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March 6 , 2007 Part B Medicare Bulletin

Posted March 6, 2007

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Annual Medicare Contractor Provider Satisfaction Survey: Make Your Voice Heard!

Provider Types Affected
All Medicare FFS providers, especially those receiving the 2007 Medicare Contractor Provider Satisfaction Survey.

Provider Action Needed
The Centers for Medicare & Medicaid Services (CMS) is publishing this Special Edition (SE) article to alert providers that in early January 2007 CMS will disseminate the 2007 Medicare Contractor Provider Satisfaction Survey (MCPSS) to a new sample of Medicare providers. If you receive the survey, CMS encourages you to respond because your input is NEEDED and will be used to support claims processing improvement by Medicare fee-for-service (FFS) contractors and to reform the Medicare Program.

Background
The 2007 MPCSS survey is designed so that it can be completed in about 15 minutes and providers can submit their responses via a secure Web site, mail, fax, or over the telephone. CMS will ask providers to respond by February 2007.

The views of each provider in the survey are important because they represent many other organizations similar in size, practice type and geographical location.

The MCPSS focuses on seven major aspects of the provider-contractor relationship:

Respondents are asked to rate their experience working with Medicare FFS contractors using a scale of 1 to 6, with “1” representing “not at all satisfied” and “6” representing “completely satisfied.”

Additional Information
More information about the MCPSS and results of the 2006 survey are available at http://www.cms.hhs.gov/MCPSS/ on the CMS Web site.

Flu Shot Reminder
It’s Not Too Late to Get the Flu Shot. We are in the midst of flu season and a flu vaccine is still the best way to prevent infection and the complications associated with the flu. But re-vaccination is necessary each year because the flu viruses change each year. Encourage your Medicare patients who haven’t already done so to get 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. It’s Not Too Late! 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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Documentation Pointers Including Correcting Errors and/or Making Late Entries to the Medical Record

Article Information
Article ID Number A9479

Article Type
Article

Key Article No

Article Title
Documentation Pointers

Primary Geographic Jurisdiction
Tennessee

Original Article Effective Date
07/01/2001

Article Revision Effective Date
07/01/2001

Article Text

Coverage Topic
Physical Exams (routine)

Coding Information
No Coding Information has been entered in this section of the article.

Other Information
There is no Other Information for this article.

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

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 revised on January 12, 2007 to reflect that CR5459 was revised by CMS. The article was revised to reflect the new CR release date, transmittal number, and the Web address for accessing CR5459. All other information remains the same.

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
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/R1152CP.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.

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Additional Changes 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 Change Request (CR) 5498 wants providers to know that payment files were issued to carriers based upon the December 1, 2006, MPFS Final Rule and Transmittal 1143, Change Request 5459, Emergency Update to the 2007 Medicare Physician Fee Schedule Database. (An MLN Matters, MM5459, is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5459.pdf on the CMS Web site.) This CR, 5498, amends those payment files and includes new outpatient prospective payment system (OPPS) payment amounts for codes subject to the OPPS cap and other miscellaneous corrections.

Key Points of CR5498
The changes to the 2007 MPFSDB are listed in Attachment 1 of CR5498 and those changes are:

CPT/HCPCS Action
31545 Bulateral Indicator = 1
31546 Bilateral Indicator = 1
70555-26 Work RVU = 2.54
76998 – 26 Work RVU = 1.20
77013 – 26 Work RVU = 3.99
77022 – 26 Work RVU = 4.24
77055 – Global Work RVU = 0.70
77055 – 26 Work RVU = 0.70
93624 – 26 Status Indictor = A
  Work RVU = 4.80
  Transitional Non-Facility PE RVU = 2.31
  Fully Implemented Non-Facility PE RVU = 2.67 (Informational Only)
  Transitional Facility PE RVU = 2.31
  Fully Implemented Facility PE RVU = 2.67 (Informational Only)
  Malpractice RVU - 0.33
96020-26 Work RVU = 3.43
G0103 Short Descriptor = PSA Screening
S0147 Status Indicator = I
S0180 Status Indicator = I
S0345 Status Indicator = I
S0346 Status Indicator = I
S0347 Status Indicator = I
S2325 Status Indicator = I
S2344 Status Indicator = I
S3855 Status Indicator = I

Note: In addition to the changes listed above, all records subject to the OPPS payment cap are also included since these payment amounts have been changed. These codes can be identified by OPPS indicator = 1.

Providers take note that the Medicare contractors will not search their files for claims affected by these changes in order to retract payment for claims already paid or retroactively pay claims. However, contractors will adjust claims that you bring to their attention.

Additional Information
You can see the official instruction issued to your Medicare carrier, FI or A/B MAC by going to CR 5498, located at http://www.cms.hhs.gov/Transmittals/downloads/R1161CP.pdf on the CMS Web site.

If you have any 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.

Flu Shot Reminder
It’s Not Too Late to Get the Flu Shot. We are in the midst of flu season and a flu vaccine is still the best way to prevent infection and the complications associated with the flu. But re-vaccination is necessary each year because the flu viruses change each year. Encourage your Medicare patients who haven’t already done so to get 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. It’s Not Too Late! 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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Assignment of Dedicated Medicare Secondary Payer Modifier Introduced in Change Request (CR) 5332

Pursuant to med-learn article MM5332-Instructions for the Coordination of Medicare Secondary Payer (MSP) Claims for the Competitive Acquisition Program (CAP), effective 01/01/2007, the M2 modifier will be the dedicated modifier for the unusual circumstances identified in MM5332 and the J3 modifier will no longer be accepted for this purpose.

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Assignment of Dedicated Medicare Secondary Payer Modifier Introduced in Change Request (CR) 5332 - MLN SE0703
(Transmittal 1088)

Flu Shot Reminder
It’s Not Too Late to Get the Flu Shot. We are in the midst of flu season and a flu vaccine is still the best way to prevent infection and the complications associated with the flu. But re-vaccination is necessary each year because the flu viruses change each year. Encourage your Medicare patients who haven’t already done so to get 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. It’s Not Too Late! Remember — Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’s Web site: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf .

Provider Types Affected
Physicians who bill Medicare Carriers and Part A/B Medicare Administrative Contractors (A/B MACs) for drugs paid under the Competitive Acquisition Program (CAP).

Key Information
In CR 5332 (Transmittal 1088) “Instructions for the Coordination of Medicare Secondary Payer (MSP) claims for the Competitive Acquisition Program (CAP),” issued October 27, 2006, the Center for Medicare & Medicaid Services (CMS) indicated that, under certain circumstances, a participating CAP physician may procure a CAP drug from a source other than the CAP vendor because of a mistake in identifying the patient’s primary insurer. Under these unusual circumstances, CR5332 instructed CAP physicians to use the J3 modifier to receive payment for the drug at the non-CAP rate.

However, the M2 “Medicare secondary payer” modifier was created for the purpose described in CR5332 and was included in the 2007 Alpha-Numeric HCPCS File posted to the CMS Web site in November 2006. Participating CAP physicians must note that, effective January 1, 2007, the M2 modifier will be the dedicated modifier for the unusual circumstances identified above, and Medicare will no longer accept the J3 modifier for this purpose.

Additional Information
For other details including the revised sections of Chapters 3 and 5 of the Medicare Secondary Payer (MSP) Manual and the revised sections of Chapter 17 of the Medicare Claims Processing Manual, please see the official instruction, CR5332, issued to your Medicare Carrier or A/B MAC regarding this change. There are two transmittals related to this instruction and they may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R57MSP.pdf and
http://www.cms.hhs.gov/Transmittals/downloads/R1088CP.pdf on the CMS Web site. In addition, an MLN Matters article, MM5332, is also available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5332.pdf on that site.

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

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Bariatric Surgery Claims

Effective for services on or after February 21, 2006, Medicare will cover open and laparoscopic Roux-en Y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB) and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) if certain criteria are met and the procedure is performed in a CMS approved facility for bariatric surgery.

When billing for bariatric surgery, be certain that the procedure is an approved procedure and include the correct CPT® code. For the diagnosis, please bill ICD-9 code 278.01 as the primary code, plus the V code that best describes the Body Mass Index (BMI), along with at least one co-morbidity code. These codes may be found in the Bariatric LCD.

Each provider should maintain documentation supporting compliance with the National Coverage Determination and medical necessity and reasonableness and should submit this documentation when requested by CIGNA Government Services. Failure to submit the documentation may result in non-payment of the claim or, if previously paid, recoupment of the payment. An LCD has been approved and will become effective 04 February 2007.

The documentation must show:

  1. The surgery is medically appropriate for the patient and
  2. The patient meets the definition of morbid obesity which is defined as a body mass index (BMI) of
    35 kg or greater and
  3. The surgery is an integral and necessary part of the management for a patient with at least one of
    the following life-threatening or disabling co-morbid conditions:
    1. Poorly controlled Type 1 or 2 diabetes mellitus
    2. Poorly controlled dyslipidema
    3. Poorly controlled hypertension
    4. Severe cardiopulmonary disease ( e.g. coronary disease, CHF, asthma, COPD, pulmonary hypertension)
    5. Obstructive sleep apnea
    6. Severe arthropathy of weight bearing joints
    7. Pseudotumor cerebri
      and
  4. There is documented evidence of compliance with and repeated failure of multiple attempts, at least three (3), to lose weight on a supervised non-surgical management weight loss program (e.g. diet, exercise, or drugs). It is expected that at least one of the weight loss attempts would consist of compliance with a physician directed program for at least a consecutive six month period without significant gaps. Monthly documentation of the beneficiary’s compliance should include:
    1. Vital signs to include weight
    2. Current dietary program
    3. Physical activity/exercise program
    4. Behavioral interventions

    5. May include consideration of/use of pharmacotherapy with FDA approved medication, if appropriate.
    and

  5. Psychological evaluation and counseling associated with the lifestyle changes associated with the
    surgery have been performed prior to the surgery and
  6. Treatable metabolic causes for obesity (e.g. adrenal, pituitary, or thyroid disorders) have been ruled out or if present have been maximally clinically treated if present and
  7. The surgery was performed in a CMS-approved facility for bariatric surgery.

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Botulinum Toxin – LCD Revision

The “Indications and Limitations” coverage section for LCD Botulinum Toxin (L6102-TN), (L13109-NC), and (L13717-ID) has been revised. Please refer to the CIGNA Government Services Web site at http://www.cignagovernmentservices.com to view the policy.

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CERT (Comprehensive Error Rate Testing) “Tech Stops”

The Comprehensive Error Rate Testing program (CERT) is a federally mandated program to monitor and improve the accuracy of Medicare payments to physicians and other providers.

The process begins when the CERT Review contractor requests records for review for each sampled claim. After initial review of these records, the CERT Review Contractor may find that required documentation is missing. As a service to the provider and in an effort to demonstrate that the requirements for a submitted claim were met, the CERT Review Contractor will request additional documentation. This request sent for the additional documentation is known as a CERT Tech Stop.

The Tech Stop request for medical records will contain:

  1. Instructions for submitting Requested Medical Records/Documentation
  2. A Medical Records/Documentation Pull List (This document lists all codes billed on the sampled claim.)
  3. A Bar Coded cover sheet (This will list what additional documentation is needed for completion of the review process and should be used on the cover page when returning the documentation.)
    Providers are asked to respond to this request within 15 days of the request letter. If the requested additional documentation is not received, the claim line(s) will remain in error which will result in an overpayment request to the provider. When the needed documentation is received timely and it supports the medical need for the items/services billed, the error is removed.

Documentation can be faxed to:
(240) 568.8622

You should receive a confirmation from the CERT Contractor that your fax has been reviewed. If you are unable to fax documents, please send information to the address noted below.

CERT Documentation Office
Attn: CID # xxxxxx
9090 Junction Drive, Suite 9
Annapolis Junction, MD 20701

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CERT (Comprehensive Error Rate Testing) Documentation Contractor Call Center-Change in Hours of Operation

Effective January 31, 2007 the CERT Documentation Contractor’s Call Center hours of operation will be from 8:00 AM to 6:00 PM EST.

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Coding Change for Lumbar Artificial Disc Replacement (LADR)

Provider Types Affected
All physicians and providers who submit claims to Medicare carriers, Part A/B Medicare Administrative Contractors (A/B MACs), for LADR.

Provider Action Needed

STOP – Impact to You
Effective for services on or after January 1, 2007, the CPT codes for billing LADR are changing.

CAUTION – What You Need to Know
No change in Medicare policy results from this coding change. But, be sure billing staff use the correct codes to assure prompt and correct payment of your claims.

GO – What You Need to Do
For services on or after January 1, 2007, use CPT code 22857 in place of CPT Category III code 0091T for LADR. Also, use new CPT Category III code 0163T in place of CPT Category III code 0092T for services on or after January 1, 2007. CPT Category III codes 0091T and 0092T are still appropriate for services on or before December 31, 2006, but are discontinued as of December 31, 2006.

Background
This article is based on Change Request (CR) 5462 and the purpose is to announce a coding change effective January 1, 2007 for LADR. A prior change request (CR) 5057, transmittal 992, issued on June 23, 2006 contains correct codes for services rendered in 2006. However, beginning with services rendered on or after January 1, 2007 there are new coding changes. If you would like to review the MLN article that resulted from CR 5057 click on the following link: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5057.pdf on the CMS Web site. Please be aware that the National Coverage Determination (NCD) issued under CR 5057 is not changing, only the codes that should be utilized have changed.

Effective for services performed on or after January 1, 2007, carriers will deny claims, for Medicare beneficiaries over sixty years of age, submitted with the following Codes:

Carriers and A/B MACs will continue to follow their normal claims processing criteria for investigational device exemptions (IDEs) for LADR performed with an implant eligible under the IDE criteria.
Carriers will allow claims submitted for approved IDEs/clinical trials submitted with:

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) please see the official instruction (CR5462) issued to your Medicare A/B MAC or carrier. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1164CP.pdf on the CMS Web site.

Flu Shot Reminder
It’s Not Too Late to Get the Flu Shot. We are in the midst of flu season and a flu vaccine is still the best way to prevent infection and the complications associated with the flu. But re-vaccination is necessary each year because the flu viruses change each year. Encourage your Medicare patients who haven’t already done so to get 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. It’s Not Too Late! 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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Colony Stimulating Factors – Draft LCD

The draft LCD for Colony Stimulating Factors (DL24589) has been published for all Part B states. Please visit the CIGNA Government Services Web site at http://www.cignagovernmentservices.com to access the policy.

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Colorectal Cancer Screening Flexible Sigmoidoscopy and Colonoscopy Coinsurance Payment Change

Note: This article was revised ton January 26, 2007, to correct an effective date in the text (The effective date is January 1, 2007.) Also, the notice to beneficiaries mentioned on page 3 is the Medicare Summary Notice.

Provider Types Affected
Non-Outpatient Prospective Payment System (non-OPPS) Hospital Outpatient Departments and Ambulatory Surgical Centers (ASCs) who bill Medicare fiscal intermediaries (FIs), carriers, or Part A/B Medicare Administrative Contractors (A/B MACs) for Colorectal Cancer Screening Flexible Sigmoidoscopy, and Colonoscopy.

Impact on Providers
Effective for services on or after January 1, 2007, Medicare requires:

  1. A 25% beneficiary coinsurance for colorectal cancer screening flexible sigmoidoscopies, and colonoscopies performed in the outpatient departments of non-Outpatient Prospective Payment System (non-OPPS) hospitals; and
  2. A 25% beneficiary coinsurance for colorectal cancer screening colonoscopies performed in ambulatory surgery centers (ASC).

Background
Section 1834(d)(2) of the Social Security Act, imposes a 25% beneficiary coinsurance for colorectal cancer screening flexible sigmoidoscopies (Healthcare Common Procedure Coding System [HCPCS] code G0104-Colorectal cancer screening; flexible sigmoidoscopy) that are performed in hospital outpatient departments. While this coinsurance has already been applied in the Outpatient Prospective Payment System (OPPS) for OPPS hospitals ( effective for services performed on or after January 1, 1999), it will now be applied to non-OPPS hospitals, effective January 1, 2007.

Similarly, Section 1834(d)(3) of the Social Security Act, in part, imposes a 25% beneficiary coinsurance for colorectal cancer screening colonoscopies (HCPCS codes G0105 - Colorectal cancer screening; colonoscopy on individual at high risk, and G0121 - Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) that are performed in Ambulatory Surgical Centers (ASCs) and in hospital outpatient departments. And while, as above, this coinsurance has already been applied in the Outpatient Prospective Payment System (OPPS) for OPPS hospitals (effective for services performed on or after January 1, 1999), it is being applied to these services performed in ASCs or non-OPPS hospitals, effective January 1, 2007.

Therefore, effective for services on or after January 1, 2007 (as is currently done for OPPS hospitals), FIs, Carriers, A/B Macs will apply the 25% coinsurance to colorectal cancer screening flexible sigmoidoscopies (G0104) and colonoscopies (G0105 and G0121) that are performed in non-OPPS hospitals and to colorectal cancer screening colonoscopies (HCPCS codes G0105 and G0121) that are performed in ASCs.

Pertinent details included in CR 5387 are:

Additional Information
You can find more information about the change in the coinsurance payment amount for colorectal cancer screening flexible sigmoidoscopy and colonoscopy performed in hospital outpatient departments and ASCs, by going to CR 5387, located at http://www.cms.hhs.gov/Transmittals/downloads/R1160CP.pdf on the CMS Web site. Attached to the CR5387, you will find updated Medicare Claims Processing Manual (Publication 100-04), Chapter 1 (General Billing Requirements), Section 30.3.1 (Mandatory Assignment on Carrier Claims); Chapter 14 (Ambulatory Surgical Centers), Section 40.2 (Carrier Adjustment of Base Payment Rates); and Chapter 18 (Preventive and Screening Services), Sections 60.1 (Payment), 60.1.1 (Deductible and Coinsurance); and 60.2.2 (Ambulatory Surgical Center [ASC] Facility Fee).

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
It’s Not Too Late to Get the Flu Shot. We are in the midst of flu season and a flu vaccine is still the best way to prevent infection and the complications associated with the flu. But re-vaccination is necessary each year because the flu viruses change each year. Encourage your Medicare patients who haven’t already done so to get 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. It’s Not Too Late! 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) – Claim Processing for Not Otherwise Classified (“NOC”) Drugs

Note: This article was revised on January 29, 2007, to alert participating physicians that the dose of the drug should be coded also in item 19 of paper claims or Loop 2300 segment NTE on electronic claims. 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:

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

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:

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) Tip for Documenting

One of the required elements in the comprehensive Error Rate Testing process is requesting documentation to support every item billed on the claims sampled claims. Many errors are found because there is lack of appropriate documentation. When errors are found and claims were paid in error, refund requests are submitted to the providers. To assist you, below are helpful tips for claim documentation and the CERT process.

What Documentation to Submit When A Request for Records is Received:

Each charge on the claim should be supported with the following:

If there is no supporting documentation that the procedure/service was performed, there will be no reimbursement.

Remember:

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Elimination of CMS-1491 and CMS-1490U Forms

Note: This article was revised on January 18, 2007, to reflect the correct title. All other information remains the same.

Provider Types Affected
Suppliers of ambulance services who submit claims to Medicare carriers or Part A/B Medicare Administrative Contractors (A/B MACs) for ambulance services to Medicare beneficiaries.

Impact on Providers
Ambulance suppliers should submit their paper ambulance claims using the Form CMS-1500 on or after April 2, 2007 (see Additional Information section for the CMS-1500 Web address). Note: The April 2, 2007, date actually refers to the date your carrier or A/B MAC receives the claim. So, be sure the claims you send that will be received on or after April 2, 2007, are sent on the Form CMS-1500.

Background
The purpose of CR 5390 is to notify suppliers of ambulance services that the Centers for Medicare & Medicaid Services (CMS) determined that paper claim forms CMS-1491 and CMS 1490U will no longer be printed effective October 1, 2006. Therefore, as of April 2, 2007, carriers and A/B MACs are no longer permitted to accept claims from ambulance suppliers on the Forms CMS-1491 and CMS1490U. If your carrier or A/B MAC receives claims on forms CMS-1491 and/or CMS-1490U on or after April 2, 2007, they will reject the claim back to you and you will need to send it again using the CMS-1500 form.

The Medicare Claims Processing Manual Chapter 1, Section 70.8.4 is being revised to eliminate all information that pertains to CMS-1491 and CMS 1490U forms and Chapter 15, Section 30.1.3 is being deleted in its entirety. (See the official instructions for CR5390 to review these manual sections)

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) please see the official instruction (CR5390) issued to your Medicare A/B MAC or carrier. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1144CP.pdf on the CMS Web site.

If you would like to review CMS-1500 you may find it at: http://www.cms.hhs.gov/cmsforms/downloads/CMS1500.pdf on the CMS Web site. In order to purchase claim forms, you should contact the U.S. Government Printing Office at (202) 512.1800, local printing companies in your area, and/or office supply stores. Vendors typically sell the CMS-1500 claim form in its various configurations (single part, multi-part, continuous feed, laser, etc). Because many carriers and A/B MACs use scanner technology to read these forms, do not submit photocopied claims. Further specifications and information about the CMS-1500 is available at http://www.cms.hhs.gov/ElectronicBillingEDITrans/16_1500.asp on the CMS Web site.

MLN Matters article MM5060 provides background information about CMS-1500 at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5060.pdf on the CMS Web site.

Flu Shot Reminder
It’s Not Too Late to Get the Flu Shot. We are in the midst of flu season and a flu vaccine is still the best way to prevent infection and the complications associated with the flu. But re-vaccination is necessary each year because the flu viruses change each year. Encourage your Medicare patients who haven’t already done so to get 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. It’s Not Too Late! 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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Enhance the Multi-Carrier System (MCS) to Avoid Duplicate Payments When a Full Claim Adjustment is Performed.

Provider Types Affected
Physicians and other providers who bill Medicare carriers or Part A/B Medicare Administrative contractors (A/B MACS) for services.

Provider Action Needed
In CR5424, from which this article was taken, CMS announces the enhancement of the Multi-Carrier System (MCS). MCS is the system that Medicare carriers and A/B MACS use to process Part B claims for physician care and other outpatient services to avoid duplicate payments when performing a full claim adjustment. CR5424 rescinds and fully replaces CR 3878. This article is mainly for informational purposes.

Background
In the MCS system, when a claim is adjusted because of an overpayment, an accounts receivable (A/R) is created and a demand letter sent by the carrier or A/B MAC to the provider. When a claim is adjusted because of an underpayment, payment is automatically sent to the provider.

If the claim adjustment (that created the overpayment) later turns out to be incorrect, the carrier or A/B MAC must adjust the claim again. This could happen for many reasons. The two most common are: problems with the original overpayment identification and an appeal decision favorable to the provider. When the claim adjustment occurs a second time (to allow for correct history) the MCS system will automatically issue payment to the provider. In many cases, this second payment is duplicative. This then requires an offset from the provider to collect the duplicate payment.

The MCS System Maintainer has designed full claim adjustment to act as a full claim void and replace in accordance with the collective understanding of the requirements for HIPAA. This design was developed using a process that if an adjustment creates an overpayment, an accounts receivable is created and a subsequent adjustment assumes that the accounts receivable has either been recouped or will be recouped.

Example:

Medicare carriers and A/B MACs have, to date, used a manual system to avoid duplicate payments. But now, the MCS system will have the ability to suppress duplicate payments when a full claim adjustment is performed on a previous overpayment adjustment.

Additional Information
You can find the official instruction, CR5424, issued to your carrier or A/B MAC by visiting http://www.cms.hhs.gov/Transmittals/downloads/R260OTN.pdf on the CMS Web site.

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

Flu Shot Reminder
It’s Not Too Late to Get the Flu Shot. We are in the midst of flu season and a flu vaccine is still the best way to prevent infection and the complications associated with the flu. But re-vaccination is necessary each year because the flu viruses change each year. Encourage your Medicare patients who haven’t already done so to get 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. It’s Not Too Late! 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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Instructions for the Coordination of Medicare Secondary Payer (MSP) Claims for the Competitive Acquisition Program (CAP)

Important Note: See special edition article SE0703, which contains important information regarding the M2 (Medicare Secondary Payer) modifier that must be used in certain circumstances. The information in SE0703 overrides the information in this article relating to the use of the M2 modifier, instead of J3, in those circumstances, effective January 1, 2007. SE0703 is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0703.pdf on the CMS site.

Provider Types Affected
Physicians who bill Medicare Carriers and Part A/B Medicare Administrative Contractors (A/B MACs) for drugs paid under the CAP program.

Background
This article and related change request (CR) 5332 provides additional details, information and instructions for CAP MSP claims and instances in which a beneficiary’s MSP status is incorrectly determined. Section 303 (d) of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 established section 1847B of the Social Security Act requiring the implementation of a competitive acquisition program (CAP) for Medicare Part B drugs and biologicals not paid on a cost or prospective payment system basis. Beginning with drugs administered on or after July 1, 2006, physicians are given a choice between buying and billing these drugs for beneficiaries with Medicare as their primary insurer under the average sales price (ASP) system or obtaining these drugs from vendors selected through a competitive bidding process.

Participating CAP physicians agree to obtain all drugs included in the CAP drug category for Medicare beneficiaries who do not have another primary insurer from the approved CAP vendor. However, Medicare statutes allow for limited exceptions to this requirement.

One such exception includes Medicare Secondary Payer (MSP) situations. Section 1862(b) establishes provisions for Medicare as a secondary payer that are codified in 42 CFR Part 411. Section 1862(b) (6) specifically instructs physicians and other suppliers to identify, from information obtained from the beneficiary, payers primary to Medicare and to bill such payers prior to billing Medicare.

This CR instructs carriers to continue allowing CAP physicians to obtain physician administered drugs from entities approved by the primary plan and bill the primary payer outside the CAP vendor when Medicare beneficiaries have other insurance primary to Medicare.

Note: the term “carrier” also refers to A/B MACS as those entities replace carriers as part of Medicare’s contracting reform implementation.

Key Points
When drugs are obtained through the CAP for beneficiaries with insurance primary to Medicare:

When drugs are obtained outside of the CAP for beneficiaries with Medicare:

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

Additional Information
For complete details including the revised sections of Chapters 3 and 5 of the Medicare Secondary Payer (MSP) Manual and the revised sections of Chapter 17 of the Medicare Claims Processing Manual, please see the official instruction, CR5332, issued to your Medicare Carrier or A/B MAC regarding this change. That instruction may be viewed by going to
http://www.cms.hhs.gov/Transmittals/downloads/R57MSP.pdf and http://www.cms.hhs.gov/Transmittals/downloads/R1088CP.pdf on the CMS Web site.

For additional information about the implementation of the CAP program you may want to review the following MLN Matters articles on the CMS Web site.

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

Flu Shot Reminder
It’s Not Too Late to Get the Flu Shot. We are in the midst of flu season and a flu vaccine is still the best way to prevent infection and the complications associated with the flu. But re-vaccination is necessary each year because the flu viruses change each year. Encourage your Medicare patients who haven’t already done so to get 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. It’s Not Too Late! 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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Intracranial Percutaneous Transluminal Angioplasty (PTA) with Stenting

Provider Types Affected
Physicians and providers who may wish to submit claims to Medicare carriers, fiscal intermediaries (FIs) and Part A/B Medicare Administrative Contractors (A/B MACs) for PTA Stenting.

Provider Action Needed
Be aware that The Centers for Medicare & Medicaid Services (CMS) has reviewed the evidence and determined that, effective for discharges on or after November 6, 2006, Medicare will cover PTA with stenting of intracranial arteries for treatment of cerebral artery stenosis ≥50% in patients with intracranial atherosclerotic disease when furnished in accordance with FDA-approved protocols governing Category B IDE clinical trials. Payment for intracranial PTA with stenting is considered reasonable and necessary under §1862(a)(1)(A) of the Social Security Act under these circumstances. All other indications for intracranial PTA with or without stenting to treat obstructive lesions of the vertebral and cerebral arteries remain non-covered.

Background
This article and related Change Request (CR) 5432 communicate the findings and revised national coverage determination (NCD) resulting from analysis to determine if PTA should be covered by Medicare.

In the past, PTA to treat obstructive lesions of the cerebral arteries was non-covered by Medicare because the safety and efficacy of the procedure had not been established. This NCD meant that the procedure was also non-covered for beneficiaries participating in Food and Drug Administration (FDA) approved Investigational Device Exemption (IDE) clinical trials. On February 9, 2006, a request for reconsideration of this NCD initiated a national coverage analysis.

Key Points

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR5432) issued to your Medicare carrier, FI or A/B MAC. That instruction is contained in two transmittals. The first transmittal is available at http://www.cms.hhs.gov/Transmittals/downloads/R1147CP.pdf on the CMS Web site and it contains the revised portions of the Medicare Claims Processing Manual. The second transmittal contains the national coverage determination and it is available at http://www.cms.hhs.gov/Transmittals/downloads/R64NCD.pdf.

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Invoice Filing Instructions for Drugs/Biologicals/Radiopharmaceuticals

When invoice information is required for processing a claim, please adhere to the following instructions:
Paper CMS—1500 Form

  1. A copy of your purchase invoice (e.g., actual invoice from the manufacturer, distributor, or pharmacy) must be attached to the claim.
  2. If you are submitting a miscellaneous code, the name of the drug and the exact dosage given must be in block 19 or as an attachment.
  3. If you are submitting a claim for compounded drugs used in an implanted infusion pump, all drugs included in the compound should be filed on one line using miscellaneous code J3490 or J9999 accordingly in conjunction with the appropriate administration code. The name and dosage of each drug in the mixture must be in block 19 or as an attachment. The attachment of the invoice from the pharmacy or supplier/distributor should include the name, quantity and strength of each drug in the mixture and the invoice cost.

Paper claims received without a copy of the purchase invoice will be denied or delayed for lack of information.

Electronic Media Claims (EMC)
Submitting actual invoice cost: The following statement may be entered in the narrative field: “Actual invoice cost”

  1. Submitting a charge greater than the actual invoice cost: You may enter the invoice information in the narrative field using the following format:
    o Des = Description/Name of agent (e.g., Des=TC99m MDP)
    o QS = Quantity shipped (e.g., QS=100 mci)
    o TA = Total amount charged for quantity shipped (e.g., TA=$57.40)
    o UP = Unit Price (e.g., UP = $0.57 per mci) (Optional)
    o DG = Dosage given (e.g., DG=25 mci)
  2. Claims submitted using miscellaneous codes (e.g., A4641, J3490, J9999, or a code that could be used for more than one drug/biological/radiopharmaceutical): The name of the agent and the exact dosage administered must be in the narrative field along with the invoice information from
    number 1 or 2 accordingly.
  3. Claim submitted for compounded medications: All drugs included in the compound should be filed on one line using miscellaneous code J3490 or J9999 accordingly in conjunction with the appropriate administration code. The name, quantity and strength of each drug in the mixture and the name and phone number of the pharmacy/supplier/ distributor, if applicable must be in the narrative field along with the invoice cost information from number 1 or 2 accordingly.

Electronic claims received without the proper information in the narrative field will be denied or delayed for lack of information.

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Medicare Fee-for-Service (FFS) and Medicare Advantage (MA) Eligibility System Issues

Provider Types Affected
Physicians and providers who bill Medicare carriers, fiscal intermediaries (FIs), or Part A/B Medicare Administrative Contractors (A/B MACs).

Provider Action Needed
Be aware that Medicare reverses FFS payments when MA enrollments with retroactive dates are processed by CMS systems. Also know what action to take when there are conflicts in CMS eligibility data.

Background
In some cases, MA enrollments with retroactive dates are processed by CMS systems. The result is that Medicare may pay for the services rendered twice; once under fee-for-service and second by the MA payment systems in the monthly capitation rate to the plan.

The FFS contractor reverses the fee-for-service payment, recovers from the provider, and the provider then bills the MA plan. The plan adjudicates the claim and pays the claim at the plan’s rate (if the provider is part of the network) or pays the provider at the Medicare fee-for-service rate if the provider is not part of the network. If the plan denies payment then the provider may bill the beneficiary.

FFS Claims Paid in Error
Due to CMS beneficiary eligibility system updates, beneficiaries enrolled in MA organizations may be identified as having been inappropriately paid on a fee-for service basis. FIs, carriers, and A/B MACs will adjust these claims and seek overpayments. Where such an overpayment is recovered from a provider, the related remittance advice for the claim adjustment will indicate Reason Code 24, which states: ‘Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan’.

Whenever CMS reverses fee-for-service payments as a result of confirmed retroactive enrollment in an MA plan, the provider must bill the MA plan. The plan adjudicates the claim and pays the claim at the plan’s rate (if the provider is part of the network) or pays the provider at the fee-for-service rate if the provider is not part of the network. If the plan denies payment then the provider may bill the beneficiary.

Information on which plan to contact can be determined through an eligibility inquiry or by contacting the beneficiary directly. To associate plan identification numbers with the plan name, go to
http://www.cms.hhs.gov/HealthPlansGenInfo/claims_processing_20060120.asp#TopOfPage on the CMS Web site.

The Medicare beneficiary call center representatives at 1.800.MEDICARE have been trained to answer beneficiary inquiries that may arise in these situations.

Eligibility Data Discrepancies: Provider Action
Despite system corrections, there remains a small number (under 1000) of beneficiary eligibility records that have not been updated. CMS is working to correct this. In the interim, if a provider has information from the MA plan that conflicts with information received from an FI, carrier, or A/B MAC in reply to an eligibility inquiry, the provider should call the FI/carrier/MAC provider call center.

The call center representative will check Medicare’s Common Working File System and if the conflict is confirmed the provider will be referred to the CMS Regional Office for resolution.

Additional Information
Your call to the FI, carrier, or A/B Mac is a toll free call and if you do not have their number, you can obtain it at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site

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Medicare Fee for Service (FFS) Implementation of the National Provider Identifier (NPI)

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 .

Provider Types Affected
ALL FFS providers who bill Medicare.

Background
The Centers for Medicare & Medicaid Services (CMS) is publishing this Special Edition (SE) article to remind providers that on May 23, 2007, the NPI will replace health care provider identifiers that are in use today in HIPAA standard transactions. Health care providers should remember that getting an NPI is free and easy. Time is running out! It is estimated that, once a provider obtains an NPI, it may take up to 120 days to implement the NPI in current business practices. The following key points will assist Medicare providers as they transition from the application stage to the implementation stage to ensure NPI readiness.

Applying for an NPI
Visit the official CMS source for NPI-related information, including how to apply for an NPI, as well as free educational products, at http://www.cms.hhs.gov/NationalProvIdentStand/ on the CMS Web site.

Key Points
The following are the critical content areas for the Medicare FFS Health plan implementation of the NPI.

Medicare Legacy Numbers
After the compliance date, Medicare providers must begin submitting their NPIs instead of their Medicare legacy identifiers on claims they send to Medicare. A provider’s Taxpayer Identification Number (TIN), which is the provider’s Social Security Number or Employer Identification Number, will continue to be used when a provider needs to be identified as a taxpayer in HIPAA standard transactions. The Implementation Guides for each of the standard transactions indicate when it is necessary to identify a provider as a taxpayer.

Electronic File Interchange (EFI)
Health industry organizations that are approved by CMS as Electronic File Interchange Organizations (EFIOs) can submit NPI application data for health care providers, including Medicare providers, in electronic files to the National Plan and Provider Enumeration System (NPPES) after obtaining the permission of the health care providers to do so. This process is called Electronic File Interchange (EFI). For health care providers who are approached by EFIOs, EFI is an alternative to having to apply for their NPIs via the Web-based or paper application process. Providers who are enumerated via EFI, receive their NPI notifications from the EFIO that had them enumerated. These notifications are not generated from NPPES.

Designation of Subparts
CMS reminds Medicare providers to visit Medicare’s Subparts Expectation Paper (entitled, “Medicare Expectations on Determination of Subparts by Medicare Organization Health Care Providers Who Are Covered Entities Under HIPAA,” and located at http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/Medsubparts01252006.pdf on the CMS NPI Web page) for suggestions on how to determine their subparts. Remember, no health plan, not even Medicare, can instruct a provider on how to enumerate subparts. This is a business decision that the organization provider must make considering it unique business operations.

Durable Medical Equipment (DME) Enumeration Requirement
As mentioned in the paper entitled, “Medicare Expectations on Determination of Subparts by Medicare Organization Health Care Providers Who Are Covered Entities Under HIPAA” (see link in preceding paragraph), Medicare DME suppliers are required to obtain an NPI for every location. The only exception to this requirement is the situation in which a Medicare DME supplier is a sole proprietor. A sole proprietor is eligible for only one NPI (the individual’s NPI) regardless of the number of locations the DME supplier may have.

Submitting your NPI on Medicare Electronic Claims Disclaimer
Until further notice, CMS recommends that Medicare providers submit claims using both the NPI and legacy number. Claims submitted with only an NPI may be rejected/returned as unprocessable if Medicare systems are unable to properly match the incoming NPI with a legacy number. The provider will then need to resubmit the claim with the appropriate legacy number. A related MLN Matters article, MM5378, may be viewed at http://www.cms.hhs.gov/mlnmattersarticles/downloads/mm5378.pdf on the CMS Web site.

Required Use of the NPI on Medicare Paper Claims
Medicare, as a health plan, will require the use of the NPI on its paper claims. The paper claim forms used by Medicare have been revised to accommodate use of the NPI. There will be transition periods for each of the revised forms. While the NPI cannot be used on the current paper claim forms, providers may begin using the NPI on the revised forms once the transition period for each form begins.

Required Use of Taxonomy Codes on Insutional Provider Claims
Effective January 1, 2007, institutional Medicare providers who submit claims for their primary facility and its subparts (such as psychiatric unit, rehabilitation unit, etc.) must report a taxonomy code on all claims submitted to their FI. Taxonomy codes shall be reported by these facilities whether or not the facility has applied for NPIs for reach of their subparts. Institutional providers that do not currently bill Medicare for services performed by their subparts are not required to use taxonomy codes on their claims to Medicare.

A recent MLN Matters article, MM5243, discusses this requirement in more detail and may be viewed
at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5243.pdf on the CMS Web site.

National Council of Prescription Drug Plans (NCPDP) Claims
The NCPDP format was designed to permit a prescription drug claim to be submitted with either an NPI or a legacy identifier, but no more than one identifier may be reported for a provider (retail pharmacy or prescribing physician) per claim. From October 1, 2006, through May 22, 2007, retail pharmacies will be allowed to report their NPI, and/or the NPI of the prescribing physician (if they have this information). (Refer to MLN Matters article MM4023 at the link provided earlier in this article.)

Medicare Remittance Advice Print Software
The 835-PC-Print and Medicare Remit Easy Print software were modified to enable either the NPI or a Medicare legacy number, or both, if included in the 835. (Refer to MLN Matters article MM4023.)

Communicating Your NPI to Medicare
Medicare providers should know that there is no “special process” or any need to call to communicate NPIs to the Medicare program. NPIs can be shared with the Medicare program by using them on your claims along with your legacy identifier. Secondly, for providers applying for Medicare enrollment, an NPI must be reported on the CMS-855 enrollment application (along with a photocopy of the NPI notification received by the provider from the NPPES or from an EFIO). Existing Medicare providers must provide their NPIs when making any changes to their Medicare provider enrollment information.

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 their NPIs. In fact, as outlined in current regulation, all providers, including Medicare providers, that are HIPAA—covered providers must share their NPI with other providers, health plans, clearinghouses, and any entity that may need those NPIs for use in standard transactions, including the need to identify an ordering or a referring physician. Providers should also consider letting health plans, or institutions for whom they work, share their NPIs for them.

Additional Information

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:
http://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_alp.php?
p_sid=Qjr3YRYh&p_lva=&p_li=&p_page= 1&p_cv=&p_pv=&p_prods=0&p_cats=
&p_hidden_prods=&prod_lvl1=0&p_search_text=NPI&p_new_search=1&p_search_type=
answers.search_nl

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

Providers needing this type of assistance may contact the enumerator at 1.800.465.3203, TTY 1.800.692.2326, or email the request to the NPI Enumerator at CustomerService@NPIenumerator.com.

Please Note: The NPI Enumerator’s operation is closed on federal holidays. The federal holidays observed are: New Year’s Day, Independence Day, Veteran’s Day, Christmas Day, Martin Luther King’s Birthday, Washington’s Birthday, Memorial Day, Labor Day, Columbus Day, and Thanksgiving.

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NPI: Get It. Share It. Use It.

Failure to prepare could result in a disruption in cash flow. Will you be ready to use your NPI? Time is running out!

To date, over 1.6M providers have obtained an NPI. Now, only 120 days are left to implement the NPI into business practices prior to the compliance date. A recent survey of the health care industry, conducted by the Workgroup for Electronic Data Interchange (WEDI), indicates that providers should have already obtained an NPI and be focusing on implementation and testing with health plans and clearinghouses. If you have not obtained your NPI by now you should do so immediately so that you can begin the implementation and testing process

Reminder to Supply Legacy Identifiers on NPI Application
CMS continues to urge providers to include legacy identifiers, as well as associated provider identifier type(s), on their NPI applications. This will help all health plans, including Medicare, to get ready for May 23, 2007. If reporting a Medicaid legacy number, include the associated State name. If providers have already been assigned NPIs, CMS asks them to go back into the NPPES and update their information with their legacy identifiers if they did not include those identifiers when they applied for NPIs. Providers should make sure that these legacy identifiers are the ones used to bill for services and should be sure that the NPPES is updated with this information for all health plans. This information is critical for health plans and health care clearinghouses in the development of crosswalks to aid in the transition to the NPI.

New MLN Matters Article Available
A new Special Edition MLN Matters article is now posted on the CMS Web site with important implementation information for Medicare providers, as well as information that may be helpful for all health care providers. You can view this article by visiting http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0679.pdf on the CMS Web site.

Upcoming WEDI Events
WEDI will host the WEDI NPI Industry Forum on February 12th, an audio cast on the impact of the NPI on standard transactions on February 28th, as well as a question and answer session on March 21st. Visit the WEDI Web site for more details at http://www.wedi.org/npioi/index.shtml on the Web. Please note that there is a charge to participate in WEDI Events.

Still Confused?
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 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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Outpatient Therapy Cap Exceptions Clarifications

Important Note: Recent legislation extended the therapy cap exceptions for calendar year 2007. For details on the 2007 exceptions and process, see the MLN Matters article MM5478 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5478.pdf on the CMS 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 website: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf

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) that have arisen about this exception process. Thus, the article is meant primarily for informational purposes. It also reminds you that the exception process stops after December 31, 2006.

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