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August 2006 Part B Medicare Bulletin

Posted August 4, 2006

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CMS Has Revised the Average Sales Price (ASP) and Not Otherwise Classified (NOC) Drug Lists for 2006.

***UPDATE***
The revised lists may be found by following the link below:
http://www.cignagovernmentservices.com/medicare_dynamic/clickwrap/clickwrap.asp?url=partbfees

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Webinar/Teleconference

Due to overwhelming response!
CIGNA Government Services is pleased to present another session of the "Most Common Claim Submission Errors" Webinar and/or Teleconference. (If you are already signed up for the July session, there is no need to reapply.)

Date: Wednesday, August 23, 2006
Time: 10:00am-11:00am Central;
11:00am-12:00pm Eastern.

Click here to register http://www.cignagovernmentservices.com/wrkshp/tn/WebinarsTele_TN.html for the Webinar/Teleconference

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Men's Preventive Health Services

In conjunction with National Men's Health Week and in commemoration of Father's Day (June 18), the Centers for Medicare & Medicaid Services (CMS) and CIGNA Government Services would like to invite you to join with us as we strive to heighten the awareness of prevention and encourage early detection and treatment of disease.

Please take advantage of the online Men's Preventive Health NetCourse offered by CIGNA Government Services to learn more about the preventive health services available to Medicare beneficiaries. NetCourses are online 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.

A wide variety of NetCourses are available at:
http://www.cignagovernmentservices.com/Webtraining/Logon.asp, to help meet your Medicare-related training needs.

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Medicare Part B Drug Competitive Acquisition Program CAP; Ask the Contractor Teleconference - Monday, June 12

In order to provide physicians and their staff an opportunity to learn more about the Medicare Part B Drug Competitive Acquisition Program (CAP) and the CAP's extended physician election period, the Centers for Medicare & Medicaid Services (CMS), and Noridian Administrative Services, the designated carrier for the Competitive Acquisition Program (CAP) for Part B Drugs and Biologicals, will host a second Ask the Contractor teleconference.

Call details:
Date: Monday, June 12, 2006,
Time: 2:00-3:30 p.m. Eastern
Title: Ask the Contractor Teleconference for CAP
Call in Number: 1.866.216.6835
Access Code: 343677

Participation information:
Please dial in 5 minutes prior to the teleconference start time.

Enter your access code, followed by the pound (#) sign.

Your line will be placed on hold with music until the teleconference begins.

Much of the call will follow a question and answer format. You may submit questions for the teleconference in advance to the following e-mail address: MMA303DdrugBid@cms.hhs.gov. Questions must be submitted by Friday June 9, 2006. PowerPoint slides for the Ask the Contractor Teleconference will be made available for download prior to the teleconference on the information for physicians page of the CMS CAP Web site (http://www.cms.hhs.gov/CompetitiveAcquisforBios/02_infophys.asp). Additional information about CAP is available on this site as well.

On May 31, 2006, CMS announced an extension to the physician election period for the CAP. The extension began on June 3, 2006, and will continue through June 30, 2006. Physicians whose completed physician election forms are returned to their carrier bearing a postmark on or after June 3, but no later than June 30, 2006, will begin participation in the CAP starting on August 1, 2006.

CAP implementation is scheduled for July 1, 2006, and physicians whose completed election forms were received by their local carrier bearing a postmark on or before June 2, 2006, will begin participation in the CAP on July 1, 2006.

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EDI Forms - Processing Changes

Please be advised, the Part B EDI department is making a process change in the handling of all the EDI forms and applications. These forms include the EDI Enrollment Form, the Part B EDI Customer Profile, the Network Service Agreement, and the MCE User Agreement. Effective July 1, 2006, all forms must be sent to the EDI department in North Carolina for processing. This includes forms for new setups as well as forms for changes to existing setups. Failure to send these forms to the North Carolina office will result in the application being retuned to you.

As a reminder, make sure to submit all of the pages included in the Part B EDI Customer Profile form and the EDI Enrollment form, whether you have to fill out information on that page or not. The Part B EDI Customer Profile form must accompany all paperwork sent into our office. Incomplete forms will be returned to you.

Please make sure you access the CIGNA Government Services' Web site to obtain the most current applications.  Outdated forms will be returned to you. If you have any questions regarding your paperwork, you may call the Part B EDI Support office at 866.352.1608.

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

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

Provider Action Needed

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

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

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

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

Because healthcare provider taxonomy is a named code set in the American National Standards Institute (ANSI) X12N 837 Professional Implementation Guide, Medicare carriers, including DMERCs, must validate the inbound taxonomy codes against their internal HPTC tables.

The HPTC is an external non-medical data code set designed for use in classifying healthcare providers in an electronic environment according to provider type, or practitioner specialty. HPTCs are scheduled to be updated twice per year (April and October).

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

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

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

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

For complete details, please see the official instruction issued to your carrier/DMERC regarding this change at http://www.cms.hhs.gov/transmittals/ on the CMS Web site. From that Web page, look for CR 4072 in the CR NUM column on the right, and click on the file for that CR.

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

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

Note: This article was revised on June 2, 2006, to show that codes K0734-K0737 are added to the fee schedule file and are effective for claims submitted with dates of service on or after July 1, 2006, not January 1, 2006.

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) 5017 and provides specific information regarding the quarterly update for the July 2006 DMEPOS Fee Schedule.

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

Payment on a fee schedule basis is required for:

Changes Made in the Update
Changes made in this update include the following:
The fee schedule amounts for the following HCPCS codes are added to the fee schedule file as part of this update and are effective for claims with dates of service on or after January 1, 2006:
L0624, L0629, L0632, L0634, L2034, L2387, L3671, L3672, L3673, L3702, L3763, L3764, L3765, L3766, L3905, L3913, L3919, L3921, L3933, L3935, L3961, L3967, L3971, L3973, L3975, L3976, L3977, L3978, L5703, L5858, L5971, L6621, L6677, L6883, L6884, L6885, L7400, L7401, L7402, L7403, L7404, L7405, E1238, E1812, E2291, E2292, E2293, E2294

The fee schedule amounts for HCPCS code K0733, Power wheelchair accessory, 12 to 24 amp hour sealed lead acid battery, each (e.g., gel cell, absorded glass mat) are added to the fee schedule file on July 1, 2006, and is effective for claims with dates of service on or after July 1, 2006.

The fee schedule amounts for HCPCS code E0762, Transcutaneous electrical joint stimulation device system, includes all accessories, are added to the fee schedule file on July 1, 2006, and are effective for claims submitted with dates of service on or after January 1, 2006. In addition, the payment category for code E0762 is being revised to move the joint stimulation device from the DME payment category for capped rental items to the DME payment category for inexpensive and routinely purchased items, effective July 1, 2006.

The fee schedule amounts for HCPCS codes L6694 and L6698 are added to the fee schedule file on July 1, 2006, and are effective for claims with dates of service on or after January 1, 2005.

The fee schedules for HCPCS code L2232, Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for custom fabricated orthosis only, are added to the fee schedule file on July 1, 2006, and are effective for claims with dates of service on or after January 1, 2005.

Code E0705 (Transfer Board or Device, Any Type, Each) was added to the HCPCS effective January 1, 2006. The payment category for E0705 is being revised to the inexpensive and routinely purchased payment category and the fee schedule amounts for previous HCPCS code E0972 will be crosswalked to code E0705 for use in paying claims with dates of service on or after January 1, 2006.

The fee schedules for HCPCS code K0606 (Automatic External Defibrillator, With Integrated Electrocardiogram Analysis, Garment Type) are added to the fee schedule file on July 1, 2006, and are effective for claims submitted with dates of service on or after January 1, 2006.

The fee schedule amounts for HCPCS code E1812 (Dynamic Knee, Extension/Flexion Device with Active Resistance Control) are added to the fee schedule file on July 1, 2006, and are effective for claims submitted with dates of service on or after January 1, 2006.

As part of this update, the common working file category for HCPCS code B4185 will be switched from CWF category 9 to CWF category 20, effective January 1, 2006. B4185 was added to the HCPCS on January 1, 2006, to replace codes B4184 and B4186 and describes parenteral nutrients (CWF category 20) as opposed to enteral nutrients (CSF category 9).

Per CR4267, the following four adjustable wheelchair cushions codes are added to the HCPCS, effective July 1, 2006:

The fee schedule amounts for the above codes, K0734, K0735, K0736, and K0737, are added to the fee schedule file on July 1, 2006, and are effective for claims submitted with dates of service on or after July 1, 2006.

HCPCS codes A6531 and A6532 were added to the HCPCS January 1, 2006, to replace L8110 and L8120; therefore, all billing and payment requirements for HCPCS codes L8110 and L8120 crosswalk directly to A6531 and A6532, including the requirement to bill modifier AW when items are furnished for use as surgical dressings (see transmittal AB-03-100).

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

Additional Information
The official instruction issued to your intermediary, carrier, or DMERC regarding this change can be found at http://www.cms.hhs.gov/Transmittals/downloads/R928CP.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/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

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Payment for Islet Cell Transplantation in NIH-Sponsored Clinical Trials

Do you have your NPI? National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007. Every health care provider needs to get an NPI. Learn more about the NPI and how to apply for an NPI by visiting http://www.cms.hhs.gov/NationalProvIdentStand/ on the CMS Web site.

Provider Types Affected
Physicians, suppliers, and providers billing Medicare contractors (carriers and fiscal intermediaries (FIs))

Provider Action Needed

STOP - Impact to You
The Centers for Medicare & Medicaid Services (CMS) is updating the modifier used for claims for islet cell transplantation and for routine follow-up care related to the transplantation in NIH-sponsored clinical trials.

CAUTION - What You Need to Know
Please note that effective for islet cell transplantation and routine follow-up services related to the islet cell transplantation on or after May 1, 2006, the QV modifier is no longer valid. The QR modifier (item or service provided in a Medicare-specified study) will replace the QV modifier for services on or after May 1, 2006.

GO - What You Need to Do
Refer to the Background and Additional Information sections of this article for more information. Be ready to use the new QR modifier for payment of islet cell transplantation and routine follow-up care when appropriate.

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

Background
As a result of section 733 of the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) (P.L.108-173), for services performed/discharges on or after October 1, 2004, Medicare covers islet cell transplantation for patients with Type I diabetes who are participating in an NIH-sponsored clinical trial. The islet cell transplantation may be done alone or in combination with kidney transplantation.

Additional Information
Effective for services on or after May 1, 2006, Medicare will accept the QR modifier for payment on claims for patients who participate in an NIH-sponsored clinical trial in conjunction with:

For additional information, please refer to MM3385, "MMA-Billing Requirements for Islet Cell Transplantation for Beneficiaries in a National Institutes of Health (NIH) Clinical Trial," which can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3385.pdf on the CMS Web site.

Also, refer to the Medicare National Coverage Determinations Manual, publication 100-03, Chapter 1, Part 4, Section 260.3.1 "Islet Cell Transplantation in the Context of a Clinical Trial (Effective October 1, 2004)," located at http://www.cms.hhs.gov/manuals/downloads/ncd103c1_Part4.pdf on the CMS Web site.

CR5140 is the official instruction issued to your Medicare carrier or FI regarding changes mentioned in this article, and the manual attachment to CR5140, the Medicare Claims Processing Manual, Publication 100-4, Chapter 32, "Billing Requirements for Special Services," Section 70 "Billing Requirements for Islet Cell Transplantation for Beneficiaries in a National Institutes of Health (NIH) Clinical Trial." CR5140 may be found at http://www.cms.hhs.gov/Transmittals/downloads/R986CP.pdf on the CMS Web site.

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

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Changes Conforming to Change Request 3648 (CR3648) for Therapy Services

Note: This article was revised on June 15, 2006, to reflect changes made to CR4014, which was re-issued on June 14, 2006. The transmittal number, CR release date (see above), and the Web address for viewing CR4014 were revised. All other information remains the same.

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 therapy services

Provider Action Needed

STOP - Impact to You
This article is based on Change Request (CR) 4014, which updates language in the Medicare National Coverage Determinations Manual (Publication 100-03) and the Medicare Claims Processing Manual (Publication 100-04) by changing the term "speech therapy" to "speech-language pathology."

CAUTION - What You Need to Know
To conform to changes in CR3648, CR4014 removes from the Medicare Claims Processing Manual (Publication 100-04) the requirement to include the date last seen by a physician for outpatient services provided by a physical or occupational therapist or speech-language pathologist. Requirements for therapy services incident to a physician have not been changed.

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) is updating language in the Medicare National Coverage Determinations (NCD) Manual (Publication 100-03) and the Medicare Claims Processing Manual (Publication 100-04) as follows: The term "speech therapy" is being changed to "speech-language pathology."

In addition, CMS is changing requirements in Chapter 1 of the Medicare Claims Processing Manual where therapists are to provide information on CMS-1500 (Health Insurance Claim Form) and the UB-92 claim form concerning the date last seen by the physician to conform with instructions in CR3648, Transmittal 36, dated June 24, 2005; subject: Publication 100-02, Chapter 15, Sections 220 and 230 Therapy Services. CR3648 can be found at http://www.cms.hhs.gov/Transmittals/downloads/R36BP.pdf on the CMS Web site.

Health Insurance Portability and Accountability Act (HIPAA) guidelines require the following information only when it impacts the payer's adjudication process:

Medicare payment is not impacted by this information except when the service is provided "incident to" the services of a physician's or non-physician practitioner's (NPP), in which case it is required. CR4014 updates instructions in CR3648 (related to claims for services "incident to" a physician's/NPP's service) by acknowledging that:

CR4014 also clarifies selected business requirements in CR3648 to indicate that some contractor actions:

CR3648 omitted the requirement for a physician visit when therapy services are billed. This change omits the requirement that the physician visit be documented on the claim.

This change does not affect the requirements for services billed "incident to" a physician.

Therefore, when a therapy service is billed "incident to," the following requirements remain in effect because they are required by "incident to" policies:

Implementation
The implementation date for this instruction is October 2, 2006.

Additional Information
CR3648 (Transmittal 36 dated June 24, 2005, subject Pub. 100-02, Chapter 15, Sections 220 and 230 Therapy Services) can be reviewed at http://www.cms.hhs.gov/manuals/pm_trans/R36BP.pdf on the CMS Web site.

The MLN Matters article, MM3648 can be viewed at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3648.pdf on the CMS Web site.

For complete details, please see the official instructions (CR4014) issued to your carrier/intermediary regarding this change. There are two transmittals for CR4014, the NCD, transmittal 55 is available at http://www.cms.hhs.gov/Transmittals/downloads/R55NCD.pdf. Transmittal 941 is the Medicare Claims Processing Manual update, which is available at http://www.cms.hhs.gov/Transmittals/downloads/R980CP.pdf on the CMS 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/MLNProducts/downloads/CallCenterTollNumDirectory.zip
on the CMS Web site.

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Claim Status Category Code and Claim Status Code Update

Provider Types Affected
Physicians, providers, and suppliers who submit 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) 5137, which provides the October 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 10/06" designation and prior dates, and they must inform affected providers of the new codes. CR5137 applies to Chapter 31 of the Medicare Claims Processing Manual, 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
Please refer to 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, and so on). Further detail is provided 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. The Committee meets at the beginning of each X12 trimester meeting and makes decisions about additions, modifications, and retirement of existing codes.

The updated Claim Status Category and Claim Status codes list is posted three times a year (after each Health Care Code Maintenance Committee X12 trimester meeting) at the Washington Publishing Company Web site at http://www.wpc-edi.com/codes. At this 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 June 2006 are to be listed to this Web site approximately thirty (30) days after the meeting concludes. For this update, Medicare will begin using the codes in place as of October 2006 in claim status responses issued on or after October 2, 2006.

Implementation
The implementation date for this instruction is October 2, 2006.

Additional Information
For complete details, please see CR5137, the official instruction issued to your Medicare carrier/DMERC or FI/RHHI regarding changes mentioned in this article. CR5137 may be found at http://www.cms.hhs.gov/Transmittals/downloads/R987CP.pdf on the CMS Web site.

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

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Clinical Laboratory Improvement Amendments

The Clinical Laboratory Improvement Amendments (CLIA) brochure has been updated and is now available in downloadable format on the Medicare Learning Network's (MLN) Products page located at http://www.cms.hhs.gov/MLNProducts/downloads/CLIABrochure.pdf

The brochure includes an overview of CLIA, why it is important, how test methods are categorized, enrollment information, as well as information regarding the five types of laboratory certificates. A hard copy of the brochure will be available early this summer and will be available for ordering on the MLN Publications Page at http://www.cms.hhs.gov/MLNProducts/MPUB/list.asp

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CMS Announces Proposed Changes To Physician Fee Schedule Methodology Substantial Increases In Payments For Time Spent With Patients

The Centers for Medicare & Medicaid Services (CMS) issued a notice proposing changes to the Medicare Physician Fee Schedule (MPFS) that will improve the accuracy of payments to physicians for the services they furnish to Medicare beneficiaries. The proposed notice includes substantial increases for "evaluation and management" services, that is, time and effort that physicians spend with patients in evaluating their condition, and advising and assisting them in managing their health. The changes reflect the recommendations of the Relative Value Update Committee (RUC) of the American Medical Association.

The proposed notice will appear in the June 29 Federal Register. Comments will be accepted until August 21, 2006. CMS responses to public comments on the proposals in this notice will be combined with those for the upcoming MPFS notice of proposed rulemaking in a final MPFS rule scheduled for publication this fall. If adopted, the RVU revisions in this proposed notice would be fully implemented for services to Medicare beneficiaries on or after January 1, 2007, while the practice expense revisions would be phased in over a four-year period.

To view the entire press release, go to http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1887 .
To view the display copy of the proposed notice (CMS-1512-PN), go to http://www.cms.hhs.gov/PhysicianFeeSched/PFSFRN/itemdetail.asp?filterType=none&filterByDID=0&sortByDID=4&sortOrder=descending&itemID=CMS1183724 .

To view more MPFS information, go to http://www.cms.hhs.gov/PhysicianFeeSched/ on the CMS Web site.

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Correction to CR4136: New Waived Tests

CR5131 corrects an incorrect Current Procedural Code (CPT) mentioned in the third sentence of the second paragraph in the background section of the Recurring Update Notification attachment for CR4136. Only this sentence has been revised. All other information remains as it is written in CR4136.

Provider Types Affected
All providers and suppliers billing Medicare carriers for laboratory tests

Background
CR5131 corrects an incorrect Current Procedural Code (CPT) mentioned in the third sentence of the second paragraph in the background section of the Recurring Update Notification attachment for CR4136.

Key Points
This article and CR5131 identifies the correction issued by the Centers for Medicare & Medicaid Services (CMS) regarding the "Waived Tests:"

Implementation
The effective date for this instruction was January 1, 2006, and the correction by CR5131 will be implemented on July 24, 2006.

Additional Information
The official instruction, CR5131, issued to your Medicare carrier regarding this change can be found at
http://www.cms.hhs.gov/transmittals/downloads/R988CP.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/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

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Ending the HIPAA Contingency for Remittance Advice

Provider Types Affected
All providers and suppliers who bill Medicare contractors (carriers, including durable medical equipment regional carriers (DMERCs), DME Medicare Administrative Contractors (DME MACs), and fiscal intermediaries (FIs), including regional home health intermediaries (RHHIs))

What You Need to Know
Effective October 1, 2006, Medicare will send only HIPAA-compliant Electronic Remittance Advice (ERA) transactions (transaction 835 version 004010A1) to all electronic remittance advice receivers.

Background
In 2003, the Centers for Medicare & Medicaid Services (CMS) addressed compliance with the HIPAA transaction and code sets, and encouraged health plans (such as Medicare) to:

Consistent with that guidance, Medicare has aggressively worked with providers to achieve HIPAA compliance. Effective October 16, 2003, in order to ensure the continuation of normal program operations, CMS implemented a contingency plan through which Medicare continued to accept and send both HIPAA-compliant and non-HIPAA transactions from/to trading partners.

CMS ended the contingency plan that addressed inbound claims on October 1, 2005, and at that time began denying non-compliant electronic claims.

Now, CMS is moving to end the contingency plan for Electronic Remittance Advice (ERA) transactions. Currently, 99% of all Electronic Remittance Advice (ERA) receivers (providers, clearinghouses, billing agencies, and others who receive ERAs on behalf of providers) are receiving the HIPAA compliant ERA.

Further, the overall compliance rate for all Medicare providers in May, 2006, was 96%. (The rate for professional providers was 97% and for institutional providers was 93%.)

Therefore, CMS announces that, effective October 1, 2006, it will end the contingency plan for the remittance advice transaction.

After that date, your carriers, FIs, DMERCs, DME MACs, and RHHIs will send only HIPAA-compliant remittance advice (transaction 835) to all electronic remittance advice receivers. In doing so, Medicare will stop sending electronic remittance advice in any version other than the standard HIPAA version (835 version 004010A1), or in any other format (e.g., NSF).

Additional Information
You can find more information about HIPAA at
http://www.cms.hhs.gov/HIPAAGenInfo/ on the CMS Web site.

If you have any questions, please contact your Medicare contractor at their tollfree number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

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Fundus Photography - LCD Revision

The LCD for Fundus Photography has been revised for Tennessee (L6471), North Carolina (L21247), and Idaho (L19583) to add additional ICD-9's. Please view the CIGNA Government Service Web site at http://cignagovernmentservices.com to view the policy in its entirety for your particular state.

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Healthcare Common Procedure Coding System (HCPCS) Correction for the Caffeine Halothane Contracture Test for Malignant Hyperthermia Susceptibility

Provider Types Affected
Providers billing Medicare carriers for laboratory tests

Provider Action Needed

STOP - Impact to You
Effective January 1, 2006, you do not have to include a Clinical Laboratory Improvement Amendments (CLIA) number on claims that you submit for HCPCS code 89049 [Caffeine halothane contracture test (CHCT) for malignant hyperthermia susceptibility, including interpretation and report].

CAUTION - What You Need to Know
CR5113 provides that HCPCS code 89049 is not considered a test under CLIA. Therefore, performing this test does not necessitate that a facility have any CLIA certificate, nor require a CLIA number on claims for its use.

GO - What You Need to Do
Make sure that your billing staffs are aware that they do not have to include a CLIA number on claims for CHPCS code 89049.

Background
The CLIA regulations require a facility to be appropriately certified for each test that it performs. Therefore, laboratory claims are currently edited at the CLIA certificate level to ensure that Medicare and Medicaid only pay for laboratory tests that are performed in facilities with valid, current CLIA certificates.

This being said, CR5113, from which this article is taken, notifies carriers of one HCPCS correction for code 89049 [Caffeine halothane contracture test (CHCT) for malignant hyperthermia susceptibility, including interpretation and report]. While, currently, HCPCS code 89049 is subject to CLIA edits and has a laboratory certification (LC) code of 610 (histopathology), CR 5113 provides that this HCPCS code is not considered a test under CLIA.

Therefore, effective January 1, 2006, carriers will remove CLIA edits for HCPCS code 89049, including the LC code 610, and will not require a CLIA number on claims submitted by facilities for the HCPCS code 89049.

You should be aware that your carriers are not required to search their files to either retract payment or retroactively pay claims processed before this change is made. However, they will adjust claims brought to their attention.

Additional Information
You can find more information about billing for HCPCS code 89049 [Caffeine halothane contracture test (CHCT) for malignant hyperthermia susceptibility, including interpretation and report] by going to CR5113, located at http://www.cms.hhs.gov/Transmittals/downloads/R984CP.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/MLNProducts/downloads/CallCenterTollNumDirectory.zip

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Instructions for Provider Notification - Announcement of Competitive Acquisition Program CAP; for Part B Drugs and Biologicals Beneficiary Fact Sheet

Visit http://www.cms.hhs.gov/CompetitiveAcquisforBios/02_infophys.asp#TopOfPage and scroll to the bottom of the page to download the Beneficiary Fact Sheet for the Competitive Acquisition Program (CAP) for Part B Drugs and Biologicals. Physicians who elect to participate in the CAP are required to provide the CAP Beneficiary Fact Sheet to Medicare beneficiaries who are receiving certain Part B physician-administered drugs.

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July 2006 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing File, Effective July 1, 2006, and Revisions to January 2006 and April 2006 Quarterly ASP Medicare Part B Drug Pricing Files

Provider Types Affected
Physicians, providers, and suppliers who submit Part A or Part B Fee-for-Service claims to Medicare contractors (fiscal intermediaries (FIs) including regional home health intermediaries (RHHIs), and carriers including durable medical equipment regional carriers (DMERCs)) for services.

Provider Action Needed

STOP - Impact to You
CR5110 provides notice of the updated payment allowance limits for Medicare Part B drugs, effective July 1, 2006, through September 30, 2006, as well as revised payment files for the January 2006, and April 2006 Quarterly ASP Medicare Part B Drug Pricing Files.

CAUTION - What You Need to Know
Certain Medicare Part B drug payment limits have been revised and the Centers for Medicare & Medicaid Services (CMS) updates the payment allowance quarterly. The revised payment limits included in the revised ASP and Not Otherwise Classified (NOC) payment files supersede the payment limits for these codes in any publication published prior to CR5110.

GO - What You Need to Do
Make certain that your billing staffs are aware of this change.

Background
According to Section 303(c) of the Medicare Modernization Act of 2004 (MMA), CMS will update the payment allowances for Medicare Part B drugs on a quarterly basis.

As mentioned in previous articles (see MM4319 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4319.pdf), beginning January 1, 2005, Part B drugs (that are not paid on a cost or prospective payment basis) are paid based on 106 % of the average sales price (ASP).

Pricing for compounded drugs is performed by the local Medicare contractor.

ESRD Drugs
Additionally, in 2006, all ESRD drugs furnished by both independent and hospitalbased ESRD facilities, as well as specified covered outpatient drugs, and drugs and biologicals with pass-through status under the OPPS, are paid based on the ASP methodology.

The ASP methodology is based on quarterly data submitted to CMS by manufacturers. CMS will supply Medicare contractors with the ASP drug pricing files for Medicare Part B drugs on a quarterly basis.

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Lumbar Artificial Disc Replacement (LADR)

Provider Types Affected
All physicians and providers who bill Medicare carriers and fiscal intermediaries (FIs) for LADR

Providers Action Needed
This article and Change Request (CR) 5057 provide specific information regarding the new national coverage determination (NCD) for LADR. The message is three pronged:

  1. Effective May 16, 2006, the LADR with the Charite lumbar artificial disc is not covered by Medicare for beneficiaries over 60 years of age, i.e., on or after the beneficiary's 61st birthday;
  2. Medicare coverage under the investigational device exemption (IDE) and/or clinical trial policy for other lumbar artificial discs is not impacted by this decision and such coverage continues if the billing requirements are met and the appropriate codes are submitted; and
  3. For patients 60 years of age and younger, there is no NCD, leaving such determinations to continue to be made by the local contractors.

Background
The Centers for Medicare & Medicaid Services (CMS), upon completion of a national coverage analysis (NCA) for LADR, determined that LADR with the Charite lumbar artificial disc is not reasonable and necessary for Medicare patients over 60 years of age and is, therefore, non-covered for this patient population. For Medicare beneficiaries 60 years of age and younger, there is no NCD, leaving such determinations to be made by the local Medicare carrier or FI. This NCD focuses on the LADR with the Charite lumbar artificial disc because it is the only United States Food and Drug Administration (FDA) approved lumbar artificial disc at this time. The FDA has approved the use of the Charite artificial disc for spine arthroplasty in skeletally mature patients with degenerative or discogenic disc disease (DDD) at one level for L4 to S1.

The addition of section 150.10 of Pub.100-03 is an NCD. NCDs are binding on all carriers, FIs, quality improvement organizations, qualified independent contractors, the Medicare Appeals Council, and administrative law judges (ALJs) (see 42 CFR section 405.1060(a)(4), effective May 1, 2005). An NCD that expands coverage is also binding on a Medicare advantage organization. In addition, an ALJ may not review an NCD. (See section 1869(f)(1)(A)(i) of the Social Security Act.)

Billing Requirements
The following are the billing requirements for LADR according to the revised Medicare Claims Processing Manual, Chapter 32, Section 170, which is effective May 16, 2006.

Information for Providers Billing Carriers

Information for Providers Billing FIs
For patients over 60 years of age, claims submitted with ICD-9 CM procedure code 84.65 (Insertion of total spinal disc prosthesis, lumbosacral) is never payable and will be denied unless performed under an approved IDE/clinical trial.

For patients over 60 years of age for procedures performed under the IDE/clinical trial and approved by the contractor, the FI will pay for LADR only when submitted with ICD-9 procedure code 84.65 with condition code 30 and diagnosis code V70.7 when submitted on type of bill (TOB) 11X.

Medicare Summary Notice (MSN) and Claim Adjustment Reason Code Messages for Denied Claims

Implementation
The implementation date for this instruction is July 17, 2006, for claims submitted to carriers and October 1, 2006, for claims submitted to Medicare FIs. But, in both instances, the change applies to services provided on or after May 16, 2006.

Additional Information
The official instructions issued to your Medicare carrier and intermediary regarding this change are in two transmittals for CR5057. Transmittal R60NCD contains the NCD instructions and can be found at http://www.cms.hhs.gov/Transmittals/downloads/R60NCD.pdf on the CMS Web site. The claims processing instructions are in Transmittal R992CP, which is at http://www.cms.hhs.gov/Transmittals/downloads/R992CP.pdf.

If you have questions, please contact your Medicare intermediary or 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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Medicare Contractor Annual Update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)

Provider Types Affected
Physicians, suppliers, and providers billing Medicare contractors (carriers, durable medical equipment regional carriers (DMERCs), and fiscal intermediaries (FIs) including regional home health intermediaries (RHHIs))

Provider Action Needed

STOP - Impact to You
Medicare has issued the annual update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9- CM) to Medicare contractors. This update will apply for claims with service dates on or after October 1, 2006, as well as discharges on or after October 1, 2006, for institutional providers.

CAUTION - What You Need to Know
An ICD-9-CM code is required for all professional claims, e.g., physicians, non-physician practitioners, independent clinical diagnostic laboratories, occupational and physical therapists, independent diagnostic testing facilities, audiologists, ambulatory surgical centers (ASCs), and for all institutional claims, but is not required for ambulance supplier claims.

GO - What You Need to Do
Be ready to use the updated codes on October 1, 2006. Please refer to the Background and Additional Information sections of this article for further details regarding this instruction.

Background
This instruction is a reminder that Medicare carriers, DMERCs, FIs, and RHHIs will use the annual International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding update effective for:

Implementation
The implementation date for this instruction is October 2, 2006.

Additional Information

Publication of ICD-9-CM Codes

The ICD-9-CM codes are updated annually as stated in the Medicare Claims Processing Manual, Pub. 100-04, Chapter 23 (Fee Schedule Administration and Coding Requirements), Section 10.2 (Relationship of ICD-9 CM Codes and Date of Service). Chapter 23 may be accessed at http://www.cms.hhs.gov/manuals/downloads/clm104c23.pdf on the CMS Web site.

To view CR5142, the official instruction issued to your Medicare carrier/DMERC or FI/RHHI, regarding changes mentioned in this article. CR5142 may be found at http://www.cms.hhs.gov/Transmittals/downloads/R990CP.pdf on the CMS Web site.

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

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Modifications to Online Medicare Secondary Payer Questionnaire: This CR Rescinds and Replaces CR4098

Provider Types Affected
Medicare physicians/providers/suppliers that, upon providing services to a Medicare patient, use a questionnaire to determine other insurance coverage that may be primary to Medicare

Provider Action Needed

STOP - Impact to You
Questions have arisen over Part V of the model Medicare Secondary Payer Questionnaire.

CAUTION - What You Need to Know
CR5087 provides clarification regarding Part V, provides major revisions to other parts of the model Medicare Secondary Payer Questionnaire, and rescinds and replaces CR4098.

GO - What You Need to Do
You should replace any previous versions of the model questionnaire with the new version, available as an attachment to CR5087.

Background
In 1980, Congress enacted provisions that made Medicare the secondary payer to certain additional primary plans (group health plans, workers' compensation plans, liability insurance, or no-fault insurance). To help you identify such Medicare Secondary Payer (MSP) situations, CMS has developed a model Medicare

Secondary Payer Questionnaire (found in IOM 100.05 (Medicare Secondary Payer Manual) Chapter 3, Section 20.2.1). You can use this model questionnaire as a guide, at each inpatient and outpatient admission, to help identify other payers that may be primary to Medicare.

CR4098 (released October 21, 2005) made changes to this model questionnaire that have generated several questions, specifically regarding PART V (Disability). In response, CR 5087 (from which this article is taken) incorporates the changes that were made in CR 4098, modifies the changes previously made to PART V to address the questions that have arisen, and makes additional changes to other parts of the model questionnaire to improve the wording and sequencing of questions in these parts.

The changes to the model questionnaire are too numerous to list here. As such, please refer directly to the revised section in the Medicare Secondary Payer (MSP) Manual, Chapter 3 (MSP Provider, Physician, and Other Supplier Billing Requirements), Section 20.2.1 (Admission Questions to Ask Medicare Beneficiaries) which contains the complete, updated model questionnaire. The changes are identified in redline and italics.

Please keep in mind the following:

  1. This questionnaire is a model. Other questions may be added to help identify other payers that may be primary to Medicare.
  2. If you choose to use this model questionnaire, please be aware that it was developed to be used in sequence.

The Instructions listed after the questions are to direct the patient to the next appropriate question to facilitate transition between questions.

Additional Information
You can find more information about the Medicare Secondary Payer Questionnaire by viewing CR5087 at
http://www.cms.hhs.gov/Transmittals/downloads/R53MSP.pdf. Attached to the CR is the revised section of the Medicare Secondary Payer (MSP) Manual, Chapter 3 (MSP Provider, Physician, and Other Supplier Billing Requirements), Section 20.2.1 (Admission Questions to Ask Medicare Beneficiaries) which contains the complete, updated model questionnaire.

If you have any questions, please contact your carrier (including durable medical equipment regional carrier), fiscal intermediary, or regional home health intermediary at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

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New Current Procedural Terminology (CPT) Code

Provider Types Affected
All Medicare providers

Provider Action Needed

STOP - Impact to You
Effective July 1, 2005, Medicare carriers and intermediaries must use the new Current Procedural Terminology (CPT) code 90714 (Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, for use in individuals seven years or older, for intramuscular use) for services previously billed under CPT code 90718.

CAUTION - What You Need to Know
Effective for services on or after July 1, 2005, if you do not use the new Current Procedural Terminology (CPT) code, 90714, reimbursements may be impacted. CR4222 provides notification of this new CPT code for tetanus and diphtheria toxoids (see table below).

GO - What You Need to Do
Make sure that your billing staffs are aware of this new CPT code.

Background
Effective July 1, 2005, the following vaccine CPT code is being added to the CPT system.

CPT Code Short Descriptor Long Descriptor
90714 Td vaccine no prsrv >/= 7 im Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, for use in individual seven years or older, for intramuscular use

Note: Your carriers and fiscal intermediaries will assign the CPT code (90714) to status indicator "E" in the Medicare Physician Fee Schedule Database. Deductible and coinsurance apply.

Effective July 1, 2005:

Additional Information
Medicare will not search its files to retract payment for claims already paid or to retroactively pay claims. However, carriers/intermediaries will adjust claims brought to their attention.

The official instruction issued to your carrier/intermediary is available at http://www.cms.hhs.gov/Transmittals/downloads/R910CP.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 athttp://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

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Non-Autologous Blood Derived Products for Chronic Non-Healing Wounds

Provider Types Affected
Physicians, providers and suppliers submitting claims to Medicare carriers, fiscal intermediaries (FIs) and/or regional home health intermediaries (RHHIs) for chronic non-healing wound related services furnished to Medicare beneficiaries.

Impact on Providers
This article is based on Change Request (CR) 5123 which instructs Medicare contractors (carriers, FIs, and RHHIs) that claims submitted for becaplermin, a self-administered, non-autologous growth factor for chronic, non-healing, subcutaneous wounds will remain non-covered.

Becaplermin, Healthcare Common Procedure Coding System (HCPCS) S0157, is nationally non-covered because it is usually self-administered by the patient.

Background
After releasing a national non-coverage determination (NCD) on Autologous Blood-Derived Products for Chronic Non-Healing Wounds in December of 2003, an error was printed in the NCD Manual.

To correct that error, the Centers for Medicare & Medicaid Services (CMS) is revising section 270.3 of the National Coverage Determinations (NCD) Manual (Publication 100-03, Chapter 1, Part 3, "Blood-Derived Products for Chronic Non- Healing Wounds") to accurately reflect the payment policy for non-autologous blood derived products for chronic non-healing wounds, effective April 27, 2006.

In this revision, the following sentence is being deleted:
"Coverage for treatments utilizing becaplermin, a non-autologous growth factor for chronic non-healing subcutaneous non-healing wounds, will remain at local carrier discretion. Becaplermin is approved by the Food and Drug Administration." The correct statement should read:
"Coverage for treatments utilizing becaplermin, a non-autologous growth factor for chronic non-healing subcutaneous wounds, will remain nationally non-covered under Part B based on §1861(s)(2)(A) and §1861(s)(2)(B) because this product is usually self-administered by the patient."

While CMS makes every effort to provide accurate and complete information, the erroneous coverage statement printed in the NCD Manual regarding nonautologous blood-derived products was not intended, and is not part of the Decision Memorandum (DM) posted on December 15, 2003. Non-autologous blood-derived products are not in the same class as the products referred to in the December 15, 2003, DM.

NCDs are binding on all carriers, FIs, quality improvement organizations, health maintenance organizations, qualified independent contractors, the Medicare Appeals Council, and administrative law judges (ALJs) (see 42 CFR 405.1060)(a)(4), effective May 1, 2005). An NCD that expands coverage is also binding on a Medicare advantage organization. In addition, an ALJ may not review an NCD (see section 1869(f)(1)(A)(i) of the Social Security Act).

Additional Information
CR5123 is the official instruction issued to your Medicare carrier or FI/RHHI regarding changes mentioned in this article. There are two transmittals for CR5123. Transmittal 59, containing the NCD revision, is available at http://www.cms.hhs.gov/Transmittals/downloads/R59NCD.pdf on the CMS Web site. Transmittal 977, containing the Medicare claims processing instructions, is at http://www.cms.hhs.gov/Transmittals/downloads/R977CP.pdf on the CMS Web site.

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

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Non-Physician Practitioner (NPP) Payment for Care Plan Oversight (CPO)

Provider Types Affected
Non-Physician Practitioners (NPPs) and suppliers billing Medicare carriers for home health CPO services

Provider Action Needed

STOP - Impact to You
This article is based on Change Request (CR) 4374 which clarifies the policy associated with NPPs billing for physician home health care plan oversight (CPO).

CAUTION - What You Need to Know
The manual revision in CR4374 effectuates a revision to the policy that the same provider that signs the plan of care does not have to be the same provider that bills for physician care plan oversight. Effective January 1, 2005, NPPs must meet certain conditions to be eligible for payment for home health care plan oversight services even though they may not sign the plan of care. This CR clarifies those conditions.
CR4374 clarifies the policy associated with NPPs billing for physician hospice CPO and clarifies the HCPCS codes for CPO. It temporarily waives the requirement to include the Home Health Agency (HHA) or hospice provider number on a CPO claim since there is currently no place on the HIPAA standard ASC X12N 837 professional format to specifically include the HHA or hospice number. CR4374 also states that the physician who bills CPO must be the same physician who signs the plan of care.

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

Background
Physician Care Plan Oversight (CPO) is paid under the Medicare Physician Fee Schedule (MPFS), and due to a provision in the Medicare Claims Processing Manual (Publication 100-04, Chapter 12, Section 180), Non-Physician Practitioners (NPPs) have been prohibited from billing for this service in a home health setting.

The current manual section (Section 180) provides that the physician who signs the plan of care for home health services must be the same person that bills for physician CPO. Since only a physician can sign the plan of care for home health services, NPPs have been unable to bill for physician home health CPO.

Under the Final Physician Fee Schedule Rule, published in the Federal Register on November 15, 2004, nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs), practicing within the scope of state law, may bill for CPO.

The intention of the Centers for Medicare & Medicaid Services (CMS), as outlined in later portions of the Medicare Claims Processing Manual, was to allow NPPs to bill for physician CPO within their state scope of practice. The current inconsistency in Section 180 will not allow NPPs to be paid for this service.

CR4374 revises the policy that states that the same provider that signs the plan of care does not have to be the same provider that bills for physician CPO.

In addition, the Medicare Claims Processing Manual (Publication 100-04, Chapter 11, Section 40.1.3.1) has been revised to clarify CPO billing requirements for beneficiaries who have elected the hospice benefit.

Currently there is no place on the HIPAA standard ASC X12N 837 professional format to specifically include the HHA or hospice number required for a CPO claim. For this reason, the requirement to include the HHA or hospice provider number on a CPO claim is temporarily waived until a new version of this electronic standard format is adopted under HIPAA and includes a place to provide the HHA and hospice provider numbers for CPO claims.

For services furnished on or after January 1, 2005, your carrier will allow NPPs to bill for physician home health CPO even though they cannot 1) certify a patient for home health services and 2) sign the plan of care.

For beneficiaries who have elected the hospice benefit, physicians or NPPs who have been identified by a beneficiary to be his or her attending physician may submit claims for CPO.

Note: For physicians or NPs who are employed by a hospice agency, CPO is not separately payable.
CR4374 instructs your carrier to:

Implementation
The implementation date for CR4374 is October 2, 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/R993CP.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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Oxaliplatin - LCD Revision

The LCD for Oxaliplatin has been revised for Tennessee (L11006), North Carolina (L11360), and Idaho (L13200) to add ICD-9 range 151.00-151.9. Please view the CIGNA Government Services Web site at http://www.cignagovernmentservices.com to view the policy in its entirety for your particular state.

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Payment Allowance Limits for Medicare Part B Drugs

Payment Allowance Limits for Medicare Part B Drugs

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3rd Quarter Update Part B Not Otherwise Classified Drug Fee Schedule

3rd Quarter Update Part B Not Otherwise Classified Drug Fee Schedule

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Prevention Awareness Continues

National Men's Health Week and Father's Day are over, but that doesn't mean that your prevention awareness messages to your patients should stop! CMS invites you to join with us as we strive to close the prevention gap by spreading the word to your patients that Medicare provides coverage for many preventive services and screenings that are meant to prevent disease from developing, detect disease early, identify risks for disease, reduce serious complications and provide early treatment when outcomes are more favorable.

What Can You Do To Help?
We still need your help to ensure that men with Medicare are aware of the many preventive and screening services covered by Medicare and that they are encouraged to take advantage of the preventive services for which they may be eligible. We ask that you:

  1. Become familiar with the preventive services for which Medicare provides payment.
  2. Ensure that your staff is educated about coverage, eligibility, frequency, coding, claim filing, and reimbursement requirements for these services.
  3. Remember to talk with your patients about their risk for disease and the importance and value of prevention, detection, early treatment, and lifestyle modifications.
  4. Encourage appropriate patient utilization of preventive services for which they may be eligible and provide follow-up on all screening results and continue to promote a prevention-oriented lifestyle.

As men increase their knowledge of their risk for disease and the benefits of prevention, they will be able to make more informed decisions about the use of preventive services, treatment options, and appropriate lifestyle modifications.

For More Information...
CMS has developed a variety of educational products and resources to help health care professionals and their staff become familiar with the coverage of and payment for the array of preventive and screening services covered by Medicare.

The MLN Preventive Services Educational Products Web Page provides descriptions and ordering information for all provider specific educational products related to preventive services. The page is located at http://www.cms.hhs.gov/MLNProducts/35_PreventiveServices.asp#TopOfPage on the CMS Web site.

The CMS Web site also has a prevention Web site which contains a section on each of the preventive services. Click on http://www.cms.hhs.gov, select "Medicare," and scroll down to "Prevention." For products to share with your Medicare patients go to www.medicare.gov on the Web. And effective immediately, beneficiaries can find out which regular checkups they may have missed by calling (800) MEDICARE (800) 633.4227 - or by visiting http://www.medicare.gov/health/overview.asp . We hope you will use these resources to assist you in communicating with your patients about Medicare preventive benefits.

Remember — Men's health conditions do not simply affect men. Wives, mothers, daughters, and sisters are all impacted, making men's health a family matter. Encourage your patients to take advantage of Medicare-covered preventive services — it could save their life. Thank you for joining with CMS to spread the message about prevention, early detection, and treatment.

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Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests; Clinical Psychologist Services

Provider Types Affected
Physicians, providers, and/or clinical psychologists who submit claims to Medicare carriers, for diagnostic psychological testing services

Impact on Providers

Background
Diagnostic psychological testing may now be performed under the general supervision of a clinical psychologist. This change may be found in the revised Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services, Section 160 - Clinical Psychologist Services.

As a reminder, to qualify as a clinical psychologist (CP), a practitioner must meet the following requirements:

Implementation
The implementation date for this instruction is September 21, 2006.

Additional Information
The revised Medicare Benefit Policy Manual, Chapter 15-Covered Medical and Other Health Services, Sections 80 and 160-Clinical Psychologist Services, is attached to CR4400, which is the official instruction issued to your carrier regarding this change. CR 4400 may be found by going to http://www.cms.hhs.gov/Transmittals/downloads/R51BP.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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Retired LCD's

The following LCD's have been retired for the following Part B states:

These policies have been replaced with Erythropoetin Analogs for Non-ESRD Use. To view the policy for your specific state, please refer to the CIGNA Government Services or CMS Web site.

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Rules Governing Provider/Clearinghouse Protection of Medicare Beneficiary Eligibility Information

Provider Types Affected
Physicians, providers, suppliers, and clearinghouses who bill Medicare fiscal intermediaries (FIs), carriers, regional home health intermediaries (RHHIs), and durable medical equipment regional carriers (DMERCs), and who use the HIPAA 270/271 beneficiary eligibility transaction data in a real-time environment via the Centers for Medicare & Medicaid Services (CMS) AT&T communication Extranet

Background
CMS is committed to maintaining the integrity and security of health care data in accordance with applicable laws and regulations. Disclosure of Medicare beneficiary eligibility data is restricted under the provisions of the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act of 1996 (HIPAA.)

This article is a reminder to physicians/providers/suppliers of the importance of protecting Medicare beneficiary information and to use it only for authorized purposes. Be sure all your representatives and employees who have authorized access to this information are aware of the importance of protecting that information as well.

Key Points of CR5138
Change Request (CR) 5138 reiterates the responsibilities of users in obtaining, disseminating, and using beneficiary's Medicare eligibility data. The following key points outline those responsibilities:

EDI Enrollment
The Medicare electronic data interchange (EDI) enrollment process must be executed by each physician/provider/supplier that submits/receives EDI either directly to or from Medicare or through a third party, such as a clearinghouse.

Each physician/provider/supplier that uses EDI, either directly or through a billing agent or clearinghouse to exchange EDI transactions with Medicare, must sign the EDI Enrollment Form and submit it to the carrier, DMERC, or FI with whom EDI transactions will be exchanged before any transaction is conducted.

Physicians/providers/suppliers should remember that they agreed to use sufficient security procedures (including compliance with all provisions of the HIPAA security regulations) to ensure that all transmissions of information are authorized and all beneficiary-specific data is protected from improper access. Acting on behalf of the beneficiary, physicians/providers/suppliers/users of Medicare data are expected to use and disclose protected health information according to the CMS regulations. The HIPAA Privacy Rule mandates the protection and privacy of all health information.

Authenticating Data Elements for HIPAA 270/271 Eligibility Data
Authenticating data elements for HIPAA 270/271 Eligibility Data must be provided by the inquirer (physician, provider, supplier, or other authorized third party) prior to the release of any beneficiary-specific eligibility information and must include:

Medicare Beneficiary as First Source of Health Insurance Eligibility Information
The Medicare beneficiary should be your first source of health insurance eligibility information. When scheduling a medical appointment for a Medicare beneficiary, remind them to bring, on the day of their appointment, all health insurance cards showing their health insurance coverage. This will not only help you determine who to bill for services rendered, but also provide you with the proper spelling of the beneficiary's first and last name and identify their Medicare Claim Number as reflected on the Medicare Health Insurance card. It is important to use the name as shown on the Medicare card.

If the beneficiary has Medicare coverage but does not have a Medicare Health Insurance card, encourage them to contact the Social Security Administration at 1.800.772.1213 to obtain a replacement Medicare Health Insurance card. Those beneficiaries receiving benefits from the Railroad Retirement Board (RRB) can call 1.800.808.0772 to request a replacement Medicare Health Insurance card from RRB.

Authorized Purposes for Requesting Medicare Beneficiary Eligibility Information
In conjunction with the intent to provide health care services to a Medicare beneficiary, authorized purposes include the following:

Medicare eligibility data is only to be used for the business of Medicare; such as preparing an accurate Medicare claim or determining eligibility for specific services.

In order to obtain access to eligibility data, as a physician/provider/supplier you will be responsible for the following:

Note: Medicare health benefit beneficiary eligibility inquiries are monitored. Providers identified as demonstrating aberrant behavior (e.g., high inquiry error rate or high ratio of eligibility inquires to claims submitted) may be contacted to verify proper use of the system, made aware of educational opportunities, or when appropriate referred for investigation of possible fraud and abuse or violation of HIPAA privacy law.

Criminal Penalties' Provisions
Remember that a number of statutes provide for severe criminal and civil penalties for misuse of information, including:

  1. Trading Partner Agreement Violation
    42 U.S.C. 1320d-6 authorizes criminal penalties against a person who, "knowingly and in violation of this part ... (2) obtains individually identifiable health information relating to an individual; or (3) discloses individually identifiable health information to another person."
    Offenders shall "(1) be fined not more than $50,000, imprisoned not more than 1 year, or both; (2) if the offense is committed under false pretenses, be fined not more than $100,000, imprisoned not more than 5 years, or both; and (3) if the offense is committed with intent to sell, transfer, or use individually identifiable health information for commercial advantage, personal gain, or malicious harm, be fined not more than $250,000, imprisoned not more than 10 years, or both."
  2. False Claim Act
    Under the False Claims Act, 31 U.S.C. §§ 3729-3733, those who knowingly submit, or cause another person or entity to submit, false claims for payment of government funds are liable for three times the government's damages plus civil penalties of $5,500 to $11,000 per false claim.
  3. Health Insurance Portability and Accountability Act of 1996 (HIPAA)
    HHS may impose civil money penalties on a covered entity of $100 per failure to comply with a Privacy Rule requirement. That penalty may not exceed $25,000 per year for multiple violations of the identical Privacy Rule requirement in a calendar year. A person who knowingly obtains or discloses individually identifiable health information in violation of HIPAA faces a fine of $50,000 and up to one-year imprisonment. The criminal penalties increase to $100,000 and up to five years imprisonment if the wrongful conduct involves false pretenses, and to $250,000 and up to ten years imprisonment if the wrongful conduct involves the intent to sell, transfer, or use individually identifiable health information for commercial