CIGNA Government Services HomeDME MAC Jurisdiction C HomePart B Home

December 5, 2006 Part B Medicare Bulletin

Posted December 5, 2006

Send this page to a colleague

Table of Contents

INSERT TOPICS - December 2006
PDF Documents
(Includes Base Topics)



Download your free copy of Acrobat Reader

Looking for archived issues of the Medicare Bulletin?

Back to the Top of the PageTop

2007 Annual HCPCS Code Updates

2007 Annual HCPCS Code Updates

Back to the Top of the PageTop

Additional Requirements Necessary to Implement the Revised Health Insurance Claim Form CMS-1500

Note: Page 3 of this article was revised on October 13, 2006, to reflect that the appropriate NPI must be entered in certain fields on Form CMS-1500. Previously, the article incorrectly stated the NPI of the billing provider. All other information remains the same.

Provider Types Affected
Physicians and suppliers who bill Medicare carriers including durable medical equipment regional carriers (DMERCs) for their services using the Form CMS-1500.

Key Points

January 2, 2007 – March 30, 2007 Providers can use either the current Form CMS-1500 (12-90) version or the revised Form CMS-1500 (08-05) version. Note: Health plans, clearinghouses, and other information support vendors should be able to handle and accept the revised Form CMS-1500 (08-05) by January 2, 2007.
April 2, 2007 The current Form CMS-1500 (12-90) version of the claim form is discontinued; only the revised Form CMS-1500 (08-05) is to be used. Note: All rebilling of claims should use the revised Form CMS-1500 (08-05) from this date forward, even though earlier submissions may have been on the current Form CMS-1500 (12-90).

Background
Form CMS-1500 is one of the basic forms prescribed by CMS for the Medicare program. It is only accepted from physicians and suppliers that are excluded from the mandatory electronic claims submission requirements set forth in the Administrative Simplification Compliance Act, Public Law 107-105 (ASCA), and the implementing regulation at 42 CFR 424.32. The CMS-1500 form is being revised to accommodate the reporting of the National Provider Identifier (NPI).

Note that a provision in the HIPAA legislation allows for an additional year for small health plans to comply with NPI guidelines. Thus, small plans may need to receive legacy provider numbers on coordination of benefits (COB) transactions through May 23, 2008. CMS will issue requirements for reporting legacy numbers in COB transactions after May 22, 2007.

In a related Change Request, CR4023, CMS required submitters of the Form CMS-1500 (12-90 version) to continue to report Provider Identification Numbers (PINs) and Unique Physician Identification Numbers (UPINs) as applicable.

There were no fields on that version of the form for reporting of NPIs in addition to those legacy identifiers. Change Request 4293 provided guidance for implementing the revised Form CMS-1500 (08-05). This article, based on CR 5060, provides additional Form CMS-1500 (08-05) information for Medicare carriers and DMERCs, related to validation edits and requirements.

Billing Guidelines

Additional Information
When the NPI Number is Effective and Required (May 23, 2007)
To enable proper processing of Form CMS-1500 (08-05) claims and to avoid claim rejections, please be sure to enter the correct identifying information for any numbers entered on the claim.
Legacy identifiers are pre-NPI provider identifiers such as:

Additional NPI-Related Information
Additional NPI-related information can be found at http://www.cms.hhs.gov/NationalProvIdentStand/ on the CMS Web site.

The change log which lists the various changes made to the Form CMS-1500 (08-05) version can be viewed at the NUCC Web site at http://www.nucc.org/images/stories/PDF/change_log.pdf.
MLN Matters article MM4320, “Stage 1 Use and Editing of National Provider Identifier Numbers Received in Electronic Data Interchange Transactions via Direct Data Entry Screen, or Paper Claim Forms,” can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4320.pdf on the CMS Web site.
CR4293, Transmittal Number 899, “Revised Health Insurance Claim Form CMS-1500,” provides contractor guidance for implementing the revised Form CMS-1500 (08-05). It can be found at http://www.cms.hhs.gov/transmittals/downloads/R899CP.pdf on the CMS Web site.

MLN Matters article MM4023, “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,” can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4023.pdf on the CMS Web site.

CR5060 is the official instruction issued to your carrier or DMERC regarding changes mentioned in this article, MM5060. CR 5060 may be found by going to http://www.cms.hhs.gov/Transmittals/downloads/R1058CP.pdf on the CMS Web site.
Please refer to your local carrier or DMERC if you have questions about this issue. To find their toll –free phone number, please go to: http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.o

Back to the Top of the PageTop

Ambulance Inflation Factor for CY 2007

Flu Shot Reminder
Flu season is here! Medicare patients give many reasons for not getting their flu shot, including—“It causes the flu; I don’t need it; it has side effects; it’s not effective; I didn’t think about it; I don’t like needles!” The fact is that out of the average 36,000 people in the U.S. who die each year from influenza and complications of the virus, greater than 90 percent of deaths occur in persons 65 years of age and older. You can help your Medicare patients overcome these odds and their personal barriers through patient education. Talk to your Medicare patients about the importance of getting their annual flu shot--and don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot. Remember–Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’s Web site:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf

Provider Types Affected
Providers and suppliers of ambulance services billing Medicare carriers, fiscal intermediaries (FIs), or Part A/B Medicare Administrative Contractors (A/B MACs) for those services.

Provider Action Needed
This article is for your information only. It provides the Ambulance Inflation Factor (AIF) for Calendar Year (CY) 2007. The AIF for CY 2007 is 4.3%.

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

The AIF for calendar year (CY) 2007 will be 4.3%. The following table displays the AIF for CY 2007 and for the previous 4 years.

Ambulance Inflation Factor by CY
2007 4.3%
2006 2.5%
2005 3.3%
2004 2.1%
2003 1.1%

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

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

Some key issues related to the AIF include:

National or Regional Fee Schedules
Either the national fee schedule or regional fee schedule applies for all providers and suppliers in the census division, depending on the payment amount that the regional methodology yields. The national fee schedule amount applies when the regional fee schedule methodology results in an amount (for a given census division) that is lower than the national ground base rate. Conversely, the regional fee schedule applies when its methodology results in an amount (for the census division) that is greater than the national ground base rate. When the regional fee schedule is used, that census division’s fee schedule portion of the base rate is equal to a blend of the national rate and the regional rate.

Payments Based on Blended Methodology
During the five-year transition period, your payments are based on a blended methodology. For CY 2007, this blend will be 20% regional ground base rate and 80% national ground base rate.

Before January 1, 2007, for each ambulance provider or supplier, the AIF was applied to both the fee schedule portion of the blended payment amount (both national and regional) and to the reasonable cost/charge portion. Then, these two amounts were added together to determine each provider or supplier’s total payment amount. As of January 1, 2007, the total payment amount for air ambulance providers and suppliers continues to be based on 100% of the national ambulance fee schedule, while the total payment amount for ground ambulance providers and suppliers will be based on either 100% of the national ambulance fee schedule or 80% of the national ambulance fee schedule and 20% of the regional ambulance fee schedule.

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

Additional Information
You can find more information about the ambulance inflation factor by going to CR 5358, located at
http://www.cms.hhs.gov/Transmittals/downloads/R1102CP.pdf on the CMS Web site. There you will find updated Medicare Claims Processing Manual (100-04), Chapter 15 (Ambulance), Section 20.6.1 (Ambulance Inflation Factor (AIF)) as an attachment to that CR.

If you have any questions, please contact your carrier, FI, or A/B MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip.

Back to the Top of the PageTop

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

Flu Shot Reminder
Flu season is here! Medicare patients give many reasons for not getting their flu shot, including—“It causes the flu; I don’t need it; it has side effects; it’s not effective; I didn’t think about it; I don’t like needles!” The fact is that out of the average 36,000 people in the U.S. who die each year from influenza and complications of the virus, greater than 90 percent of deaths occur in persons 65 years of age and older. You can help your Medicare patients overcome these odds and their personal barriers through patient education. Talk to your Medicare patients about the importance of getting their annual flu shot--and don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot. Remember – Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’s Web site: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf.

Provider Types Affected
Physicians, suppliers, and providers who bill Medicare contractors (Fiscal Intermediaries (FIs), Carriers, Durable Medical Equipment Regional Carriers (DMERC), regional home health intermediaries (RHHIs), and DME Medicare Administrative Contractors (DME MACs) and Part A/B Medicare Administrative Contractors (A/B MACs)) for medical supply or therapy services.

Provider Action Needed
The Centers for Medicare & Medicaid Services (CMS) periodically updates the lists of Healthcare Common Procedure Codes System (HCPCS) codes subject to the consolidated billing provision of the Home Health Prospective Payment System (HH PPS). This article provides the annual HH consolidated billing update effective January 1, 2007. Affected providers may note the changes in the table listed within this article or consult the instruction issued to the Medicare contractors as listed in the Additional information section of this article.

Background
Section 1842(b)(6) of the Social Security Act (SSA) requires that payment for home health services provided under a home health plan of care be made to the home health agency (HHA.) As a result, billing for all such items and services is to be made by a single HHA overseeing that plan. This HHA is known as the primary agency for HH PPS for billing purposes. Services appearing on this list that are submitted on claims to Medicare contractors will not be paid separately on dates when a beneficiary for whom such a service is being billed is in a home health episode (i.e., under a home health plan of care administered by an HHA). Exceptions include the following:

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

Key Points
CR5356 provides the annual HH consolidated billing update effective January 1, 2007. The following tables describe the HCPCS codes and the specific changes to each that this notification is implementing on January 2, 2007.

Table 1: Non Routine Supplies

Code Description Action Replacement Code or Code being Replaced
A4213 Syringe, Sterile, 20 CC or Greater Add  
A4215 Needle, Sterile, Any Size, Each Add  
A4348 Male External Catheter with Integral Collection Compartment, Extended Wear, Each (e.g., 2 per month) Delete  
A4359 Urinary Suspensory without Leg Bag Delete  
A4244 Alcohol or Peroxide, per Pint Add  
A4245 Alcohol Wipes, per Box Add  
A4246 Betadine or Phisohex Solution, per Pint Add  
A4247 Betadine or Iodine Swabs/Wipes, per Box Add  
A4461 Surgical Dressing Holder, Non-reusable, Each Add Replaced code: A4462
A4462 Abdominal Dressing Holder, Each Delete Replacement code: A4461 and A4463
A4463 Surgical Dressing Holder, Reusable, Each Add Replaces code: A4462
A4932 Rectal Thermometer, Reusable, Any Type, Each Add  
A6412 Eye Patch, Occlusive, Each Add  

Table 2: Therapies

Code Description Action Replacement Code or Code being Replaced
97020 Application Microwave Delete Replacement code: 97024
97024 Application of a Modality to One or More Areas: Diathermy (e.g., Microwave) Redefine Replaced code: 97020
97504 Orthotic(s) Fitting and Training, Upper Extremity(ies), Lower Extremity(ies), and/or Trunk, Each 15 Minutes Delete Replacement code: 97760
97520 Prosthetic Training, Upper and/or Lower Extremity(ies), Each 15 Minutes Delete Replacement code: 97761
97703 Checkout for Orthotic/Prosthetic Use, Established Patient, Each 15 Minutes Delete Replacement code: 97762
97760 Orthotic(s) Management and Training Including Assessment and Fitting when not Otherwise Reported), Upper Extremity(s), Lower Extremity(s) and/or Trunk, Each 15 Minutes Add Replaces code: 97504
97761 Prosthetic Training, Upper and/or Lower Extremity(s), Each 15 Minutes Add Replaces code: 97520
97762 Checkout for Orthotic/Prosthetic Use, Established Patient, Each 15 Minutes Add Replaces code: 97703

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

For complete details regarding this CR please see the official instruction issued to your Medicare FI, carrier, A/B MAC, DMERC, RHHI, or DME MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1082CP.pdf on the CMS Web site.

A complete historical listing of codes subject to HH consolidated billing can be found at http://www.cms.hhs.gov/HomeHealthPPS/03_coding&billing.asp on the CMS Web site.

To review the Medicare regulations discussed in this article see the Medicare Claims Processing Manual Chapter 10, Section 10.1.25 at http://www.cms.hhs.gov/manuals/downloads/clm104c10.pdf on the CMS Web site.

Back to the Top of the PageTop

Application Update to Medicare Deductible, Coinsurance, and Premium Rates for 2007

Provider Types Affected
Physicians, providers, and suppliers submitting claims to Medicare carriers, Durable Medical Equipment Regional Carriers (DMERCs), DME Medicare Administrative Contractors (DME MACs), Fiscal Intermediaries (FIs) including Regional Home Health Intermediaries (RHHIs), and Part A/B MACs for services provided to Medicare beneficiaries.

Provider Action Needed
This article is based on Change Request (CR) 5345 which announces the 2007 Medicare rates and instructs your Medicare contractors to make necessary updates to their claims processing systems.

Background
There are beneficiary-related costs for using certain services under Parts A and B of Medicare, typically in the form of deductibles, co-payments, and/or premium payments. Beneficiaries who use covered Part A services may be subject to deductible and coinsurance requirements. A beneficiary is responsible for an inpatient hospital deductible amount, which is deducted from the amount payable by the Medicare program to the hospital, for inpatient hospital services furnished in a spell of illness.

When a beneficiary receives such services for more than 60 days during a spell of illness, he or she is responsible for a coinsurance amount equal to one-fourth of the inpatient hospital deductible per day for the 61st-90th day spent in the hospital.

An individual has 60 lifetime reserve days (LRDs) of coverage, which they may elect to use after the
90th day in a spell of illness. The coinsurance amount for these LRDs is equal to one-half of the inpatient hospital deductible.

For Skilled Nursing Facility (SNF) services furnished during a spell of illness, a beneficiary is responsible for a coinsurance amount equal to one-eighth of the inpatient hospital deductible per day for the 21st through the 100th day.

Most individuals age 65 and older, and many disabled individuals under age 65, are insured for Health Insurance (HI) benefits without a premium payment. The Social Security Act provides that certain aged and disabled persons who are not insured may voluntarily enroll, but are subject to the payment of a monthly premium.

Since 1994, voluntary enrollees may qualify for a reduced premium if they have 30-39 quarters of covered employment. When voluntary enrollment occurs more than 12 months after the date a person is initial eligibility to enroll, a 10 percent penalty is assessed for 2 years for every year they could have enrolled and failed to enroll in Part A.

Under Supplementary Medical Insurance (SMI) or Part B, all enrollees are subject to a monthly premium. Most SMI services are subject to an annual deductible and coinsurance (percent of costs that the enrollee must pay), which are set by statute. When SMI enrollment takes place more than 12 months after a person’s initial enrollment period, there is a permanent 10 percent increase in the premium for each year the beneficiary could have enrolled and failed to enroll.

Medicare Part A for 2007
For Calendar Year (CY) 2007, the following rates are applicable for Medicare Part A Deductible, Coinsurance, and Premium amounts:

Deductible $992.00 per benefit period
Coinsurance $248.00 a day for days 61-90 in each period
  $496.00 a day for days 91-150 for each LRD used
  $124.00 a day in a SNF for days 21-100 in each benefit period
Premium $410.00 per month for those who must pay a premium
  $451.00 per month for those who must pay both a premium and a 10 % increase
  $226.00 per month for those who have 30-39 quarters of coverage
  $248.60 per month for those who have 30-39 quarters of coverage and must pay a 10 % increase Medicare Part B for 2007

Medicare Part B for 2007
For CY 2007, the following rates are applicable for Medicare Part B Deductible and Coinsurance :

Deductible $131.00 per year
Coinsurance 20 percent

CMS updates the Part B premium each year. These adjustments are made according to formulas set by statute. By law, the monthly Part B premium must be sufficient to cover 25 percent of the program’s costs, including the costs of maintaining a reserve against unexpected spending increases. The federal government pays the remaining 75 percent.

Below are the annual Part B premium amounts from Calendar Year (CY) 1996 to 2006. For these years, and years prior to 1996, the Part B premium is a single established rate for all beneficiaries.

Year Part B Premium Year Part B Premium Year Part B Premium
1996 $42.50 2000 $45.50 2004 $66.60
1997 $43.80 2001 $50.00 2005 $78.20
1998 $43.80 2002 $54.00 2006 $88.50
1999 $45.50 2003 $58.70    

Beginning on January 1, 2007, the Part B premium will be based on the income of the beneficiary. Below are the CY 2007 Part B premium amounts based on beneficiary income parameters.

  Income Parameters for Determining Part B Premium
Premium/mon Individual Income Combined Income (Married)
$ 93.50 $ 80,000.00 or less $160,000.00 or less
$105.80 $ 80,000.01 - $100,000.00 $160,000.01 - $200,000.00
$124.40 $100,000.01 - $150,000.00 $200,000.01 - $300,000.00
$142.90 $150,000.01 - $200,000.00 $300,000.01 - $400,000

Implementation
The implementation date for CR5345 is January 2, 2007.

Additional Information
For complete details, please see the official instruction issued to your carrier, DMERC, DME MAC, intermediary, RHHI, or A/B MAC regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R41GI.pdf on the CMS Web site.

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

Flu Season is upon us! Begin now to take advantage of each office visit as an opportunity to talk with your patients about the flu virus and their risks for complications associated with the flu, and encourage them to get their flu shot. And don’t forget, health care professionals need to protect themselves also. Get Your Flu Shot – Protect yourself, your patients, and your family and friends. Remember – Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For information about Medicare’s coverage of adult immunizations and educational resources, go to http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf on the CMS Web site.

Back to the Top of the PageTop

Bexxar and Ibritumomab Tiuxetan Therapy (Zevalin) - LCD Revisions

Local Coverage Determinations (LCD) for Bexxar and Ibritumomab Tiuxetan Therapy (Zevalin) have been revised for Idaho, North Carolina, and Tennessee to include ICD-9 coverage codes, 200.00-200.88 and 202.00-202.88. Please select one of the links below to view the LCD for your specific state.

Idaho: http://www.cignagovernmentservices.com/medicare_dynamic/clickwrap/lcdclickwrap.asp?sendto=IDcurrent

North Carolina:
http://www.cignagovernmentservices.com/medicare_dynamic/clickwrap/lcdclickwrap.asp?sendto=NCcurrent

Tennessee:
http://www.cignagovernmentservices.com/medicare_dynamic/clickwrap/lcdclickwrap.asp?sendto=TNcurrent

Back to the Top of the PageTop

Carrier Jurisdiction for Ambulance Supplier Claims

Provider Types Affected
Ambulance suppliers who submit claims to Medicare carriers or Part A/B Medicare Administrative Contractors (A/B MACs) for ambulance services furnished to Medicare beneficiaries

Provider Action Needed

STOP – Impact to You
Effective for claims processed January 1, 2008 and later, a claim for an ambulance service furnished by a supplier must be filed with the carrier or A/B MAC having jurisdiction for the “point of pickup” (POP).

CAUTION – What You Need to Know
Effective April 1, 2007, each carrier will begin processing applications from ambulance suppliers that are rendering services in their jurisdiction. For claims with dates of service January 1, 2008 and later, carriers will return claims as unprocessable any claim for a ground or air ambulance service where the POP is not within its jurisdiction.

GO – What You Need to Do
Be sure your staff knows to file Medicare claims with the carrier or A/B MAC having jurisdiction for the POP to assure prompt and accurate payment.

Background
The Medicare claims filing jurisdiction rule for ambulance services has been that an ambulance must file the claim with the carrier or A/B MAC having jurisdiction for where the service was furnished. When the ambulance fee schedule policies and systems changes were being developed, most carriers interpreted this rule to mean that a claim for an ambulance service must be filed with the carrier or A/B MAC having jurisdiction for the area where the vehicle is garaged or hangered. When the ambulance fee schedule was implemented beginning January 1, 2000, CMS determined that this de facto interpretation of the claims filing jurisdiction rule would not be changed during the fee schedule transition period which was completed on January 1, 2006. (See Program Memorandum (PM) AB-00-88, Change Request (CR) 1281, dated September 18, 2000 which was re-issued as PM AB-01-185 dated December 14, 2001. CR1281 can be found at the following link http://www.cms.hhs.gov/Transmittals/Downloads/AB01185.pdf on the CMS Web site.)

Currently all ambulance services are paid under the fee schedule which is based on the location from which the beneficiary is transported, i.e., the “point of pickup” (POP). Because the basis for payment under the fee schedule is based on the POP, it is reasonable for the claims filing jurisdiction rule to also be based on the POP.

Changing the claims filing jurisdiction to the POP will ensure jurisdictional congruence between the policies for payment and claims filing. It will additionally ensure that the ambulance supplier meets the State and local requirements where the service was furnished, which was the original intent of the claim filing jurisdiction rule. This change will:

For dates of service of January 1, 2008, or later, ground and air ambulance supplier claims for a point of pick-up not rendered in the carrier’s (or A/B MAC’s) jurisdiction will be returned to the supplier as “unprocessable”, accompanied by the following remittance advice message:

Carriers and A/B MACs will not apply this rule to:

As a consequence of changing the claims filing rule to the POP, ambulance suppliers (including those who operate in multiple States) must be enrolled with the carrier in each jurisdiction where they furnish services to Medicare beneficiaries. This is the case even if that supplier does not garage or hanger its vehicles in each State in which the supplier operates (Required by 42 C.F.R. § 410.41 located at http://www.cms.hhs.gov/AmbulanceFeeSchedule/downloads/cfr410_41.pdf on the Centers for Medicare & Medicaid (CMS) Web site).

Note: As early as April 1, 2007, each carrier or A/B will begin processing applications from ambulance suppliers that are rendering services in their jurisdiction.

Exception: Where the POP is outside the United States, the claim for an ambulance service furnished by a supplier must be filed in accordance with the instructions in Publication 100-4, The Medicare Claims Processing Manual, Chapter 1 § 10.1.4.1. Carrier jurisdiction is defined in Publication 100-04, Chapter 1 § 10.1.4.2. These instructions can be found at http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf on the CMS Web site.

Additional Information
CR5203 is the official instruction issued to your Medicare carrier or A/B MAC regarding changes mentioned in this article. CR 5203 may be found at http://www.cms.hhs.gov/Transmittals/downloads/R1100CP.pdf on the CMS Web site.

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

Flu Shot Reminder
Flu season is here! Medicare patients give many reasons for not getting their flu shot, including—“It causes the flu; I don’t need it; it has side effects; it’s not effective; I didn’t think about it; I don’t like needles!” The fact is that out of the average 36,000 people in the U.S. who die each year from influenza and complications of the virus, greater than 90 percent of deaths occur in persons 65 years of age and older. You can help your Medicare patients overcome these odds and their personal barriers through patient education. Talk to your Medicare patients about the importance of getting their annual flu shot–and don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot. Remember – Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’s Web site:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf

Back to the Top of the PageTop

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2007

Flu Season is upon us! Begin now to take advantage of each office visit as an opportunity to talk with your patients about the flu virus and their risks for complications associated with the flu, and encourage them to get their flu shot. And don’t forget, health care professionals need to protect themselves also. Get Your Flu Shot. – Protect yourself, your patients, and your family and friends. Remember - Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For information about Medicare’s coverage of adult immunizations and educational resources, go to http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf on the CMS Web site.

Provider Types Affected
Physicians, providers, and suppliers submitting claims to Medicare carriers, fiscal intermediaries (FIs), or Part A/B Medicare Administrative Contractors (A/B MACs) for clinical diagnostic laboratory services provided for Medicare beneficiaries.

Provider Action Needed
This article is based on Change Request (CR) 5384, which announces the changes that will be included in the January, 2007 release of the edit module for clinical diagnostic laboratory NCDs.

Background
The National Coverage Determinations (NCDs) for clinical diagnostic laboratory services were developed by the laboratory negotiated rulemaking committee and published as a final rule on November 23, 2001. Subsequently, the Centers for Medicare & Medicaid Services (CMS) contracted for nationally uniform software to be developed and incorporated into its shared systems so that laboratory claims subject to one of the 23 NCDs can be processed uniformly throughout the nation effective January 1, 2003.

The laboratory edit module for the NCDs is updated quarterly (as necessary) to reflect coding updates and substantive changes to the NCDs developed through the NCD process. (See the Medicare Claims Processing Manual (Pub. 100-04), Chapter 16, Section120.2., available at http://www.cms.hhs.gov/manuals/downloads/clm104c16.pdf on the CMS Web site.)
These updating changes are a result of coding analysis decisions developed under the procedures for maintenance of codes in the negotiated NCDs, and biannual updates of the ICD-9-CM codes. In addition, many of the listed changes may correct Current Procedural Terminology (CPT) codes to reflect the current CPT update.

CR5384 informs your Medicare carrier, FI, or A/B MAC about changes to the laboratory edit module and changes in laboratory NCD code lists effective for services furnished on or after January 1, 2007.

CR5384 specifically announces the addition of the following ICD-9-CM code(s):

CR5384 also modifies the descriptor for CPT code 87088 in Urine Culture, Bacterial NCD (190.12) to read “Culture, bacterial; with isolation and presumptive identification of each isolates, urine;”.

Additional Information
For complete details, please see the official instruction issued to your carrier, FI, or A/B MAC regarding this change. That instruction may be viewed at
http://www.cms.hhs.gov/Transmittals/downloads/R1093CP.pdf on the CMS Web site.

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

Back to the Top of the PageTop

CIGNA Government Services NetCourses

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

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

General Courses

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

Back to the Top of the PageTop

Electronic Data Interchange (EDI) Media Changes

CIGNA Government Services (CGS) Part B and Jurisdiction D EDI departments will reject any EDI claims received via fax-imaging, diskette, tape, or other similar storage media after March 31, 2007. You may find more information on the Centers for Medicare & Medicaid (CMS) Web site at http://www.cms.hhs.gov/transmittals/downloads/R1077CP.pdf .

Back to the Top of the PageTop

Ending the Contingency Plan for Remittance Advice (RA) and Charging for PC Print, Medicare Remit Easy Print (MREP), and Duplicate RAs

Note: Idaho, North Carolina, and Tennessee providers:
At this time, CIGNA Government Services will not be implementing a charge for duplicate remittances, PC Print, or Medicare Remit Easy Print. This determination may be subject to change in the future, based on CMS directives or business decisions.

Provider Types Affected
Physicians, providers, and suppliers submitting claims to A/B Medicare Administrative Contractors (A/B MACs) carriers, Durable Medical Equipment Regional Carriers (DMERCs), DME Medicare Administrative Contractors (DME MACs), Fiscal Intermediaries (FIs), and/or Regional Home Health Intermediaries (RHHIs) for services provided to Medicare beneficiaries.

Impact on Providers
This Change Request (CR) updates the Medicare Claims Processing Manual (Publication 100-04) for ending the contingency plan for Electronic Remittance Advice (ERA), and instructs contractors about charging for PC Print, Medicare Remit Easy Print (MREP), and duplicate Remittance Advice (RA).

Background
This article is based on Change Request (CR) 5308 which:

CMS implemented a contingency plan (as of October 16, 2003) to continue to accept and send HIPAA-compliant and non HIPAA-compliant transactions from/to trading partners beyond October 16, 2003, for a limited time.

CMS ended the contingency period for claims in October 2005, and in a Joint Signature Memorandum (JSM/TDL-06518) issued on June 28, 2006, CMS instructed Medicare contractors that it is ending the contingency period for ERAs on September 30, 2006.

CR 5308 instructs Medicare Contractors that, on or after October 1, 2006, all ERAs must be provided in the standard HIPAA (ANSI ASC X12N 835 version 004010A1) format.

Implementation
The implementation date for CR5308 is October 23, 2006.

Additional Information
For complete details, please see the official instruction issued to your A/B MAC, carrier, intermediary regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1063CP.pdf on the CMS Web site. The revised sections of the Medicare Claims Processing Manual are attached to CR5308.

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

Flu Season is upon us! Begin now to take advantage of each office visit as an opportunity to talk with your patients about the flu virus and their risks for complications associated with the flu, and encourage them to get their flu shot. And don’t forget, health care professionals need to protect themselves also. Get Your Flu Shot. – Protect yourself, your patients, and your family and friends. Remember - Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For information about Medicare’s coverage of adult immunizations and educational resources, go to
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf on the CMS Web site.

Back to the Top of the PageTop

Holding of Pancreas Transplant Alone (PA) Claims - Amendment to MLN Matters Article MM5093

Flu Season is upon us! Begin now to take advantage of each office visit as an opportunity to talk with your patients about the flu virus and their risks for complications associated with the flu, and encourage them to get their flu shot. And don’t forget, health care professionals need to protect themselves also. Get Your Flu Shot. – Protect yourself, your patients, and your family and friends. Remember – Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For information about Medicare’s coverage of adult immunizations and educational resources, go to http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf on the CMS Web site.

Provider Types Affected
Providers who bill Medicare Fiscal Intermediaries (FIs) or A/B Medicare Administrative Contractors (MACs) for PA services to Medicare beneficiaries.

Key Points

Background
The Centers for Medicare & Medicaid Services (CMS) is publishing this Special Edition (SE) article to amend a prior notice to providers on May 19, 2006, Change Request (CR) 5093 (see Additional Information section for the Web address). That prior notice announced that PA claims for discharges on or after April 26, 2006 through September 30, 2006, would be held until further notice. The PA claims were scheduled to be released October 2, 2006.

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

The MLN Matters article on CR 5093 may be found at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5093.pdf on the CMS Web site.

Back to the Top of the PageTop

Lockbox for Overpayments and Voluntary Refunds

CIGNA Government Services has a lockbox established for your convenience to deposit checks for overpayments or voluntary refunds in a faster and more secure environment. This process will cut down on misdirected mail and ensure that your payment is accurately posted.

Please mail all checks to the lockbox address below:

NORTH CAROLINA
CIGNA Government Services
P.O. Box 10820
Newark, NJ 07193 – 0820

TENNESSEE
CIGNA Government Services
P.O. Box 10924
Newark, NJ 07193 - 0924

IDAHO
CIGNA Government Services
P.O. Box 10957
Newark, NJ 07193 - 0957

If you have any questions, you may call Overpayment Recovery Customer Service at 877.286.6801.

Back to the Top of the PageTop

Locum Tenens and Reciprocal Billing

Periodically, we remind providers of the Centers for Medicare & Medicaid Services (CMS) guidelines for locum tenens and reciprocal billing arrangements.

Reciprocal Billing Arrangements
Under reciprocal billing arrangements, the patient’s regular physician may submit the claim for covered services (including emergency visits and related services) which the regular physician arranges to be provided by a substitute physician (who is in practice for themselves or part of another group practice) on an occasional reciprocal basis, if:

A physician may have reciprocal arrangements with more than one physician. The arrangements need not be in writing.

Covered Visit Service — The term “covered visit service” includes not only those services ordinarily characterized as a covered physician visit, but also any other covered items and services furnished by the substitute physician or by others as incident to his/her services.

Items and services furnished by the staff of the substitute physician covered as incident to his/her services if billed by him/her are still covered if billed by the regular physician under this section.
Items and services furnished by the staff of the regular physician covered as incident to his/her services if furnished under his/her supervision are still covered under the supervision of the substitute physician.

Continuous Period of Covered Visit Services — A continuous period of covered visit services begins with the first day on which the substitute physician provides covered visit services to Medicare Part B patients of the regular physician. It ends with the last day on which the substitute physician provides these services to these patients before the regular physician returns to work. This period continues without interruption on days in which no covered visit services are provided to patients on behalf of the regular physician or are furnished by some other substitute physician on behalf of the regular physician. A new period of covered services can begin after the regular physician has returned to work.

Example: The regular physician goes on vacation on January 30, 1998, and returns to work on April 6, 1998. A substitute physician provides services to Medicare Part B patients of the regular physician on February 2, 1998, and at various times thereafter, including April 2nd and April 3, 1998. The continuous period of covered visit services begins on February 2nd and runs through April 3rd, a period of 61 days. Since the April 3rd services are furnished after the expiration of 60 days of the period, the regular physician is not entitled to bill and receive direct payment for them. The substitute physician must bill for these services in his/her own name. The regular physician may, however, bill and receive payment for the services which the substitute physician provides on his/her behalf in the period February 2nd through April 2nd.

Unassigned Claims Under Reciprocal Billing Arrangements — The requirements for the submission of claims under reciprocal billing arrangements are the same for assigned and unassigned claims.

Medical Group Claims Under Reciprocal Billing Arrangements — The requirements of this section do not apply to the substitution arrangements among physicians in the same medical group where claims are submitted in the name of the group. On claims submitted by the group, the group physician who actually performed the service must be identified.

For a medical group to submit assigned and unassigned claims for the covered visit services of a substitute physician who is not a member of the group, the above requirements must be met. The medical group must enter HCPCS modifier -Q5 after the procedure code. Until further notice, the medical group must keep in file a record of each service provided by the substitute physician, associated with the substitute physician’s NPI/UPIN, and make this record available to the Medicare Carrier upon request. In addition, the medical group physician for whom the substitution services are furnished must be identified by his/her provider identification number (NPI/PIN).

For an independent physician to submit assigned and unassigned claims for the substitution services of a physician who is a member of a medical group, the above requirements must be met. The independent physician must enter HCPCS modifier - Q5 after the procedure code. Until further notice, the independent physician must keep in file a record of each service provided by the substitute medical group physician, associated with the substitute physician’s NPI/UPIN, and make this record available to the Carrier upon request.

Physicians who are members of a group but who bill in their own names are treated as independent physicians for purposes of applying the requirements of this section.

Locum Tenens Arrangements
It is a longstanding and widespread practice for physicians to retain substitute physicians to take over their professional practices when the regular physicians are absent for reasons such as illness, pregnancy, vacation, or continuing medical education, and for the regular physician to bill and receive payment for the substitute physician’s services as though he/she performed them. The substitute physician generally has no practice of his/her own and moves from area to area as needed. The regular physician generally pays the substitute physician a fixed amount per diem, with the substitute physician having the status of an independent contractor rather than of an employee. These substitute physicians are generally called “locum tenens” physicians.

Payment Procedure —The patient’s regular physician may submit the claim for services furnished, and (if assignment is accepted) receive the Part B payment for covered visit services (including emergency visits and related services) of a locum tenens physician who is not an employee of the regular physician and whose services for patients of the regular physician are not restricted to the regular physician’s offices, if:

If the only substitution services a physician performs in connection with an operation are post-operative services furnished during the period covered by the global fee, these services need not be identified on the claim as substitution services.

Covered Visit Service - Same as for Reciprocal Billing Arrangements

Continuous Period of Covered Visit Services – Same as for Reciprocal Billing Arrangements

Unassigned Claims – Same as for Reciprocal Billing Arrangements

Medical Group Claims Under Locum Tenens Arrangements — For a medical group to submit assigned and unassigned claims for the services a locum tenens physician provides for patients of the regular physician who is a member of the group, the above requirements must be met. For purposes of these requirements, per diem or similar fee-for-time compensation which the group pays the locum tenens physician is considered paid by the regular physician.

Also, a physician who has left the group and for whom the group has engaged a locum tenens physician as a temporary replacement may still be considered a member of the group until a permanent replacement is obtained. The group must enter HCPCS modifier -Q6 after the procedure code. Until further notice, the group must keep on file a record of each service provided by the substitute physician, associated with the substitute physician’s NPI/UPIN, and make this record available to the Medicare Carrier upon request. In addition, the medical group physician for whom the substitution services are furnished must be identified as the performing physician by his/her provider identification number (NPI/PIN).

Physicians who are members of a group but who bill in their own names are generally treated as independent physicians for purposes of applying the requirements of subsection A for payment for locum tenens physician services. Compensation paid by the group to the locum tenens physician is considered paid by the regular physician for purposes of those requirements. The term “regular physician” includes a physician who has left the group and for whom the group has hired the locum tenens physician as a replacement.

Main Points to Remember

Reference : CMS publication 100-4 Medicare Claims Processing Manual

Back to the Top of the PageTop

Medicare Administrative Contractors (MACs)

DME MAC Contract Numbers
Jurisdiction A ~ HHSM-500-2006-M0001Z
Jurisdiction B ~ HHSM-500-2006-M0002Z
Jurisdiction C ~ HHSM-500-2006-M0003Z
Jurisdiction D ~ HHSM-500-2006-M0004Z

A/B MAC Contract Numbers
Jurisdiction 3 ~ HHSM-500-2006-M0005Z

National Recovery Contractor for New Medicare Secondary Payer (MSP) Recovery Claims

The Centers for Medicare & Medicaid Services (CMS) has awarded a contract for a national Medicare Secondary Payer Recovery Contractor (MSPRC) to Chickasaw Nation Industries, Inc. – Administration Services, LLC (CNI). This contract will be implemented on October 2, 2006 .

Please read the sections immediately below to determine how the change to a national MSPRC will affect you, as some existing MSP recovery claims will remain the responsibility of the claims processing contractors.

What does implementation of the MSPRC mean for you if you are a provider, physician, or other supplier?

The recovery of provider, physician or other supplier MSP recovery claims will continue to be the responsibility of the contractor which processed the underlying Medicare claim. Consequently, providers, physicians, and other suppliers should not see any changes in CMS’ processes for recovering debts where the provider, physician, or other supplier is overpaid due to receiving a duplicate payment from both an insurer or workers’ compensation carrier and Medicare.

What does implementation of the MSPRC mean for you if you are: (a) an employer, insurer, GHP, third party administrator, or other plan sponsor subject to the MSP GHP provisions of the Social Security Act; (b) a workers’ compensation plan/carrier or a liability or no-fault insurer; (c) a beneficiary (or the representative of a beneficiary)?

For all new MSP initial recovery demand letters issued on or after the implementation date for the MSPRC
(October 2, 2006 ), you should respond to the entity which issues the recovery demand letter to you. Except for provider, physician, or other supplier MSP recovery claims and a limited number of GHP debts in certain states, this will routinely be the MSPRC.

General Rules:
The MSPRC will have responsibility for all new MSP recovery demand letters issued on or after the implementation date for the MSPRC (October 2, 2006), as well as all subsequent CMS actions on those recovery claims. The two exceptions to this are recovery demand letters issued by the MSP Recovery Audit Contractors (RACs) implemented as a demonstration under the Medicare Modernization Act of 2003 and MSP recovery demand letters issued by the claims processing contractors to providers, physician, and other suppliers. The RACs will continue to have responsibility for certain MSP GHP based recovery demands for the States of California, Florida , and New York .

The three MSP RACs are:

The MSPRC will have responsibility for all further CMS collection actions for MSP recovery demand letters issued before the implementation date for the MSPRC ( October 2, 2006 ) unless the recovery demand letter was: (1) issued by one of the Medicare contractors listed immediately above; (2) issued by one of the RACs; or (3) issued to a provider, physician, or other supplier.

Once a recovery claim is referred to the Department of the Treasury, the contractor which issued the recovery demand letter and the notice of intent to refer the debt to Treasury will take no further collection action. You should direct any further correspondence to the Department of the Treasury (or its contractor if you have received correspondence from an entity under contract to the Department of the Treasury).

Contact Information for the MSPRC:
MSPRC telephone access will not be available before October 2, 2006 . The number for the MSPRC’s dedicated call center will be 1.866.MSP.RC20 (1.866.677.7220), available from 8AM to 8PM Eastern time, Monday through Friday, with the exception of holidays.

The MSPRC will not accept mail until September 25, 2006 . Mailing information for the MSPRC will be available on CMS’ website after September 22, 2006 .

The MSPRC is a recovery contractor.

Back to the Top of the PageTop

New NPI Educational Products Available

NPI: Get It. Share It. Use It.

9/26 NPI Roundtable Transcript Available Now
The transcript for the 9/26 NPI Roundtable can be found at http://www.cms.hhs.gov/EducationMaterials/Downloads/NationalProviderIdentifierRoundtable.pdf on the CMS Web site.

NPI Training Package: Module 5 Available Now
Module 5, Medicare Implementation, provides the NPI requirements specific to Medicare providers. This module will be updated as new requirements are announced or changes are made. Module 5 is now posted at http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPI_Training_Package.pdf on the CMS NPI Page.

As always, more information and education on the NPI can be found at the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS Web site. Providers can apply for an NPI online at https://www.nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1.800.465.3203.

Getting an NPI is free – not having one can be costly.

Back to the Top of the PageTop

NPI: Get It. Share It. Use It

October 23rd means only 7 months remain until the National Provider Identifier (NPI) compliance date. Over 1,300,000 NPIs have been issued so far – do you have your NPI yet?

Act Now!
Don’t procrastinate; getting your NPI is only the first step in preparing for the compliance date. You should allow time to share your NPI with payers and other trading partners, update your referral lists, as well as modify and test computer systems.

Resources for Commonly Asked Questions
CMS has compiled a list of resources that will help to answer many questions on NPI. Visit http://www.cms.hhs.gov/NationalProvIdentStand/07_Questions.asp#TopOfPage to view this resource.

Additionally, CMS continues to build its database of Frequently Asked Questions (FAQs) on NPI. Recently, an FAQ on Electronic File Transfer (EFT) of payments from health plans to health care providers was added. You can view all existing NPI FAQs on the CMS Web site.

Participate in the Latest WEDI Industry Survey
WEDI is currently conducting a survey to measure the next stage of NPI readiness across the healthcare industry. To access the survey, go to: http://www.surveymonkey.com/s.asp?u=415952639752 on the Web. Also note, this survey will only be open for a short time. The last day to participate is October 31, 2006.

***Special Information for Medicare Providers***

Billing Medicare
Medicare is testing the new software that has been developed to use the National Provider Identifier (NPI) in the existing Medicare fee-for-service claims processing systems. Providers have until May 23, 2007, before they are required to submit claims with only an NPI.

Until testing is complete within the Medicare processing systems, Medicare urges providers to continue submitting Medicare fee-for-service claims in one of two ways:

Until testing of the new software that uses the NPI in the Medicare systems is complete and until further notice from Medicare, the following may occur if you submit Medicare claims with only an NPI:

Required Use of NPI on Medicare Paper Claim Forms
Medicare will require the NPI on its paper claim forms. A variety of MLN Matters articles are available on this topic at http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/MMArticles_npi.pdf on the CMS NPI Web page.

How to Share Your NPI with Medicare
Medicare providers may share their NPIs with Medicare in three different ways:
For new Medicare providers, an NPI must be included on CMS-855 enrollment application
Existing Medicare providers must provide their NPIs when making any changes to their Medicare enrollment information Medicare providers should use their NPI, along with appropriate legacy identifiers, on their Medicare claims.

Still not sure what an NPI is and how you can get it, share it and use it? As always, more information and education on the NPI can be found at the CMS NPI page http://www.cms.hhs.gov/NationalProvIdentStand on the CMS Web site. Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1.800.465.3203.

Getting an NPI is free - not having one can be costly.

Back to the Top of the PageTop

October Update to the 2006 Medicare Physician Fee Schedule (MPFS) Database

Provider Types Affected
Physicians and other providers who bill Medicare for professional services paid under the MPFS.

What you need to know
CR5272, from which this article was taken, amends the payment files (based upon the November 21, 2005 Medicare Physician Fee Schedule Final Rule) that were previously issued to your carriers.

Background
Section 1848(c)(4) of the Social Security Act authorizes the Secretary to establish ancillary policies necessary to implement relative values for physicians’ services. Carriers, in accordance with the Medicare Claims Processing Manual (Publication 100-4), Chapter 23, Section 30.1, give providers 30 days notice before implementing the revised payment amounts, which (unless otherwise stated in the CR5272) will be retroactive to January 1, 2006.

You should be aware that carriers will adjust claims that you bring to their attention, but are not required to search their files to either retract payment for claims already paid or to retroactively pay claims. The changes made as a result of CR5272 are as follows:

CPT/HCPCS Action
15000 Assistant at Surgery Indicator = 0
15001 Assistant at Surgery Indicator = 0
47145 Global Period = XXX
Preoperative Time = 0.00
Intraoperative Time = 0.00
Postoperative Time = 0.00
52402 Endoscopic Base Code = 52000
G0289 Multiple Surgery Indicator = 0

In addition, some Type of Service (TOS) Codes have been adjusted, effective for services on or after July 1, 2006. Specifically, carriers will apply TOS 4 to the Category III codes of 0159T, 0159T-TC, and 0159T-26 and they will apply TOS 6 to the Category III codes of 0160T and 0 161T.

Additional Information
You can find the official instruction about the October update to the 2006 Medicare Physician Fee Schedule Database by going to CR 5272, which is available at http://www.cms.hhs.gov/Transmittals/downloads/R1047CP.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 on the CMS Web site.

Flu Shot Reminder
September is the perfect time to start talking with your patients about getting the flu shot. Medicare provides coverage for the flu vaccine and its administration. Please encourage your Medicare patients to take advantage of this vital benefit. And don’t forget – health care professionals and their staff benefit from the flu vaccine also.

Protect Yourself. Protect Your Patients. Get Your Flu Shot.

Back to the Top of the PageTop

“Own Your Future”: Long-Term Care (LTC) Campaign

Provider Types Affected
Physicians, providers, and their staff who provide health care to individuals between the ages of 45 - 65.

Provider Action Needed
This special edition article is being provided by the Centers for Medicare & Medicaid Services (CMS) to inform you about the Long-Term Care Awareness Campaign ‘Own Your Future’ - the first effort of its kind designed to increase public awareness about the need to plan for future long-term care needs. Providers in Georgia, Massachusetts, Michigan, Nebraska, South Dakota, and Texas, may want to take special note as consumers in those States will receive letters over the next year alerting them of the campaign to promote LTC planning and of the availability of a free Long-Term Care Planning Kit. You may want to reinforce the importance of such planning as you counsel your patients.

Background
Components of the U.S. Department of Health and Human Services (HHS), including the Office of the Assistant Secretary for Planning & Evaluation (ASPE), the Centers for Medicare & Medicaid Services (CMS), and the Administration on Aging (AoA), are working with the National Governors Association to sponsor the Long-Term Care (LTC) Awareness Campaign, “Own Your Future.” The LTC Awareness Campaign represents a unique partnership between the federal government and the states to offer an important message to consumers about planning ahead for long-term care.

The LTC Awareness Campaign is an effort to increase public awareness of the need to plan for future long-term care needs. Many people today do not think about their future long-term care needs and therefore fail to plan appropriately. It is strongly felt that if individuals and families are more aware of their potential need for long-term care, they will be more likely to take steps to prepare for the future and determine how they would like their needs to be met.

The LTC Awareness Campaign includes evaluation activities designed to identify communication strategies that prove most effective in increasing awareness and promoting increased long-term care planning activities. The lessons learned from this campaign will be used in the design of future long-term care awareness campaigns in other states.

The Campaign is now entering a third phase and builds upon the successes achieved in the first two phases in which nine states participated (Arkansas, Idaho, Kansas, Maryland, Nevada, New Jersey, Rhode Island, Virginia and Washington). It is supported with additional funds made available by Congress under the Deficit Reduction Act of 2005.

Additional Information
The LTC Awareness Campaign uses long-term care
awareness materials that were designed, tested, and approved as part of an earlier awareness effort, and the materials include the following:

Flu Season is upon us! Begin now to take advantage of each office visit as an opportunity to talk with your patients about the flu virus and their risks for complications associated with the flu, and encourage them to get their flu shot. And don’t forget, health care professionals need to protect themselves also. Get Your Flu Shot. – Protect yourself, your patients, and your family and friends. Remember - Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For information about Medicare’s coverage of adult immunizations and educational resources, go to http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf on the CMS Web site.

Back to the Top of the PageTop

Pancreas Transplants Alone (PA)

Note: This article was revised on October 5, 2006, to include this statement alerting affected providers to review MLN Matters article SE0674 for important information regarding the continued hold of affected claims.

This article is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0674.pdf on the CMS site.

Provider Types Affected
Physicians and providers billing Medicare fiscal intermediaries (FIs) and carriers for PA

Background
Medicare covers whole organ pancreas transplantation when it is performed in conjunction with or after kidney transplantation (National Coverage Determination (NCD) Manual, Section 260.3). However, Medicare does not cover PA in diabetes patients without end-stage renal failure because of a lack of sufficient evidence, based in large part on a 1994 Office of Health Technology Assessment report.

Key Points
This article is based on information contained in Change Request (CR) 5093, which informs physicians and providers that, effective for services performed on or after April 26, 2006, Medicare will cover PA for beneficiaries in the following limited circumstances:

Billing and Claims Processing

Note: Carriers and FIs will hold any PA claims with dates of service on or after April 26, 2006, until the claims can be processed in their systems. For FIs this date is October 2, 2006, and for carriers the date is July 3, 2006.

Implementation
The implementation date for this instruction is no later than:

Additional Information
The official instructions issued to your Medicare FI or carrier regarding this change can be found at
http://www.cms.hhs.gov/Transmittals/downloads/R56NCD.pdf for the NCD manual revision and
http://www.cms.hhs.gov/Transmittals/downloads/R957CP.pdf for changes to the Medicare Claims Processing Manual.

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

Back to the Top of the PageTop

Pegfilgrastim Article - Retired

The article for Covered Indications for Pegfilgrastim is being retired effective August 14, 2006 for all Part B states. Idaho (A13255), Tennessee (A10144), and North Carolina (A13256).

Back to the Top of the PageTop

Physicians Participating in the Medicare Part B Drug Competitive Acquisition Program (CAP)

Physicians participating in the Medicare Part B Drug Competitive Acquisition Program (CAP) are encouraged to subscribe to the new CMS-CAP-Physicians-L mailing list to receive pertinent and timely information regarding the CAP. Go to http://www.cms.hhs.gov/apps/mailinglists/default.asp?audience=3, then subscribe to the CMS-CAP-Physicians-L mailing list.

As a reminder, the 2007 physician election period for the Medicare Part B Drug Competitive Acquisition Program (CAP) began on October 1, 2006 and concludes on November 15, 2006. The CAP is an alternative to the Average Sales Price (ASP) method of acquiring many drugs and biologicals administered incident to a physician’s services.

CAP physician election is an annual process that provides an opportunity for physicians who are not participating in the CAP to join. Physicians who are currently participating in the CAP must submit an election form in order to continue participation or to terminate participation. Physicians who are not participating in the CAP and do not wish to participate in the CAP at this time are not required to take any action. Completed and signed physician election forms should be returned by mail to your local carrier. Forms must be postmarked on or before November 15, 2006.

Additional information about the CAP is available at http://www.cms.hhs.gov/CompetitiveAcquisforBios/01_overview.asp .

Additional information about the 2007 CAP physician election process is at http://www.cms.hhs.gov/CompetitiveAcquisforBios/02_infophys.asp .

The list of drugs supplied by the CAP vendor, including NDCs, is in the Downloads section at http://www.cms.hhs.gov/CompetitiveAcquisforBios/15_Approved_Vendor.asp.

Flu Season is upon us! Begin now to take advantage of each office visit as an opportunity to talk with your patients about the flu virus and their risks for complications associated with the flu, and encourage them to get their flu shot. And don’t forget, health care professionals need to protect themselves also. Get Your Flu Shot. - Protect yourself, your patients, and your family and friends. Remember - Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For information about Medicare’s coverage of adult immunizations and educational resources, go to (http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf )

Back to the Top of the PageTop

Remicade – Local Coverage Determination Revision

The LCD for Remicade has been revised for Idaho, North Carolina, and Tennessee to add ICD-9 696.1, indication for plaque psoriasis. To view the policy in its entirety, please visit the CMS Web site at
http://www.cms.hhs.gov/mcd/search.asp .

Back to the Top of the PageTop

Reopenings and Revisions of Claim Determinations and Decisions

Provider Types Affected