (Subsequent Nursing Facility Care, per day) shall be used to report federally mandated physician visits and other medically necessary visits.

These codes are effective January 1, 2006, and replace codes 99311-99313 which are deleted after 12/31/05.

Medicare will pay for federally mandated visits that monitor and evaluate residents at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. You shall also use these codes to report medically necessary E/M visits even if they are provided prior to the initial visit by the physician.

You shall also use these codes to report medically complex care in an SNF upon discharge from an acute care visit, again even if the visits are provided prior to the physician's initial visit.

Codes 99315-99316 - Discharge Day Management Service
Codes 99315-99316 (Discharge Day Management Service) shall be used to report the physician or NPP's face-to-face visit with the patient to meet the SNF/NF discharge day management service requirement. You shall report the visit as the actual date of the visit even if the patient is discharged from the facility on a different calendar date.

These codes may be used (depending on the code requirement) to report a death pronouncement of a patient who has expired, but only if the physician or qualified NPP personally performed the death pronouncement.

Code 99318 - Other Nursing Facility Service
Code 99318 (Other Nursing Facility Service) shall be used to report an annual nursing facility assessment visit on the required schedule of visits if an annual assessment is performed. For Medicare Part B payment policy, an annual assessment visit code shall substitute as meeting (but not be in addition to) one of the federally mandated physician visits if the code requirements for CPT code 99318 are fully met and in lieu of reporting a subsequent nursing facility care code (codes 99307-99310). This new code does not represent a new benefit service for Medicare Part B physician services.

Other Important Information to Remember

Other Visit Information

Additional Information
For further reference on Survey and Certification issues applicable to the SNF/NF settings refer to Medlearn Matters article number SE0418 at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0418.pdf on the CMS Web site.

To view the official instruction (CR4246) issued to your carrier or fiscal intermediary, please visit
http://www.cms.hhs.gov/Transmittals/downloads/R808CP.pdf on the CMS Web site. You might also want to look at the Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, Section 30.6.13 (Nursing Facility Services (Codes 99304-99318), which you can find as an attachment to CR4246.

Questions pertaining to writing orders or certification and recertification issues in the SNF and NF settings shall be addressed to the appropriate State Survey and Certification Agency departments for clarification.

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/apps/contacts/ on the CMS Web site.

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Revision to the Medicare Claims Processing Manual Regarding Accessing Information on Use of the "AQ" Modifier

Provider Types Affected
Physicians and providers billing Medicare carriers for services provided in a Health Professional Shortage Area (HPSA)

Provider Action Needed

STOP - Impact to You
This article is based on Change Request (CR) 4182, which revises the Medicare Claims Processing Manual (Chapter 12, Sections 90.4.1.1 and 90.4.2).

CAUTION - What You Need to Know
CR4182 instructs carriers and providers to visit the Health Professional Shortage Areas (HPSAs) and Physician Scarcity Areas (PSAs) bonus payments Web pages on the Centers for Medicare & Medicaid Services (CMS) Web site for instructions on determining a census tract when self designating through the use of the "AQ" modifier.

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

Background
CMS is removing instructions on how to determine census tracts when selfdesignating through the use of the "AQ" modifier (physician providing a service in a HPSA) from the Medicare Claims Processing Manual (Pub. 100-04) and placing the instructions on the HPSAs and PSAs specialty Web pages. This is being done as a result of recent inquiries CMS has received and because of the volatility of data on other government Web sites that CMS depends upon to determine census tract information.

Beginning with 2005, an automated file of designations is updated on an annual basis and will be effective for services rendered with dates of service on or after January 1 of each calendar year beginning January 1, 2005, through December 31, 2005.

Physicians are allowed to self-designate throughout the year for newly designated HPSAs and HPSAs not included in the automated file based on the date of the data run used to create the file. To determine whether an "AQ" modifier is needed, physicians must review the information (referred to as "Instructions on Using the HPSA/PSA Specialty Page") provided on the CMS Web site for HPSA designations to determine if the location where they render services is, indeed, within a HPSA bonus area. The specific CMS Web site for this information is at http://new.cms.hhs.gov/HPSAPSAPhysicianBonuses.

Implementation
The implementation date for this instruction is February 6, 2006.

Additional Information
For complete details, please see the official instruction issued to your carrier http://www.cms.hhs.gov/Transmittals/downloads/R807CP.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/apps/contacts/ on the CMS Web site.

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Rituximab LCD-Revision

The LCD for Rituximab (Rituxan) has been revised for all Part B states. ICD-9's 714.0 and 714.2 and rheumatoid arthritis was added as a covered diagnosis. Please refer to the LCD for your specific state to view the policy in its entirety.

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Sentinel Node Biopsy-LCD Revision

There has been some confusion over billing for this procedure recently. This article is to clarify current correct billing procedure.

In the usual scenario, a nuclear medicine Radiologist may inject the radionuclide, followed by hand-held scintigraphy by the surgeon, and injection of isosulfan blue dye by the surgeon. In this scenario, the Radiologist would bill for CPT 38792, injection procedure, lymphangiography for identification of sentinel node. The surgeon would also bill a CPT 38792, but would append a - 77 modifier, to indicate a "repeat procedure by another physician." Then the surgeon would also bill for the appropriate CPT code(s) for the biopsy or excision of the node.

If the nuclear medicine physician also performed scintigraphy in addition to the injection of radionuclide, then that physician could bill CPT 78195, Lymphatics and lymph node imaging. The surgeon could still bill for the injection of the Isosulfan blue dye.

It is imperative for the physician performing the initial service, the radionuclide injection, to submit a claim for 38792 first, and the surgeon to submit the second claim for 38792 with the - 77 modifier appended. If the claim with the - 77 is submitted first, it will deny as having no prior claim, since it is to denote a "repeat" claim.

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Botulinum Toxin-LCD Revision

LCD for Botulinum Toxin has been revised by adding ICD-9 596.59 as medically necessary. To view the policy for your particular state, please access the link below: http://www.cignagovernmentservices.com/partb/index.html

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Virtual Colonoscopy-LCD Revision

The LCD for Virtual Colonoscopy has been revised for Tennessee, Idaho, and North Carolina. To view the policy in its entirety for your particular state, please refer to CIGNA Government Services Web site at http://www.cignagovernmentservices.com.

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Extracorporeal Shock Wave Therapy for Musculoskeletal Problems-LCD Revision

LCD for Extracorporeal Shock Wave Therapy for Musculoskeletal Problems has been revised for all Part B carriers. To access your state specific policy, please refer to the following link: http://www.cignagovernmentservices.com/partb/index.html

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Stem Cell Transplantation

Note: This article was revised on January 10, 2006, to reflect changes in the revised CR4173. The correct effective date is November 28, 2005. The article had incorrectly stated the effective date as December 28, 2005. The transmittal numbers were also changed from 43 and 766 to 45 and 776 respectively. All other information remains the same.

Provider Types Affected
Physicians, suppliers, and providers billing Medicare carriers and/or fiscal intermediaries (FIs) for services related to stem cell transplantation

Provider Action Needed

STOP - Impact to You
This article is based on Change Request (CR) 4173, which includes clarifying language specific to the current national coverage policy on stem cell transplantation.

CAUTION - What You Need to Know
CR4173 clarifies that stem cell transplantation and high-dose chemotherapy are both integral to the course of treatment and are covered as a single entity.

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

Background
The Centers for Medicare & Medicaid Services (CMS) has a coverage policy for stem cell transplantation, and the Medicare National Coverage Determination (NCD) Manual (Publication 100-03, Section 110.8) states that stem cell transplantation is a process in which stem cells are harvested from either a patient's or donor's bone marrow or peripheral blood for intravenous infusion.

Autologous stem cell transplants (AuSCT) must be used to effect hematopoietic reconstitution following severely myelotoxic doses of chemotherapy (High Dose Chemotherapy (HDCT)) and/or radiotherapy used to treat various malignancies. Allogeneic stem cell transplantation is a procedure in which a portion of a healthy donor's stem cell or bone marrow is obtained and prepared for intravenous infusion and may also be used to restore function.

CR4173 clarifies existing NCD policy language and corresponding claims processing language as follows:
"Bone marrow and peripheral blood stem cell transplantation is a process which includes mobilization, harvesting, and transplant of bone marrow or peripheral blood stem cells and the administration of high dose chemotherapy or radiotherapy prior to the actual transplant. When bone marrow or peripheral blood stem cell transplantation is covered, all necessary steps are included in coverage. When bone marrow or
peripheral blood stem cell transplantation is non-covered, none of the steps are covered."

Note: There is no change to existing CMS coverage policy or claims processing instructions.

Implementation
The implementation date for the instruction is January 3, 2006, and will be effective for dates of service on or after November 28, 2005.

Additional Information
For complete details, please see the official instruction issued to your carrier/intermediary regarding this change. Those instructions are in two parts. The first part is the actual change to the Medicare National Coverage Determinations (NCD) Manual, which includes the actual policy language regarding stem cell transplantation. That part may be viewed at http://new.cms.hhs.gov/transmittals/downloads/R45NCD.pdf on the CMS Web site.

The second part contains the changes to the Medicare Claims Processing Manual. Those changes are available at http://new.cms.hhs.gov/transmittals/downloads/R766CP.pdf on the CMS Web site.

If you have questions, please contact your carrier or FI 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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Surrogate Unique Physician Identification Numbers (UPINs) Reported on Independent Diagnostic Testing Facilities (IDTFs) Claims

Provider Types Affected
Independent Diagnostic Testing Facilities (IDTFs) billing Medicare carriers for services

Provider Action Needed

STOP - Impact to You
This article is based on Change Request (CR) 4096, which directs Medicare carriers to reject IDTF claims submitted with Surrogate Unique Physician Identification Number (UPIN) "OTH000," effective for claims with dates of service on or after January 3, 2006.

CAUTION - What You Need to Know
The Centers for Medicare & Medicaid Services (CMS) will no longer accept the Surrogate UPINs (e.g., OTH000, RES000, VAD000, PHS000, and RET000) on claims submitted by a supplier enrolled as an IDTF.

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

Background
IDTFs have been allowed to bill for diagnostic services with the use of Surrogate UPINs.

To help ensure future program integrity, CMS will no longer accept the Surrogate UPINs on IDTF claims.

In addition, effective for dates of service of January 3, 2006, and later:

Implementation
The implementation date for CR4096 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://www.cms.hhs.gov/Transmittals/downloads/R769CP.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/apps/contacts/ on the CMS Web site.

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Therapy Caps To Be Effective January 1, 2006

Note: This article was revised on January 12, 2006, to clarify that the limits do not apply to services provided in outpatient hospitals.

Provider Types Affected
Therapists and providers who bill Medicare carriers or fiscal intermediaries (FIs) for therapy services for their patients

Provider Action Needed

STOP - Impact to You
Beginning January 1, 2006, financial limitation of therapy services (therapy caps) will be implemented. The dollar amount for the 2006 limitation on physical therapy and speechlanguage pathology services from January 1, 2006, through December 31, 2006, will be $1,740.00. The limitation on occupational therapy services is also $1,740.00. The limits do not apply to outpatient Part B therapy services in outpatient hospital or hospital emergency room settings.

CAUTION - What You Need to Know
Please be aware of the January 1, 2006, therapy services caps.

GO - What You Need to Do
Remember that services must meet the Medicare policies in the Medicare Benefit Policy Manual (publication 100-02), Chapter 15, Sections 220and 230. This manual is available at http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage on the CMS Web site.

Background
Financial limitations on therapy services (therapy caps) are currently described in the Medicare Claims Processing Manual (Pub. 100-04), chapter 5, section 10.2, which is available at http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage on the CMS Web site. The dollar amount for the limitations in 2006 is based on the Medicare Economic Index that is published in the final rule for the Medicare Physician Fee Schedule in November, 2005.

Section 4541(a)(2) of the Balanced Budget Act (BBA) (P.L. 105-33) of 1997, required payment under a prospective payment system for outpatient rehabilitation services (physical therapy, including outpatient speech-language pathology, and occupational therapy). Section 4541(c) of the BBA required the application of a financial limitation to all outpatient rehabilitation services (except outpatient departments of hospitals). These limits were in effect in 1999, but were removed by law in 2000-2002. The statutory limits went back into effect September 1, 2003. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 re-enacted the moratorium and extended it until December 31, 2005.

Additional Information
There is additional information located on the Rehabilitation Therapy Information Resource for Medicare Web site located at http://new.cms.hhs.gov/TherapyServices/01_overview.asp#TopOfPage on the CMS Web site.

The official instruction issued to your FI or carrier regarding this change may be found by going to http://www.cms.hhs.gov/transmittals/downloads/R759CP.pdf on the CMS Web site.

Please refer to your local FI or carrier if you have any questions. To find the toll free phone number, go to http://www.cms.hhs.gov/apps/contacts/ on the CMS Web site.

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ANNOUNCEMENT: Second Participation Enrollment Period for 2006

On February 8, 2006, the Deficit Reduction Act of 2005 was enacted. This new legislation changed the 2006 Medicare Physician Fee Schedule (MPFS) rate from-4.4% to a 0% update. As a result, CMS is offering a second enrollment period for providers to reconsider their election decisions in light of the revised 0% update. The second enrollment period will run for 45 days, commencing on February 15, 2006, and ending on March 31, 2006. The effective date for any participation changes made during this second enrollment period will be retroactive to January 1, 2006.

You may access the Participation Agreement at http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp. (Form CMS 460-10/05)

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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 20, 2006, to show the effective and implementation dates (see
above) as January 3, 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 3, 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 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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Healthcare Provider Taxonomy Codes (HPTC) Update

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 Part A and Part B services.

Provider Action Needed

STOP - Impact to You
This article is based on Change Request (CR) 4254 which informs Medicare contractors (carriers, durable medical equipment regional carriers (DMERCs), fiscal intermediaries (FIs) and regional home health intermediaries (RHHIs)) to obtain the most recent Healthcare Provider Taxonomy Codes (HPTC) and use it to update their internal HPTC tables.

CAUTION - What You Need to Know
HIPAA requires that submitted data, which is part of a named code set, be valid data from that code set. Claims accepted with invalid data are non-compliant. Because health care provider taxonomy is a named code set in the 837 Institutional and Professional implementation guides, Medicare must validate the inbound taxonomy codes against their internal HPTC tables.

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

Background
The Healthcare Provider Taxonomy Codes (HPTC) set is an external non-medical data code set designed for use in classifying health care providers according to provider type or practitioner specialty in an electronic environment (specifically within the American National Standards Institute (ANSI) Accredited Standards Committee (ASC) health care claim transaction).

HPTCs are scheduled for update twice per year (April and October). The HPTC list is available from the Washington Publishing Company at http://www.wpc-edi.com/codes/taxonomy in two forms:

Note: Claims received with invalid data are non-compliant with HIPAA and will not be processed by Medicare.

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/intermediary regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R815CP.pdf on the CMS Web site.

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/apps/contacts/ 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 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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2006 Medicare Participating Physicians and Suppliers Directory (MEDPARD)

In the continued effort to provide Medicare beneficiaries with information to assist them in making health care choices, the Centers for Medicare & Medicaid Services has a Participating Physicians Directory. The directory contains the names, addresses, telephone numbers and specialties of Medicare participating physicians, practitioners, and suppliers who have agreed to accept assignment on all Medicare covered services. In addition, the directory contains information about the physician's medical school attended, year of graduation, any board certification(s) in a medical specialty, gender, and hospitals at which the physician has admitting privileges. The directory is updated monthly and includes any foreign language capabilities of the physician. The directory can be found on the Centers for Medicare & Medicaid Services Web site at www.medicare.gov, and the CIGNA Government Services Part B Web site at http://www.cignagovernmentservices.com/medicare_dynamic/medpard/index.html. The directory is available at no cost to the public.

Any questions regarding the MEDPARD should be addressed to CIGNA Government Services' Customer Service Units:

• Idaho - 866.502.9051
• North Carolina - 866.238.9651
• Tennessee - 866.502.9056

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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. 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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Comprehensive Error Rate Testing (CERT) CERT Documentation Contractor (CDC) Updated Call Center Operations Process

The CDC Call Center Customer Service Representatives (CSR's) place calls to providers prior to sending letters requesting medical records in order to verify phone, fax numbers and mailing addresses. Previously the CDC Call Center Operations Process included a second call 15 days after the first call. Many providers have complained saying this time period is too brief. Therefore, in order to reduce the strain on provider offices, the 15 day call has been changed to a call on day 30. CMS (Centers for Medicare & Medicaid Services) agreed to this change.

New CERT CDC Proposed Call Center Ops Process

Day 0: Initial Call/Letter
Day 30: Second Call/Letter
Day 50: Third Call
Day 60: Third Letter
Day 75: OIG Letter
Past Day 75: Follow up calls as required
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New 276/277 Edits for NPI

When an NPI number is submitted in a 276 4010A1 Claim Status file, editing will occur in the following loops. The qualifier XX is required in NM108 and a valid 10 digit NPI must be present in NM109.

Loop Element Segment  
2100B NM1 08 Identifier Qualifier
2100B NM1 09 NPI Identifier
2100C NM1 08 Identifier Qualifier
2100C NM1 09 NPI Identifier

Please note you must also send the Medicare legacy provider number in addition to the NPI number. To submit the Medicare legacy provider number you must send a second Service Provider loop.

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Weekly Physician Open Q&A Conference Call For The Medicare Part D Prescription Drug Benefit

Reminder: Please join CMS officials every Tuesday at 2pm EST for the Physician/Part D implementation Open Q&A conference call. 1.800.619.2457 Pass code: RBDML. This call is intended for physicians and other prescribers, we have similar weekly conference calls for pharmacies and long term care.

Medicare prescription drug coverage is here. Retail Pharmacies filled several hundred thousand Medicare prescriptions on January 1st alone. CMS staff and the PDPs have been working around the clock to fix problems and refine processes. Pharmacists have become "Part D experts" and have made the benefit work despite the inevitable challenges associated with a the first few days of a huge new program. The Centers for Medicare & Medicaid Service recognizes the important role physicians and other health care professionals have played in helping people learn about the new benefit and we appreciate your efforts this fall to help us raise awareness and educate people with Medicare about this new program.

To help you care for your patients and easily obtain information about Part D formularies and whether a specific drug is covered by a Part D plan, Epocrates, Inc. has provided Part D formulary information through their free Epocrates Rx® software, which is available through their Web-based system or hand-held PDA system. This is online and operati