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May 2006 Part B Medicare Bulletin

Posted May 2, 2006

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Instructions for Provider Notification Regarding Streamlined Drug Coverage Materials for Health Care Professionals, a New Fact Sheet and Script for Recent Audio Conference

Provider Types Affected
Providers, physicians, and suppliers and their staff who prescribe medications for Medicare patients

Key Points
The Centers for Medicare & Medicaid Services (CMS) has developed three new products as part of the Medicare Prescription Drug Coverage (Part D) campaign for health care professionals:

Consolidated List of Links
A consolidated list of links to resources for prescribers is located at http://www.cms.hhs.gov/center/provider.asp on the CMS Web site. At this Web page, offices can get access to direct telephone numbers to a Medicare drug plan's coverage determination staff, as well as to obtain model forms that will help speed this process. Educational information for Fee-For-Service (FFS) providers is always available through our Medicare Learning Network drug coverage page at http://www.cms.hhs.gov/MedlearnProducts/23_DrugCoverage.asp on the CMS Web site.

Transition Policy Fact Sheet
A new fact sheet regarding the new transition policy, as well as the exceptions and appeals process for Medicare Prescription Drug Coverage, is available for use in prescriber offices. This resource fact sheet provides ready links to tools that will streamline the prescribing process under the new coverage.

CMS continues to work with groups representing physicians, pharmacists, patients, and Part D plans to simplify and standardize the information that physicians need to provide to plans.

The fact sheet is at http://www.cms.hhs.gov/MedlearnProducts/downloads/Part_D_Resource_Factsheet.pdf on the CMS Web site.

An Important Message for Providers Regarding Medicare Part D from CMS Administrator Dr. Mark McClellan Dr. McClellan's message to providers describes the steps CMS is taking to implement the new Medicare prescription drug coverage. Dr. McClellan also discusses helpful resources for providers. Streaming video of this message is available at http://media.cms.hhs.gov/cms/McClellanPartDProvider.wmv on the CMS Web site.

Phone Conference Training Session
A PowerPoint presentation and audio replay of a recent phone conference training session is available, entitled "Working with Plan Formularies: Transition Supplies, Prior Authorization, Quantity Limits, Step Therapy, and Exceptions." This training session is geared towards guiding office staff through the exceptions process. These materials are located at http://media.cms.hhs.gov/cms/partner03022006.wma on the CMS Web site.

Other Special Edition Articles
Other special edition articles regarding the prescription drug program include, but are not limited to the following:

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Botulinum Toxin LCD - Revision

The LCD for Botulinum Toxin has been revised for all Part B states. To view the policy in its entirety for your particular state, please refer to the CIGNA Government Services Web site at:

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Instructions for Provider Notification Regarding Streamlined Drug Coverage Materials for Health Care Professionals, a New Fact Sheet and Script for Recent Audio Conference

NEW! Visit http://www.cms.hhs.gov/center/provider.asp and scroll down to "Part D Tools for Health Care Professionals" for a comprehensive list of links to agency-wide resources for providers on Medicare Rx coverage. These resources can help providers and office staff access direct phone numbers to a Medicare drug plan's coverage determination staff, as well as obtain model forms that will help speed the process.

Additionally, a new fact sheet, as well as other educational products for the FFS community, is now available at http://www.cms.hhs.gov/medlearn/drugcoverage.asp on the CMS Web site.

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Therapy Caps To Be Effective January 1, 2006

Note: This article was revised on March 3, 2006, to include clarifying language (bold, italicized print) in the STOP section under "Provider Action Needed".

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 speech-language pathology services from January 1, 2006, through December 31, 2006, will be $1,740.00 for both services combined. The limitation on occupational therapy services separately is also $1,740.00. The limits do not apply to outpatient Part B therapy services in outpatient hospital or hospital emergency room settings or to services that meet Medicare criteria for exceptions.

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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2006 Oncology Demonstration Project - Inclusion of Gynecological Oncology

Note: This article was revised on March 13, 2006, to reflect revisions made to CR4347, which was reissued on March 10 as Transmittal 41. CR4347 was revised because the specialty code for medical oncology should have shown as 90 (not 83) and for hematology/oncology should have shown as 83 (not 90).

Provider Types Affected
Gynecological oncologists who bill Medicare for office-based oncological services

What You Need to Know
CR4347 (from which this article was taken) adds gynecological oncologists to the list of physician specialties qualified to participate in the 2006 Oncology Demonstration Project.

Background
CMS initiated a one-year oncology demonstration project for 2006 designed to identify and assess particular oncology office practice-based services that improve outcomes in the Medicare population (as stated in CR4219, Transmittal 36, 2006 Oncology Demonstration Project, issued on December 30, 2005).

That CR included the physician specialties of hematology (82), medical oncology (90), and hematology/oncology (83), as qualifying under the 2006 oncology demonstration.

In CR4347, CMS adds the specialty of gynecological oncology (98) to this list. Therefore, unless otherwise noted, the policy, instructions, messages, and business requirements in CR4219 apply equally to gynecological oncology. Your carriers will not search their records for claims previously submitted for gynecological oncology services in 2006 that were denied payment under the oncology demonstration. They will, however, adjust claims that are brought to their attention.

Additional Information
You can find more information about the inclusion of gynecological oncologists in the 2006 Oncology Demonstration Project by going to http://www.cms.hhs.gov/Transmittals/downloads/R41DEMO.pdf on the CMS Web site.

In addition, you can learn more about the 2006 Oncology Demonstration Project itself by reading MedLearn Matters article MM4219. This article is at http://www.cms.hhs.gov/MedLearnMattersArticles/downloads/MM4219.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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NPI Information for Provider

NPI Tip
When applying for your NPI, CMS urges you to include your legacy identifiers, not only for Medicare but for all payors. If reporting a Medicaid number, include the associated State name. This information is critical for payors in the development of crosswalks to aid in the transition to the NPI.

New Educational Products
CMS has released three new educational products on the National Provider Identifer (NPI): Suitable for All Health Care Providers A Subparts Fact Sheet that contains high-level information on Medicare's guidance on subpart designation. Although the guidance is geared toward Medicare organization providers, non-Medicare organization providers may find it helpful.

An Electronic File Interchange (EFI) Fact Sheet that contains basic information and links to helpful resources that will prepare providers and their staff for the release of the EFI system. This information is essential for organizations that wish to submit electronic files for bulk enumeration, and may be of interest to any health care provider for whom an organization will be submitting NPI application data.

Suitable for Medicare Providers
A MLN Matters Article (SE0608) that takes a detailed look at Medicare's guidance on subpart designation and the impact on Medicare providers.

Visit the Educational Resources link at http://www.cms.hhs.gov/NationalProvIdentStand/ to view these new products, as well as existing products such as: four MLN Matters articles, two fact sheets, and the NPI Viewlet.

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

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Coverage and Billing for Ultrasound Stimulation for Nonunion Fracture Healing

Provider Types Affected
Physicians, suppliers, and providers billing Medicare fiscal intermediaries (FIs), including regional home health intermediaries (RHHIs) for Ultrasound Stimulation for Nonunion Fracture Healing.

Provider Action Needed

STOP - Impact to You
This article is based on Change Request (CR) 4085, which supplements CR3836 - Coverage and Billing Requirements for Ultrasound Stimulation for Nonunion Fracture Healing.

CAUTION - What You Need to Know
Effective for services performed on or after April 27, 2005, ultrasonic osteogenic stimulators are covered as medically reasonable and necessary for the treatment of nonunion bone fractures prior to surgery. Please note that there have been changes made to CR3836 business requirements.

These changes are discussed in the Additional Information section of this article. All other material and information remain the same as in the original CR3836.

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) determined that evidence is adequate to conclude that it is reasonable and necessary to use non-invasive ultrasound stimulation for the treatment of nonunion bone fractures prior to surgical intervention.

Therefore, effective for services performed on or after April 27, 2005, ultrasonic osteogenic stimulators are covered as medically reasonable and necessary for the treatment of nonunion bone fractures prior to surgery.

Coverage and Billing for Ultrasound Stimulation for Nonunion Fracture Healing
An ultrasonic osteogenic stimulator is a non-invasive device that emits low intensity, pulsed ultrasound. This device is applied to the surface of the skin at the fracture site and ultrasound waves are emitted via a conductive coupling gel to stimulate fracture healing.

Ultrasonic osteogenic stimulators are not to be used concurrently with other non-invasive osteogenic devices.

Coverage Requirements
Effective for dates of service on and after April 27, 2005, ultrasonic osteogenic stimulators are covered as medically reasonable and necessary for the treatment of nonunion bone fractures prior to surgical intervention. In demonstrating nonunion fractures, CMS expects a minimum of two sets of radiographs, obtained prior to starting treatment with the osteogenic stimulator, separated by a minimum of 90 days.

Each radiograph set must include multiple views of the fracture site, accompanied with a written interpretation by a physician stating that there has been no clinically significant evidence of fracture healing between the two sets of radiographs.

For further coverage information, please refer to the Medicare National Coverage Determinations Manual (Pub.100-03), Chapter 1, Section 150.2, which can be found at http://www.cms.hhs.gov/manuals/downloads/ncd103c1_Part2.pdf on the CMS Web site.

Note: Hospitals should note that there are no covered services for Ultrasonic Osteogenic Stimulation for which hospitals can be paid by the FI. Thus, hospitals can not bill for Ultrasonic Osteogenic Stimulators.

Bill Types When Billing RHHIs
When billed to RHHIs, Ultrasonic Osteogenic Stimulators must be billed on type of bill 32X, 33X, 34X, and is payable under the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule.

Note: Ultrasonic Osteogenic Stimulators must be in the patient's home health plan of care if billed on TOBs 32X or 33X.

Billing Instructions When Billing Medicare Carriers
Effective for dates of service on or after April 27, 2005, carriers will allow payment for ultrasonic osteogenic stimulators with the following current procedural terminology (CPT) code:

Billing Instructions for Durable Medical Equipment Regional Carriers (DMERCs) and Regional Home Health Intermediaries (RHHIs)

Effective for dates of service on or after April 27, 2005:

Note: Medicare carriers, FIs, and RHHIs will adjust claims with dates of service on and after April 27, 2005, if brought to their attention.

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

Additional Information
Some of the differences between CR3836 and the new CR4085 include the following:

For complete details, please see the official instruction issued to your carrier/DMERC/FI/RHHI regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R816CP.pdf on the CMS Web site.

If you have any questions, please contact your carrier/DMERC/FI/RHHI 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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Patient Choice Guaranteed

AdvanceMed, the Program Safeguard Contractor for the states of TN, NC, AR, LA, and OK, has recently become aware that discharge planners in some facilities limit a beneficiary's choice of skilled nursing, home health, etc., in their efforts to steer patients toward providers with whom the facility has a financial relationship. Please be advised that this is inappropriate and against federal law.

Sec. 1802. [42 U.S.C. 1395a] of the Social Security Act seeks to ensure that free choice is guaranteed to all Medicare patients:

  1. Basic freedom of choice —Any individual entitled to insurance benefits [i.e., Medicare] under this title may obtain health services from any institution, agency, or person qualified to participate under this title if such institution, agency, or person undertakes to provide him such services.

Further, Sec. 1861(ee)(2) of the Act, defines discharge planning as including an evaluation of need and availability of services through individuals and entities that participate in the program and that serve the area in which the patient resides, and requires facilities to disclose any identified providers with whom the facility has a financial relationship. (Note that instructions differ for Medicare+Choice.)

In accordance with Medicare guidelines, please ensure that discharge-planning procedures in your facility respect the Medicare beneficiary's right to choice.

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2006 Standard Medicare Prescription Drug Coverage: Understanding Costs to Beneficiaries- The Twelfth in the Medlearn Matters Series on Drug Plans

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

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

This penalty consists of an additional 1% of the base premium for every month the person went without coverage, and is levied as long as the person is enrolled in a Medicare drug plan.

General Information
One of the issues that may be most important for your patients involves what Medicare prescription drug coverage means to them in terms of cost. This article focuses on the out-of-pocket expenses that your patients will incur under this new program and highlights the costs covered by a standard plan.

Actual costs of the specific Medicare Prescription Drug Plans and the Medicare Advantage Plans or other Medicare Health Plans in each area are available in the "Medicare & You 2006" handbook and at http://www.medicare.gov on the Web site.

Costs Covered by a Standard Plan
Costs for your patients who join a Medicare drug plan will vary depending on their financial situation and which Medicare drug plan they join. All Medicare drug plans will offer at least the standard level of coverage described below.

Medicare drug plans may design their plans differently as long as what their plan offers is, on average, at least as good as the standard coverage. Some plans may offer more coverage for higher premiums.

Patient costs under standard Medicare drug coverage as defined by the MMA for 2006 will include the following:

Individuals with standard coverage will pay the full cost of their prescriptions for drug spending between $2,250 and up to their true out-of-pocket limit of $3,600.

However, plan enrollees will still be able to obtain their plan's discounted price for prescription drugs in this coverage gap.

Alternate Coverage
Plans are able to offer alternative coverage structures. For example, a plan can offer a deductible lower than $250, or use tiered copayments rather than coinsurance - provided that the alternative coverage structure meets certain tests of actuarial equivalence.

Also, plans may offer additional drug coverage that supplements the standard coverage. Medicare payments to plans do not subsidize such supplemental coverage.

Costs for Patients With Medicare and Full Medicaid Benefits
Under Part D, starting in 2006, Medicare will provide primary drug coverage for individuals who are dually eligible for Medicare and Medicaid. Dually eligible individuals who earn incomes up to 100% of the federal poverty level will have Medicare prescription drug coverage with no deductibles, no premiums, nominal copays, and no coverage gap.

Beneficiaries who do not qualify for Medicaid, but whose incomes are below 150 percent of poverty and who meet an asset test, will qualify for extra help paying for Medicare prescription drug coverage. Beneficiaries who qualify for extra help can join a Medicare drug plan with full or partial coverage for premiums and cost sharing and no coverage gap.

Specific Information on Out-of-Pocket Expenses Medicare Drug Plan Premiums
Medicare drug plan monthly premiums vary, depending on the plan; however:

True Out-Of-Pocket Costs
The cost to beneficiaries with Medicare for Medicare prescription drug coverage over and above the monthly premium is often referred to as "true out-of-pocket expenses" or TrOOP.

The TrOOP represents the amount a beneficiary must spend on Part D covered drugs until catastrophic coverage begins. That catastrophic coverage begins when the beneficiary's out-of-pocket expenses reach $3,600 in a year.

In addition to paying the base premium for their plan, Medicare beneficiaries will also pay TrOOP costs including the following:

These additional TrOOP expenses are explained as follows:

Deductible (From $0 to $250: A net value of $250)
Under standard coverage, plan enrollees pay a $250 deductible each calendar year out of their own pockets for Part D covered drugs.

Plan Payments + Coinsurance (From $251 to $2,250)
Once the annual ($250) deductible is met, standard coverage pays for 75% of the next $2,000 (or up to $1,500) for covered (allowable) drugs and biologicals. The remaining 25% (a maximum of $500) of the cost is covered by the beneficiary via coinsurance/copayments.

Coverage Gap (From $2,251 to $3,600 TROOP limit)
Once covered drug costs have reached the plan payment + coinsurance + deductible limit of $2,250, the plan does not pay again until the plan enrollee has reached the $3,600 limit in out-of-pocket spending. The beneficiary pays all covered drug costs incurred in this "gap." The total out of pocket cost (not including premiums) to this point (deductible + plan payments + coinsurance + coverage gap) is $3,600 for coverage through the full "gap" (see TrOOP discussion below.)

Catastrophic Coverage (Costs over $3,600 TrOOP limit)
Once the individual's true out-of-pocket spending reaches $3,600, costs for necessary covered drugs are covered as follows:

What Counts Toward True Out-of-Pocket (TrOOP) Costs?
Beneficiaries must adhere to their plan's formulary, prior authorization, and formulary exceptions processes in order for their out-of-pocket spending to count toward the $3,600 limit.

The following types of spending count toward the $3,600 threshold:

In summary, the amount that a beneficiary must spend on part D-covered drugs until catastrophic coverage is reached, based on the 2006 standard coverage, is as follows:

$250
   deductible
+ $500
   plan enrollee coinsurance during initial coverage
+ $2,850
   coverage gap
= $3,600
   (plus the monthly premium, which averages $384/year)

Once this cost has been reached for covered drugs, catastrophic coverage begins.

Related Links
HHS Secretary Mike Leavitt recently released a two-month progress report on Medicare Prescription Drug Coverage that takes a hard look at what is working and what needs to improve. To view the report, visit: http://www.hhs.gov/medicare2final.pdf on the Web site.

For more information about Medicare Prescription Drug Coverage for Providers, visit http://www.cms.hhs.gov/MedlearnProducts/23_DrugCoverage.asp#TopOfPage on the CMS Web site.

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Medicare to Stop Mailing Standard Paper Remittance (SPR) for Those Providers/Suppliers Also Receiving the Electronic Remittance Advice (ERA)

Beginning June 1, 2006, the SPR received through the mail will no longer be available to providers/suppliers who also receive an ERA, whether the ERA is received directly or through a billing agent, clearing house, or other entity representing a provider/supplier. In response to the provider/supplier communities continued need for SPRs, CMS has developed free software call Medicare Remit Easy Print (MREP) that gives providers/suppliers a tool to read and print a remittance advice (RA) from the HIPAA compliant Health Care Claim Payment/Advice (835) file.

The MREP software was designed to incorporate new functionality to save providers/suppliers time and money. The paper output generated by MREP is similar to the SPR format. The CMS has worked with other payers to insure their acceptance of the SPR generated by the MREP software for Coordination of Benefit claim submission. Additionally, CMS has worked with clearinghouses to assure similar software is available to read and print an ERA for those providers/suppliers that utilize clearinghouse services. We encourage providers/suppliers currently receiving the ERA, who don't use software to read and print RAs from these files, to begin using MREP or other similar software before the June 1st cutoff.

Please go to http://www.cignagovernmentservices.com/edi/partb/easy_print.html for further information regarding MREP software. We appreciate your continued cooperation as the Medicare program moves toward a more electronic environment.

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Least Costly Alternative (LCA) based on Local Coverage Decision (LCD) for Luteinizing Hormone-Releasing Hormone Analogues in the Treatment of Prostate Cancer

The allowable for procedure codes J3315 Triptorelin Pamoate Injection (Trelstar Depot & Trelstar LA-1 and 3 month doses), J9202 Goserelin Acetate Implant (Zoladex-1 and 3 month doses), J9217 Leuprolide Acetate for Depot Suspension (Eligard & Lupron Depot-1, 3, 4, and 6 month doses), and J9225 Histrelin Implant (Vantas-one per year) will be based on the least costly alternative J9219 Leuprolide Acetate Implant (Viadur Implant-one per year).

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Electronic Billing Provider ID Number Update

The CIGNA Government Services Part B EDI Department has identified a significant number of individual providers set up for electronic billing who are members of groups. For groups, only the group provider ID should be set up for EDI with all the individual providers affiliated with that group being linked to the group provider ID.

We are in the process of preparing to remove these extra records from our EDI system. Only records of individual providers that are affiliated with groups will be removed. No group provider records will be removed. This process will be completed as soon as possible and by April 1, 2006.

If you are a member of a group, your group provider ID must be submitted as your Billing Provider ID on your electronic claims. This should be sent in the 2010AA loop in the REF02 segment and element with a 1C qualifier in the 2010AA.REF01 as indicated in past notifications such as this one from February 23, 2005: http://www.cignagovernmentservices.com/articles/feb05/cope2123.html

If you are unsure how you are billing your electronic claims, please contact your software support representative to make sure that your system is set up correctly. If it is not, your claims may reject with an M012 error once our cleanup process is complete.

If you have any questions, please feel free to call the appropriate CIGNA Government Services EDI department.

NC 866.352.1608
TN/ID 866.520.4022

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Intravenous Immunoglobulin (IVIG) - LCD Revision

The LCD for Intravenous Immunoglobulin (IVIG) has been revised for all Part B states to include coverage for pre and post renal transplants. Please refer to the CIGNA Government Services Web site to view the policy in its entirety for your particular state.

• Idaho -
http://www.cignagovernmentservices.com/medicare_dynamic/clickwrap/clickwrap.asp?url=idpolicies
• North Carolina -
http://www.cignagovernmentservices.com/medicare_dynamic/clickwrap/clickwrap.asp?url=ncpolicies
• Tennessee -
http://www.cignagovernmentservices.com/medicare_dynamic/clickwrap/clickwrap.asp?url=tnpolicies

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Repeat Tests for Automated Multi-Channel Chemistries for End Stage Renal Disease (ESRD) Beneficiaries

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

Provider Action Needed

STOP - Impact to You
This article is based on Change Request (CR) 4101 provides details regarding the payment policy for End Stage Renal Disease (ESRD)-related Automated Multi-Channel Chemistry (AMCC) Tests (i.e., the ESRD 50/50 rule), and clarifies a coding issue concerning repeat tests using the Current Procedure Terminology (CPT) modifier 91.

CAUTION - What You Need to Know
Clinical diagnostic laboratory tests ordered by an ESRD facility must follow accepted CPT guidelines. Specifically, Modifier 91 must be used on any subsequent service being billed if 1) any single service (same CPT code) is ordered (for the same beneficiary), and 2) the specimen is collected more than once in a single day, and the service is medically necessary. Also, any line item on a claim with a modifier 91 will be included into the calculation of the 50/50 rule, and after the calculation of the 50/50 rule, services used to determine the payment amount may never exceed 22.

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

Background

ESRD 50/50 Rule
The Centers for Medicare & Medicaid Services (CMS) previously issued instructions to Medicare carriers regarding procedures to enforce compliance with the payment policy for End Stage Renal Disease (ESRD)-related Automated Multi-Channel Chemistry (AMCC) Tests (i.e., the ESRD 50/50 rule). The ESRD 50/50
rule requires a count of AMCC tests ordered to capture:

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

In CR2813, CMS directed Medicare carriers to make the necessary systems changes to implement front-end edits in preparation for the standard system implementation of CR2813 in the January 2005 release.

Note: The carrier standard system changes needed to implement the new ESRD 50/50 rule compliance guidelines were partially implemented in the October 2004 release. Intermediary billing guidelines for ESRD 50/50 rule compliance have been in effect since October 2003.

CR2813 also directed the carriers not to post any information concerning the business requirements associated with the implementation of CR2813 until receiving further guidance from CMS.

Business Requirements Relating to Modifier 91
In June 2005, CMS issued CR3890, which required the implementation of the ESRD 50/50 rule for Carriers, effective January 2006. During the preparation for implementation, the provider community commented that business requirements relating to the use of Modifier 91 (Repeat Clinical Diagnostic Laboratory Test) were inconsistent with Current Procedural Terminology (CPT) procedures. CMS is adjusting the business requirements for proper use of Modifier 91.

A Medlearn Matters article, MM3890, is available
for CR3890 at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3890.pdf on the CMS Web site.

Therefore, CR4101 directs that clinical diagnostic laboratory tests ordered by an ESRD facility must follow accepted CPT guidelines. Specifically, Modifier 91 must be used on any subsequent service being billed if:

In addition, when using CPT Modifier 91, it must be used without regard to whether it is a:

Note: Any claim with a modifier 91 will be included into the calculation of the 50/50 rule, and after the calculation of the 50/50 rule, services used to determine the payment amount may never exceed 22.

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

Additional Information
For complete details regarding CR4101, please see the official instruction issued to your carrier or intermediary regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R733CP.pdf on the CMS Web site.

From that Web site page, look for CR4101 in the CR NUM column on the right, and click on the file for that CR.

If you have any questions, please contact your carrier 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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Changes to Chapter 29 - Appeals of Claims Decisions: Redeterminations and Reconsiderations (Implementation Date May 1, 2005) - MMA

Note: This article was revised on February 21, 2006, to update the language regarding the appeals process. In addition, the article now contains Web addresses that conform to the new CMS Web site.

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

Provider Action Needed
The new second level in the administrative appeals process is called a "reconsideration." Reconsiderations are processed by Qualified Independent Contractors (QICs).

Background
The Medicare claim appeals process was amended by the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA). Section 1869(c) of the Social Security Act (the Act), as amended by BIPA, now requires a new second level in the administrative appeals process called a reconsideration.

Requests for reconsideration of appeal decisions (redeterminations) should go either to the Qualified

Independent Contractor (QIC), or the Hearing Officer (HO), when the redetermination was issued by a carrier prior to January 1, 2006.

Time Limit for Filing a Request for Reconsideration
A request for reconsideration must be filed within 180 days of the date of receipt of the notice of redetermination. For requests filed in writing - the date received is defined as the date received by the QIC in the corporate mailroom.

Please refer to the following table for clarification.

Appeal Rights for Requests for Reconsideration The Second Level of Appeal

Medicare
Claims		 Medicare Contractor
Issuing Redetermination		 Date Redetermination Issued and Mailed

Where to Appeal the
Redetermination*
Part A/Part B FI On or after May 1, 2005 QIC
Part B Carrier On or after January 1, 2006 QIC
Part A FI Before May 1, 2005 ALJ
Part B FI Before May 1, 2005 HO
Part B Carrier Before January 1, 2006 HO

*Qualified Independent Contractor (QIC); Administrative Law Judge (ALJ); Hearing Officer (HO)

Additional Information
Medicare Claims Processing Manual, Chapter 29 - Appeals of Claims Decisions, 310.2, 310.3, can be found at http://www.cms.hhs.gov/manuals/downloads/clm104c29.pdf on the CMS Web site.

Medlearn Matters article MM3530 - "MMA - Revisions to Medicare Appeals Process for Fiscal Intermediaries Revised: 4/12/2005" (CR Title - Appeals Transition - BIPA 521 Appeals), can be found at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3530.pdf on the CMS Web site.

Change Request CR3530 "Revisions to Medicare Appeals Process for Fiscal Intermediaries Revised: 4/12/2005" (CR Title-Appeals Transition - BIPA 521 Appeals), can be found at http://www.cms.hhs.gov/Transmittals/downloads/R146OTN.pdf on the CMS Web site.

The official instruction issued to your FI, DMERC, or carrier regarding this change may be found by going to http://www.cms.hhs.gov/Transmittals/downloads/R697CP.pdf on the CMS Web site. The new sections of Chapter 29 of the Medicare Claims Processing Manual are attached to CR3942.

Please refer to your local carrier/DMERC/FI 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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Mammography Facility Certification File - Updated Procedures and Content

Provider Types Affected
Providers (facilities certified by the Food and Drug Administration (FDA)), who submit screening and diagnostic mammography claims to Medicare fiscal intermediaries (FIs) and to carriers

Key Points

Background
The Mammography Quality Standards Act (MQSA) ensures that all facilities that provide mammography services meet national quality standards.

The FDA, Center for Devices and Radiological Health, is responsible for collecting certificate fees and surveying mammography facilities (screening and diagnostic). FDA provides CMS with a file which contains a listing of all facilities that have been issued certificates to perform mammography services. CMS then provides the list to Medicare carriers and FIs, which also contains information about terminated facilities.

Additional Information
Section 104 of the Benefits Improvement and Protection Act (BIPA) of 2000, "Modernization of Screening Mammography Benefit," provided new payment methodologies for both diagnostic and screening mammograms that utilize digital technology.

For Medicare to determine whether the mammography facility is certified to perform digital mammography (due a higher payment rate), the FDA sends an updated file via the CMS Mainframe Telecommunications System (CMSTS) on a weekly basis.

Effective July 1, 2006, CMS will be populating a new Mammography Quality Standards Act (MQSA) file with terminated FDA-certified facilities (designated with a "T" value). This will enable carriers/intermediaries to pay for screening and diagnostic mammography services for terminated facilities prior to the date of termination and to deny services furnished after the date of termination. By doing so, it will enable the payment of claims that come into Medicare from a terminated facility if the date of service occurred before the facility was terminated.

Relevant Links
CR4303 is the official instruction issued to your FI or carrier, regarding this change. CR4303 may be found by going to http://www.cms.hhs.gov/Transmittals/downloads/R828CP.pdf on the CMS Web site.

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

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Suppression of Standard Paper Remittance Advice (SPR) to Providers and Suppliers Also Receiving Electronic Remittance Advice (ERA) for 45 Days or More

Provider Types Affected
All Medicare providers, physicians, suppliers, and qualified non-physician practitioners billing Medicare carriers and durable medical equipment regional carriers (DMERCs)

Provider Action Needed

STOP - Impact to You
CR4376 provides notice that beginning June 1, 2006, carriers and DMERCs will stop sending standard paper remittance (SPR) advices to you (or a billing agent, clearinghouse, or other entity representing you) if you have been receiving 835s or electronic remittance advice (ERA) transactions, either directly or through a billing agent, clearinghouse, or other entity representing you, for 45 days or more.

CAUTION - What You Need to Know
If you need a paper copy of a remittance advice for accounts reconciliation or to forward to secondary/tertiary payers, be aware that the Centers for Medicare & Medicaid Services (CMS) has developed software that gives you a tool to view and print an 835 in a readable format locally on your computer. This software is called Medicare Remit Easy Print (MREP). See the Additional Information section of this article to learn how to access MREP software. Your clearinghouse may also offer software that allows you to view and print your remittance advice.

GO - What You Need to Do
Make certain that your billing staffs are aware of these changes. Try MREP software to view and print your own remittance and see the benefits for yourself. Or, check with your clearinghouse to see if it provides similar software.

Background
The Medicare Claims Processing Manual, Chapter 22, Section 40.1, Remittance Advice, describes the instructions issued by CMS to carriers and DMERCs. The section instructs carriers and DMERCs to eliminate SPRs to those providers/suppliers who were receiving ERA transactions for 45 days or more. MREP was developed in response to comments CMS received from the provider/supplier community that they need a paper document for accounts reconciliation, and claim submission for secondary/tertiary payments. Providers/suppliers who use the MREP software package have the ability to print paper remittances and reports that can be used to reconcile accounts receivable, as well as to create document(s) that can be included with claim submissions to secondary/tertiary payers. The output of MREP is similar to the current SPR Format. Benefits of using MREP software include the ability to: Save Time and Money You can print remittance information directly from your computer the day the HIPAA 835 is available. No more time is spent waiting for the mail.

Create and Print Special Reports
With MREP, you can run, export, or print several useful reports including:

Print and Forward Claims for Other Payers
MREP provides the ability to print remittance information for individual or multiple selected claims, and it allows you to forward only those claims that are needed by other payers for secondary payment. You may view and/or print as many or as few claims as needed. This eliminates the need for you to darken individually identifiable data on the SPR, as you may do today, that does not pertain to the claim for which you are requesting payment.

Navigate and View Remittance Information
MREP organizes and presents information in a manner that makes it easy for you to view. It also provides separate tabs to access the following:

Note: MREP software will be revised three times per year to accommodate Claim Adjustment Reason and Remittance Advice Remark Code set changes. You can sign up to be notified automatically when a new version of MREP is available at your carrier's/DMERC's Web site.

Search for Claim(s) Information Quickly and Easily
MREP's search function can help you find a claim (or multiple claims) based on your customized search criteria. Using it, you can search by names, numbers, and even portions of information such as:

Note: MREP's search capability provides a powerful way to save time and money when examining remittance information.

Eliminate Need for Physical Filing and Storage Space
MREP software imports a HIPAA 835 (once you have received it from your carrier/DMERC) and saves the information as a separate Import file to help ensure that the original HIPAA 835 file remains intact. It also provides an easy-to-use method to archive, restore, and delete these Import files as you maintain your remittance records (further reducing the need for physical filing of printed copies and additional storage space).

As you gain familiarity with the MREP software, you will be able to take advantage of the numerous keystroke shortcuts designed to streamline use of the software and save you time while viewing your remittance information.

Implementation
The implementation date for this instruction is June 1, 2006

Additional Information
To learn about more MREP benefits, download the brochure available at http://www.cms.hhs.gov/MLNProducts/downloads/remit_easy_print.pdf on the CMS Web site. Or, you can view Special Edition MLN Matters article SE0611 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0611.pdf on the CMS Web site.

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

For more information about the MREP software and how to receive the HIPAA 835, please contact your carrier/DMERC. Medicare Part B Electronic Data Interchange (EDI) helpline phone numbers are available at http://www.cms.hhs.gov/ElectronicBillingEDITrans/ on the CMS Web site.

The official instructions issued to your carrier/DMERC regarding this change can be found at http://www.cms.hhs.gov/transmittals/downloads/R885CP.pdf on the CMS Web site.

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Denial of Claims Not Timely Filed

Provider Types Affected
Providers billing fiscal intermediaries (FIs), regional home health intermediaries (RHHIs), carriers, and durable medical equipment regional carriers (DMERCs) for services provided to Medicare beneficiaries

Provider Action Needed

STOP - Impact to You
This article is based on information contained in CR4041, which clarifies that a determination relating to the untimely submission of a Medicare claim by a provider or supplier is not an initial determination and cannot be appealed.

CAUTION - What You Need to Know
Claims that are filed after the "timely filing period" will be denied as specified in the Medicare Claims Processing Manual, Publication 100-4, Chapter 1, Section 70.1. When a claim is denied because it was filed after the timely filing period, the denial will not constitute an "initial determination." As such, the determination that a claim was not filed timely cannot be appealed.

GO - What You Need to Do
Be aware of the time limits for filing Medicare claims and the consequences of untimely filing.

Background
The Centers For Medicare & Medicaid Services (CMS) issued a technical correction to the June 30, 2005 Federal Register, Interim Final Rule, "Medicare Program: Changes to the Medicare Claims Appeal Procedures (42 CFR Parts 401 and 405)," that clarified that a determination regarding the untimely submission of a Medicare claim is not an initial determination and cannot be appealed. Specifically, 42 CFR Section 405.926(n) indicates that a determination that a provider or supplier failed to submit a claim timely or failed to submit a timely claim, despite being requested to do so by the beneficiary or the beneficiary's subrogee, is not an initial determination and cannot be appealed.

CR4041 informs all Medicare providers of the above technical correction to the June 30, 2005 interim final rule, "Medicare Program: Changes to the Medicare Claims Appeal Procedures" and revises the Medicare Claims Processing Manual, Publication 100-4, Chapter 1 (General Billing Requirements), Sections 70.4 and 70.8.6 to incorporate these changes.

Additional Information
For complete details, including the revised sections of the Medicare Claims Processing Manual and a table that illustrates the timely filing limit for dates of service in each calendar month, please see the official instruction issued to your carriers, FIs, DMERCS, or RHHIs regarding this change. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R830CP.pdf on the CMS Web site.

If you have any questions, please contact your Medicare contractor (carrier, FI, etc.) 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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Announcing a New Name for Medicare's Provider Education Articles - MLN Matters

Provider Types Affected
All Medicare physicians, providers, and suppliers

Background
The Medicare Learning Network is pleased to announce a new name for our very popular provider education articles. To more closely associate these articles with the Medicare Learning Network, i.e., the official educational information source for Medicare Fee-for-Service (FFS) providers, the articles previously known as "Medlearn Matters" articles will now be known as "MLN Matters" articles (the MLN standing for "Medicare Learning Network").

You will also notice a new logo at the top of the articles indicating the name change. The Centers for Medicare & Medicaid Services (CMS) knows that you have come to rely on these articles to help you more easily understand new or changed Medicare policy and to help you gain quick access to accurate Medicare program information.

The articles can now be accessed from http://www.cms.hhs.gov/MLNMattersArticles on the CMS Web site. If you have previously bookmarked the "Medlearn Matters" page, please update your bookmark to the new URL.

We hope that you will continue to utilize these articles that are always prepared with the affected provider audience in mind.

In conjunction with the above referenced change, the URLs for the Medicare Learning Network (MLN) Web pages have also been changed. You can reach our MLN Web pages from the http://www.cms.hhs.gov main page - just click on "Outreach and Education." The full URLs to access the various MLN sections on the CMS Web site are:

MLN General Information - http://www.cms.hhs.gov/MLNGenInfo
MLN Products - http://www.cms.hhs.gov/MLNProducts

Additional Information
Also, note that if you know the specific number of an article you are after, such as SE0620, you can go directly to the specific URL for an article by using the format below. For example, the Web site for SE0620 is http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0620.pdf.

For any other article, just substitute its number for the SE0620 in this URL to go directly to the PDF version of the article 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 March 17, 2006, to show the data collection period will continue through April 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 gather quantifiable data on provider satisfaction with the performance of FFS contractors. The MCPSS is one of the tools CMS will use to measure 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 April 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 provider contractor interface:

It contains a total of 76 questions and takes approximately 21 minutes to complete. The target date to respond is approximately three weeks after receipt of the notification packet. 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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Changes to Chapter 29 - Appeals of Claims Decisions: Administrative Law Judge; Departmental Appeals Board; U.S. District Court Review - MMA

Provider Types Affected
Physicians, providers, and suppliers who submit Part A or Part B Fee-for-Service claims to Medicare for services

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

The purpose of this article is to notify you about changes to the manual provisions that address Administrative Law Judge, Departmental Appeals Board, and U.S District Court review levels of appeal.

Key Points
Administrative Law Judge (ALJ) - The Third Level of Appeal
Parties to an appeal who are not satisfied with decisions made by the QIC at the second level of appeal (reconsideration), have the right to request an ALJ hearing as long as all of the ALJ hearing request requirements are met (see Medicare Claims Processing Manual, Chapter 29, Section 330 for details). Outlined below is some pertinent information about the ALJ level of the appeal process.

ALJ Hearing Amount in Controversy
Parties requesting an ALJ Hearing must meet the Amount in Controversy requirements:

Time Limits and Responsibilities
Decisions: The official ALJ decision is a signed copy of the ALJ decision. When issuing decisions, the ALJ will either:

Effectuation (No Agency Referral): Often, the ALJ's decision will require an effectuation action (payment of the claim) on the Medicare contractor's part. Contractors will effectuate ALJ decisions within 30 days of the receipt of the official ALJ decision if:

Computation of the Amount (No Agency Referral): If the amount must be computed by the Medicare contractor, the decision must be effectuated within 30 days after the contractor computes the amount to be paid to the appellant. The computation should be done as soon as possible, but no later than 30 calendar days of the date of receipt of the official ALJ decision or effectuation notice.

Clarification (No Agency Referral): If clarification from the ALJ is necessary, then the date of the clarification is considered to be the final determination for purposes of effectuation. If clarification is needed from the physician/supplier (e.g., splitting charges), this clarification should be requested as soon as possible and the amount payable should be computed within 30 calendar days after the receipt of the necessary clarification. The date of receipt of the clarification is considered to be the final determination for purposes of effectuation.

Departmental Appeals Board (DAB) - The Fourth Level of Appeal
The DAB evaluates requests for review, and makes final decisions whether to review, or to decline to review, decisions of ALJs as well as orders of dismissal by ALJs.

DAB Effectuation Time Limits: DAB decisions requiring contractor effectuation must be initiated within 30 days of receipt of a DAB decision. Effectuation must be completed within 60 days.

U.S. District Court: The Fifth Level of Appeal
A party may request court review of the DAB's decision. Medicare contractors are not responsible for reviewing ALJ decisions issued by the Department of Health and Human Services (HHS) ALJs to determine if an agency referral is appropriate, and will not accept a request for U.S District Court review by a party.

Relevant Links
The official instruction issued to your FI including Regional Home Health Intermediaries (RHHIs), or carrier including DMERCs, regarding this change may be found by going to http://www.cms.hhs.gov/Transmittals/downloads/R862CP.pdf on the CMS Web site. The new sections of Chapter 29 of the Medicare Claims Processing Manual are attached to CR4152.

Please refer to your local FI/RHHI or carrier/DMERC if you have questions 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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April Update to the 2006 Medicare Physician Fee Schedule (MPFS) Database Provider Types Affected

Physicians, suppliers, and providers billing Medicare carriers, and/or fiscal intermediaries (FIs) for services paid under the Medicare Physician Fee Schedule (MPFS)

Provider Action Needed
This article is based on Change Request (CR) 4399, which informs your carrier/intermediary that payment files were issued to carriers based upon the November 21, 2005, Medicare Physician Fee Schedule Final Rule. CR 4399 amends those payment files and includes new G-codes for the Low Vision Rehabilitation Demonstration Project and new Category II codes 3046F through 3050F and 3076F through 3080F.

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

Note: CR4399 amends those payment files and includes new G-codes for the Low Vision Rehabilitation Demonstration Project and new Category II codes 3046F through 3050F and 3076F through 3080F. In the October 2005 update to the Medicare Physician Fee Schedule Database (MPFSDB) the multiple procedure indicators were inadvertently changed from a "0" to a "2" for CPT codes 20931, 20937, and 20938.

The emergency update to the 2006 MPFSDB reinstated the multiple procedure indicators for these codes to a "0" effective January 1, 2006. Also in the October 2005 update to the MPFSDB the bilateral surgical indicators were inadvertently changed from "1" to "0" for CPT codes 63035, 63043, 63044, 64480, and 64484. This CR reinstates the bilateral surgical indicators for these codes to a "1" effective January 1, 2006.

Your carrier will not search their files for claims paid incorrectly from October 1, 2005, through December 31, 2005, but will adjust claims brought to their attention. In addition, your carrier will manually adjust their systems and the 2005 MPFSDB to reflect a multiple procedure indicator of a "0" for CPT codes 20931, 20937, and 20938 and a bilateral surgical indicator of a "1" for CPT codes 63035, 63043, 63044, 64480, and 64484.

CR4399 informs your carrier/intermediary to accomplish the following:

Note: Your carrier/intermediary will not search their files to either retract payment for claims already paid or to retroactively pay claims. However, your carrier/intermediary will adjust claims brought to their attention.

Unless otherwise stated in CR 4399, changes are retroactive to January 1, 2006.

Implementation
The implementation date for CR4399 is April 3, 2006.

Additional Information
Other changes included in the April update of the MPFS are attached to CR4399. To see that official instruction issued to your carrier/intermediary, go to http://www.cms.hhs.gov/Transmittals/downloads/R889CP.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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Payment for Power Mobility Device (PMD) Claims

Note: This article was revised on March 24, 2006, to emphasize that providers submitting claims on or after April 1, 2006, must bill the E/M and the G0372 code on the same claim.

Provider Types Affected
Physicians, providers, and non-physician practitioners billing Medicare carriers, durable medical equipment regional carriers (DMERCs), regional home health intermediaries (RHHIs), and/or fiscal intermediaries (FIs) for PMDs and services related to prescribing PMDs

Important Points to Remember

Options for Submitting G0372 and E/M Codes
Providers billing a Medicare carrier have the following options for submitting the G0372 code and the E/M code during January 1, 2006, through March 31, 2006:

The E/M service will be paid now. Note that this is not intended to require that Medicare fiscal intermediaries or carriers split claims submitted with both the E/M and G0372 code. Rather, the physician/provider may choose to submit two separate claims for the individual services.

Providers submitting claims on or after April 1, 2006, must bill the E/M and the G0372 code on the same claim.
Critical access hospitals (CAHs) billing the fiscal intermediary (FI) under Method II have the following options from January 1, 2006, through July 2, 2006, for submitting the G0372 code and the E/M code:

Rather, the physician or treating practitioner may choose to submit two separate claims for the individual services. Method II Critical Access Hospitals submitting claims on or after July 2, 2006, must bill the E/M and the G0372 code on the same claim.

Background
The Centers for Medicare & Medicaid Services (CMS) published an interim final rule on PMDs to conform its regulations to section 302(a)(2)(E)(iv) of the Medicare Modernization Act (MMA), which is codified at section 1834(a)(1)(E)(iv) of the Social Security Act (SSA). The effective date of the rule was October 25, 2005.

For PMDs, the MMA mandated that:

Submission of Medical Record and Prescription
Apart from the MMA requirements, the other key change made by this regulation is a requirement that the physician or treating practitioner must submit pertinent parts of the medical record (in lieu of the Certificate of Medical Necessity (CMN)), along with the prescription, to the durable medical equipment (DME) supplier within 30 days of the face-to-face examination.

A separate add-on payment (an add-on payment to the office visit billed with the code of G0372) was established by the rule to recognize the additional physician work and resources required for submitting pertinent parts of the medical record.

Payment for the history and physical examination is made through the appropriate evaluation and management (E&M) code along with the add-on payment (G0372) which goes to the local Medicare fiscal intermediary or carrier. The PMD claim will go to the local durable medical equipment regional carrier (DMERC).

Appropriations Act
Title II, Section 222, of the Departments of Labor, Health and Human Services, and Education and Related Agencies Appropriations Act, 2006 (H.R. 3010) (the Appropriations Act) was signed into law on December 30, 2005. It states, in part:

SEC. 222. None of the funds made available under this Act may be used to implement or enforce the interim final rule published in the Federal Register by the

Centers for Medicare & Medicaid Services on August 26, 2005, (70 Fed. Reg. 50940) prior to April 1, 2006.

Although this section of the Appropriations Act does not allow federal funds to implement or enforce the rule, CMS believes that this section does not affect the validity of the rule. Therefore, CMS is instructing DMERCs and/or DME PSCs that, between January 1, 2006, to April 1, 2006, contractors will only pay PMD
claims that satisfy the requirements of section 1834(a)(1)(E)(iv) of the SSA.

Based on the Appropriations Act, CMS is instructing fiscal intermediaries and carriers to hold claims that contain G0372. These claims must be held through March 31, 2006. Carriers will begin to release physician claims for processing on April 3, 2006.

Implementation
The implementation date for this instruction is no later than two weeks after release of CR4372 or March 24, 2006.

Additional Information
For additional information regarding PMDs you may want to review the following MLN Matters articles:

The official instructions issued to your carrier, DMERC, FI, or RHHI regarding this change can be found at http://www.cms.hhs.gov/Transmittals/downloads/R215OTN.pdf on the CMS Web site.

If you have questions, please contact your Medicare carrier, DMERC, FI, or RHHI 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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Eliminate the Use of Surrogate Unique Physician Identification Numbers (UPINs) on Medicare Claims

Note: This article was rescinded on March 21, 2006, because CR4177 was rescinded. A new CR will be released on this issue in the future.

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Laparoscopic Incisional and Ventral Hernia Repair Billing Procedures April 3, 2006

These instructions supercede those given in the January 2005 edition of CGS's Frequently Asked Questions. http://www.cignagovernmentservices.com/partb/faq/mr/mr0105.html

These procedures are becoming more common even though they have not received their own CPT codes yet. At a recent Medicare workshop providers requested an alternative to waiting for additional documentation request letters using the electronic note pad to indicate the procedure being performed.

In an attempt to reduce the turn around time for payment of these claims, the following billing guidelines will become effective immediately:

When performing a laparoscopic incisional or ventral hernia repair, providers should use the CPT code 49659. Please do not bill the add-on code 49568 for implantation of mesh with the unlisted code 49659. Based on the provider's description of the procedure performed, payment for the mesh implantation will be included in the payment for 49659 when indicated.

The following information needs to be entered into the electronic notepad to ensure prompt payment and avoid delay due to requests for additional documentation.

For laparoscopic repair of an initial incisional or ventral hernia w/out mesh implantations enter:
‘Lap Repair Int. I/V hernia w/out mesh'

For laparoscopic repair of an initial incisional or ventral hernia w/ mesh implantation enter
‘Lap Repair Int. I/V hernia w/mesh'

For laparoscopic repair of an initial incarcerated or strangulated incisional or ventral hernia w/out mesh implantation enter:
‘Lap Repair Int. I/S I/V hernia w/out mesh'

For laparoscopic repair of an initial incarcerated or strangulated incisional or ventral hernia w/ mesh implantation enter:
‘Lap Repair Int. I/S I/V hernia w/ mesh'

For laparoscopic repair of a recurrent incisional or ventral hernia w/ out mesh implantations enter:
‘Lap Repair Recur I/V hernia w/out mesh'

For laparoscopic repair of a recurrent incisional or ventral hernia w/ mesh implantations enter:
‘Lap Repair Recur I/V hernia w/ mesh'

For laparoscopic repair of a recurrent incarcerated or strangulated incisional or ventral hernia w/ out mesh implantation enter:
‘Lap Repair Recur I/S I/V hernia w/out mesh'

For laparoscopic repair of a recurrent incarcerated or strangulated incisional or ventral hernia w/ mesh implantation enter:
‘Lap Repair Recur I/S I/V hernia w/ mesh'

Anything other than the above information documented in the electronic notepad, will result in the claim being developed for additional documentation before payment can be determined.

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Cultural Competency: A National Health Concern

Provider Types Affected
This article is for informational purposes only and does not affect Medicare billing processes.

Background
The increasing diversity of the racial, ethnic, and linguistic composition of the U.S. challenges providers as they strive to deliver health care services. Cultural and language differences between patients and providers may generate miscommunication of critical health care information, a lack of compliance with prescribed treatment or medication, or other factors that negatively influence clinical situations and health outcomes. The existence of racial and ethnic disparities in health has been well documented by organizations such as the Institute of Medicine and the Agency for Healthcare Research and Quality.

Cultural competency, or the ability of health care providers to work effectively with colleagues and patients in cross-cultural situations, is a vital component of professional competence. Culturally competent practice can offer a variety of benefits to health care providers and their organizations, including:

Highlights of the Centers for Medicare & Medicaid Services' (CMS) Activities to Address Health Disparities
To ensure that providers are prepared for the challenges they face to deliver the right care to every person every time, CMS's Quality Improvement Organizations (QIOs) are working with healthcare providers to become more effective and culturally aware of how they provide care to diverse populations. As part of a national initiative, QIOs are recruiting health providers to participate in a FREE online (web-based) program A Family Physician's Practical Guide to Culturally Competent Care to ensure that Medicare providers are prepared to effectively serve the increasingly diverse patient population. QIOs have adopted the Guide as the "Program of Choice" for health care provider cultural competency education. The Guide is an innovative educational product designed to equip health care providers with the cultural and linguistic competencies required to improve the quality of care for minority, immigrant, and ethnically diverse communities.

A Family Physician's Practical Guide to Culturally Competent Care is anchored in the three themes of the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS) and serves a key initiative in helping the Department of Health and Human Services' Office of Minority Health to achieve its mission of "improving the health of racial and ethnic minority populations' through the development of effective health policies and programs that help to eliminate disparities in health care."

A Family Physician's Practical Guide to Culturally Competent Care is a case study based curriculum, featuring video vignettes and a diverse group of providers and clinic staff at a fictional practice setting that reinforce learning points throughout the modules. Participants can also share their reactions to the case studies in an online bulletin-board feature. This program was designed with the busy health care provider in mind, offering "anytime, anywhere" continuing education credit in an engaging and innovative format.

This curriculum is available to all health care providers at http://www.thinkculturalhealth.org. The program is accredited for Continuing Medical Education (CME) credits for physicians and Continuing Education Units (CEUs) for nurses and pharmacists.

Please visit http://www.thinkculturalhealth.org to access the free accredited continuing education program, A Family Physician's Practical Guide to Culturally Competent Care, and to view updates about the nursing program.

Additional Information
To access the free program, A Family Physician's Practical Guide to Culturally Competent Care, please visit http://www.thinkculturalhealth.org.

The National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care are available at http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15.

For more information about the QIO cultural competency initiative, please visit http://www.qsource.org/uqiosc/.

Additional information about the Office of Minority Health is available at http://www.omhrc.gov/.

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

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) 4335 and provides specific information regarding the quarterly update for the April 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:

Changes made in this update include the following:

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

Additional Information
The official instructions issued to your intermediary, carrier, or DMERC regarding this change can be found at http://www.cms.hhs.gov/Transmittals/downloads/R880CP.pdf on the CMS web site.
If you have questions, please contact your Medicare intermediary, carrier, or DMERC 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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Payment for Category III Codes 0144T through 0151T

Effective 4/1/2006 CIGNA Government Services has established prices for the above codes. The allowables listed are for states North Carolina, Idaho, and Tennessee. They are retroactive to 1/1/2006

CODE
GLOBAL
TECHNICAL (TC)
PROFESSIONAL (26)
0144T
$258.90
$200.20
$58.70
0145T
$602.99
$496.41
$112.58
0146T
$708.50
$587.54
$120.96
0147T
$715.54
$587.54
$126.00
0148T
$720.54
$589.54
$131.00