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January 5, 2007 Part B Medicare Bulletin

Posted January 5, 2007

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Anesthesia Conversion Factors

The 2007 anesthesia conversion factor for the state of Idaho is $13.92.
The 2007 anesthesia conversion factor for the state of North Carolina is $14.32.
The 2007 anesthesia conversion factor for the state of Tennessee is $14.30.

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Cavernous Nerves Electrical Stimulation with Penile Plethysmograph

Flu Shot Reminder - As a respected source of health care information, patients trust their doctors' recommendations. If you have Medicare patients who haven't yet received their flu shot, help protect them by recommending an annual influenza and a one time pneumococcal vaccination. Medicare provides coverage for flu and pneumococcal vaccines and their administration. 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 .
Note: This article was changed on December 6, 2006 to correct the HCPCS code for the test. The article had incorrectly stated to use HCPCS code 58899 (page 3), but it should have stated HCPCS code 55899. The reference to carriers and FIs was also changed to add a reference to A/B MACs. All other information remains the same.

Provider Types Affected
Physicians and hospitals who bill Medicare fiscal intermediaries (FI) and carriers for performing Cavernous Nerves Electrical Stimulation with Penile Plethysmography in Medicare beneficiaries undergoing nerve-sparing prostatic or colorectal surgical procedures.

Provider Action Needed

STOP – Impact to You
Effective for claims with dates of service on or after August 24, 2006, Medicare will not pay for performing Cavernous Nerves Electrical Stimulation with Penile Plethysmography in Medicare beneficiaries undergoing nerve-sparing prostatic or colorectal surgical procedures.

CAUTION – What You Need to Know
CR 5294, from which this article is taken, announces` the results of a national coverage determination (NCD) addressing Cavernous Nerves Electrical Stimulation with Penile Plethysmography performed for Medicare beneficiaries undergoing nerve-sparing prostatic or colorectal surgical procedures. It states that CMS, after reviewing the evidence, has determined that this test is not reasonable and necessary for Medicare beneficiaries undergoing these procedures.

GO – What You Need to Do
Make sure that your billing staffs are aware of this NCD.

Background
The direct application of electrical stimulation with penile plethysmography (also referred to as cavernosal nerve mapping) may be performed, in nerve-sparing prostatic and colorectal surgical procedures, to assess the integrity and function of the cavernous nerves.

Through either an open or laparoscopic approach, the surgeon can assess the function of the cavernous nerves by stimulating, with an electrical nerve stimulator, the most distal end of the nerve that can be located. A functioning and stimulated nerve will trigger blood flow either into or out of the penis, which can be detected via a penile plethysmography sensor fitted around the penis and connected to a nerve stimulator control unit. If the nerves are intact, cavernous blood flow will cause slight changes in penile girth, which the sensor can detect. The presence (and degree) of a response may be used to provide the surgeon with a more realistic assessment of the chance of the patient regaining potency and assist in choosing appropriate therapy.

Heretofore, local Medicare carriers/FIs had the discretion to cover this test whenever it was determined to be medically necessary for the individual patient, because a national coverage determination (NCD) or national Medicare coverage policy had not been issued. However, on December 9, 2005, a request for review of this test initiated a national coverage analysis.

CR 5294, from which this article is taken, announces the results of this NCD. It provides that CMS has reviewed the evidence and determined that: 1) Cavernous Nerves Electrical Stimulation with Penile Plethysmography is not reasonable and necessary for Medicare beneficiaries undergoing nerve-sparing prostatic or colorectal surgical procedures, and 2) this test is noncovered under Medicare (as specified the Medicare National Coverage Manual (100-03, Section 160.26 (Cavernous Nerves Electrical Stimulation with Penile Plethysmography).

Effective with claims with dates of service on or after August 24, 2006, your FIs and carriers will not pay for these services.

Physicians should use HCPCS code 55899 to bill this for test. Your FIs and carriers will suspend claims containing this code to determine whether this test is the service being billed, and will deny the line item associated with it, using Medicare Summary Notice 21.11 (This test was not covered by Medicare at the time you received it).

You should be aware that your FIs, A/B MACs and carriers will not search for, and adjust, claims for tests that have been paid prior to January 8, 2007, but they will adjust claims brought to their attention.

Further, physicians and hospitals should, as appropriate:

  1. Issue the appropriate liability notice for Medicare beneficiaries having this test;
  2. Include the following language when issuing an Advanced Beneficiary Notice (ABN):
  1. Issue a hospital Issued Notice of Noncoverage (HINN).

If a physician does not issue an ABN, the physician is liable for the service.

Additional Information
You can find more information about payment for Cavernous Nerves Electrical Stimulation with Penile Plethysmography by going to CR5294, which is available at http://www.cms.hhs.gov/Transmittals/downloads/R61NCD.pdf on the CMS site. You will find revised section 160.26 (Cavernous Nerves Electrical Stimulation with Penile Plethysmography) of the Medicare National Coverage Manual (Publication 100-03) as an attachment to this CR.

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

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Claims Submitted With Only a National Provider Identifier (NPI) During the Stage 2 NPI Transition Period

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

Provider Action Needed

STOP – Impact to You
Beginning October 1, 2006 and until further notice, claims that you submit containing only an NPI will be returned you as unprocessable if a properly matching legacy number cannot be found.

CAUTION – What You Need to Know
From the beginning of Medicare's Stage 2 NPI transition period on October 1, 2006 and until further notice, you should submit both NPIs and legacy provider numbers on your Medicare claims to ensure that they are properly processed. During this period, claims submitted with only a NPI that Medicare systems are unable to properly match with a legacy number (e.g., PIN, OSCAR number), may be rejected, and you will be required to resubmit the claim with the appropriate legacy number.

GO – What You Need to Do
You should make sure that when submitting Medicare claims with dates of service on or after October 1, 2006, your billing staff submit both your NPI and legacy provider numbers until further notice from CMS.

Background
As previously announced, the Centers for Medicare & Medicaid Services (CMS) plans to begin testing new software it has been developed to use the NPI in the existing Medicare fee-for-service claims processing systems. (Remember that you will be required to submit claims and other HIPAA transactions with only an NPI beginning on May 23, 2007).

During the Stage 2 NPI transition period of October 1, 2006, through May 22, 2007, Medicare will accept claims having only NPIs (as well as those having only legacy provider numbers); however in CR 5378, from which this article is taken, CMS recommends that during this period you submit claims using:

Note: Until January 2, 2007, NPIs are not to be submitted on paper claims via CMS-1500 forms. Institutional providers are advised that the NPI will not be accepted on paper claims by FIs or A/B MACs until implementation of the UB-04 on May 23, 2007.


Until testing of Medicare's new software is complete, if you submit Medicare claims with only your NPI:

  1. They may be processed and paid, or
  2. If the Medicare systems are unable to properly match the incoming NPI with a legacy number (e.g., PIN, OSCAR number), they may be rejected, and you will be required to resubmit the claim with the
    appropriate legacy number.

Additional Information
The official instruction issued to your Medicare contractor on this issue, CR 5378, is available at
http://www.cms.hhs.gov/Transmittals/downloads/R249OTN.pdf on the CMS Web site.

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

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

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Common Working File (CWF) Duplicate Claim Edit for the Technical Component (TC) of Radiology and Pathology Laboratory Services Provided to Hospital Patients

Provider Types Affected
Radiology suppliers, physicians and non-physician practitioners billing Medicare carriers for the TC of radiology laboratory services provided to Medicare fee-for-service hospital inpatients. Also affected are independent laboratories billing Medicare carriers for the TC of pathology laboratory services provided to Medicare fee-for-service hospital patients.

Provider Action Needed
Effective April 1, 2007, CMS will install systems edits to prevent improper payments to radiology suppliers, physicians and non-physician practitioners for the TC of radiology laboratory services during an inpatient stay. The system edits will also apply to independent laboratories for the TC of pathology laboratory services provided to beneficiaries during a covered inpatient hospital stay or provided on the same date of service as an outpatient service. This change applies to claims with dates of service on or after January 1, 2007, where the claim is received on or after April 1, 2007. Please be sure billing staff are aware of these changes.


Background
Current Medicare billing practices allow either the hospital or the supplier performing the technical component (TC) of physician pathology laboratory services to bill the carrier for these services. This policy has contributed to the Medicare program paying twice for the TC service, first through the Prospective Payment System (PPS) to the hospital and again to the supplier that bills the carrier, instead of the hospital, for the TC service.

Effective for claims received on or after April 1, 2007 for services on or after January 1, 2007, CMS will install systems edits to prevent additional improper payments to radiology suppliers, physicians and non-physician practitioners billing Medicare carriers for the TC of radiology laboratory services during an inpatient stay. The edits will also apply to independent laboratories for the TC of pathology services provided to beneficiaries during an inpatient stay or for the same date of service as an outpatient service.

Key Points

Implementation
This change will be implemented on April 2, 2007.

Additional Information
If you have questions, please contact your Medicare fiscal intermediary (FI), 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.

For complete details regarding this CR, please see the official instruction issued to your Medicare FI, Carrier or A/B MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1098CP.pdf 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

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Competitive Acquisition Program (CAP) for Part B Drug - Appeals

Provider Types Affected
Physicians billing Medicare carriers for Part B drugs and biologicals under the Medicare CAP program

Provider Action Needed

STOP – Impact to You
This article is based on Change Request (CR) 5207, which instructs local Medicare carriers and the CAP designated carrier how to execute the appeals process within the unique requirements of CAP. Please note that the CAP claims processing arrangement is not the same as the standard Part B claims processing routine.

CAUTION – What You Need to Know
CR5207 provides additional information and instructions for the implementation of the CAP pertaining to the CAP appeals and dispute resolution process. This is not a stand-alone CR. It builds on previously published related CAP CRs which include: CRs 4064, 4306, 4309, and 4404. The links to those CRs and the related Medicare Learning Network (MLN) articles are provided in the Additional Information section below.

GO – What You Need to Do
See the Background section of this article and the information in CR5207 for further details regarding these special CAP appeals requirements and delivery of dispute resolution services.

Background
Section 303 (d) of the Medicare Prescription Drug Improvement and Modernization Act (MMA) of 2003, requires the implementation of a competitive acquisition program (CAP) for Medicare Part B drugs and biologicals ("drugs") not paid on a cost or prospective payment system basis. Beginning with drugs administered on or after July 1, 2006, physicians will be given a choice between buying and billing these drugs under the average sales price (ASP) system, or obtaining these drugs from vendors selected in a competitive bidding process. A participating CAP physician will submit a claim for drug administration to the Medicare local carrier. An approved CAP vendor will submit a claim for the drug product to the CAP Medicare designated carrier.

Appeal Process for CAP Drug Claims l
As mentioned above, the CAP claims processing arrangement departs from the standard Part B claims processing routine specifically, the CAP uses a local carrier's determination about the physician's drug administration claim that is associated with a CAP drug's claim as an indicator of whether a CAP vendor's matching drug claim should be paid. Therefore, if a local carrier denies the physician's drug administration claim that is to be matched to a CAP vendor's drug claim and causes the vendor's CAP drug claim to deny, the appeals process for the vendor's drug claim's denial must begin with the local carrier that denied the claim. In this situation, in order to pursue an appeal of a denied CAP drug claim, the approved CAP vendor becomes a party to the appeal of a denied drug administration claim filed by a participating CAP physician with the local carrier.

If a CAP vendor's drug claim has been denied because there is no matching participating CAP physician claim on file with the local carrier, the Medicare designated carrier will deny the claim and will suppress appeal rights if there is still no matching drug administration claim after 90 days. The remittance notice will instruct the approved CAP vendor that it may request a reopening. In this case, if the approved CAP vendor accepts the designated Medicare carrier's offer and requests a reopening, the designated carrier will call the participating CAP physician to encourage the physician to file the drug administration claim. If the participating CAP physician does not file the claim, the designated Medicare carrier will engage in dispute resolution activities which may result in a recommendation to terminate the participating CAP physician's involvement in CAP.

The Medicare designated carrier will use group code CO for claims that are denied because the participating CAP physician has not filed his/her claim, will return the following messages:

Additional Information
CR5207 adds sections 100.9-100.94 to Publication 100-04, the Medicare Claims Processing Manual, Chapter 17, "Drugs and Biologicals for CAP." CR5207 is the official instruction issued to your Medicare carrier regarding changes mentioned in this article. CR 5207 may be found at http://www.cms.hhs.gov/Transmittals/downloads/R1076CP.pdf on the CMS Web site.

CR4064, dated December, 9 2005, "Competitive Acquisition Program (CAP) for Part B Drugs" is located at http://www.cms.hhs.gov/transmittals/downloads/R777CP.pdf on the CMS Web site. The related MLN article, MM4064 "Competitive Acquisition Program (CAP) for Part B Drugs" can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4064.pdf on the CMS Web site.

CR4306, dated February 6, 2006, "MCS Screen Expansion for the Prescription Order Number for the Competitive Acquisition Program (CAP) for Part B Drugs to be Developed Over the July 2006 and October 2006 Release, With Final Implementation on October 2, 2006" is available at the following link http://www.cms.hhs.gov/transmittals/downloads/R841CP.pdf on the CMS Web site.

CR 4309, dated February 17, 2006, "Additional Requirements for the Competitive Acquisition Program (CAP) for Part B Drugs" can be found at the following link http://www.cms.hhs.gov/transmittals/downloads/R866CP.pdf on the CMS Web site.

The related MLN article, MM4309 "Additional Requirements for the Competitive Acquisition Program (CAP) for Part B Drugs" can be reached at
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4309.pdf on the CMS Web site.

CR4404, dated April 28, 2006 "Competitive Acquisition Program (CAP) for Part B Drugs Physician Election" is located at http://www.cms.hhs.gov/transmittals/downloads/R932CP.pdf on the CMS Web site. MM4404, "Competitive Acquisition Program (CAP) for Part B Drugs Physician Election" the related MLN article can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4404.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/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 do not 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

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Computed Tomographic Angiography of the Chest – LCD Revision

The LCD for Computed Tomographic Angiography of the Chest, Heart and Coronary Arteries has been revised for TN (L21382), NC (L20553), and ID (L21374) to include ICD-9's 441.03, 441.2, and 441.7. These codes are applicable to CPT 71275 only. Please visit the CIGNA Government Services Web site at to view the policies at:

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

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First Coast Service Options, Inc. Begins QIC Part B North operations effective November 15, 2006

As you are aware, a separate contractor called a Qualified Independent Contractor, or "QIC," handles second level appeals, termed "reconsiderations." Beginning November 6, 2006, all redetermination letters, which communicate the results of the first level of appeal, will include instructions on how to request a reconsideration to the new QIC contractor, First Coast Service Options, Inc. (FCSO).

FCSO will begin processing these reconsiderations on November 15, 2006 for the North jurisdiction, which includes: Alaska, Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, District of Columbia, New York, Pennsylvania, New Jersey, Delaware, Maryland, Ohio, Kentucky, Indiana, Illinois, Michigan, Wisconsin, Minnesota, Missouri, Iowa, Kansas, Nebraska, South Dakota, North Dakota, Wyoming, Montana, Idaho, Washington, Oregon, California, Nevada, Arizona, Utah, Hawaii, Guam, Northern Mariana Islands, and American Samoa. The address to send the QIC reconsiderations to will be:

First Coast Service Options, Inc.
QIC Part B North Reconsiderations
P.O. Box 45208
Jacksonville, FL 32232-5208

Any additional documentation, new information or medical evidence that may assist the QIC in reevaluating the claim(s) should be attached to the written reconsideration request. If no additional information is submitted, a decision will be made based on the documentation contained in the AC's redetermination case file.

NOTE: To aid in the processing of your request and to avoid significant delays, a copy of the redetermination letter should accompany your reconsideration request.

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Implementation of a One-Time Only Ultrasound Screening for Abdominal Aortic Aneurysms (AAA), Resulting from a Referral from an Initial Preventive Physical Examination

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

Note: This article was changed on December 8, 2006 to add emphasize that this coverage is for a one-time only service and it must also be as a result of a referral from an initial preventive physical exam and is also subject to other limitations as discussed in this article and in CR5235.

Provider Types Affected
All physicians and providers who bill Medicare carriers, fiscal intermediaries (FIs), and Medicare Administrative Contractors (MACs) for subject services

Background
This article and related CR5235 highlight the fact that section 5112 of the Deficit Reduction Act (DRA) of 2005 allows for one ultrasound screening for Abdominal Aortic Aneurysms (AAA) under Medicare Part B, effective for services furnished on or after January 1, 2007, as a result of a referral from an Initial Preventive Physical Examination (IPPE) and subject to certain eligibility and other limitations. This provision also waives the annual Part B deductible for the AAA screening test.

Key Points
Effective for dates of service on and after January 1, 2007 Medicare will pay for a one-time ultrasound screening for AAA, for beneficiaries who meet the following criteria:

Payment

FIs will pay for the AAA screening only when the services are performed in a hospital, including a CAH, IHS facility, an SNF, RHC, or FQHC and submitted on one of the following types of bills (TOBs): 12X, 13X, 22X, 23X, 71X, 73X, 85X.

The following table describes the payment methodology Medicare will use for AAA Screening:

Facility Type of Bill Payment
Hospitals subject to OPPS 12X, 13X OPPS
Method I and Method II Critical Access Hospitals (CAHs) 12X and 85X 101% of reasonable cost
IHS providers 13X, revenue code 051X OMB-approved outpatient per visit all inclusive rate (AIR)
IHS providers 12X, revenue code 024X All-inclusive inpatient ancillary per diem rate
IHS CAHs 85X, revenue code 051X
101% of the all-inclusive facility specific per visit rate
IHS CAHs 12X, revenue code 024X 101% of the all-inclusive facility specific per diem rate
SNFs ** 22X, 23X Non-facility rate on the MPFS
RHCs* 71X, revenue code 052X All-inclusive encounter rate
FQHCs* 73X, revenue code 052X All-inclusive encounter rate
Maryland Hospitals under jurisdiction of the Health Services Cost Review Commission (HSCRC) 12X, 13X 94% of provider submitted charges or according to the terms of the Maryland Waiver

*If the screening is provided in an RHC or FQHC, the professional portion of the service is billed to the FI using TOBs 71x and 73x, respectively, and the appropriate site of service revenue code in the 052x revenue code series. If the screening is provided in an independent RHC or freestanding FQHC, the technical component of the service can be billed by the practitioner to the carrier under the practitioner's ID following instructions for submitting practitioner claims to the Medicare carrier. If the screening is provided in a provider-based RHC/FQHC, the technical component of the service can be billed by the base provider to the FI under the base provider's ID, following instructions for submitting claims to the FI from the base provider.

** The SNF consolidated billing provision allows separate part B payment for screening services for beneficiaries that are in skilled Part A SNF stays, however, the SNF must submit these services on a 22x bill type. Screening services provided by other provider types must be reimbursed by the SNF.

Implementation
The implementation date for this instruction is January 2, 2007.
Information Regarding Advanced Beneficiary Notices: Medicare contractors will deny an AAA screening service billed more than one in a beneficiary's lifetime.

If a second G0389 is billed for AAA for the same beneficiary or if any of the other statutory criteria for coverage listed in Section 1861(s)(2)(AA) of the Social Security Act are not met, the service would be denied as a statutory (technical) denial under Section 1861(s)(2)(AA), not a medical necessity denial.
If a provider cannot determine whether or not the beneficiary has previously had an AAA screening, but all of the other statutory requirements for coverage have been met, the provider should issue the ABN-G. Likewise, if all of the statutory requirements for coverage have been met, but a question of medical necessity still exists, the provider should issue the ABN-G.

Additional Information
The official instructions for CR 5235, issued to your Medicare carrier, FI, MAC, FQHC, RHC, SNF, or CAH regarding this change can be found at http://www.cms.hhs.gov/Transmittals/downloads/R1113CP.pdf on the CMS Web site. The Medicare Claims Processing Manual, Publication 100-04, Chapter 18, has been updated to include the requirements to implement section 5112 of the DRA of 2005. The new sections of this chapter address the payment and allowable settings for AAA and the sections are attached to CR5235.
If you have questions, please contact your Medicare carrier, MAC, 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.

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

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Implementation of Revised Fee Schedule Amounts for New Healthcare Common Procedure Coding System (HCPCS) Codes for Power Mobility Devices (PMD)

Joint Signature Memorandum/Technical Direction Letter (JSM/TDL)-06688, issued on September 20, 2006, included instructions for implementation on November 15, 2006, of HCPCS codes K0813 thru K0899 for power wheelchairs and corresponding fee schedule amounts. The fee schedule amounts for codes K0813 thru K0864 have been refined and are being transmitted to replace the fee schedule amounts previously transmitted in accordance with the September 20, 2006, JSM/TDL. The effective date of November 15, 2006, for the codes and fees remains unchanged. In addition, the fee schedule amounts for codes K0868 thru K0891 are being removed from the fee schedule since these are items that will rarely be covered under Medicare.

The revised fee schedule amounts for codes K0813 thru K0864 will be transmitted to contractors in addendum DMEPOS fee schedule files by 8 pm EST on November 9, 2006, in the following files:

Carriers, A/B MACs, DMERCs, DME MACs: MU00.@BF12393.DMEPOS.T060101.V1108 

FIs, A/B MACs: MU00.@BF12393.DMEPOS.T060101.V1108.FI 

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Intra-articular Injections of Hyaluronates in the Knee Joints - Update

Sodium hyaluronates and hyaluronic acid derivatives approved by the FDA for the treatment of osteoarthritis of the knee joints are covered for patients who have failed to respond, or who have had inadequate response to other treatments. There are currently five available drugs (Euflexxa, Hyalgan, Orthovisc, Supartz, and Synvisc).


For dates of service January 01, 2007 forward, the following codes will no longer be accepted: J7317 Sodium Hyaluronate, per 20 to 25 mg dose (Euflexxa, Hyalgan, Orthovisc, and Supartz) and J7320 Hylan G-F 20, 16 mg (Synvisc). (Use these codes for dates of service on or before 12/31/2006.)

Effective January 01, 2007 forward, the following new procedure codes will be accepted for intra-articular injection of hyaluronates in the knee joints: Q4083 Hyalgan/Supartz, inj., per dose; Q4084 Synvisc, inj., per dose; Q4085 Euflexxa, inj., per dose; Q4086 Orthovisc, inj., per dose. (Use these codes for dates of service on or after 01/01/2007.)

The only approved indication for using hyaluronates is osteoarthritis of the knee joint. One of the following ICD-9 codes is required on the claim when submitting charges for hyaluronates:
715.16 Osteoarthrosis, localized, primary, lower leg 715.26 Osteoarthrosis, localized, secondary, lower leg
715.36 Osteoarthrosis, localized, not specified whether primary or secondary, lower leg
715.96 Osteoarthrosis, unspecified whether generalized or localized, lower leg

Before starting treatment with hyaluronates, the diagnosis of osteoarthritis must be supported by x-ray. In addition, the patient must have had at least one aspiration of the joint showing clear viscous aspirate followed by instillation of a steroid product that resulted in either unsatisfactory relief or relief that lasted less than three months. The patient's medical record must include evidence that these requirements have been met.

If the first series of hyaluronates does not prove beneficial, there is no medical necessity to repeat the therapy. If beneficial, it is not expected that the series of injections would be repeated within six months. Frequency of the therapy will be monitored.

When submitting claims for either hyaluronate product, use HCPCS codes 20610 (Arthrocentesis, aspiration and or injection, major joint or bursa) on one claim line and enter the appropriate drug code on a separate line. Link both of them to one of the above-mentioned ICD-9 codes that may support medical necessity.

Providers are allowed to bill for an appropriate Evaluation and Management (E&M) service if the decision to start the series of injections is made after evaluating the patient during the same visit. If the decision to inject has been made during an earlier evaluation and the patient is seen for a scheduled injection, an E&M service should not be billed with code 20610. After the first injection, during the visit for the subsequent injections, an E&M service will not be paid by Medicare unless there was a separately identifiable problem for the service. The -25 modifier should be appended to the E&M code on the claim to indicate a decision for treatment the same day as the injection or an E&M service that is for a problem separate from the hyaluronate injection. Office notes that justify adding the -25 modifier should be in the patients medical records.

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Laboratory Competitive Bidding Demonstration

Note: This article was changed on November 27, 2006 to specify that the only hospitals affected were those that bill type of bill (TOB) 14X. All other information remains the same. Also, the article was previously published as MM5205, based on CR5205, which discussed the initial phase of implementing this demonstration.

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

Provider Types Affected
Physicians and hospitals (TOB 14X only) who bill Medicare carriers, fiscal intermediaries (FIs), or Part A/B Medicare Administrative Contractors (A/B MACs) for clinical 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) 5359 provides instructions for the implementation of a laboratory competitive bidding demonstration. The requirements specified in this article and CR5359 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
CR5359 is being implemented in multiple phases. The requirements specified in this instruction are for the implementation of the demonstration in the first CBA (CBA1).

During the first quarter of 2007, CMS will provide Medicare carriers, FIs, and A/B MACs with a national zip code pricing file identifying the zip codes included in the first CBA. Also, in that same timeframe, CMS will provide to the carriers, FIs, and A/B MACs 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 non-demonstration 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).

Medicare contractors will be prepared to begin processing claims under the laboratory competitive bidding demonstration in the first CBA on April 1, 2007. 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 April 2, 2007.

Additional Information
The official instructions issued to your Medicare carrier, FI, or A/B MAC regarding this change can be found at http://www.cms.hhs.gov/Transmittals/downloads/R50DEMO.pdf on the CMS Web site.

If you have questions, please contact your Medicare 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 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

  1. Please note that the demonstration design described  in Transmittals  R49DEMO and R50DEMO, which provide instructions to Medicare contractors for the implementation of a CMS laboratory competitive bidding demonstration, is a proposed design and has not yet received final approval from the Office of Management and  Budget.
  2. 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


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Luteinizing Hormone-Releasing Hormone Analogues in the Treatment of Prostate Cancer – LCD Revision

The LCD for Luteinizing Hormone-Releasing Hormone Analogues in the Treatment of Prostate Cancer has been revised for TN (L21380), ID (L21376), and NC (L21246) to provide for LCA in each grouping, allowing a more equitable pricing allowance.

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Medicare Part B Dug Competitive Acquisition Program (CAP): Do Not Bill a Prescription Order Number More Than Once

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

Provider Types Affected
Physicians participating in the CAP for Part B Drugs and Biologicals

Provider Action Needed

STOP – Impact to You
A CAP prescription order number must only be used on one claim line. It should not be reused on another claim line on the same claim, and it should not be reused on any other claim.

CAUTION – What You Need to Know
The Centers for Medicare & Medicaid Services (CMS) has found some CAP claims are being processed incorrectly when CAP prescription order numbers are reused when billing for CAP drugs.

GO – What You Need to Do
The prescription order number is intended to be a unique identifier, and it should not be reused.

Background
This special edition article is being released by the CMS to provide a clarification on billing for drugs under the CAP for Part B Drugs and Biologicals.

CAP Claims Processing
In order for the CAP vendor's drug claim to be processed and paid, physicians must submit:

The vendor's drug claim and the physician's claim are then matched in the claims processing system by the prescription order number, and the vendor is paid for the drug that was administered.
A physician's no-pay claim line consists of:

The CAP prescription order number is:

CMS has found that some CAP claims are being processed incorrectly due the following:


Note: A CAP prescription order number must only be used on ONE claim line. It should not be reused on another claim line on the same claim, and it should not be reused on any other claim.

CAP Billing Example
If a CAP vendor has shipped a drug using one prescription order number but the drug is administered in several doses, the total amount administered should be identified in the number of billing units.

Example:
The approved CAP vendor has shipped 20 Heparin Units of J1642 Heparin Sodium (Heparin Lock Flush) under the prescription order number QXXXJ1642YYYYY. (Note: HCPCS Code J1642 has the descriptor: Inj heparin sodium per 10 u.)

Additional Information
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.

For additional information about CAP billing refer to the billing tip sheet at http://www.cms.hhs.gov/CompetitiveAcquisforBios/Downloads/cap_billtips.pdf on the CMS Web site.

Physician billing information on the Competitive Acquisition Program (CAP) may be found at
http://www.cms.hhs.gov/CompetitiveAcquisforBios/02_infophys.asp on the CMS Web site.

In addition, you can find MM4064 (MMA- Competitive Acquisition Program (CAP) for Part B Drugs – Coding, Testing, and Implementation) at http://www.cms.hhs.gov/MLNMattersArticles/downloads/mm4064.pdf on the CMS Web site.

You can also find SE0672 (Clarification of Requirements for the Competitive Acquisition Program (CAP) for Part B Drugs and Biologicals) at
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0672.pdf on the CMS Web site.

Modifier 76- Repeat Procedure by Same Physician: The physician may need to indicate that a procedure or service was repeated subsequent to the original service. This circumstance may be reported by adding the modifier 76 to the repeated service.

Note: When it is medically necessary to repeat a service, the first service should be reported in the usual manner. The repeat service should be reported on the next line with modifier 76 appended to the procedure code. In the event it is medically necessary to repeat a procedure more than twice, report the second line with the 76 modifier and the appropriate number of units in the units field. If a service is repeated more than once, additional documentation should be provided in the narrative field of the claim to support the medical necessity of the repeat services. The patient's medical records must always document the medical necessity of performing repeat procedures and be available to the carrier upon request.

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

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MSP Calculations

Providers should familiarize themselves with how Medicare secondary payments are calculated. Secondary payments are calculated as follows:

  1. The amount Medicare would pay as primary payer is calculated in the usual way.
  2. Medicare's allowed amount is compared to the allowed amount of the primary insurer. The higher allowed amount is identified. (On a nonassigned claim, the primary insurer's allowed amount is
    reduced to the Medicare limiting charge in the computation.)
  3. The amount paid by the primary insurer is subtracted from the allowed amount determined in step 2.
  4. Medicare pays the lower of Medicare's primary payment amount (step 1) or the difference between the higher allowed amount and the primary insurer's payment amount (step 3).

The following examples show the calculation of MSP payments for both assigned and nonassigned claims.

  Example 1 Assigned Example 2
Assigned		 Example 3
Nonassigned		 Example 4
Nonassigned
Amount of claim $ 2,000.00 $ 135.00 $ 1,420.25 $ 117.99
Primary insurer
allowable charge		 $ 1,800.00 $ 135.00 $ 1,420.25 $ 117.99
Primary insurer payment $ 1,440.00 $ 108.00 $ 1,136.20 $ 94.39
Medicare allowable charge $ 1,300.00 $ 108.00 $ 1,235.00 $ 102.60
Medicare deductible withheld $ 00.00 $ 100.00 $ 00.00 $ 100.00
MSP payment $ 360.00 $ 6.40 $ 284.05 $ 2.08
Limiting Charge        

MSP Refund Calculation

  1. Determine amounts allowed by Medicare and the primary insurer

Medicare Allowed Amount =          
Primary Ins. Allowed Amount =          

  1. Compare the allowed amounts and use the higher allowed amount in the MSP calculation.

Higher Allowed Amount =          

  1. Subtract the primary insurer's payment amount from the amount determined in Step 2.
              Higher Allowed Amount
    -           Primary Payment Amount
    =           Potential Secondary Payment
  2. Compare the amount paid by Medicare with the amount of the potential secondary payment

Medicare payment =          
Potential secondary payment =          

  1. If the Medicare payment is higher than the potential secondary payment (determined in step 3), subtract the amount of the potential secondary payment from the amount paid by Medicare. Refund the difference to Medicare.

Medicare Payment

-           Potential Secondary Payment
=           Amount to be refunded

  1. If the Medicare payment is lower than the potential secondary payment, no refund is necessary.

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New 2007 Current Procedural Terminology (CPT) Mammography Codes

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
All physicians and providers who bill Medicare carriers, fiscal intermediaries (FI), or Part A/B Medicare Administrative Contractors (A/B MACs) for providing mammography services.

Provider Action Needed

STOP – Impact to You
As part of the annual HCPCS update, CMS has assigned new 2007 Current Procedural Terminology (CPT) mammography codes for screening and diagnostic mammography services. Effective January 1, 2007, these codes ((77051, 77052, 77055, 77056, and 77057) will replace the current CPT codes; however the CPT code descriptors for the services are unchanged.

CAUTION – What You Need to Know
Failure to submit the correct codes will cause your claims to be returned and not processed.

GO – What You Need to Do
Make sure that your billing staffs are aware of the CPT code changes.

Background
CR 5327, from which this article was taken, announces the assignment of new CPT codes for screening and diagnostic mammography services.


As part of the annual HCPCS update, CMS has assigned new 2007 CPT mammography codes for screening and diagnostic mammography services. Effective January 1, 2007, these codes ((77051, 77052, 77055, 77056, and 77057) will replace the current CPT codes; however the CPT code descriptors for the services are unchanged.

The following table displays the new (and old) replacement codes and their description.

2007 Screening and Diagnostic Mammography CPT codes
New Code Old Code Description
77051 76082 Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images, diagnostic mammography. (list separately in addition to code for primary procedure)
77052 76083 Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images, screening mammography. (list separately in addition to code for primary procedure)
77055 76090 Diagnostic mammography, unilateral
77056 76091 Diagnostic mammography, bilateral
77057 76092 Screening mammography, bilateral (two view film study of each breast)

Be advised that your carriers and FIs will return claims (with dates of service on or after January 1, 2007) that contain the old screening and diagnostic mammography codes. And also effective January 1, 2007, frequency standards for screening mammography will be applied to the new screening codes (77052 and 77057).

Additional Information
You can find more information about the new 2007 mammography CPT codes by going to CR5327, located at http://www.cms.hhs.gov/Transmittals/downloads/R1070CP.pdf on the CMS Web site.

There, as an attachment to that CR, you will find revised Chapter 18 (Preventive and Screening Services), Section 20 (Mammography Services) of the Medicare Claims Processing Manual (100-04),

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

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New Waived Tests

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

Provider Action Needed
This article is based on Change Request (CR) 5404 which informs carriers and A/B MACS of new waived tests approved by the Food and Drug Administration (FDA) under Clinical Laboratory Improvement Amendments of 1988 (CLIA).

Background
The Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations require a facility to be appropriately certified for each test they perform. Laboratory claims are currently edited at the CLIA certificate level in order to ensure that the Centers for Medicare & Medicaid Services (CMS) only pays for laboratory tests categorized as waived complexity under CLIA (for facilities with a CLIA certificate of waiver).


New waived tests are approved by the FDA on a flow basis, and the tests are valid as soon as they are approved. The new waived tests announced by CR5404 are in the following table:

Newly Added CLIA Waived Tests Effective Date Current Procedural Terminology (CPT) Code(s) / Modifier
Immunostics, Inc., hema-screen Specific Immunochemical Fecal Occult Blood Test June 15, 2006 82274QW, G0328QW;
Gryphus Diagnostics BVBlue June 30, 2006 87899QW
ESA Biosciences LeadCare II Blood Lead Testing System (whole blood) September 18, 2006 83655QW

Note: The Current Procedural Terminology (CPT) codes for these new waived tests must have the modifier QW to be recognized as a waived test. Also, for 2007, the new CPT/HCPCS code 87808QW (Infectious agent antigen detection by immunoassay with direct optical observation; Trichomonas vaginalis) replaces the code 87899QW that was assigned to the Genzyme OSOM Trichomonas Rapid Test.

Additional Information
For complete details, please see the official instruction, CR5404, issued to your carrier or A/B MAC regarding this change. That instruction may be viewed at
http://www.cms.hhs.gov/transmittals/downloads/R1115CP.pdf on the CMS Web site. The attachment to CR 5404 includes the list of tests granted waived status under CLIA, and the tests mentioned on the first page of the attachment (i.e., CPT codes: 81002, 81025, 82270, 82272, G0394, 82962, 83026, 84830, 85013, and 85651) do not require a QW modifier to be recognized as a waived test.
As mentioned in Change Request 5292 (Transmittal 1062, dated September 22, 2006), the HCPCS code G0107 (Colorectal Cancer Screening; fecal-occult blood test, 1-3 simultaneous determinations) will be retired effective January 1, 2007 and has been replaced with CPT code 82270 [Blood, occult, by peroxidase activity (e.g., Guaiac) qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided three cards or single triple card for consecutive collection)].

For 2007, the new CPT/HCPCS code G0394 is for Blood occult test (e.g., guaiac), feces, for single determination for colorectal neoplasm (i.e., patient was provided three cards or single triple card for consecutive collection). This code does not require a QW modifier.

To view CR5292 (Transmittal 1062, dated September 22, 2006), please go to http://www.cms.hhs.gov/Transmittals/downloads/R1062CP.pdf on the CMS Web site.
The MLN Matters article based on CR5292 is located at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5292.pdf on the CMS Web site.

If you have any questions, please contact your 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

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Non-Physicians Acting as Scribes for Physicians

The following article was previously published in the general release of the September/October 2001 Medicare Bulletin. Probe reviews of evaluation and management services conducted in the Part B Medical Review department continue to find physicians utilizing staff in the process of documenting the E&M encounters performed. The article below sets forth the guidelines providers should follow when using staff as scribes to record the work done by the physician in either office or facility settings.

Of particular importance, please note that evaluation and management services documented by a nonphysician practitioner/physician extender (such as a nurse practitioner or physician assistant) for work that he/she actually performs independently then is later reviewed/cosigned by a physician is not a scribe situation. We have particularly seen this in facility settings (i.e. hospital or nursing facility) where, for example, a nurse practitioner performs the E&M encounter then the physician rounds later only to review and/or cosign the nurse practitioner's note. The service has then been billed to Medicare under the physician's number. This scenario is neither a scribe situation nor an appropriate split/shared visit, and the "incident to" concept would not apply to facility settings either. In this situation, the service would have to be billed under the nurse practitioner's number and paid at that rate.

In the office setting, the physician's staff may act as a scribe for the physician (according to the guidelines below) and may even independently record the past, family, social history and review of systems which the physician may count towards the level of work he/she ultimately bills. If the staff member is a nonphysician practitioner/physician extender (i.e. a physician's assistant or nurse practitioner) and this clinician not only does the PFSH and ROS but performs the entire visit, this is not a scribe situation either. This service would have to be reported under the nonphysician practitioner's number unless "incident to" guidelines have been met in which case would permit the service to be billed under the physician's number.

In conclusion, the article below advises how providers should document appropriate scribed situations. Providers may review "incident to" guidelines in CMS Publication 100-2, the Medicare Benefit Policy Manual, Chapter 15, section 60.2. Split/shared guidelines are described in CMS Publication 100-4, the Medicare Claims Processing Manual, Chapter 12, section 30.6.1, subsection B. Both of these manuals can be found on the CMS Web site via the following link: http://www.cms.hhs.gov/Manuals/IOM/list.asp
Recently we have noted some physicians having individuals writing notes in the medical record for them, and then merely signing the note. This may be inappropriate.

If a nurse or mid-level provider (PA, NP, CNS) acts as a scribe for the physician, the individual writing the note (or history or discharge summary, or any entry in the record) should note "written by xxxx, acting as scribe for Dr. yyy." Then, Dr. yyyy should co-sign, indicating that the note accurately reflects work and decisions made by him/her. Note: The scribe is functioning as a "living recorder," recording in real time the actions and words of the physician as they are done. If this is done in any other way, it is inappropriate. This should be clearly documented as noted, by both the scribe and the physician. Failure to comply with these instructions may result in denial of claims.

It is inappropriate for an employee of the physician to round at one time and make entries in the record, and then for the physician to round several hours later and note "agree with above," unless the employee is a licensed, certified provider (PA, NP, CNS) billing Medicare for services under his/her own name and number.

Record entries made by a "scribe" should be made upon dictation by the physician, and should document clearly the level of service provided at that encounter. This requirement is no different from any other encounter documentation requirement. Medicare pays for medically necessary and reasonable services, and expects the person receiving payment to be the one delivering the services and creating the record. There is no "incident to" billing in the hospital setting (in-patient or out-patient). Thus, the scribe should be merely that, a person who writes what the physician dictates and does. This individual should not act independently, and there is no payment for this activity.

It is acceptable for a physician to use a scribe, but current documentation guidelines must be followed. The physician is ultimately accountable for the documentation, and should sign and note after the scribe's entry the affirmation above, that the note accurately reflects work done by the physician.

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NPI: Get It. Share It. Use It.

Over 1.4M National Provider Identifiers (NPIs) have been issued. Do you have yours?

Think you don't need an NPI? Think again, and be sure. If you are a health care provider who bills for services, you probably do need an NPI. If you bill Medicare for services, you definitely do!

The bad news is that as of November 23, only six months remain until the NPI compliance date. The implementation of the NPI is a complex process that will impact all business functions of your practice, office or institution including: billing, reporting and payment. This is why providers are urged to get, share, and use their NPI NOW to avoid a disruption in cash flow.


If you don't have an NPI, get one. If you have one, start the testing process with your health plan and use it on your claims and other transactions.

CMS continues to urge providers to include legacy identifiers on their NPI applications. This information is critical for health plans and health care clearinghouses in the development of crosswalks to aid in the transition to the NPI.

Key NPI Facts
The Centers for Medicare & Medicaid Services (CMS) along with the Workgroup for Electronic Data Interchange (WEDI) and other industry health plans would like to remind providers of the following key NPI facts:

Sharing NPIs
Once providers have received their NPIs, they should share their NPIs with other providers with whom they do business, and with health plans that request it. In fact, as outlined in current regulation, all providers must share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes – including designation of ordering or referring physician. Providers should also consider letting health plans, or institutions for whom they work, share their numbers for them.

NPIs are FREE!
Health care providers should know that getting an NPI is free. You do not need to pay an outside source to obtain your NPI for you. All CMS education on the NPI is also free. CMS does not charge for its education or materials.

NPI Questions
 CMS continues to update our Frequently Asked Questions (FAQs) to answer many of the NPI questions we receive on a daily basis. Visit the following link to view all NPI FAQs:

NPI Frequently Asked Questions (FAQs)

Providers should remember that the NPI Enumerator can only answer/address the following types of questions/issues:

Upcoming WEDI Events
WEDI has several NPI events scheduled in the upcoming month. Visit http://www.wedi.org/npioi/index.shtml to learn more about these events. Please note that there is a charge to participate in WEDI events.

Important Information for Medicare Providers

Communicating NPIs to Medicare
Medicare providers should know that there is no "special process" or need to call to communicate NPIs to the Medicare program. NPIs can be shared with the Medicare program in three different ways, as part of the following standard procedures:

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.

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Offset Information Now Available On The IVR

Providers obtain offset information from the Customer Service IVR. You will need the FCN from your Medicare Payment Report. The following offset information is available: letter date, interest amount accrued, balance remaining, claim detail that created the overpayment (including claim number, Medicare number, date of service, and patient account number).

Remember that CMS requires providers to utilize the IVR for claim status and eligibility information. Below is a list of items that are available through the IVR:

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

To view the full IVR script, please visit http://www.cignagovernmentservices.com, Part B Provider Resources, Interactive Voice Response.

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Outpatient Therapy Cap Exceptions Clarifications

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 do not 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

Note: This article was revised on December 4, 2006, to reflect the correct effective and implementation dates as described in CR5271, which CMS recently revised. While CR5271 also reflects effective and implementation dates in January 2007 for Medicare system changes, the information in this article clarifies existing processes.

Provider Types Affected
Providers, physicians, and non-physician practitioners (NPPs) who bill Medicare contractors (fiscal intermediaries (FIs) including regional home health intermediaries (RHHIs), Part A/B Medicare Administrative Contractors (A/B MACs), and carriers) under the Part B benefit for therapy services.

Provider Action Needed
CR 4364, released February 15, 2006, described the exception process to the caps set on outpatient therapy services (physical therapy and occupational therapy). CR 5271, upon which this article is based, clarifies questions (below)

Background
A brief history may be beneficial at this point. The Balanced Budget Act of 1997 placed Financial limitations on Medicare covered therapy services (therapy caps), that were implemented in 1999 and again for a short time in 2003. Congress placed moratoria on these caps for 2004 and 2005, but the moratoria are no longer in place, and the caps were re-implemented on January 1, 2006. However, Congress, through the Deficit Reduction Act has provided that (only for calendar year 2006) exceptions to caps may be made when provision of additional therapy services is determined to be medically necessary. This process ends after December 31, 2006.

Review of this exception process
Section 1833(g)(5) of the Social Security Act provides that, for services provided during calendar year 2006, FIs, RHHIs, and carriers can, in certain circumstances, grant an exception to the therapy cap when requested by the individual enrolled under the Part B benefit (or by a person acting on behalf of that individual).

Exception Processes fall into two categories:

  1. Automatic Process Exceptions
    Medicare beneficiaries will be automatically excepted from the therapy cap and will not be required to submit requests for exception or supporting documentation if they meet specific conditions and complexities listed in the Medicare Claims Processing Manual, Publication 100-04, Chapter 5, (as revised by CR5271) for exception from the therapy cap for 2006.
  2. Manual Process Exceptions
    Medicare beneficiaries may request an exception using the manual process for exception from the therapy cap if their providers believe that the beneficiaries will require more therapy visits than those payable under the therapy cap, but the patients do not meet at least one of the criteria for automatic exceptions.

The clarifications to questions generated from CR 4364 Your FI, RHHI, or carrier:

  1. Will grant exceptions for any number of medically necessary services for 2006 that meet the automatic process exception criteria, if the beneficiary meets the conditions described in Medicare Claims Processing Manual, Pub. 100-04, Chapter 5, (as revised by CR5271)
  2. Will grant an exception to the therapy cap, by approving any number of additional therapy
    treatment days, when these additional treatment days are deemed medically necessary based on documentation that you have submitted for services provided in 2006.
  3. Will utilize clinical judgment in approving or disapproving requests for additional treatment days in the exceptional circumstance in which you do not submit all required documentation with the exception request for services provided in 2006.
  4. Must reply as soon as practicable to a request for exception for services provided in 2006. They will grant an exception to the therapy cap, approving the number of treatment days that you or the beneficiary request (not to exceed 15 future treatment days), if they do not make a decision within 10 business days of receipt of any request and appropriate documentation.
  5. Will allow automatic process exceptions