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February 6, 2007 Part B Medicare Bulletin

Posted February 6, 2007

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2007 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

Provider Types Affected
Clinical laboratories billing Medicare carriers, intermediaries, or Part A/B Medicare Administrative Contractors (A/B MACs)

Provider Action Needed
This article and related CR5362 contain important information regarding:

It is important that affected laboratories understand these changes to ensure correct and accurate payments from Medicare.

Key Points

Update to Fees
In accordance with §1833(h)(2)(A)(i) of the Social Security Act (the Act), as amended by Section 628 of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, the annual update to the local clinical laboratory fees for 2007 is zero (0) percent.

Section 1833(a)(1)(D) of the Act provides that payment for a clinical laboratory test is the lesser of the actual charge billed for the test, the local fee, or the National Limitation Amount (NLA).

The Part B deductible and coinsurance do not apply for services paid under the clinical laboratory fee schedule.

National Minimum Payment Amounts
For a cervical or vaginal smear test (pap smear), §1833(h)(7) of the Act requires payment to be the lesser of the local fee or the NLA, but not less than a national minimum payment amount. Also, payment may not exceed the actual charge.

The 2007 national minimum payment amount is $14.76 ($14.76 plus zero percent update for 2007). The affected codes for the national minimum payment amount include the following Current Procedure Terminology (CPT) codes:

88142 88143 88147 88148 88150 88152 88153
88154 88164 88165 88166 88167 88174 88175
G0123 G1043 G1044 G1045 G0147 G0148 P3000

National Limitation Amounts (Maximum)
For tests for which NLAs were established before January 1, 2001, the NLA is 74 percent of the median of the local fees. For tests for which NLAs are first established on or after January 1, 2001, the NLA is 100 percent of the median of the local fees in accordance with §1833(h)(4)(B)(viii) of the Act.

Access to 2007 Clinical Laboratory Fee Schedule
Internet access to the 2007 clinical laboratory fee schedule data file should be available after November 20, 2006, at http://www.cms.hhs.gov/ClinicalLabFeeSched on the Centers for Medicare & Medicaid Services (CMS) Web site.

Medicaid State agencies, the Indian Health Service, the United Mine Workers, Railroad Retirement Board, and other interested parties should use the Internet to retrieve the 2007 clinical laboratory fee schedule. It will be available in multiple formats: Excel, text, and comma delimited.

Public Comments
On July 17, 2006, CMS hosted a public meeting to solicit input on the payment relationship between 2006 codes and new 2007 Current Procedural Terminology codes. Notice of the meeting was published in the Federal Register on May 26, 2006 and on the CMS Web site on June 19, 2006.

Recommendations were received from many attendees, including individuals representing laboratories, manufacturers, and medical societies. CMS posted a summary of the meeting and the tentative payment determinations on the Web site http://www.cms.hhs.gov/ClinicalLabFeeSched. Additional written comments from the public were accepted until September 26, 2006.

Additional Pricing Information
The 2006 laboratory fee schedule includes separately payable fees for certain specimen collection methods (codes 36415, P9612, and P9615).

For dates of service January 1, 2007 through December 2007, the fee for clinical laboratory travel code P9603 is $0.935 per mile and for code P9604 is $9.35 per flat rate trip basis. The clinical laboratory travel codes are billable only for traveling to perform a specimen collection for either a nursing home or homebound patient. The standard mileage rate for transportation costs was increased by the Federal Government's Treasury Department to 48.5 cents a mile and this amount is incorporated into the fees for travel codes P9603 and P9604.

The 2007 laboratory fee schedule also includes codes that have a 'QW' modifier to both identify codes and determine payment for tests performed by a laboratory registered with only a certificate of waiver under the Clinical Laboratory Improvement Amendments (CLIA).

Based on comments and data submitted, codes 83037 and 83037QW are priced by crosswalking to code 82985.

Organ or Disease Oriented Panel Codes
Similar to prior years, the 2006 pricing amounts for certain organ or disease panel codes and evocative/suppression test codes were determined by Medicare by summing the lower of the fee schedule amount or the NLA for each individual test code included in the panel code.

Mapping Information
CMS advises the following:

Laboratory Costs Subject to Reasonable Charge Payment in 2006
For outpatients, the following codes are paid under a reasonable charge basis. In accordance with 42 CFR 405.502 – 405.508, the reasonable charge may not exceed the lowest of the actual charge or the customary or prevailing charge for the previous 12-month period ending June 30, updated by the inflation-indexed update. The inflation-indexed update is calculated using the change in the applicable Consumer Price Index for the 12-month period ending June 30 of each year as prescribed by §1842(b)(3) of the Act and 42 CFR 405.509(b)(1). The inflation-indexed update for year 2007 is 4.3 percent.


Manual instructions for determining the reasonable charge payment can be found in the Medicare Claims Processing Manual, Chapter 23, §80-80.8. If there is insufficient charge data for a code, the instructions permit considering charges for other similar services and price lists. The Medicare Claims Processing Manual, is located at http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage on the CMS Web site.


When these services are performed for independent dialysis facility patients, Medicare Claims Processing Manual, Chapter 8, §60.3 instructs the reasonable charge basis applies. However, when these services are performed for hospital based renal dialysis facility patients, payment is made on a reasonable cost basis. Also, when these services are performed for hospital outpatients, payment is made under the hospital outpatient prospective payment system (OPPS).

Blood Products

P9010 P9011 P9012 P9016 P9017 P9019 P9020
P9021 P9022 P9023 P9031 P9032 P9033 P9034
P9035 P9036 P9037 P9038 P9039 P9040 P9044
P9050 P9051 P9052 P9053 P9054 P9055 P9056
P9057 P9058 P9059 P9060      

Also, the following codes should be applied to the blood deductible, as instructed in the Medicare General Information, Eligibility and Entitlement Manual, (also available at http://www.cms.hhs.gov/Manuals/IOM/list.asp#Top OfPage) Chapter 3, Section 20.5-20.54:

P9010 P9011 P9016 P9021 P9022 P9038 P9039
P9040 P9051 P9054 P9056 P9057 P9058  

NOTE: Biologic products not paid on a cost or prospective payment basis are paid based on §1842(o) of the Act. The payment limits based on section 1842(o), including the payment limits for codes P9041, P9043, P9045, P9046, P9047, and P9048, should be obtained from the Medicare Part B Drug Pricing Files.

Transfusion Medicine

86850 86860 86870 86880 86885 86886 86890
86891 86900 86901 86903 86904 86905 86906
86920 86921 86922 86923 86927 86930 86931
86932 86945 86950 86960 86965 86970 86971
86972 86975 86976 86977 86978 86985 G0267

Reproductive Medicine Procedures

89250 89251 89253 89254 89255 89257 89258
89259 89260 89261 89264 89268 89272 89280
89281 89290 89291 89335 89342 89343 89344
89346 89352 89353 89354 89356    

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 CR5362, 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/R1122CP.pdf on the CMS Web site.

Instructions for calculating reasonable charges are located in the Medicare Claims Processing Manual (Pub. 100-04) Chapter 23, Sections 80-80.8 at
http://www.cms.hhs.gov/manuals/downloads/clm104c23.pdf on the CMS Web site

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2007 Medicare Physician Fee Schedule

The Tax Relief and Health Care Act of 2006 set the 2007 Conversion Factor for physician payment at the same level as in 2006 ($37.8975), reversing the statutorily mandated 5.0 percent negative update. However, it does not maintain 2007 physician payments at 2006 levels. There are a number of other factors that may affect payment rates for 2007.

Medicare Physician Fee Schedule amounts are calculated based on a specific methodology. With the reversal of the 5.0 percent reduction in the Conversion Factor, there have been numerous questions regarding the 2007 Physician Fee Schedule. The correct 2007 Physician Fee Schedule has been posted to the CIGNA Government Services Web site at the following link: http://www.cignagovernmentservices.com/partb/fsch/index.html#2007updates.

The 2007 Medicare Physician Fee Schedule amounts may or may not match the amounts from 2006. Differences occur as a result of 2007 changes to the Relative Value Units (RVUs) and/or Geographic Practice Cost Indices (GPCIs) for a specific procedure or service.

The Physician Fee Schedule formula to calculate allowable amounts uses RVUs and GPCIs multiplied by the annual Conversion Factor to equal the allowed amounts.

Relative Value Units (RVUs)
Three RVUs are set for each procedure code. Each procedure code has an RVU for:

  1. Physician Work (RVUw) - includes:
    • Time required to furnish the service
    • Intensity of the effort
    • Technical skills required
  2. Practice Expense (RVUpe) - includes costs for:
    • Office rent
    • Employee salaries
    • Supplies
  3. Malpractice Expense (RVUm)
    • Based on historical data
    • Weighted by specialty

Geographic Practice Cost Indices (GPCIs)
RVUs are adjusted to reflect the variation in practice costs from area to area. Each payment locality has three separate GPCIs:

  1. Physician Work (GPCIw)
  2. Practice Expense (GPCIpe)
  3. Malpractice Insurance (GPCIm)

National Conversion Factor (CF)
The National Conversion Factor is a multiplier that transforms relative values into payment amounts.

Calculation and Payment Information
The calculation for the Medicare Physician Fee Schedule is:
[(RVUw X GPCIw) + (RVUpe X GPCIpe) + (RVUm X GPCIm) X CF]=MPFS Amount

Medicare's approved amount would be the lower of the:

  1. Physicians actual charge, or
  2. Medicare Physician Fee Schedule amount

Medicare's payment is generally 80% of the approved amount after the annual deductible has been met.

For more information regarding updates to the 2007 Medicare Physician Fee Schedule, see MLN Matters article 5443, available at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5443.pdf.

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2007 Physician Fee Schedule Payment Policies

Provider Types Affected
Physicians and other providers who bill Medicare carriers, fiscal intermediaries (FI) and A/B MACs for services, including ambulance and telehealth services.

What you Need to Know
CR 5443, from which this article was taken:

  1. Summarizes significant issues contained in the Medicare Physician Fee Schedule Regulation for 2007 (including publishing the Ambulance Inflation Factor (AIF) for CY 2007); and
  2. Announces the telehealth originating site facility fee for 2007. CR5443 also discusses several provisions of the recently-enacted Tax Relief and Health Care Act of 2006. You should refer to the Background and Additional Information sections, below, for more details and information on how to find the background/reference documents.

Background

Tax Relief and Health Care Act of 2006
The Tax Relief and Health Care Act of 2006 set the 2007 conversion factor for physician payment at the same level as in 2006 ($37.8975), reversing the statutorily mandated 5.0 percent negative update. However, it does not maintain 2007 physician payments at 2006 levels. There are a number of other factors that affect payment rates for 2007 and this article discusses several of those factors. The legislation also extends the 1.0 floor on work Geographic Practice Cost Indices (GPCIs) through December 31, 2007. Practice expense GPCIs and malpractice GPCIs are not affected by this provision.

Section 202 of this act mandates that Medicare Part B will cover, for 2007 only, the administration of vaccines that are covered under Part D of Medicare. A new G code (G0377) has been created for the administration of Part D vaccines and payment for G0377 will be crosswalked to CPT code 90471 for one year. When a physician administers a Part D vaccine, the physician should use G0377 to bill the local carrier for the administration of the vaccine. Payment to the physician will be on an assigned basis only. Normal beneficiary deductible and coinsurance requirements apply to the administration. Payment for Part D covered vaccines is made solely by the participating Prescription Drug Plan. Medicare Part B will not pay for the vaccine itself.

Medicare Physician Fee Schedule Regulation for 2007
Section 1848(b)(1) of the Social Security Act requires the Centers for Medicare and Medicaid Services (CMS) to establish (by regulation, before November 1 of each year) fee schedules that establish payment amounts for physicians' services for the subsequent year.

Accordingly, on November 1, 2006, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule (MPFS) final rule for calendar year 2007. In this rule (effective January 1, 2007) Medicare:

The final rule also:

Lastly, the final rule addresses comments received on the separate notice published June 29, 2006 (Five Year Review of Work Relative Value Units Under the Physician Fee Schedule and Proposed Changes to the Practice Expense Methodology (CMS-1521-PN)), which is contained in an attachment to CR 5443. Further discussion of the above summarized items is in that same attachment to CR5443.

Telehealth originating site facility fee for 2007
Section 1834(m) of the Social Security Act established the Medicare telehealth originating site facility fee payment amount for telehealth services provided from October 1, 2001, through December 31, 2002, at $20.

For telehealth services provided on or after January 1 of each subsequent calendar year, the telehealth originating site facility fee is increased as of the first day of the year by the percentage increase in the Medicare Economic Index (MEI).

The MEI increase for 2007 is 2.1%. Thus for calendar year 2007, the payment amount for HCPCS code "Q3014, telehealth originating site facility fee" is 80%t of the lesser of the actual charge, or $22.94.

Note that the beneficiary is responsible for any unmet deductible amount or coinsurance.

The Medicare telehealth originating site facility fee and MEI increase by applicable time period is shown in Table 1, below.
Table 1

Medicare Telehealth Originating site Facility Fee and MEI by Time Period Facility Fee MEI Time Period
Facility Fee MEI Time Period
$20.00 N/A 10/01/2001-12/31/2002
$20.60 3.0% 01/01/2003-12/31/2003
$21.20 2.9% 01/01/2004-12/31/2004
$21.86 3.1% 01/01/2005-12/31/2005
$22.47 2.8% 01/01/2006-12/31/2006
$22.94 2.1% 01/01/2007-12/21/2007

Additional Information
You can find more information about the 2007 Physician Fee Schedule Payment Policies by going to CR 5443, located at http://www.cms.hhs.gov/Transmittals/downloads/R258OTN.pdf on the CMS Web site.

Please see, as an attachment to that CR, a document entitled Revisions to Payment Policies and Five-Year Review of Work Relative Value Units Under the Physician Fee Schedules for CY 2007, and Other Changes to Payment Under Part B; Revisions to the Payment Policies of Ambulance Services Under the Fee Schedule for Ambulance Services; Ambulance Inflation Factor Update for CY 2007, for more details on the significant issues discussed in the final rule.

You can find the November 1, 2006 CMS press release entitled MEDICARE ANNOUNCES FINAL RULE SETTING PHYSICIAN PAYMENT RATES AND POLICIES FOR 2007, by going to http://cms.hhs.gov/apps/media/press/release.asp?Counter=2044; and other information about the physician fee schedule by going to the CMS Physician Center Web site at http://cms.hhs.gov/center/physician.asp.

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.

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

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Cardiac Output Monitoring by Thoracic Electrical Bioimpedance (TEB)

Note: This article was revised on December 29, 2006, to correct, on page 2, the Web address for accessing CR5414. All other information remains the same.

Provider Types Affected
Physicians who bill Part A/B Medicare Administrative Contractors (A/B MACs), or Medicare carriers for services to Medicare beneficiaries.

Background
The Centers for Medicare & Medicaid Services (CMS) reconsidered the Medicare coverage policy for TEB for drug-resistant hypertension and decided to retain current coverage as written in section 20.16 of the National Coverage Determinations (NCD) Manual.

Effective for dates of service on and after November 24, 2006, the current policies for cardiac output monitoring by TEB listed at section 20.16 of the NCD Manual will remain the same. Medicare A/B MACs and carriers will continue to make reasonable and necessary determinations for the use of TEB related to drug-resistant hypertension only. All other coverage and non-coverage policies at section 20.16 remain in effect.

Additional Information
If you have questions, please contact your Medicare A/B MAC or 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 complete details regarding this Change Request (CR) including the revised section of 20.16 of the NCD manual, please see the official instruction (CR5414) issued to your Medicare A/B MAC or carrier. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R63NCD.pdf on the CMS Web site.

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Cardiac Output Monitoring by Thoracic Electrical Bioimpedance (TEB)

Cardiac Ouput Monitoring by Thoracic Electrical Bioimpedance

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Cavernous Nerves Electrical Stimulation with Penile Plethysmograph

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):


3. 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 Web site.

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Competitive Acquisition Program (CAP) – Claim Processing for Not Otherwise Classified ("NOC") Drugs

Note: This article was revised on December 14, 2006, to correct the Web address on page 4 for accessing CR5079. All other information remains the same.

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

Impact on Providers
This article is based on Change Request (CR) 5259, which describes the process for adding Not Otherwise Classified (NOC) Drugs to the CAP beginning in 2007. It provides additional details, information and instructions for the implementation of the CAP as outlined previously in CRs 4064, 4306, 4309 and 5079 and the MLN Matters articles related to those CRs.

Background
As discussed in the November 21, 2005 CAP final rule (http://www.access.gpo.gov/su_docs/fedreg/a051121c.html) and in response to public comments about beneficiary access to new medications, CMS provided for the addition of NOC drugs to the CAP beginning in 2007. CMS believes that the addition of NOC drugs to the CAP will improve beneficiaries' access to newly marketed drugs that have a national sales price, will decrease the reliance on buy and bill acquisition and will further simplify the drug acquisition process for physicians who have elected to participate in the CAP.


PROCESS TO ADD NOC DRUGS TO A CAP VENDOR'S DRUG LIST
The process for adding NOC drugs to the CAP will basically follow the process for adding other drugs to the CAP as described in CR5079. An approved CAP vendor will be required to submit a written request to add specific NOC drugs to the CAP designated carrier. The request must include:


CMS will define a list of CAP NOC drugs that the approved CAP vendor must use when requesting the addition of NOC drugs to the CAP. The CAP NOC drug list will be based on the ASP NOC list, but will include only drugs that are both likely to fit the existing CAP drug category (or categories) and drugs that have a single national ASP-based payment amount. The CAP NOC drug list will be posted on the CMS CAP Web site and updated quarterly.

If approved, changes will become effective at the beginning of the following quarter. CMS will post the changes on the CMS Web site (http://www.cms.hhs.gov/CompetitiveAcquisforBios/ ) and notify the carriers and participating CAP physicians of any changes on a quarterly basis. Participating CAP physicians will be notified of changes to their approved CAP vendor's CAP drug list on a quarterly basis and at least 30 days before the approved changes are due to take effect. CAP drug list approvals apply only to the CAP vendor who submitted the request and to the category identified on the request. Therefore, each vendor's drug list may contain different drugs after changes to the initial drug list are approved. The CAP NOC drug payment amount will be at the same rate as published on the ASP NOC file consistent with the next quarterly update, and the payment amount will be updated annually as for other CAP drugs.

CAP NOC CLAIMS SUBMISSION REQUIREMENTS
CMS requires the use of a CAP-specific Q code (Q4082 Drug/bio NOC part B drug CAP) for CAP NOC drug claims in order to distinguish CAP NOC drug claims from ASP NOC claims and to prevent the CAP claims from being paid outside the Medicare Part B drug CAP. Physician drug administration claims for CAP NOC drugs are required to

Note: Physicians who have elected to participate in the CAP should continue to use ASP NOC codes when billing for NOC drugs that are outside the CAP. Also remember that physicians who participate in the CAP are required to obtain all CAP drugs on the updates from the approved CAP vendor unless medical necessity requires the use of a formulation not supplied by the vendor.

RETURNED CAP NOC CLAIMS
For the following three situations, if:

Then:

Implementation
The implementation date for CR5259 is January 2, 2007.

Additional Information
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.

Change Request (CR) 5259 is not a stand-alone CR. It provides additional details, information, and instructions for the implementation of the Competitive Acquisition Program (CAP) as outlined in:
CR 4064 (http://www.cms.hhs.gov/transmittals/downloads/R777CP.pdf; http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4064.pdf),
CR4306 (http://www.cms.hhs.gov/transmittals/downloads/R841CP.pdf),
CR4309 (http://www.cms.hhs.gov/transmittals/downloads/R866CP.pdf; http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4309.pdf) and
CR 5079 (http://www.cms.hhs.gov/Transmittals/downloads/R1055CP.pdf; http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5079.pdf).

For complete details, please see the official instruction issued to your carrier regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1034CP.pdf on the CMS Web site.

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

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.

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Comprehensive Error Rate Testing (CERT)

Remember the importance to complying with requests from the CERT Documentation Contractor (CDC) office for medical records needed for the CERT program.

The CERT program produces national, contractor-specific and service-specific paid claim error rates, as well as a provider compliance error rate. The paid claim error rate is a measure of the extent to which the Medicare program is paying claims correctly. The provider compliance error rate is a measure of the extent to which providers are submitting claims correctly. A portion of this error rate was due to providers not sending requested supporting documentation to the designated CERT contractor.

REMINDER

The CDC sends a written request for medical records to an individual provider that includes a checklist of the types of documentation required. Medical records should be submitted to the CDC within 75 days from the receipt date of the initial letter or the claim will be denied.

Providers should submit this documentation to the CDC via fax or mail at the number/address specified below:

FAX: 240.568.6222

CERT Documentation Office
Attn: CID #: (Claim Identifier listed at the top of the checklist)
9090 Junction Drive, Suite 9
Annapolis Junction, MD 20701

Providers may call the CDC at 301.957.2380 with questions regarding specific documentation to submit.

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Emergency Update to the 2007 Medicare Physician Fee Schedule Database (MPFSDB)

Provider Types Affected
Physicians and other providers who bill Medicare contractors (carriers, fiscal intermediaries (FIs), or Part A/B Medicare administrative contractors (A/B MACs)) for professional services paid under the Medicare Physician Fee Schedule (MPFS).

Background
This article and related Change Request (CR) 5459 wants providers to know that payment files were issued to contractors based upon the December 1, 2006, MPFS Final Rule. CR5459 amends those payment files.

Key Points http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf
You may wish to review Attachment 1 of the CR5459, which is located at http://www.cms.hhs.gov/Transmittals/downloads/R1143CP.pdf on the CMS Web site. The following key points summarize the specifics that are identified in the attachment to CR5459.

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR5459) issued to your Medicare carrier, FI or A/B MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1143CP.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
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.

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2007 Update of HCPCS Codes and Payments for Ambulatory Surgical Centers (ASCs)

Note: This article was revised on December 21, 2006, to reflect changes made to CR5211. CR5211 was amended to provide the Web address for accessing the "2007 ASC Approved HCPCS Codes and Payment Rates." That address is in the Additional Information section of this article. The article was also revised to reflect the new CR release date, transmittal number, and Web address for accessing the revised CR5211. All other information remains the same.

Provider Types Affected
Ambulatory surgical centers (ASCs) submitting claims to Medicare carriers or fiscal intermediaries (FIs) for ASC services provided to Medicare beneficiaries.

Impact on Providers
This article is based on Change Request (CR) 5211, which updates the 2007 HCPCS codes and ASC payment rates, effective for services furnished on or after January 1, 2007.

Background
Section 5103 of the Deficit Reduction Act of 2005 (DRA) limits ASC payments to:

Also, §1833(i)(1) of the Social Security Act requires that the list of payable ASC procedures be updated as least every two years.

\CR5211, from which this article is taken, implements the required biennial ASC update, which includes changes made by the American Medical Association for the CY 2007 Common Procedural Terminology (CPT). These changes include replacing the ASC 2-digit payment group code designation next to the ASC-approved Healthcare Common Procedure Coding System (HCPCS) codes with a "yy" designation for these codes, which will be defined as "the procedure is approved to be performed in an ambulatory surgical center."

CR5211 also revises the manner in which ASC payment groups are defined. The number of ASC payment groups that carriers and fiscal intermediaries (FI) currently use to identify ASC payment amounts for individual HCPCS codes is being expanded in order to accommodate the new payment amounts that will be assigned to certain ASC services in Calendar Year (CY) 2007 under the DRA requirement. The ASC payment groups will now be called ASC PRICER groups.

The additional ASC PRICER groups reflect the DRA-driven payment amounts, which will be included in the ASC PRICER files that carriers, and certain FIs, use to process ASC facility claims.

And lastly, CR5211 includes payment file retrieval instructions that your carriers and FIs will use to access the final payment files on, or after, the specified retrieval date provided in CMS's notification.

You should be aware that final ASC payment rates are established after publication of the OPPS final rule and the code change update will be published as part of the OPPS final rule in the Federal Register. This publication usually occurs in late October. Shortly after publication, you can reach this rule through a link at http://www.cms.hhs.gov/center/asc.asp on the CMS Web site.

Also note that your carriers and FIs will continue to use the wage index values contained in Transmittal 51, dated February 4, 2004, to calculate payment amounts for all type of service F Healthcare Common Procedural Coding System (HCPCS) codes until further notice.
This transmittal is available at http://www.cms.hhs.gov/Transmittals/downloads/R51OTN.pdf on the CMS site.

Additional Information
For complete details, please see CR 5211, the official instruction issued to your carrier/intermediary regarding this change, located at http://www.cms.hhs.gov/Transmittals/downloads/R1134CP.pdf on the CMS Web site. The "2007 ASC Approved HCPCS Codes and Payment Rates" changes are available at http://www.cms.hhs.gov/ASCPayment/01_Overview.asp on the CMS 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
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

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FDA Alert: Erythropoiesis Stimulating Agents (ESA)

[Aranesp (darbepoetin), Epogen (epoetin alfa), and Procrit (epoetin alfa)]

FDA ALERT [11/16/2006]: FDA is issuing this alert to advise you of a newly published clinical study showing that patients treated with an erythropoiesis-stimulating agent (ESA) and dosed to a target hemoglobin concentration of 13.5 g/dL are at a significantly increased risk for serious and life threatening cardiovascular complications, as compared to use of the ESA to target a hemoglobin concentration of 11.3 g/dL. The "Correction of Hemoglobin and Outcomes in Renal Insufficiency" (CHOIR) study, published November 16, 2006 in the New England Journal of Medicine, reports the adverse cardiovascular complications as a composite of the occurrence of one of the following events: death, myocardial infarction, hospitalization for congestive heart failure, or stroke.

The CHOIR study findings underscore the importance of following the currently approved prescribing information for Procrit, Epogen, and Aranesp, including the dosing recommendation that the target hemoglobin not exceed 12 g/dL.

This information reflects FDA's current analysis of data available to FDA concerning these drugs. FDA intends to update this sheet when additional information or analyses become available.

To report any serious adverse events associated with the use of these drugs, please contact the FDA MedWatch program using the contact information at the bottom of this sheet.

Considerations
Physicians and other healthcare professionals should consider the following when using erythropoiesis stimulating agents:

Information for the Patient
Physicians and other healthcare professionals should discuss the following with their patients:

Data Summary
Safety concerns related to the use of erythropoiesis-stimulating agents in the treatment of the anemia of chronic renal failure (CRF) is the topic of two clinical studies and an editorial published in The New England Journal of Medicine on November, 16, 2006. The 1,432 subject CHOIR study demonstrated increases in serious and potentially life threatening cardiovascular events when epoetin alfa (Procrit) is administered to reach higher target hemoglobin levels than lower target hemoglobin levels. The 603 subject CREATE study showed a trend toward more cardiovascular events in a pattern similar to the CHOIR study, thus supporting the findings of the CHOIR study. The CREATE study examined the use of epoetin beta, a product not approved in the USA.

The CHOIR and CREATE study findings underscore the importance of the existing warnings regarding cardiovascular risks that include thrombotic events and increased mortality observed in hemodialysis patients with cardiac disease targeted to higher hemoglobin levels (~14 g/dL), and recommendations not to exceed hemoglobin levels of 12 g/dL in approved labeling for Procrit, Epogen, and Aranesp. Please refer to the full prescribing information for additional information. Internet links to the full prescribing information for all approved ESA products may be found at the FDA page for this alert.

Report serious adverse events to FDA's MedWatch reporting system by completing a form on line at http://www.fda.gov/medwatch/report.htm, by faxing (1.800.FDA.0178), by mail using the postage-paid address form provided online (5600 Fishers Lane, Rockville, MD 20852-9787), or by telephone (1.800.FDA.1088).

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Fee Schedule Update for 2007 for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

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

Provider Types Affected
Physicians, suppliers, and providers who bill Medicare contractors (Part A/B Medicare Administrative Contractors (A/B MACs), durable medical equipment regional carriers (DMERCs), DME Medicare administrative contractors (DME MACs), fiscal intermediaries (FIs), carriers, and/or regional home health intermediaries (RHHIs)), for services paid under the DMEPOS Fee Schedule.

Provider Action Needed
This article is based on Change Request (CR) 5417, and it provides specific information regarding the annual update for the 2007 DMEPOS Fee Schedule. Be sure billing staff are aware of this update.

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

Payment on a fee schedule basis is required for:

A4348 L0100 L6745 L6825 L6872
A4359 L0110 L6750 L6830 L6873
A4462 L3902 L6755 L6835 L6875
A4632 L3914 L6765 L6840 L6880
E0164 L6700 L6770 L6845 L7010
E0166 L6705 L6775 L6850 L7015
E0180 L6710 L6780 L6855 L7020
E0701 L6715 L6790 L6860 L7025
E0977 thru E0999 L6725 L6795 L6865 L7030
E2320 L6730 L6800 L6867 L7035
K0090 thru K0097 L6735 L6806 thru L6809 L6868  
K0099 L6740 L6830 L6870  

Note: DMERCs and DME MACS will use the 2007 PEN fee schedule payment amounts to pay claims for items furnished from January 1, 2007 through December 31, 2007

Deleted HCPCS Codes
The following codes are being deleted from the HCPCS effective January 1, 2007, and are therefore being removed from the DMEPOS and PEN fee schedule files.

Added HCPCS
The HCPCS codes listed below are being added to the HCPCS on January 1, 2007:

A4461 A8003 L1001 L6639
A4463 A004 L3806 L6703
A4559 A9279 L3808 L6704
A4600 E0676 L3915 L6706
A4601 E0936 L5993 L6707 thru L6709
A8000 E2373 thru E2377 L5994 L7007 thru L7009
A8001 E2381 thru E2396 L661 L8690
A8002 K0733 thru K0737 L6624 L8691
      L8695

Payment Rates for Oxygen and Oxygen Equipment
As part of this fee schedule update, the Centers for Medicare & Medicaid Services (CMS) is implementing national monthly payment rates for oxygen and oxygen equipment effective for claims with dates of service on or after January 1, 2007. The 2007 national monthly payment rates are listed in the table below. As a result of these changes, CMS is revising the fee schedule amounts for codes E1405 and E1406. Since 1989, the fees for E1405 and E1406 have been established based on a combination of the Medicare payment amounts for stationary oxygen equipment and nebulizer codes E0585 and E0570, respectively.

As part of these changes, suppliers must submit claims with both the code for stationary oxygen contents (E0441 or E0442) and the code for portable oxygen contents (E0443 or E0444) when billing for payment for furnishing both stationary and portable oxygen contents for beneficiary-owned gaseous or liquid stationary and portable oxygen equipment.

HCPCS Codes Amount Class
E0424, E0439, E1390, and E1391 $198.40 Stationary Oxygen Equipment (including stationary concentrator, liquid and gaseous equipment) and Oxygen Contents (stationary and portable)
E0431 and E0434 $31.79 Portable Equipment Only (gaseous or liquid tanks)
E1392 and K0738 $51.63 Oxygen Generating Portable Equipment (OGPE) Only
E0441 and E0442 $77.45 Oxygen Contents for Beneficiary-Owned Stationary Gaseous or Liquid Oxygen Equipment
E0443 and E0444 $77.45
Oxygen Contents for Beneficiary-Owned Portable Gaseous or Liquid Oxygen Equipment

The fee schedules for HCPCS code E0461 (Volume Control Ventilator, Without Pressure Support Mode, May Include Pressure Control Mode, Used with Non-Invasive Interface (E.G. Mask)) are being revised as part of this update to correct calculation errors and are effective for dates of service on or after January 1, 2007.

Gap-Fill Items
The Medicare DMERCS and DME MACs will gap-fill base fee schedule amounts for each State in their region for the following new and revised HCPCS codes that will be subject to the DMEPOS fee schedules in 2007:

Additional Information
If you have questions, please contact your Medicare A/B MAC, FI, DMERC, DME/MAC, RHHI or 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 complete details regarding this Change Request (CR) please see the official instruction (CR5417) issued to your Medicare A/B MAC, DMERC, DME MAC, FI, RHHI, or carrier. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1125CP.pdf on the CMS Web site.

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.

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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

Note: This article was changed on December 8, 2006 to 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

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 jurisdication 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 (PMDs)

Joint Signature Memorandum/Technical Direction Letter (JSM/TDL)-07074, issued on November 16, 2006, included instructions for implementation on November 15, 2006, of refined fee schedule amounts for HCPCS codes K0813 thru K0864. The revised fee schedule amounts for codes K0813 thru K0864 were transmitted to contractors in addendum Durable Medical Equipment Prosthetic, Orthotics, & Supplies (DMEPOS) fee schedule files on November 16, 2006.


This is to advise that the fee schedule amounts for codes K0813 thru K0864 have been further refined and will be transmitted to contractors in addendum DMEPOS fee schedule files by 8 pm EST on December 13, 2006.

Contractors must adjust previously processed claims for codes K0813 thru K0864 with dates of service on or after November 15, 2006, if they are resubmitted as adjustments.

As a result of the PMD revisions, a revised 2007 DMEPOS Fee Schedule file will be released to the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC), the Durable Medical Equipment Medicare Administrative Contractors (DME MACs), DMERCS, and local Part B carriers via CMS' mainframe telecommunications system on December 13, 2006. A revised 2007 DMEPOS Fee Schedule file will also be released to the intermediaries, regional home health intermediaries, Railroad Retirement Board (RRB), Indian Health Service, and United Mine Workers on December 13, 2006.

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

Joint Signature Memorandum/Technical Direction Letter (JSM/TDL)-07145, issued on December 13, 2006, included instructions for implementation on November 15, 2006, of refined fee schedule amounts for HCPCS codes K0813 thru K0864. The revised fee schedule amounts for codes K0813 thru K0864 were transmitted to contractors in addendum Durable Medical Equipment Prosthetic, Orthotics, & Supplies (DMEPOS) fee schedule files on December 13, 2006.

This is to advise that the fee schedule amounts for codes K0827, K0829 and K0864 have been further refined and will be transmitted to contractors in addendum DMEPOS fee schedule files by 8 pm EST on December 21, 2006.

Contractors must adjust previously processed claims for codes K0827, K0829, and K0864 with dates of service on or after November 15, 2006, if they are resubmitted as adjustments.

As a result of the PMD revisions, a revised 2007 DMEPOS Fee Schedule file will be released to the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC), the Durable Medical Equipment Medicare Administrative Contractors (DME MACs), DMERCS, and local Part B carriers via CMS' mainframe telecommunications system on December 21, 2006. A revised 2007 DMEPOS Fee Schedule file will also be released to the intermediaries, regional home health intermediaries, Railroad Retirement Board (RRB), Indian Health Service, and United Mine Workers on December 21, 2006.

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Infrared Therapy Devices

Provider Types Affected
Physicians, suppliers, and providers who submit claims to Medicare carriers, Part A/B Medicare Administrative Contractors (A/B MACs), durable medical equipment regional carriers (DMERCs), DME Medicare administrative contractors (DME/MACs), fiscal intermediaries (FIs), and/or regional home health intermediaries (RHHIs), for the use of infrared therapy devices for treatment of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues in Medicare beneficiaries.

Impact on Providers
This article is based on Change Request (CR) 5421. Effective for services performed on or after October 24, 2006, the Centers for Medicare & Medicaid Services (CMS) has made a National Coverage Determination (NCD) stating the use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy (MIRE), is non-covered for the treatment, including symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues in Medicare beneficiaries.

Background
The use of infrared therapy devices has been proposed for a variety of disorders, including treatment of diabetic neuropathy, other peripheral neuropathy, skin ulcers and wounds, and similar related conditions, including symptoms such as pain arising from these conditions. A wide variety of devices are currently available. Previously there was no NCD concerning the use of infrared therapy devices, leaving the decision to cover or not cover up to local Medicare contractors.

The following requirements are in effect as of October 24, 2006:

Additional Information
If you have questions, please contact your Medicare A/B MAC, FI, DMERC, DME/MAC, RHHI or 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 complete details regarding this Change Request (CR) please see the official instruction (CR5421) issued to your Medicare A/B MAC, FI, DME MAC, RHHI, or carrier. There are actually two transmittals associated with CR5421. The first is the national coverage determination transmittal, located at