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October 2006 Part B Medicare Bulletin

Posted October 6, 2006

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2007 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments

Attention Physicians and Providers!
Medicare will delay claims payments during the last nine days of fiscal year 2006 (September 22 through September 30). For complete details, see MLN Matters article MM4349 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4349.pdf. Get your Medicare news as it happens!

Provider Types Affected
Physicians and providers submitting claims to Medicare carriers and fiscal intermediaries (FIs) for services provided in HPSAs

Impact on Providers
This article is based on Change Request (CR) 5237, which alerts affected physicians, providers, carriers, and FIs that the new HPSA bonus payment information for 2007 will soon be available.

Background
The Medicare Prescription Drug Improvement and Modernization Act of 2003 (Section 413(b)) mandated an annual update to the automated HPSA bonus payment files, and the Centers for Medicare & Medicaid Services (CMS) creates these new automated HPSA bonus payment files annually.

CR5237 instructs carriers and FIs to use the new HPSA bonus payment file for the automated bonus payment for claims with dates of service on or after January 1, 2007, through December 31, 2007.

In addition, CMS is notifying affected physicians/providers that it will post the new HPSA information to the CMS Web site on or about October 1, 2006.

Implementation
The implementation date for the instruction is January 2, 2007.

Additional Information
For complete details, please see the official instruction issued to your carrier or FI regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1021CP.pdf on the CMS Web site.

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

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Additional Requriements Necessary to Implement to the Revised Health Insurance Claim Form CMS-1500 (08/05)

Additional Requriements Necessary to Implement to the Revised Health Insurance Claim Form CMS-1500 (08/05)

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Attention Skilled Nursing Facilities!

Correction to Skilled Nursing Facility (SNF) Consolidated Billing (CB) Coding File

Provider Types Affected
Physicians and providers billing Medicare carriers for SNF services to Medicare beneficiaries

What You Need to Know
Because claims for the procedure codes in Table 1 below have been processing incorrectly, carriers will begin reopening and reprocessing affected claims, when brought to their attention.

Background
CMS has become aware that claims for the procedure codes listed below, have not been processing correctly. In order to ensure that you receive payment for these procedure codes, CR 5103, from which this article is taken, instructs Medicare carriers to reopen and reprocess these claims, when brought to the carrier’s attention.

Table 1, shown below, displays the procedure codes (and applicable claim dates of service) subject to the overriding of the SNF consolidated billing edit. When brought to their attention, carriers will use the SNF consolidated billing override code to bypass the edits and adjust claims (claims with the dates of service as shown, and processed prior to July 3, 2006) to pay appropriately for these procedure codes.

Table 1
Procedure Codes Subject Reopening and Reprocessing*
Code Date of Service
54150
90471
90472		 92977
93790


On or after April 1, 2001

0019T   On or after January 1, 2002
90871
90918
90919		 90920
90921
92617
On or after January 1, 2003
G0345
J9395
L6697
L6698
L7181		 36818
44137
90467
90468

On or after January 1, 2005
G0375
G0376 		  On or after March 22, 2005
G0372   On or after October 25, 2005

*All processed prior to July 3, 2006

Additional Information
You can find more information about the correction to the skilled nursing facility (SNF) consolidated billing (CB) coding file by going to CR5103, located at http://www.cms.hhs.gov/Transmittals/downloads/R1032CP.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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Clarification on Billing Requirements for Percutaneous Transluminal Angioplasty (PTA) Concurrent with the Placement of an FDA-Approved Carotid Stent


Note: This article was revised on August 28, 2006, to reflect changes made to CR5022, which CMS re-issued on August 25. The transmittal number, CR release date, and Web address for accessing CR5022 were changed. All other information remains the same.

Provider Types Affected
Providers, physicians, and suppliers that bill Medicare contractors (fiscal intermediaries (FIs) and carriers) for their services

Key Points

Background
Percutaneous Transluminal Angioplasty (PTA) involves inserting a balloon catheter into a narrow or occluded blood vessel to recanalize and dilate the vessel by inflating the balloon. The objective of PTA is to improve the blood flow through the diseased segment of a vessel so that vessel patency is increased and embolization is decreased. With the development and use of balloon angioplasty for treatment of atherosclerotic and other vascular stenoses, PTA (with and without the placement of a stent) is a widely used technique for dilating lesions of peripheral, renal, and coronary arteries.

Please refer to the manual attachment to CR5022, Transmittal 53, (Publication 100-03, The Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.7) for more information about the nationally covered indications for PTA concurrent with carotid stent placement, and for facilities accepted for services related to CAS with embolic protection. This is available at http://www.cms.hhs.gov/Transmittals/downloads/R53NCD.pdf on the CMS Web site.

Category B IDE Study Claims and Post-approval Study Claims
Effective for dates of service on or after March 17, 2005, the following claims are not subject to the approved facility list. These are CAS claims:

CAS with Embolic Protection Claims

CAS with embolic protection claims from non-approved facilities will be rejected rather than denied. (CR 3811) • Effective for dates of service on or after March 17, 2005, CAS with embolic protection claims that contain procedure code 37216 (transcatheter placement of intravascular stent(s) without distal embolic protection) will not be paid. CMS has deemed procedure code 37216 a non covered service for Medicare purposes.


Related Links
CR1660, Claims Processing Instructions for Clinical Trials on Carotid Stenting With Category B Investigational Device Exemptions (IDEs) can be found at http://www.cms.hhs.gov/Transmittals/Downloads/AB0174.pdf on the CMS Web site. MM3489, Percutaneous Transluminal Angioplasty (PTA) can be found at the following link http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3489.pdf on the CMS Web site.
MM3811, Expansion of Coverage for Percutaneous Transluminal Angioplasty (PTA) is located at
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3811.pdf on the CMS Web site.

CR5022 is the official instruction issued to your FI or carrier regarding changes mentioned in this article, MM5022. CR5022 may be found by going to Transmittal 911CP at http://www.cms.hhs.gov/Transmittals/downloads/R1042CP.pdf for the claims processing instructions and to Transmittal 53NCD for the NCD Manual section, which is at http://www.cms.hhs.gov/Transmittals/downloads/R53NCD.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/MLNProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.

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Clarification Regarding Effective Dates for Carrier Claim Adjustments: Denied Replacement Defibrillator Claims Lacking a QR Modifier

Provider Types Affected
Providers who bill carriers for Automatic Implantable Cardiac Defibrillator (ICD) services rendered to Medicare beneficiaries

Provider Action Needed

STOP – Impact to You
If you have a claim for a replacement ICD that was denied solely because it lacked a QR modifier, you may request an adjustment for that claim for any date of service for which the replacement ICD was otherwise covered.

CAUTION – What You Need to Know
CR5104 clarifies CR4273 to establish that your carrier will consider any payable date of service when you seek an adjustment of a replacement ICD claim previously denied solely because it did not contain a QR modifier.

GO – What You Need to Do
Make sure that your billing staff are aware that they can seek an adjustment for your replacement ICD claim denied due to lack of the QR modifier for any date of service for which the claim would otherwise have been payable.

Background
CR3604 (Transmittal 497), effective January 27, 2005, gave CMS carriers instructions on how to process Automatic Implantable Cardiac Defibrillator (ICD) claims for services provided under expanded coverage for new indications. One of these instructions was the requirement that the patient be enrolled in a data collection system.

Such patient enrollment is noted on the claim by the QR modifier, which identifies services being covered under a clinical study, and is required as a condition for payment on claims for ICD services rendered as:

To identify these instances, CMS systems maintainers created an edit to check the diagnosis code on the claim. If the diagnosis code was not a secondary prevention diagnosis code, then the QR modifier was required in order to cover the services.

Carriers turned on this edit, effective April 1, 2005. In order to ensure that the QR modifier was being applied to the extent possible to claims for ICD services rendered for the primary prevention of cardiac arrest, carriers were instructed to turn on the original edit such that claims with dates of service prior to April 1, 2005, would also be checked for this modifier as appropriate.

Note: When any of the secondary prevention diagnosis codes appear on an ICD claim, the QR modifier is not required. However, you can append the QR modifier for secondary prevention diagnoses when it is appropriate, i.e., when the data is submitted to a data collection registry.

After CR3604’s publication, CMS became aware of additional possible diagnoses which show neither primary nor secondary prevention of cardiac arrest, for example when the ICD is replaced, due to ICD recall or device complication (such as the end of battery-life).

Since claims such as these should not be denied because they lack a QR modifier, on January 27, 2006, CMS issued CR4273 (Transmittal 819). CR4273 added two new ICD-9-CM diagnosis codes to the list of those that do not require a QR modifier and which do not, by themselves, represent a condition where primary or secondary prevention can be ascertained:

To ensure that replacement ICD claims are not erroneously denied for a lack of QR modifier, the new edit accompanying CR4273 affects claims with dates of service on and after April 1, 2005. However, because the original carrier edit considered all dates of services as it checked for a QR modifier, including dates prior to April 1, 2005, it is possible that there will be replacement ICD claims erroneously denied with dates of service prior to April 1, 2005.

For this reason, when this issue is brought to their attention, Medicare carriers are to consider for possible adjustment all payable dates of service for replacement ICD claims when these claims have been denied solely for the lack of a QR modifier.

CR5104, from which this article is taken, makes this clarification and instructs carriers to inform you that you may have had claims for replacement ICDs erroneously denied for lack of a QR modifier and requiring such an adjustment.

Be aware, however, that the carriers do not have to search their files to retroactively pay claims, nor does this instruction apply to claims submitted to fiscal intermediaries (FIs), who implemented the original and revised edits according to dates of service.

Additional Information
You can find more information about the effective dates for carrier claim adjustments for replacement ICD claims denied because they lacked a QR modifier by going to CR5104, which is available at http://www.cms.hhs.gov/Transmittals/downloads/R971CP.pdf on the CMS Web site.

Additionally, more information about ICD claims may be found in MLN Matters articles MM3604 and MM4273, which you can find at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3604.pdf and
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4273.pdf, respectively.

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 on the CMS Web site.

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Clarifications and Additions to Chapter 19, Indian Health Services (IHS)

Change Request 5230 includes new sections and clarifications to previously released sections of Chapter 19, Indian Health Services (IHS) in the Medicare Claims Processing Manual. This update to Chapter 19 includes documentation pertinent to the fiscal intermediary (FI), carrier and Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for IHS and should be reviewed in its entirety. Documentation for all CMS approved transmittals issued prior to this CR is included in this revision. There are no policy or system changes associated with this CR. All policy and system changes were implemented based upon the implementation date associated with the specific CRs previously released.

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Clinical Laboratory Improvement Amendments (CLIA) Brochure

The updated Clinical Laboratory Improvement Amendments (CLIA) brochure which has been available in a downloadable format is now available in print format on the Medicare Learning Network’s (MLN). A print version of the brochure is available for ordering on the MLN Publications Page at http://www.cms.hhs.gov/MLNProducts/ and access the MLN Products Ordering Page.

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.

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CMS Announces Outreach Conferences for Section 1011 (of the Medicare Modernization Act of 2003): Federal Reimbursement of Emergency Health Services Furnished to Undocumented Aliens

Provider Types Affected
Physicians, hospitals, including Medicare critical access hospitals, Indian Health Service facilities, and ambulance service providers treating patients eligible for payment of Section 1011 of the Medicare Modernization Act of 2003 (MMA).

Provider Action Needed

STOP – Impact to You
You may be eligible for reimbursement for treating certain individuals under Section 1011 of the MMA. This article announces outreach sessions that will help you learn more about this program.

CAUTION – What You Need to Know
As of August 2006, over 15,500 physician and provider enrollment applications have been approved nationwide to participate in the Section 1011 reimbursement process. But, the Centers for Medicare & Medicaid Services (CMS) advises that funds remain available and you may be eligible.

GO – What You Need to Do
CMS has scheduled two national outreach conferences to inform providers of their potential eligibility to participate and to provide more details. See the remainder of this article for details of these sessions and how this program may help you.

Background
Section 1011 of the MMA provides up to $250 million per year for federal fiscal years 2005-2008 for payments to eligible providers for emergency services furnished to:

The covered services are the same as those required by the Emergency Medical Treatment and Labor Act (EMTALA), as well as related hospital inpatient and outpatient services. Providers do not have to be enrolled in the Medicare program to receive Section 1011 eligibility and payments. However, you do have to enroll in the Section 1011 Program by submitting an application to TrailBlazer Health Enterprises, LLC, the national contractor for the Section 1011 Program.

To provide you with more details about this program, Medicare, through TrailBlazer Health Enterprises, is offering two national outreach sessions for the medical community and the general public. Sessions are open to interested registrants in all states. The two sessions scheduled are as follows:

These sessions will include an overview of Section 1011, as well as updates regarding Provider Enrollment, Medical Review, Payment Request Processing and Provider Education and Customer Service related to Section 1011.You may register for either session by going to https://www.TrailBlazerhealth.com/Section1011/CalendarOfEvents/ on the TrailBlazer site.

Additional Information
Additional Information regarding the Section 1011 Program may be found at http://www.cms.hhs.gov/UndocAliens on the CMS Web site.

To learn more details, or to enroll as a provider, visit the TrailBlazer site at http://www.TrailBlazerhealth.com/Section1011 on the Web. You may also reach TrailBlazer by telephone at 1.866.860.1011.

The September 28, 2006, session in Newark, NJ, will also be available via teleconference. In addition, at the above Web site, you will find information on a Web-based training event scheduled for September 13.

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Collection of Fee-for-Service Payments Made During Periods of Managed Care Enrollment (Previously CR2801 Program Memorandum Transmittal AB-03-101) - MANUALIZATION

Note: This article was revised on August 28, 2006, to reflect revisions made to CR5105, which CMS released on August 25, 2006. The Transmittal number, CR release date, and Web address for accessing CR5105 have been changed. All other information remains the same.

Provider Types Affected
Physicians, providers, and suppliers submitting fee-for-service claims to Medicare carriers, durable medical equipment regional carriers (DMERCs), fiscal intermediaries (FIs), and/or regional home health intermediaries (RHHIs) for services furnished to Medicare beneficiaries enrolled in Medicare Advantage (MA) Organizations.

Impact on Providers
This article is based on Change Request (CR) 5105, which was issued to manualize the process that ensures that any duplicate payments for services rendered to Medicare beneficiaries are collected. CR5105 ensures that any fee-for-service claims that were approved for payment during a period when the beneficiary was enrolled in a Managed Care Organization are submitted to the normal collection process used by the Medicare contractors (carriers/DMERCs/FIs) for overpayments.

Background
The Centers for Medicare & Medicaid Services (CMS) pays for a beneficiary’s medical services more than once when a specific set of circumstances occurs. When CMS data systems recognize a beneficiary has enrolled in a MA Organization, the MA Organization receives capitation payments for the Medicare beneficiary. In some cases, enrollments with retroactive payments are processed.

The result is that Medicare may pay for the services rendered during a specific period twice:

Overview of the MA plan Enrollment Process
When an MA plan enrollment is processed retroactively:

In essence, the retroactive enrollment triggers a search for fee-for-service claims that were incorrectly paid for services rendered when the beneficiary was covered by the managed care plan. If such claims are found, the system generates an adjustment and initiation by Medicare systems of overpayment recovery procedures. The current policy/procedures, as outlined in CR2801 (Transmittal AB-03-101, dated July 18, 2003) and CR 5105, dictates that:

Note: CR 2801 (Transmittal AB-03-101, dated July 18, 2003) can be found at http://www.cms.hhs.gov/Transmittals/Downloads/AB03101.pdf on the CMS Web site:

Because of the inherent retroactivity in the enrollment process, (e.g., beneficiaries can enroll in plans up to the last day of the month, and the effective date would be the first of the following month), the CWF may receive this information after the enrollment is effective. For this reason, these kinds of adjustments occur routinely.


A variety of the CMS systems issues over the past 18 months have prompted CMS to recently synchronize MA enrollment and disenrollment information for the period September 2003 to April 2006. As a result, providers may have claims that were affected by this synchronization. For details of the impact of this synchronization on providers, please see MLN Matters article, SE0638, which is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0638.pdf on the CMS Web site.

When claims are identified as needing payment recovery, the related remittance advice for the claim adjustment will indicate Reason Code 24, which states: “Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.” Upon receipt, providers are to contact the managed care plan for payment.

Providers who bill carriers will be alerted by their carrier (via letter or alternate method) of the following:

Note: To associate plan identification numbers with the plan name, go to http://www.cms.hhs.gov/HealthPlansGenInfo/claims_processing_20060120.asp#TopOfPage on the CMS Web site.

In summary, CMS issued CR5105 to:

Instructions for accessing CR5105 are in the Additional Information section of this article.

Implementation
The implementation date for the instruction is June 26, 2006.

Additional Information
For complete details, please see the official instruction issued to your carrier, DMERC, intermediary, or RHHI regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R106FM.pdf on the CMS Web site.

Also, if you have any questions, please contact your carrier/DMERC/intermediary/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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Correction of Business Requirement 4320.19 as Contained in CR4320 Regarding National Provider Identifier Information

Provider Types Affected
Physicians, providers, and suppliers who submit claims to Medicare contractors (carriers, including durable medical equipment regional carriers (DMERCs) and DME Medicare administrative contractors (DME MACs), fiscal intermediaries (FIs), and regional home health intermediaries (RHHIs))

Impact on Providers
This article is based on change request CR5217, which instructs your Medicare carrier/DMERC/DME MAC, or FI/RHHI to provide specific National Provider Identifiers (NPIs) for those providers identified in electronic claims, such as a billing, pay-to, rendering or other provider, that have already obtained NPIs.

Prior to May 23, 2007, providers should report the Medicare legacy identifiers of those providers enrolled to submit claims to Medicare, as well as their NPI.

Note: Pending Medicare implementation of the UB-04 and the revised CMS-1500, providers are not to report NPIs on the current paper claim forms. If not already available, the following information will be posted on your local Medicare contractor’s Web site, or included in provider newsletters from your local Medicare contractor:

Additional Information
CR4320, “Stage 1 Use and Editing of National Provider Identifier Numbers Received in Electronic Data Interchange Transactions, via Direct Data Entry Screens, or on Paper Claim Forms” can be located at http://www.cms.hhs.gov/transmittals/downloads/R204OTN.pdf on the CMS Web site.

MM4320, the similarly titled Medicare Learning Network (MLN) article associated with CR4320, is found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4320.pdf on the CMS Web site.

CR5217 is the official instruction issued to your Medicare carrier/DMERC/DME MAC/FI/RHHI regarding changes mentioned in this article. CR5217 may be found at http://www.cms.hhs.gov/Transmittals/downloads/R235OTN.pdf on the CMS Web site.

If you have questions, please contact your local Medicare carrier/DMERC/DME MAC/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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Correction to Skilled Nursing Facility (SNF) Consolidated Billing (CB) Coding File

Provider Types Affected
Physicians and providers billing Medicare carriers for SNF services to Medicare beneficiaries

What You Need to Know
Because claims for the procedure codes in Table 1 below have been processing incorrectly, carriers will begin reopen and reprocess affected claims, when brought to their attention.

Background
CMS has become aware that claims for the procedure codes listed below, have not been processing correctly. In order to ensure that you receive payment for these procedure codes, CR 5103, from which this article is taken, instructs Medicare carriers to reopen and reprocess these claims, when brought to the carrier’s attention.

Table 1, shown below, displays the procedure codes (and applicable claim dates of service) subject to the overriding of the SNF consolidated billing edit. When brought to their attention, carriers will use the SNF consolidated billing override code to bypass the edits and adjust claims (claims with the dates of service as shown, and processed prior to July 3, 2006) to pay appropriately for these procedure codes.

Table 1
Procedure Codes Subject Reopening and Reprocessing*
Code Date of Service
54150 90471
90472		 92977
93790
On or after April 1, 2001
0019T   On or after January 1, 2002
90871
90918
90919		 90920
90921
92617
On or after January 1, 2003
G0345
J9395
L6697
L6698
L7181		 36818
44137
90467
90468

On or after January 1, 2005
G0375
G0376		   On or after March 22, 2005
G0372   On or after October 25, 2005

*All processed prior to July 3, 2006

Additional Information
You can find more information about the correction to the skilled nursing facility (SNF) consolidated billing (CB) coding file by going to CR5103, located at http://www.cms.hhs.gov/Transmittals/downloads/R1032CP.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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Customer Service Update

To help provide you with the most efficient customer service, CIGNA Government Services Customer Service has implemented an enhancement to the phone system that will route callers to the customer service representative able to answer your call within the shortest wait time. With this system you may talk to a customer service representative located in either our Nashville or High Point office. Please be advised that each of the Customer Service Representatives has access to records and information for all states serviced by the CIGNA Government Services Part B contract and are able to assist you with all of your questions.

Note that your primary resource should be the Interactive Voice Response System, which is available to you during regular business hours and outside regular business hours, except for daily maintenance of the data. CMS requires that items that are available through the Interactive Voice Response System must be accessed through the IVR. The items that are available through the IVR are listed below:

Eligibility (including Medicare HMO)
Deductible
Physical and Occupational Therapy limitations
Claim Status
Allowable information
Outstanding checks
Ordering a duplicate remittance

The IVR selections are constantly being updated to provide additional information. In August, additional information for claim status inquiries was added. In addition to providing the claim payment information, the check number and check date are now available to assist in record reconciliation. To view the full IVR script, please visit http://www.cignagovernmentservices.com, Part B Provider Resources, Interactive Voice Response.

This staff is dedicated to helping the provider community. Therefore, we ask that you not give the provider customer service phone numbers to your patients. They should call 1.800.MEDICARE for assistance, where they will speak with staff specifically trained to assist Medicare beneficiaries.

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End of Contingency for Electronic Remittance Advice (ERA) – ACTION

Attention Physicians and Providers!
Medicare will delay claims payments during the last nine days of fiscal year 2006 (September 22 through September 30). For complete details, see MLN Matters article 4349 at http://www.cms.hhs.gov/MNLMattersArticles/downloads/MM4349.pdf

Provider Types Affected
Providers and physicians who bill Medicare fiscal intermediaries (FIs), regional home health intermediaries (RHHIs), and carriers, including durable medical equipment regional carriers (DMERCs)

Background
The purpose of this Special Edition article is to clarify for providers the information issued by the Centers for Medicare & Medicaid (CMS) regarding the date to end the contingency plan for ERAs.

Key Points
Effective October 1, 2006, Medicare will only generate Health Insurance Portability and Accountability Act (HIPAA) compliant remittance advice – transaction 835 version 004010A1 – to all electronic remittance advice receivers. In addition, CMS - issued instructions in Change Request (CR) 5047 that required a one-time hold of Medicare payments for the period of September 22, 2006, to September 30, 2006, for claims that would have been paid during the last nine business days of fiscal year 2006. (See the MLN Matters article on CR5047 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5047.pdf on the CMS Web site.)

CMS has further instructed that on or after October 1, 2006:

Current figures indicate that 99% of all ERA receivers (providers and other entities that receive the ERA on behalf of providers) are receiving a HIPAA compliant ERA format and they are unaffected by the end of the contingency plan. The remaining 1% of legacy ERA receivers need to transition to a HIPAA-compliant ERA format between now and October 1, 2006. The following are the options available to you as a legacy ERA receiver:

These free software packages are 835 version 004010A1 compatible and will not work with any legacy ERA. Both software packages have important advantages over the SPR. Both packages can also be used to generate a hard copy remittance to be sent for secondary/tertiary billing, and for accounts receivable reconciliation. See the additional information section of this article for MREP details.

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 or a related MLN Matters article (MM4376) at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4376.pdf on the CMS Web site.

For more information about the MREP software and how to receive the HIPAA 835, please contact your FI, RHHI, carrier/DMERC. Medicare Part B Electronic Data Interchange (EDI) helpline phone numbers are available at http://www.cms.hhs.gov/ElectronicBillingEDITrans/Downloads/MedicarePartBEDIHelpline.pdf on the CMS Web site. Those billing for Part A services can find the appropriate toll-free number at http://www.cms.hhs.gov/ElectronicBillingEDITrans/Downloads/MedicarePartAEDIHelpline.pdf on the CMS Web site.

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Important Guidance Regarding National Provider Identifier (NPI) Usage in Medicare Claims

Provider Types Affected
Physicians, providers, and suppliers who conduct HIPAA standard transactions, such as claims and eligibility inquiries

Provider Action Needed

STOP – Impact to You
You must report your NPI correctly on all electronic data interchange (EDI) transactions that you submit, as well as on paper claims you send to Medicare and telephone Interactive Voice Response (IVR) queries by no later than May 23, 2007, or your transactions will be rejected.

CAUTION – What You Need to Know
Carriers have reported errors on claims (see Background, below) that will impact your payment when you begin to submit NPIs. Although not mandated until May 23, 2007, providers are currently allowed to submit NPIs in Medicare transactions other than paper claims. NPI will be accepted on the revised paper claim CMS-1500 (0805) and UB-04 forms early in 2007.

GO – What You Need to Do
Make sure that your billing staffs are using your NPI correctly when they submit your claims for services provided to Medicare beneficiaries or submit electronic beneficiary or claim status queries to Medicare.

Disclaimer
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
All HIPAA-covered healthcare providers who would either bill Medicare; render care to Medicare beneficiaries; order durable medical equipment, supplies, or services for beneficiaries; refer beneficiaries for other health care services; act as an attending physician when a beneficiary is hospitalized; prescribe covered retail prescription drugs for beneficiaries; operate on beneficiaries; or could otherwise be identified on a claim submitted to Medicare for payment must obtain an NPI. This applies whether providers are individuals (such as physicians, nurses, dentists, chiropractors, physical therapists, or pharmacists) or organizations (such as hospitals, home health agencies, clinics, nursing homes, residential treatment centers, laboratories, ambulance companies, group practices, managed care organizations, suppliers of durable medical equipment, pharmacies, etc.) must obtain an NPI for use to identify themselves in HIPAA standard transactions. Although the NPI requirement applies by law to covered entities such as healthcare providers, healthcare clearinghouses, and health plans in the U.S. when exchanging electronic transactions for which a national standard has been adopted under HIPAA, HIPAA permits healthcare plans to elect to require reporting of NPIs in paper claims and for non-HIPAA transaction purposes.

Medicare will also require NPIs for identification of all providers listed on the UB-04 institutional paper claim form and of physicians and suppliers listed on the revised CMS-1500 (08-05) professional paper claim form by May 23, 2007.

Medicare will reject paper claims received after May 22, 2007 that do not identify each provider, physician, or supplier listed on a paper or electronic claim with an NPI. Medicare will also begin to require an NPI in Interactive Voice Response (IVR) queries effective May 23, 2007. Retail pharmacies are required to use the NCPDP format adopted as a HIPAA standard for submission of prescription drug claims to Medicare. Since that format permits entry of only one provider identifier each for a pharmacy and the physician who prescribed the medication, retail pharmacies that use the NCPDP HIPAA format can use either their National Supplier Clearinghouse (NSC) number or their NPI to identify themselves, and either the Unique Provider Identification Number (UPIN) or the NPI to identify the prescribing physician prior to May 23, 2007.

May 23, 2007 and later, only an NPI may be reported for identification of pharmacies and prescribing physicians. NCPDP claims received by Medicare after May 22, 2007 that lack an NPI for either the pharmacy or the prescribing physician will be rejected.

This being said, Medicare carriers and fiscal intermediaries (FIs) have reportedreceiving X12 837-P (professional) and X12-837–I (institutional) claims containing errors that will result in claim rejection, and/or processing delays, if they continue to occur once NPI reporting begins.

Some of the errors seen by Medicare carriers include the following:
Incorrect information in the 2010A/A Billing Provider Loop in X12 837-P Claims Prior to May 23, 2007, carriers will reject claims when the NPI in a loop does not belong to the owner of the Provider Identification Number (PIN) or UPIN that should also be reported in REF02 of the same loop, or if the name and address of the provider in that loop do not correlate with either the NPI, PIN or UPIN in the same loop. The same edits will also be applied to NPIs when received on paper claims prior to May 23, 2007.

Carriers have also detected claims where the rendering physician’s or supplier’s NPI is reported in the 2010A/A NM1 segment when the claim was submitted by a group to which the physician belongs or the home office of a chain to which a supplier belongs. The 2010A/A loop of an 837-P claim must contain the identifier that applies to the groups/chains (NPI entity 2) that submitted the claims. This rule also applies to identification of the billing provider on a paper claim. Information concerning a billing agent or a healthcare clearinghouse may never be reported in the billing provider loop for a Medicare claim.

To prevent this error, you must report the rendering physician’s or supplier’s NPI in the NM109 data element in the rendering provider claim level loop (2310B), unless multiple services were furnished by different members of the group/chain.

If multiple rendering providers were involved, the information for each must be reported in the service level 2420A loop along with the service(s) each of them rendered. To facilitate claim processing prior to May 23, 2007, you should also report the rendering provider(s) PIN(s) as the REF02 data element with 1C in REF01 in that same rendering provider loop (2310B for the claim or 2420A for individual services, as applicable).

Reporting of the Pay-to Address in the Billing Provider (2010A/A) Loop
Once NPI reporting begins, carriers will reject claims when the pay-to-address, if different than the actual practice location address, is in the 2010A/A (billing provider) loop, rather than in the 2010A/B (pay-to-provider) loop.

When groups or organizations submit claims, and the billing and the pay-to providers are different individuals or entities, the pay-to information must always be reported in the 2010A/B loop and the billing provider information in the 2010A/A loop.

Reporting of the Name and Address of a Billing Provider in the 2010A/A Loop of an X12 837-I (Institutional) Electronic Claim
FIs will reject claims in which the billing provider and the rendering provider are different entities, and you report the billing provider’s name and address in the 2010A/A loop of an X12 837-I (institutional) electronic claim, and the OSCAR number of the rendering provider in that same loop.

If the home office of a chain has obtained one NPI for all facilities it owns, or one of a chain’s facilities bills for all (or other) facilities owned by that chain, or a hospital bills for its special units, the home office, hospital or other facility submitting those claims is considered a form of billing agent for Medicare purposes.

In this instance, you must identify the specific provider, for whom the claim is being submitted, as the billing provider for that claim. If a provider that furnished the care had a separate OSCAR number than the entity submitting its claims, the provider that furnished the care must be identified in the billing provider loop. You must also report the name of the facility for whom the claim is being submitted, that facility’s address, and should report applicable NPI (when obtained prior to May 23, 2007), as well as the Medicare OSCAR number assigned to that provider in the 2010A/A (billing provider) loop of the claim.

If the home office, hospital, or other entity that prepared the claim is to be sent payment for the claim, you must report the name and address, and should report the NPI if issued, and the applicable OSCAR number associated with that entity in the 2010A/B (pay-to-provider) loop prior to May 23, 2007.

However, you should note that Medicare will not issue payment to a third party for a provider solely as result of completion of the 2010A/B loop of an electronic claim.

The facility that furnished the care, or the established owner of that facility, must have indicated on their 855 provider enrollment form filed when that facility enrolled in Medicare (or via a subsequent 855 used to update enrollment information) that payments for that facility are to be issued to that home office, hospital, other facility or an alternate third party.

Additional Information
For those providers still permitted to submit any paper claims under the restrictions imposed by the Administrative Simplification Compliance Act, Medicare plans to begin accepting paper claims on the revised CMS-1500 (08-05 version) beginning January 2, 2007 (allowing you to report a provider’s NPI as well as the applicable PIN or UPIN); and on the revised UB-04 (CMS-1450) form beginning March 1, 2007 (allowing you to report a provider’s NPI as well as the applicable OSCAR or UPIN). Medicare carriers plan to reject “old” CMS-1500 forms received after March 31, 2007, and FIs plan to reject UB-92 forms received after April 30, 2007.

Note: Medicare does not accept NPIs on the “old” versions of the CMS-1500 or UB-92 forms. There are no fields on those forms designed for NPI reporting.

CMS highly recommends that for electronic or paper Medicare claims that you submit during the transition period to full NPI implementation on May 23, 2007, you include both the NPI and the Medicare legacy identifier of each provider for whom you report information.

Remember that failure to report information as described here may result in delayed processing or rejection of your claims.

You can find more information about the National Provider Identifier (NPI) by going to the NPI page at http://www.cms.hhs.gov/apps/npi/01_overview.asp on the CMS Web site. In addition, if you have any questions on the NPI, you may call your 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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Independent Laboratory Billing for the Technical Component (TC) of Physician Pathology Services

Attention Providers!
Effective October 1, 2006, Medicare will only generate Health Insurance Portability and Accountability Act (HIPAA) compliant remittance advice transactions—835 version 004010A1—to all electronic remittance advice receivers. For more details, see MLN Matters article SE0656 at
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0656.pdf.

Provider Types Affected
Independent laboratories that bill Medicare carriers Impact of CR5210 on Independent Laboratories
Independent laboratories may not bill for the Technical Component (TC) of physician pathology services furnished to a patient of a hospital after December 31, 2006.

Background
In CR5210, the Centers for Medicare & Medicaid Services’ (CMS) proposes to implement the 1999 final physician fee schedule regulations (at 42 CFR § 415.130).


Prior to this proposal, any independent laboratory could bill the carrier under the physician fee schedule for the TC of physician pathology services for hospital inpatients.

Section 732 of the Medicare Modernization Act (MMA) extended, for 2005 and 2006, the provision of section 542 of the Benefits Improvement Act of 2000 (BIPA) that allowed certain independent laboratories to bill under the physician fee schedule for the technical component of physician pathology services furnished to patients of a covered hospital.

CR5210 instructs Medicare carriers to notify all independent laboratories that they may no longer bill for these services after the MMA provision expires on December 31, 2006.

Implementation
The implementation date for this instruction is December 1, 2006.

Additional Information
To review the related article that extended the provision of Section 542 of the Benefits Improvement Protection Act of 200 (BIPA) for services furnished in 2005 and 2006 go to http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3467.pdf on the CMS Web site.

The official instructions, CR 5210, issued to your Medicare carrier regarding this change can be found at http://www.cms.hhs.gov/Transmittals/downloads/R1046CP.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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Influenza Billing for Part B Medicare and Medicare Advantage Plans

Recently there have been questions regarding Medicare reimbursement for influenza vaccinations and the impact that Medicare Part D may have upon the Medicare providers who bill for these services.  Providers should note that Medicare Part D is a prescription drug program and does not have any impact on billing for influenza vaccinations. 

There are four parts to Medicare: Medicare Part A (Hospital Insurance), Part B (Medical Insurance), Part C (Medicare Advantage) and Part D (Prescription Drug). For health care coverage, Medicare beneficiaries have the option to choose between Traditional Medicare (Part A and Part B) and Medicare Advantage Plans (Part C) which include Medicare Health Maintenance Organizations (HMOs), Medicare Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS), Medicare Provider Sponsored Organizations (PSOs) and Medicare Medical Savings Accounts (MSAs).

Depending on the type of coverage a beneficiary chooses, Medicare providers may be impacted in their billing for influenza vaccinations. There are two possible scenarios listed below:

  1. Traditional Medicare Plan – The beneficiary is covered by Medicare Part B. The patient should present their original red, white, and blue Medicare card used for coverage of the influenza vaccine under Medicare Part B.  Beneficiaries enrolled in the traditional Medicare program may see any Medicare-enrolled provider to obtain their influenza vaccination. The provider should submit the claim for the vaccination and its administration to Medicare Part B for reimbursement.
  2. Medicare Advantage Plan – These plans provide the beneficiary with a membership card that is used in place of their original red, white, and blue Medicare card. The card will indicate which type of plan the patient is enrolled in (i.e., an HMO, PPO, PFFS, etc).  Rules and guidelines of the companies representing the Medicare Advantage plans vary.  For example, a patient enrolled in an HMO or PPO plan may be required to see providers within their plan’s network for their influenza vaccination.  If they obtain their vaccination from a facility or provider outside of their network, it is possible that the Medicare beneficiary may have to pay all or part of the fees charged for the vaccination (this too will vary from plan to plan). When serving beneficiaries enrolled in Medicare Advantage plans, providers may wish to verify the terms and guidelines of the Medicare Advantage plan prior to the service being rendered. In these cases, providers should contact the Medicare Advantage plan directly.

As a reminder, CIGNA Government Services offers a NetCourse entitled “Influenza, Pneumococcal, and Hepatitis B Immunizations” to assist providers in learning more about these immunizations available to Medicare beneficiaries.

NetCourses are online tutorials and training courses available on demand, any time of the day. Each course contains a pre-test and a post-test so you can evaluate your knowledge of the subject. If you feel you missed something, you can go back and review the information at any time the “Influenza, Pneumococcal, and Hepatitis B Immunizations”  NetCourse provides information regarding billing guidelines for three types of Part B covered immunizations - influenza, pneumococcal, and hepatitis B. This interactive course also provides users with helpful resources for finding key Medicare information. Providers may access the complete list of CIGNA Government Services NetCourses at: http://www.cignagovernmentservices.com/Webtraining/logon.asp.

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Laboratory Competitive Bidding Demonstration

Provider Types Affected
Physicians and all providers who bill Medicare carriers and fiscal intermediaries (FIs) for laboratory tests performed for Medicare Part B beneficiaries who live within the competitive bidding demonstration area (CBA) sites

Background
Section 302(b) of the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) requires the Centers for Medicare & Medicaid Services (CMS) to conduct a demonstration project on the application of competitive acquisition for payment of most clinical laboratory services that would otherwise be payable under the Medicare Part B fee schedule.

Under this statute, pap smears and colorectal cancer screening tests are excluded from this demonstration. Requirements under the Clinical Laboratory Improvement Amendments (CLIA), as mandated in section 353 of the Public Health Service Act, are applicable.

The payment basis determined for each CBA will be substituted for payment under the existing clinical laboratory fee schedule. Multiple winners are expected in each CBA.

Key Points
This article and Change Request (CR) 5205 provides instructions for the implementation of a laboratory competitive bidding demonstration. CR5205 is being implemented in multiple phases. The requirements specified in this article and CR5205 are in preparation for the implementation of the demonstration in the first CBA on April 1, 2007.

Required Bidders
Laboratory firms with $100,000 or more in annual Medicare Part B (fee-for-service) payments as of calendar year (CY) 2005 for “demonstration tests” provided to beneficiaries residing in the CBAs (regardless of where the laboratory firm is located) will be required to bid in the demonstration.

These laboratory firms will be referred to as “required bidders.”

Passive Laboratories
Small laboratories or laboratory firms with less than $100,000 in annual Medicare Part B (fee-for-service) payments for demonstration tests provided to beneficiaries residing in the CBAs will not be required to bid in the demonstration. These laboratories are considered “passive” laboratories.” Passive laboratories will be paid the laboratory competitive bidding demonstration fee schedule for demonstration tests provided to beneficiaries residing in the CBA. During the demonstration period, CMS will monitor the volume of services performed by passive laboratories to ensure that their annual payments under Medicare Part B for demonstration tests provided to beneficiaries residing in the demonstration sites do not exceed the annual ceiling of $100,000.

Passive laboratory firms exceeding the annual ceiling of $100,000 will be:

Winners
Both required and non-required bidders that bid and win will be paid the laboratory competitive bidding demonstration fee schedule for demonstration tests provided to beneficiaries residing in the CBAs (regardless of where the laboratory firm is located). These laboratories will be labeled “winners.”

Non-Winners
Both required and non-required bidders that bid and do not win will not be paid anything by Medicare (neither under the Part B clinical laboratory fee schedule nor under the competitively bid price) for demonstration tests provided to beneficiaries residing in the CBAs (regardless of where the laboratory firm is located) for the duration of the demonstration. These laboratories will be labeled “non-winners.”

Similarly, required bidders that do not bid will not be paid anything by Medicare for demonstration tests provided to beneficiaries residing in the CBAs (regardless of where the laboratory firm is located) for the duration of the demonstration.

Non-winner laboratories that furnish a demonstration test to a Medicare beneficiary residing in the CBA during the demonstration have no appeal rights when Medicare payment for the test is denied. Moreover, non-winner laboratories may not charge the beneficiary for Part B laboratory services.

Demonstration-Covered Laboratory Tests
Only the laboratory that performs the test may bill for the service and only winning or passive laboratories are eligible to receive the laboratory competitive bidding demonstration fee schedule payment for services covered under the demonstration.

Although non-winner laboratories may not bill either Medicare or the beneficiary for any demonstration-covered services, such laboratories may refer such services to a winner laboratory or a passive laboratory.

For all other tests (i.e., those not covered under the demonstration or for tests for beneficiaries not residing in the service area), all laboratories will be paid according to the clinical laboratory fee schedule and in accordance with Medicare payment policies.

Demonstration Sites
There are two demonstration sites and each site runs for three years with a staggered start of one year. The demonstration uses Metropolitan Statistical Areas (MSAs) to define the CBAs.

The residence status of beneficiaries will be determined by information in the Medicare system as of the date the claim is processed. The residence of the beneficiary receiving services must be in the same CBA as determined by review of a beneficiary’s zip code of residence.

CMS will provide the contractors with a list of zip codes included in each MSA, which will be used to determine whether a beneficiary’s residence is included in one of the CBAs.

The demonstration will set (competitively bid) fees in the demonstration areas for all tests paid under the Medicare Part B clinical laboratory fee schedule, with the exception of pap smears, colorectal cancer screening tests, and new tests added to the Medicare Part B clinical laboratory fee schedule during the course of the demonstration. Demonstration fees will be set for each service payable under the demonstration in each of the CBAs.

Only CLIA-certified laboratories will be allowed to participate in the demonstration.

Implementation
CR5205 is being implemented in multiple phases. The requirements specified in this instruction are for the implementation of the demonstration in the first CBA (CBA1).

By January 1, 2007, CMS will provide Medicare carriers and fiscal intermediaries (FIs) with a national zip code pricing file identifying the zip codes included in the first CBA. Also, by the same date, CMS will provide to the carriers/FIs a list of the laboratories eligible to participate in the first CBA demonstration (“winners” and passive laboratories) and a list of those laboratories not selected to participate in CBA1.
For covered demonstration laboratory services in CBA1 with dates of service between April 1, 2007, and March 31, 2010, Medicare will pay the laboratory competitive bidding demonstration fee schedule amounts for laboratory services on that schedule. For services not on the demonstration schedule, Medicare will pay based on the clinical laboratory fee schedule.

Claims submitted by non-winner laboratories for dates of service of April 1, 2007, through March 31, 2010, for Medicare beneficiaries in CBA1 will be denied using:

Using these same reason and remark codes, Medicare will reject any laboratory claims with a date of service between April 1, 2007, and March 31, 2010 with a modifier of “90” submitted by laboratories for demonstration-covered services provided to beneficiaries residing in the CBA, regardless of the referring laboratory’s participation status.

Medicare will pay claims during the demonstration period submitted by nondemonstration laboratories for beneficiaries residing in the CBA who receive services outside of those areas (e.g., “snow birds”) according to the laboratory competitive bidding demonstration.

Non-winning laboratories should know that Advance Beneficiary Notices (ABNs) and Notices of Beneficiary Exclusion from Medicare Benefits (NEMBs) are not to be used to transfer liability to beneficiaries when services under the demonstration are obtained at non-winner laboratories.

Line items for demonstration services and for non-demonstration services may be submitted on the same claim.

A subsequent CR will be issued with requirements to implement the demonstration in the second CBA (CBA2).

The demonstration in the first CBA is scheduled to begin on April 1, 2007 and the tentative start date for the demonstration in the second CBA is April 1, 2008.


Remember that required and non-required bidders that bid and lose will be paid nothing under the Part B clinical laboratory fee schedule and will have no appeal rights for demonstration tests provided to beneficiaries residing in the CBAs, regardless of the location of the laboratory itself.

Implementation
The implementation date for this instruction is January 2, 2007.

Additional Information
The official instructions issued to your Medicare carrier/FI regarding this change can be found at http://www.cms.hhs.gov/Transmittals/downloads/R49DEMO.pdf on the CMS Web site.

If you have questions, please contact your Medicare carrier/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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Medicare Part B Drug Competitive Acquisition Program (CAP) Additions to Approved CAP Vendor’s Drug List Effective October 1, 2006; Information On Price File Updates

Attention Physicians and Providers!
Effective October 1, 2006, Medicare will only generate the Health Insurance Portability and Accountability Act (HIPAA) compliant remittance advice – transaction 835 version 004010A1 – to all electronic remittance advice receivers. For more details, see MLN Matters article SE0656 at
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0656.pdf.

Provider Types Affected
Physicians participating in the Medicare Part B Drug CAP

Impact on Providers
This Special Edition article is being provided to inform physicians participating in the CAP program that, effective October 1, 2006, drugs are being added to the CAP drug table.

Background
The list of drugs supplied under the CAP is subject to quarterly updates, and this Special Edition article is being provided by the Centers for Medicare & Medicaid Services (CMS) to inform you of additions to the CAP drug list (Per Change Request (CR) 5079, Business Rules (BRs) 5079.3 and 5079.4. For more details, see the related MLN Matters article, MM5079 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5079.pdf on the CMS site.)

Effective October 1, 2006, the CAP designated carrier will add the drugs listed in the following table to the CAP drug table, and the following Healthcare Common Procedure Coding System (HCPCS) codes will be available through the CAP:

HCPCS Code Descriptor
J3240 INJECTION, THYROTROPIN ALPHA, 0.9 MG, PROVIDED IN 1.1 MG VIAL (trade name Thyrogen®)
J9160 DENILEUKIN DIFTITOX, 300 MCG (trade name: Ontak®)
J9010 ALEMTUZUMAB, 10 MG (trade name Campath®)

An updated CAP drug list which includes the drugs listed above and updates to the NDC codes available through the CAP will be posted on the Approved CAP vendor page of the CMS CAP Web site (http://www.cms.hhs.gov/CompetitiveAcquisforBios/15_Approved_Vendor.asp#TopOfPage) and on the approved CAP vendor’s Web site (http://www.bioscrip.com/) on or about September 1, 2006.

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

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Medicare Part B Versus Part D Drug Coverage Determinations

Provider Types Affected
Physicians, pharmacists, providers, health care professionals, suppliers, and their staff

Impact on Providers
This Special Edition article is being provided by the Centers for Medicare & Medicaid Services (CMS) to assist physicians, providers, other prescribers, and pharmacists to understand CMS’ recommended approach to simplifying and expediting the coverage determination process for Medicare Part B versus
Part D.

Affected physicians, pharmacists, providers, and their staff may also wish to review MLN Matters article number SE0570, which provides a good summary of Medicare’s drug coverage under Parts A, B, and D of Medicare. That article is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0570.pdf on the CMS Web site.

Background
Part B — Medical Insurance Medicare Part B covers drugs that are:

Medicare Part B covers other selected drugs, such as the following:

Regional differences in Part B drug coverage policies can occur in the absence of a national coverage decision. For more information on local coverage determinations, go to http://www.cms.hhs.gov/coverage on the CMS Web site.

Part D — Prescription Drug Insurance Part D-covered drugs are defined as:

• Drugs available only by prescription, approved by the FDA, and used for a medically accepted indication which are not covered under part B (or Part A)

Certain drugs or classes of drugs (or their medical uses) are excluded by law from Part D coverage. These exclusions include the following:

Recommended Process to Expedite Part B versus Part D Coverage Determinations Plans may rely on physician information included with the prescription, such as diagnosis information (e.g., to determine if the prescription is related to a Medicare covered transplant) or location of administration (e.g., to determine if the prescription is being dispensed for a beneficiary in a nursing home) to the same extent they rely on similar information acquired through documentation from physicians on prior authorization forms. Assuming the indication on the script is sufficient to make the coverage determination, there is no need in such cases to require additional information to be obtained from the physician.

To the extent that the plan requires their contracted pharmacies to report the information provided on the prescription to assist in the determination of Part B versus Part D coverage, the plan may rely on the pharmacist’s report of appropriate information to make the coverage determination under Part D. For example, for cases in which prednisone is prescribed for a condition other than immunosuppression secondary to a Medicare-covered transplant, and this is indicated on the prescription, a plan may authorize the pharmacy to dispense the drug under Part D without seeking further information from the prescribing physician.

PDPs are prohibited from paying for drugs that are covered under Part B. Certain drugs such as prednisone are covered under Part B when they are used to prevent organ rejection for a patient who has had a Medicare covered transplant. When a plan gets a prescription for prednisone, they must have a process by which they can verify that the prednisone is being used for a disease which would not trigger Part B coverage. Initially the plans instituted cumbersome prior authorizations procedures which required that the prescriber fill out a prior authorization form and send the form to the plan. In order to simplify the process CMS has instructed the plans that if a prescription is written for a B/D drug and the prescription has written on it the words “Part D” and a part D diagnosis such as “contact dermatitis” the prescription should be filled.

CMS is not requiring physicians to fill out prescriptions in the manner described below; instead, it is suggested as a way to save time and bypass what may be a burdensome process of completing a prior authorization form and faxing it back.

For example, prednisone used for immunosuppression following Medicare covered transplants or methotrexate used for cancer would be Part B drugs for these diagnoses, but they would be Part D drugs if they were used to treat rheumatoid arthritis.

Using the CMS guidance outlined above, if prednisone is prescribed for rheumatoid arthritis:

The information recommended by CMS for inclusion on the written prescription for prednisone prescribed for Rheumatoid Arthritis is “Rheumatoid Arthritis for
Part D.

Note: This clarification should not be construed to indicate that a Part D plan may not impose prior authorization or other procedures to ensure appropriate coverage under the Medicare drug benefit.

The Part D Plan is ultimately responsible for making the Part D coverage determination. However, CMS believes that the Part D plan will have met appropriate due diligence standards without further contacting a physician if:

This Special Edition information does not supersede any existing guidance concerning documentation for Part B prescriptions.

CMS is preparing additional guidance to assist plans, pharmacies, and physicians in operationalizing these Part B versus Part D coverage determinations.

Additional Information
For more detailed information on Part B versus Part D coverage, see the following CMS Web sites:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0570.pdf

http://www.cms.hhs.gov/PrescriptionDrugCovContra/downloads/DueDiligenceQA_03.24.06.pdf

http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/Downloads/PartBandPartDdoc_07.27.05.pdf

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Modification of National Provider Identifier (NPI) Editing Requirements in CR4023 and an Attachment to CR4320

Attention Physicians, Providers, and Suppliers!
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Provider Types Affected
Providers, physicians, and suppliers who bill Medicare fiscal intermediaries (FIs), including regional home health intermediaries (RHHIs), and Medicare carriers including durable medical equipment regional carriers (DMERCs) (or durable medical equipment Medicare administrative contractors (DME MACs) if appropriate)

Provider Action Needed

STOP – Impact to You
This article is based on CR5229, which corrects certain business requirements from CR4023 that relate to edits for National Provider Identifiers (NPIs) and provider legacy identifiers when reported on claims, particularly for referring/ordering or other secondary providers, effective October 1, 2006 and later. Additionally, CR5229 revises Attachment 1 to CR4320.

CAUTION – What You Need to Know
Some of those business requirements erroneously assumed that any provider for whom information is reported in a claim, including a referring/ordering or other secondary provider, would need to be enrolled in Medicare and therefore listed in the Medicare Provider Identifier Crosswalk. This is not always the case. CR5229 modifies those business requirements.

GO – What You Need to Do
These modifications will enable correct processing of affected claims in October 2006 and later, and will avoid the unnecessary rejection of many claims that involve a referring/ordering or other secondary provider. Please refer to the Background section of this article and to CR5229 for additional important information regarding these modifications.

Background
The Medicare Learning Network (MLN) articles, MM4023 and MM4320 which are based on CR4023 and CR4320 respectively, contain important information about the stages of the NPI implementation process. Some of this information is updated in the current article. The links to these articles are located in the Additional Information section of this article.

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires issuance of a unique national provider identifier (NPI) to each physician, supplier, and other provider of health care (45 CFR Part 162, Subpart D (162.402-162.414). To comply with this requirement, The Centers for Medicare & Medicaid Services (CMS) began to accept applications for, and to issue NPIs on May 23, 2005. Applications can be made by mail and online at https://nppes.cms.hhs.gov.

During Stage 2 of the NPI implementation process (October 2, 2006 - May 22, 2007), Medicare will utilize a Medicare Provider Identifier Crosswalk between NPIs and legacy identifiers to validate NPIs received in transactions, assist with population of NPIs in Medicare data center provider files, and to report NPIs on remittance advice (RA) and coordination of benefit (COB) transactions.

Primary and Secondary Providers, for NPI provider identifier editing purposes, are categorized as either “primary” or “secondary” providers. Primary providers include billing, pay-to, and rendering providers. Primary providers are required to be enrolled in Medicare for the claim to qualify for payment.

Secondary providers are all other providers for which data could be reported on an institutional (837-I) or professional (837-P), free billing software or direct data entry (DDE) claim, or on a revised CMS-1500 or a UB-04 (once those paper claims are accepted by Medicare). Since the UB-92, the currently used CMS-1500, and the HIPAA NCPDP format do not allow reporting of both NPIs and legacy identifiers, information on secondary providers in those claims is not included in the following requirements. Secondary providers may be enrolled, but are not required to be enrolled in Medicare (unless they plan to bill or be paid by Medicare for care rendered to Medicare beneficiaries).

Secondary Provider Claims
Claims Submitted with NPI and Medicare Legacy Identifier:
During Stage 2, claim submitters should submit a provider’s Medicare legacy identifier whenever reporting an NPI for a provider. Failure to report a Medicare legacy number for a provider enrolled in Medicare could result in a delay in processing of the claim. When an NPI and a legacy identifier are reported for a provider, Medicare contractors will apply the same edits to those numbers that would have been applied if that provider was a primary provider. (See MM4023.)

There are two exceptions:

  1. A Medicare contractor cannot edit a surrogate Unique Provider Identification Number (sometimes called a dummy UPIN, such as OTN000). Despite its name, a surrogate is not actually unique for a specific provider.
  2. Only a National Supplier Clearinghouse (NSC) identification number or a UPIN should ever be reported as the legacy numbers on a claim sent to a DMERC/DME MAC. If a carrier Provider Identification Number (PIN) is reported as a legacy identifier with an NPI, DMERCs/DME MACs will edit as if the NPI was the only provider identifier reported for that provider.

Claims Submitted with NPI Only:
The NPI is edited to determine if it meets with the physical requirements of the NPI (10 digits begins with a 1, 2, 3, or 4, and the check digit in the 10th position is correct), and whether there is a Medicare Provider Identifier Crosswalk entry for that NPI.

If the NPI is located in the Crosswalk:

If the NPI is not located in the Crosswalk:

Claims (including UB-92 or the current CMS-1500 paper claims) submitted with Medicare Legacy Identifier Only

COB and Medigap Trading Partners
Legacy identifiers will not be reported to these trading partners for secondary providers if they are not submitted on the claim sent to Medicare, are surrogate UPINs or if the provider is not enrolled in Medicare. If not enrolled, a legacy identifier or a TIN cannot be sent for a“secondary” provider because Medicare would not have issued a legacy identifier to or collected a TIN from that provider.

837-I or 837-P version 4010A1 Claims
Attachment 1 to CR4320 which is being revised as part of CR5229 addresses (among other issues), the identification of secondary providers for which the 837-I or 837-P version 4010A1 implementation guides only require reporting of an NPI or other identifier “if known.” Unless there is a pre-existing Medicare instruction that mandates the reporting of a specific identifier for those “if known” types of providers, there is no requirement for entry of any identifier for those entities/individuals. If there is no such requirement, claims received that lack an identifier for those types of providers will not be denied..

Note that “secondary” providers such as a referring/ordering physician are not required to be enrolled in Medicare as a condition for payment of the services or supplies they order, furnish, supervise delivery of, etc. for beneficiaries when those services are billed, paid-to or rendered by “primary” providers. For example, Medicare could pay:

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

Additional Information
CR4320, issued February 1, 2006, “Stage 1 Use and Editing of National Provider Identifier Numbers Received in Electronic Data Interchange Transactions, via Direct Data Entry Screens, or on Paper Claim Forms” is located at http://www.cms.hhs.gov/transmittals/downloads/R204OTN.pdf on the CMS
Web site.

The associated MLN article (with the same title) MM4320, can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4320.pdf on the CMS Web site.

CR4023, dated November 3, 2005, “Stage 2 Requirements for Use and Editing of National Provider Identifier (NPI) Numbers Received in Electronic Data Interchange (EDI) Transactions, via Direct Data Entry (DDE) Screens, or Paper Claim Forms” is located at http://www.cms.hhs.gov/transmittals/downloads/R190OTN.pdf on the CMS Web site. MM4023; the associated MLN article, is located at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4023.pdf on the CMS Web site.

CR5229 is the official instruction issued to your Medicare carrier/DMERC (DME MAC if appropriate), FI/RHHI regarding changes mentioned in this article. CR5229 may be found at http://www.cms.hhs.gov/Transmittals/downloads/R234OTN.pdf on the CMS Web site.

If you have questions, please contact your local Medicare carrier/DMERC (DME MAC if appropriate), 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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