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April 6, 2007 Part B Medicare Bulletin

Posted April 6, 2007

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

Note: This article was revised on February 9, 2007, to clarify the language in the first bullet point under “Billing Guidelines” on page 2. All other information remains the same.

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

Key Points

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

Note that a provision in the HIPAA legislation allows for an additional year for small health plans to comply with NPI guidelines. Thus, small plans may need to receive legacy provider numbers on coordination of benefits (COB) transactions through May 23, 2008. CMS will issue requirements for reporting legacy numbers in COB transactions after May 22, 2007. In a related Change Request, CR4023, CMS required submitters of the Form CMS-1500 (12-90 version) to continue to report Provider Identification Numbers (PINs) and Unique Physician Identification Numbers (UPINs) as applicable.

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

Billing Guidelines

Additional Information

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

Legacy identifiers are pre-NPI provider identifiers such as:

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

The change log which lists the various changes made to the Form CMS-1500 (08-05) version can be viewed at the NUCC Web site at http://www.nucc.org/images/stories/PDF/change_log.pdf.

MLN Matters article MM4320, “Stage 1 Use and Editing of National Provider Identifier Numbers Received in Electronic Data Interchange Transactions via Direct Data Entry Screen, or Paper Claim Forms,” can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4320.pdf on the CMS Web site.

CR4293, Transmittal Number 899, “Revised Health Insurance Claim Form CMS-1500,” provides contractor guidance for implementing the revised Form CMS-1500 (08-05). It can be found at http://www.cms.hhs.gov/transmittals/downloads/R899CP.pdf on the CMS Web site.

MLN Matters article MM4023, “Stage 2 Requirements for Use and Editing of National Provider Identifier (NPI) Numbers Received in Electronic Data Interchange (EDI) Transactions, via Direct Data Entry (DDE) Screens, or Paper Claim Forms,” can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4023.pdf on the CMS Web site.

CR5060 is the official instruction issued to your carrier or DMERC regarding changes mentioned in this article, MM5060. CR 5060 may be found by going to http://www.cms.hhs.gov/Transmittals/downloads/R1058CP.pdf on the CMS Web site.

Please refer to your local carrier or DMERC if you have questions about this issue. To find their toll free phone number, please go to: http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

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Ambulance Fee Schedule - Medical Conditions List - Manualization Revisions

Ambulance Fee Schedule - Medical Conditions List - Manualization Revisions

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April 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) 5528 wants providers to know that payment files were issued to contractors based upon the December 1, 2006, MPFS Final Rule. CR5528 amends those payment files.

The following table reflects the key changes from CR5528:

CPT/HCPCS Action
17311 Multiple Procedure Indicator - 0
17313 Multiple Procedure Indicator - 0
36478

Transitional Non-Facility PE RVU = 41.71 Fully Implemented Non-facility PE RVU = 26.53 (Informational Only)
37210 Transitional Non-Facility PE RVU = 79.88
Fully Implemented Non-Facility PE RVU=79.88 (Informational Only)
77056 Global Fully Implemented Non-Facility PE RVU = 1.96 (Informational Only)
Fully Implemented Facility PE RVU = 1.96 (Informational Only)
77056 – TC

Fully Implemented Non-Facility PE RVU = 1.72 (Informational Only)
Fully Implemented Facility PE RVU = 1.72 (Informational Only)

93225 Transitional Non-Facility PE RVU = 1.14
Fully Implemented Non-Facility PE RVU = 0.85 (Informational Only)
Transitional Facility PE RVU = 1.14
Fully Implemented Facility PE RVU = 0.85 (Informational Only)
93226 Transitional Non-Facility PE RVU = 1.93
Fully Implemented Non-Facility PE RVU = 1.18 (Informational Only)
Transitional Facility PE RVU = 1.93
Fully Implemented Facility PE RVU = 1.18 (Informational Only)
93231 Transitional Non-Facility PE RVU = 1.32
Fully Implemented Non-Facility PE RVU = 0.71 (Informational Only)
Transitional Facility PE RVU = 1.32
Fully Implemented Facility PE RVU = 0.71 (Informational Only)
93232 Transitional Non-Facility PE RVU = 1.97
Fully Implemented Non-Facility PE RVU = 1.34 (Informational Only)
Transitional Facility PE RVU = 1.97
Fully Implemented Facility PE RVU = 1.34 (Informational Only)
95991 Transitional Facility PE RVU = 0.17
Fully Implemented Facility PE RVU = 0.18 (Informational Only)

The codes in the following table are either bundled or not valid for Medicare purposes. Values for these codes have been established as a courtesy to the general public. These codes will remain bundled or not valid for Medicare purposes even though relative value units have been established.

CPT/HCPCS ACTION
78351 Transitional Non-Facility PE
RVU = 1.41 Fully Implement
Non-Facility PE RVU = 0.47 (Informational Only)
98960 Transitional Non-Facility PE RVU = 0.57
Fully Implemented Non-Facility PE RVU = 0.57 (Informational Only)
Transitional Facility PE RVU = 0.57
Fully Implemented Facility PE RVU = 0.57 (Informational Only)
98961 Transitional Non-Facility PE RVU = 0.27
Fully Implemented Non-Facility PE RVU = 0.27 (Informational Only)
Transitional Facility PE RVU = 0.27
Fully Implemented Facility PE RVU = 0.27 (Informational Only)
98962 Transitional Non-Facility PE RVU = 0.20
Fully Implemented Non-Facility PE RVU = 0.20 (Informational Only)
Transitional Facility PE RVU = 0.20
Fully Implemented Facility PE RVU = 0.20 (Informational Only)

These changes are effective January 1, 2007. However, providers may wish to note that Medicare contractors will not search their files to either retract payment for claims already paid or to retroactively pay claims. However, contractors will adjust claims that you bring to their attention.

Additional Information
CR5528 is the official instruction (CR5528) 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/R1188CP.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
It’s Not Too Late to Give and Get the Flu Shot! The peak of flu season typically occurs between late December and March; however, flu season can last until May. Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a lifetime pneumococcal vaccination. Remember — influenza and pneumococcal vaccination and their administration are covered Part B benefits. Note that influenza and pneumococcal vaccines are NOT Part D covered drugs. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’ Web site: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf .

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Azacitidine for Injectable Suspensions (Vidaza) – LCD Revision

The LCD for Azacitidine for Injectable Suspensions (Vidaza) has been revised for Tennessee (L18069), North Carolina (L18986) and Idaho (L18715) to include CPT code 96413. Please refer to the CIGNA Government Services Web site at http://www.cignagovernmentservices.com to view the policy.

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Bexxar (Tositumomab and Iodine 131 Tositumomab) – LCD Revision

The Article for Bexxar (Tositumomab and Iodine131Tositumomab) has been revised. CPT code 90780 was changed to 90765 effective January 1, 2007 for Tennessee (A20562), Idaho (A17193) and North Carolina (A20632). 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) Third Party Documentation

During a CERT review, you may be asked to provide more information related to a claim you submitted, such as medical records or certificates of medical necessity, so that the CERT review contractor can verify that billing was proper. The CERT Documentation Contractor sends requests for this additional information via fax and/or postal mail. There are times when the response received might be one of the following:

In most cases, the patients were seen at a different facility. As a Medicare provider it is your responsibility to obtain additional supporting documentation from a third party (hospital, nursing home, etc.), as necessary (in accordance with 42 U.S.C. 1320C-5 (a) (3) and 1833 of the Social Security Act). Providing medical records of Medicare patients to the Comprehensive Error Rate Testing (CERT) contractor is within the scope of compliance with the Health Insurance Portability and Accountability Act (HIPAA).

If you fail to submit the requested information in a timely fashion, an “error” is called on the claim and a refund of the overpayment will be requested from you, the billing provider. As you can see, it is very important that supporting documentation is provided whenever it is requested by the CERT contractor.
If you have any questions, call CERT Customer Service at (301) 957.2380 between the hours of 8:00 AM to 6:00 PM EST.

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CERT (Comprehensive Error Rate Testing) vs HIPAA (Health Insurance Portability and Accountability) Compliance

During a CERT review, you may be asked to provide more information related to a claim you submitted, such as medical records or certificates of medical necessity, so that the CERT review contractor can verify that billing was proper. Be assured that forwarding specifically requested records to the designated CERT contractor does NOT violate privacy provisions under the HIPAA law. The Centers for Medicare & Medicaid Services (CMS) has contracted with the CERT Documentation Contractor and the CERT Review Contractor to conduct the activities of the CERT program. As a Medicare contractor and in accordance with Section 1816 and 1842 of the Social Security Act, the CERT contractors are authorized to request claims and medical records from providers and suppliers of Medicare services. Physicians, providers, and suppliers do not need to obtain additional beneficiary authorization to forward medical records to the designated CERT contractor.

Should you receive a letter from CMS regarding a CERT request for medical documentation, you should respond promptly by submitting the requested supporting documentation within the time frame outlined in the request.

If you have any questions, call CERT Customer Service at (301) 957.2380 between the hours of 8:00 AM to 6:00 PM EST.

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Coding Change for Lumbar Artificial Disc Replacement (LADR)

Note: This article was revised on February 1, 2007, to show the correct code of 0163T in the last bullet point on page 2. The article had incorrectly reflected 0263T. All other information remains the same.

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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Colorectal Cancer Screening Flexible Sigmoidoscopy and Colonoscopy Coinsurance Payment Change

Note: This article was revised on 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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Cytometry and Cytogenetic Studies – LCD Revisions

LCD’s for Flow Cytometry and Cytogenetic Studies have been revised for North Carolina and Tennessee to include ICD-9 codes 288.60, 288.61, 288.62, 288.63, 288.64, 288.65, and 288.69 for CPT code range 88184-88189. Please refer to the CIGNA Government Services Web site at http://www.cignagovernmentservices.com to view the policy.

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Differentiating Mass Adjustments from Other Types of Adjustments and Claims for Crossover Purposes and Revising the Detailed Error Report Special Provider Notification Letters

PQRI Information Available
A new CMS Web page dedicated to providing information on the Physician Quality Reporting Initiative (PQRI) is now available.


On December 20, 2006, the President signed the Tax Relief and Health Care Act of 2006 (TRHCA). Section 101 under Title I authorizes the establishment of a physician quality reporting system by CMS. CMS has titled the statutory program the Physician Quality Reporting Initiative. For more information, visit http://www.cms.hhs.gov/pqri on the CMS Web site.

Note: This article was revised on March 1, 2007, to reflect changes made to CR5472, which CMS revised on February 28, 2007. The CR transmittal number, release date, and Web address for accessing CR5472 have been revised. All other information remains the same.

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

Provider Action Needed

STOP – Impact to You
This article is based on Change Request (CR) 5472 which implements changes to Medicare contractor systems so that their claim transmissions to the Coordination of Benefits Contractor (COBC) for mass adjustments and other kinds of adjustments may be differentiated from all other types of claims sent for crossover.

CAUTION – What You Need to Know
This will be accomplished through modifications to the 837 COB flat files and National Council for Prescription Drug Programs (NCPDP) Part B drug claim files, all of which are transmitted to the COBC on a daily basis.

Through CR5472, Medicare contractors’ systems will be modified so that the COBC Detailed Error Report information that is printed on the outgoing special provider notification letters/report that you receive when claims will not be crossed over due to claim data errors will be modified to also include the error/trading partner rejection code and accompanying description. These changes to the special provider letters should enable your billing service to determine why claims that were previously selected by Medicare for crossover were not actually crossed over.

Without these changes, CMS would be unable to isolate mass adjustment claims as part of the national COBA crossover process. This change corrects a problem that the Centers for Medicare & Medicaid Services (CMS) encountered as part of its implementation of the Deficit Reduction Act (DRA). Also, providers would continue to be unaware of the specific reasons as to why their patients’ claims were not crossed over.

GO – What You Need to Do
See the Background and Additional Information Sections of this article for further details regarding these changes.

Background
All Medicare contractors currently send processed claims, for which Medicare systems show the beneficiary has other insurance to the COBC for crossover under the national Coordination of Benefits Agreement (COBA) program.

The Centers for Medicare & Medicaid Services (CMS) requires a method whereby its Coordination of Benefits Contractor (COBC) can differentiate among the various categories of adjustment crossover claims including:

Having the ability to differentiate among the various categories of adjustment crossover claims will enable CMS (and the COBC) to better address the kinds of contingencies that arise with the passage of legislation such as the Deficit Reduction Act, which mandate changes for Medicare that can affect claims already processed.


CR5472 instructs that the COBC Detailed Error Report process be modified to ensure that the contractor-generated special provider letters which are created and sent in accordance with CR 3709 contain the specific Claredi rejection code returned for the claim along with its description. (See the MLN Matters article at http://www.cms.hhs.gov/mlnMattersArticles/downloads/MM3709.pdf for information on CR3709.)

Providers may wish to contact their billing agent/vendor to obtain a better understanding of these error codes and accompanying descriptions, which, in turn, explains why their patients’ claims were not crossed over successfully. In addition, providers should notify their billing agent/vendor when they receive special provider letters or reports stating why their patients’ claims were not crossed over.

Additional Information
The official instruction, CR5472, issued to your carrier, FI, RHHI, A/B MAC, DMERC, or DME MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1189CP.pdf on the CMS Web site. Attached to CR5472, you will find the new chapter of the Medicare Claims Processing Manual explaining in detail the new special mass adjustment process for COB. In addition, you will also find revised chapters for other portions of that manual, which discuss the COB process.
If you have any questions, please contact your carrier, FI, RHHI, A/B MAC, DMERC, or DME MAC at their toll-free number, which may be found on the CMS Web site at: http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip.

Flu Shot Reminder
It’s Not Too Late to Give and Get the Flu Shot
The peak of flu season typically occurs between late December and March; however, flu season can last until May. Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a lifetime pneumococcal vaccination. Remember— influenza and pneumococcal vaccination and their administration are covered Part B benefits. Note that influenza and pneumococcal vaccines are NOT Part D covered drugs. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’ Web site:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf.

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Differentiating Mass Adjustments from Other Types of Adjustments and Claims for Crossover Purposes and Revising the Detailed Error Report Special Provider Notification Letters

PQRI Information Available
A new CMS Web page dedicated to providing information on the Physician Quality Reporting Initiative (PQRI) is now available.

On December 20, 2006, the President signed the Tax Relief and Health Care Act of 2006 (TRHCA). Section 101 under Title I authorizes the establishment of a physician quality reporting system by CMS. CMS has titled the statutory program the Physician Quality Reporting Initiative. For more information, visit
http://www.cms.hhs.gov/pqri on the CMS Web site.

Note: This article was revised on March 1, 2007, to reflect changes made to CR5472, which CMS revised on February 28, 2007. The CR transmittal number, release date, and Web address for accessing CR5472 have been revised. All other information remains the same

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

Provider Action Needed

STOP – Impact to You
This article is based on Change Request (CR) 5472 which implements changes to Medicare contractor systems so that their claim transmissions to the Coordination of Benefits Contractor (COBC) for mass adjustments and other kinds of adjustments may be differentiated from all other types of claims sent for crossover.

This will be accomplished through modifications to the 837 COB flat files and National Council for Prescription Drug Programs (NCPDP) Part B drug claim files, all of which are transmitted to the COBC on a daily basis.

Through CR5472, Medicare contractors’ systems will be modified so that the COBC Detailed Error Report information that is printed on the outgoing special provider notification letters/report that you receive when claims will not be crossed over due to claim data errors will be modified to also include the error/trading partner rejection code and accompanying description. These changes to the special provider letters should enable your billing service to determine why claims that were previously selected by Medicare for crossover were not actually crossed over.

Without these changes, CMS would be unable to isolate mass adjustment claims as part of the national COBA crossover process. This change corrects a problem that the Centers for Medicare & Medicaid Services (CMS) encountered as part of its implementation of the Deficit Reduction Act (DRA). Also, providers would continue to be unaware of the specific reasons as to why their patients’ claims were not crossed over.

GO – What You Need to Do
See the Background and Additional Information Sections of this article for further details regarding these changes.

Background
All Medicare contractors currently send processed claims, for which Medicare systems show the beneficiary has other insurance to the COBC for crossover under the national Coordination of Benefits Agreement (COBA) program.

The Centers for Medicare & Medicaid Services (CMS) requires a method whereby its Coordination of Benefits Contractor (COBC) can differentiate among the various categories of adjustment crossover claims including:


Having the ability to differentiate among the various categories of adjustment crossover claims will enable CMS (and the COBC) to better address the kinds of contingencies that arise with the passage of legislation such as the Deficit Reduction Act, which mandate changes for Medicare that can affect claims already processed.

5472 CR5472 instructs that the COBC Detailed Error Report process be modified to ensure that the contractor-generated special provider letters which are created and sent in accordance with CR 3709 contain the specific Claredi rejection code returned for the claim along with its description. (See the MLN Matters article at http://www.cms.hhs.gov/mlnMattersArticles/downloads/MM3709.pdf for information on CR3709.)

Providers may wish to contact their billing agent/vendor to obtain a better understanding of these error codes and accompanying descriptions, which, in turn, explains why their patients’ claims were not crossed over successfully. In addition, providers should notify their billing agent/vendor when they receive special provider letters or reports stating why their patients’ claims were not crossed over.

Additional Information
The official instruction, CR5472, issued to your carrier, FI, RHHI, A/B MAC, DMERC, or DME MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1189CP.pdf on the CMS Web site. Attached to CR5472, you will find the new chapter of the Medicare Claims Processing Manual explaining in detail the new special mass adjustment process for COB. In addition, you will also find revised chapters for other portions of that manual, which discuss the COB process.

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

Flu Shot Reminder
It’s Not Too Late to Give and Get the Flu Shot
The peak of flu season typically occurs between late December and March; however, flu season can last until May. Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a lifetime pneumococcal vaccination. Remember — influenza and pneumococcal vaccination and their administration are covered Part B benefits. Note that influenza and pneumococcal vaccines are NOT Part D covered drugs. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’ Web site:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf.

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Direct Billing and Payment for Non-Physician Practitioner (NPP) Services Furnished to Hospital Inpatients and Outpatients

Flu Shot Reminder
It’s Not Too Late to Give and Get the Flu Shot!
The peak of flu season typically occurs between late December and March; however, flu season can last until May. Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a lifetime pneumococcal vaccination. Remember — influenza and pneumococcal vaccination and their administration are covered Part B benefits. Note that influenza and pneumococcal vaccines are NOT Part D covered drugs. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’ Web site:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf .

Provider Types Affected
All hospitals, clinical nurse specialists (CNSs), nurse practitioners (NPs), and the employers of physician assistants (PAs) who bill Medicare for hospital inpatient and outpatient services.

Background
Section 4511(a)(2)(B) of the Balanced Budget Act of 1997 amended section 1861(b)(4) of the Social Security Act to exclude the professional services of NPs, CNSs and PAs from hospital inpatient services. Accordingly, upon the effective date of Change Request (CR) 5221, NPs and CNSs are authorized to bill Medicare carriers directly for their professional services when furnished to hospital patients, both inpatients and outpatients. The employer of a PA, rather than the hospital, must bill the carrier for their professional services when furnished to hospital patients. Hospitals should not bill for the professional services of a PA, unless the PA is employed by the hospital.

This article and Change Request (CR) 5221 describe the removal of the paragraph in the Medicare Claims Processing Manual, Chapter 12 section 120.1 that contains outdated policy on payment for NP and CNS services furnished in a hospital setting. The changes are as follows:

Additional Information
The official instructions, CR5221, issued to your Medicare carrier regarding this change can be found at http://www.cms.hhs.gov/Transmittals/downloads/R1168CP.pdf on the CMS Web site. A revised Chapter 12, Section 120.1—Direct Billing and Payment—of the Medicare Claims Processing Manual is attached to CR 5221.


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

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Guidelines for Payment of Diabetes Self-Management Training (DSMT)

Flu Shot Reminder
It’s Not Too Late to Give and Get a Flu Shot!
The peak of flu season typically occurs between late December and March; however, flu season can last until May. Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a lifetime pneumococcal vaccination. Remember —influenza and pneumococcal vaccination and their administration are covered Part B benefits. Note that influenza and pneumococcal vaccines are NOT Part D covered drugs. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’ Web site:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf .

Provider Types Affected
Providers submitting claims to Medicare Fiscal Intermediaries (FIs), Part A/B Medicare Administrative Contractors (A/B MACs), and/or Regional Home Health Intermediaries (RHHIs) for DSMT services provided in institutional settings to Medicare beneficiaries.

Provider Action Needed

STOP – Impact to You
This article is based on Change Request (CR) 5433 which corrects, clarifies, and provides guidelines for the payment of DSMT services in various institutional provider settings.

CAUTION – What You Need to Know
Medicare Part B covers 10 hours of initial training for a beneficiary who has been diagnosed with diabetes, and beneficiaries are eligible to receive 2 hours of follow-up training each calendar year following the year in which they were certified as requiring initial training. DSMT must be ordered by the physician or qualified non-physician practitioner who is managing the beneficiary’s diabetic condition.

GO – What You Need to Do
See the Background and Additional Information Sections of this article for further details regarding these changes.

Background
The Balanced Budget Act of 1997 (Section 4105) permits Medicare coverage of diabetes self-management training (DSMT) services when these services are furnished by a certified provider who meets certain quality standards, and CR 5433 corrects, clarifies, and provides guidelines for the payment of DSMT services in various institutional provider settings. Note that no new codes are being created by CR5433. Also, deductible and coinsurance apply to these services.

The DSMT program is intended to educate beneficiaries in the successful self-management of diabetes. The program includes instructions in self-monitoring of blood glucose; education about diet and exercise; an insulin treatment plan developed specifically for the patient who is insulin-dependent; and motivation for patients to use the skills for self-management.

Initial Training
The initial year for DSMT is the 12 month period following the initial date, and Medicare will cover initial training that meets the following conditions:


Follow-Up Training
Medicare covers follow-up training under the following conditions:

NOTE: All entities billing for DSMT under the fee-for-service payment system or other payment systems must meet all national coverage requirements.

Examples
Example #1: Beneficiary Exhausts 10 hours in the Initial Year (12 continuous months)
Beneficiary receives first service in April 2006.
Beneficiary completes initial 10 hours DSMT training in April 2007.
Beneficiary is eligible for follow-up training in May 2007 (13th month begins the subsequent year).
Beneficiary completes follow-up training in December 2007.
Beneficiary is eligible for next year training in January 2008.


Example #2: Beneficiary Exhausts 10 Hours Within the Initial Calendar Year
Beneficiary receives first service in April 2006.
Beneficiary completes initial 10 hours of DSMT training in December 2006.
Beneficiary is eligible for follow-up training in January 2007.
Beneficiary completes follow-up training in July 2007.
Beneficiary is eligible for next year follow-up training in January 2008.

Coding and Payment of DSMT Services
The following HCPCS codes should be used for DSMT:


Payment to physicians and providers for outpatient DSMT is made as follows:

Type of Facility/Provider Payment Method Type of Bill
Physician/non-physician practitioner (billing carrier/MAC) Medicare Physician Fee Schedule N/A
Hospitals subject to Outpatient Prospective Payment System (OPPS) OPPS 12x, 13x
Method I and Method II Critical Access Hospitals (CAHs) (technical services) 101% of reasonable cost 12X and 85X
Indian Health Service (IHS) providers billing hospital outpatient Office of Management and Budget (OMB)-approved outpatient per visit all inclusive rate (AIR) 13X and revenue code 051X
IHS providers billing inpatient Part B All-inclusive inpatient ancillary per diem rate 12X and revenue code 024X
IHS CAHs billing outpatient 101% of the all-inclusive facility specific per visit rate 85X and revenue code 051X
IHS CAHs billing inpatient Part B 101% of the all-inclusive facility specific per diem rate 12X and revenue code 024X
Rural Health Clinics (RHCs) All-inclusive encounter rate 71X with revenue code 0520, 0521, 0522, 0524, 05225, 0527, 0528, or 0900
Federally Qualified Health Centers (FQHCs)* All-inclusive encounter rate 73X with revenue code 0520, 0521, 0522, 0524, 0525, 0527, 0528, 0r 0900
Skilled Nursing Facilities (SNFs) ** Medicare Physician Fee Schedule (MPFS) non-facility rate 22X, 23X
Maryland Hospitals under jurisdiction of the Health Services Cost Review Commission (HSCRC) Payment in accordance with the terms of the Maryland Waiver 12X, 13X
Home Health Agencies (can be billed if service is outside of the treatment plan) MPFS non-facility rate 34x

* Effective January 1, 2006, payment for DSMT provided in an FQHC, that meets all the requirements as above, may be made in addition to one other visit the beneficiary had during the same day, if this qualifying visit is billed on TOB 73X, with HCPCS code G0108 or G0109, and revenue codes 0520, 0521, 0522, 0524, 0525, 0527, 0528, or 0900.

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

NOTE: An End Stage Renal Disease (ESRD) facility is a reasonable site for this DSMT service, however, because it is required to provide dietician and nutritional services as part of the care covered in the composite rate, ESRD facilities are not allowed to bill for it separately and do not receive separate reimbursement.

Advanced Beneficiary Notices (ABNs)
Providers should also be aware that the beneficiary is liable for services denied over the limited number of hours with referrals for DSMT. An ABN should be issued in these situations and absent evidence of a valid ABN, the provider would be held liable.

However, an ABN should not be issued for Medicare-covered services such as those provided by hospital dieticians or nutrition professionals who are qualified to render the service in their State, but who have not obtained Medicare provider numbers.

Additional Information
For complete details, please see the official instruction, CR5433, issued to your FI, RHHI, and A/B MAC regarding this change. There are two transmittals related to CR5433, one which revises the Medicare Benefit Policy Manual and one that modifies the Medicare Claims Processing Manual. These transmittals are at http://www.cms.hhs.gov/Transmittals/downloads/R64BP.pdf and http://www.cms.hhs.gov/Transmittals/downloads/R1158CP.pdf, respectively.

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

Flu Shot Reminder
It’s Not Too Late to Give and Get a Flu Shot!
The peak of flu season typically occurs between late December and March; however, flu season can last until May. Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a lifetime pneumococcal vaccination. Remember — influenza and pneumococcal vaccination and their administration are covered Part B benefits. Note that influenza and pneumococcal vaccines are NOT Part D covered drugs. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’ Web site:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf .

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Health Insurance Claim (HIC) Number

Traditional
All claims require the complete HIC number in Block 1A of the CMS-1500 claim form or in the appropriate field for electronic claims. Enter the patient’s Medicare HIC exactly as it appears on the patient’s Medicare card whether Medicare is the primary or secondary payer. Enter the number without spaces and/or hyphens. The HIC number should be nine digits, followed by a valid suffix.

Example: 1233456789A

The following is a list of valid Health Insurance Claim number suffixes:

A Primary claimant
B Aged wife A62 (1st claimant)
B1 Aged husband (1st claimant)
B2 Young wife (1st claimant)
B3 Aged wife (2nd claimant)
B4 Aged husband (2nd claimant)
B5 Young wife (2nd claimant)
B6 Divorced wife (1st claimant)
B7 Young wife (3rd claimant)
B8 Aged wife (3rd claimant)
B9 Divorced wife (2nd claimant)
BA Aged wife (4th claimant)
BD Aged wife (5th claimant)
BG Aged husband (3rd claimant)
BH Aged husband (4th claimant)
BJ Aged husband (5th claimant)
BK Young wife (4th claimant)
BL Young wife (5th claimant)
BN Divorced wife (3rd claimant)
BP Divorced wife (4th claimant)
BQ Divorced wife (5th claimant)
BR Divorced husband A62+ (1st claimant)
BT Divorced husband (2nd claimant)
BW Young husband (2nd claimant)
BY Young husband/child-in-care (1st claimant)
C1 - C9 Child (includes disabled or student child)
CA - CK Same as C1 – C9
D Aged widow A60 (1st claimant)
D1 Aged widower (1st claimant)
D2 Aged widow (2nd claimant)
D3 Aged widower (2nd claimant)
D4 Widow (remarried after age 60) (1st claimant)
D5 Widower (remarried after age 60) (1st claimant)
D6 Surviving divorced wife A60 (1st claimant)
D7 Surviving divorced wife (2nd claimant)
D8 Aged widow (3rd claimant)
D9 Remarried widow (2nd claimant)
DA Remarried widow (3rd claimant)
DC Surviving divorced husband, A60+
(1st claimant)
DD Aged widow (4th claimant)
DG Aged widow (5th claimant)
DH Aged widower (3rd claimant)
DJ Aged widower (4th claimant)
DK Aged widower (5th claimant)
DL Remarried widow (4th claimant)
DM Surviving divorced husband (2nd claimant)
DN Remarried widow (5th claimant)
DP Remarried widower (2nd claimant)
DQ Remarried widower (3rd claimant)
DR Remarried widower (4th claimant)
DS Surviving divorced husband (3rd claimant)
DT Remarried widower (5th claimant)
DV Surviving divorced wife (3rd claimant)
DW Surviving divorced wife (4th claimant)
DX Surviving divorced husband (4th claimant)
DY Surviving divorced wife (5th claimant)
DZ Surviving divorced husband (5th claimant)
E Mother (widow) (1st claimant)
E1 Surviving divorced mother (1st claimant)
E2 Mother (widow) (2nd claimant)
E3 Surviving divorced mother (2nd claimant)
E4 Father (widower) (1st claimant)
E5 Surviving divorced father (1st claimant)
E6 Father (widower) (2nd claimant)
E7 Mother (widow) (3rd claimant)
E8 Mother (widow) (4th claimant)
E9 Surviving divorced father (2nd claimant)
EA Mother (widow) (5th claimant)
EB Surviving divorced mother (3rd claimant)
EC Surviving divorced mother (4th claimant)

ED Surviving divorced mother (5th claimant)
EF Father (widower) (3rd claimant)
EG Father (widower) (4th claimant)
EH Father (widower) (5th claimant)
EJ Surviving divorced father (3rd claimant)
EK Surviving divorced father (4th claimant)
EM Surviving divorced father (5th claimant)
F1 Parent (father)
F2 Parent (mother)
F3 Parent (stepfather)
F4 Parent (stepmother)
F5 Parent (adopting father)
F6 Parent (adopting mother)
F7 Parent (2nd alleged father)
F8 Parent (2nd alleged mother)
G1-9 Claimant for LSDP
M Uninsured beneficiary (not qualified for automatic HIB)
M1 Uninsured beneficiary (qualified for automatic HIB but requests SMI only)
T Uninsured beneficiary

  • Fully insured beneficiary elected entitlement only to HIB (usually but not always along with SMIB)
  • Renal disease only
  • Deemed insured HIB only


TA Medicare Qualified Government Employment (MQGE) primary beneficiary
TB MQGE aged spouse (1st claimant)
TC MQGE disabled adult child (DAC)
TD MQGE aged widow(er) (1st claimant)
TE MQGE young widow(er) (1st claimant)
TF MQGE parent (male)
TG MQGE aged spouse (2nd claimant)
TH MQGE aged spouse (3rd claimant)
TJ MQGE aged spouse (4th claimant)
TK MQGE aged spouse (5th claimant)
TL MQGE aged widow(er) (2nd claimant)
TM MQGE aged widow(er) (3rd claimant)
TN MQGE aged widow(er) (4th claimant)
TP MQGE aged widow(er) (5th claimant)
TQ MQGE parent (female)
TR MQGE young widow(er) (2nd claimant)
TS MQGE young widow(er) (3rd claimant)
TT MQGE young widow(er) (4th claimant)
TU MQGE young widow(er) (5th claimant)
TV MQGE disabled widow(er) (1st claimant)
TW MQGE disabled widow(er) (2nd claimant)
TX MQGE disabled widow(er) (3rd claimant)
TY MQGE disabled widow(er) (4th claimant)
TZ MQGE disabled widow(er) (5th claimant)
T2 -T9 MQGE (DAC) (2nd to 9th claimant)
W Disabled widow A50 (1st claimant)
W1 Disabled widower (1st claimant)
W2 Disabled widow (2nd claimant)
W3 Disabled widower (2nd claimant)
W4 Disabled widow (3rd claimant)
W5 Disabled widower (3rd claimant)
W6 Disabled surviving divorced wife
(1st claimant)
W8 Disabled surviving divorced wife
(3rd claimant)
W7 Disabled surviving divorced wife
(2nd claimant)
W9 Disabled widow (4th claimant)
WB Disabled widower (4th claimant)
WC Disabled surviving divorced wife
(4th claimant)
WF Disabled widow (5th claimant)
WG Disabled widower (5th claimant)
WJ Disabled surviving divorced wife
(5th claimant)
WR Disabled surviving divorced husband
(1st claimant)
WT Disabled surviving divorced husband
(2nd claimant)

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Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits

Provider Types Affected
Clinical diagnostic laboratories billing Medicare carriers or Part A/B Medicare Administrative Contractors (A/B MACs) for laboratory tests.

Provider Action Needed

STOP – Impact to You
If you do not have a valid, current, CLIA certificate and submit a claim to your Medicare carrier or A/B MAC for a HCPCS code that is considered to be a laboratory test, your Medicare payment may be impacted.

CAUTION – What You Need to Know
The Clinical Laboratory Improvement Amendments of 1998 (CLIA) requires that for each test it performs, a laboratory facility must be appropriately certified. The HCPCS codes that CMS considers to be laboratory tests under CLIA (and thus requiring certification) change each year. CR 5457, from which this article is taken, informs carriers and A/B MACS about the new HCPCS codes for 2007 that are subject to CLIA edits and also about those that are now excluded from CLIA edits.

GO – What You Need to Do
Make sure that your billing staffs are aware of these CLIA-related HCPCS changes for 2007 and that you remain current with certification requirements.

The Clinical Laboratory Improvement Amendments of 1998 (CLIA) require a laboratory facility to be appropriately certified for each test it performs.

To ensure that Medicare and Medicaid only pay for laboratory tests that are performed by certified facilities, carriers and A/B MACs will edit each Medicare claim submitted for a HCPCS code considered to be a CLIA laboratory test. These HCPCS codes change each year, and CR 5457, from which this article is taken, informs carriers and A/B MACs about the new HCPCS codes for 2007 that are both subject to, and excluded from, CLIA edits.

The HCPCS codes listed in the Table 1, below, are new for 2007 and are subject to CLIA edits (the list does not include new HCPCS codes for waived tests or provider-performed procedures.) This means that laboratory facilities performing these tests must have either a CLIA certificate of registration (certificate type code 9), a CLIA certificate of compliance (certificate type code 1), or a CLIA certificate of accreditation (certificate type code 3). Conversely, a facility without a valid, current, CLIA certificate, or with a current CLIA certificate of waiver (certificate type code 2) or a current CLIA certificate for provider-performed microscopy procedures (certificate type code 4) will not be paid for these tests and the claims will be denied..

Table 1

New 2007 HCPCS Codes Subject to CLIA Edits
HCPCS Code Description
17311 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including the routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5 tissue blocks;
17312 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including the routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; each additional stage after the first stage, up to 5 tissue blocks (list separately in addition to code for primary procedure);
17313 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including the routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to 5 tissue blocks;
17314 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including the routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; each additional stage after the first stage, up to 5 tissue blocks (list separately in addition to code for primary procedure)
17315 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including the routine stain(s) (eg, hematoxylin and eosin, toluidine blue), each additional block after the first 5 tissue blocks, any stage (list separately in addition to code for primary procedure)
82107 Alpha-fetoprotein (AFP); APF-L3 fraction isoform and total AFP (including ratio)
83698 Lipoprotein-associated phospholipase A2, (Lp-PLA2)
83913 Molecular diagnostics; RNA stabilization
86788 Antibody; West Nile virus, IgM
86789 Antibody; West Nile virus
87305 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Aspergillus
87498 Infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique
87640 Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique
87641 Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique
87653 Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus , group B, amplified probe technique
87808 Infectious agent detection by immunoassay with direct optical observation; Trichomonas vaginalis

CR 5457 also provides HCPCS codes that were discontinuted on 12/31/2006.

Table 2

HCPCS Codes discontinued in 2007
HCPCS Code Description
17304 Chemosurgery (Mohs micrographic technique), including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and complete histological preparation including the first routine stain (eg, hematoxylin and eosin, toluidine blue); first stage, fresh tissue technique, up to five specimens;
17305 Chemosurgery (Mohs micrographic technique), including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and complete histological preparation including the first routine stain (eg, hematoxylin and eosin, toluidine blue); second stage, fixed or fresh tissue technique, up to five specimens;
17306 Chemosurgery (Mohs micrographic technique), including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and complete histological preparation including the first routine stain (eg, hematoxylin and eosin, toluidine blue); third stage, fixed or fresh tissue technique, up to five specimens;
17307 Chemosurgery (Mohs micrographic technique), including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and complete histological preparation including the first routine stain (eg, hematoxylin and eosin, toluidine blue); additional stage(s), up to five specimens, each stage; and
17310 Chemosurgery (Mohs micrographic technique), including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and complete histological preparation including the first routine stain (eg, hematoxylin and eosin, toluidine blue); each additional specimen, after the first five specimens, fixed or fresh tissue any stage (list separately in addition to code for primary procedure).

Note: Carriers and A/B MACS will add the LC code of 610 for the specialty of histopathology to the new Mohs HCPCS codes (17311, 17312, 17313, 17314, and 17315) even though are not currently edited at the laboratory certification (LC) level.

Remember that carriers and A/B MACs will return as unprocessable claims submitted with the HCPCS codes displayed in Table 1, above, without a CLIA number. Also, carriers and A/B MACs will deny payment for claims submitted without a valid current CLIA certificate, or with a CLIA certificate of waiver (certificate type code 2), or a CLIA certificate for provider-performed microscopy procedures (certificate type code 4). Finally, carriers and A/B MACs will not search their files to either retract payment for claims already paid or to retroactively pay claims processed prior to the April 2, 2007, implementation date. They will adjust claims that are brought to their attention.

Additional Information
You can find the official instruction, CR 5457, issued to your carrier or A/B MAC by visiting http://www.cms.hhs.gov/Transmittals/downloads/R1165CP.pdf on the CMS Web site.

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

Flu Shot Reminder
It’s Not Too Late to Give and Get the Flu Shot!
The peak of flu season typically occurs between late December and March; however, flu season can last until May. Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a lifetime pneumococcal vaccination. Remember — influenza and pneumococcal vaccination and their administration are covered Part B benefits. Note that influenza and pneumococcal vaccines are NOT Part D covered drugs. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’ Web site:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf .

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Infrared Therapy Devices

Note: This article was revised on February 9, 2007, to correct the range of ICD-9 codes shown in bold print on page 2. The range is 880.00-887.7. Originally, CR5421 and the related article incorrectly showed 880.00-887.79 for that range. The CR transmittal number, release date, and Web address for accessing CR5421 are also revised, but all other information remains the same.

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 http://www.cms.hhs.gov/Transmittals/downloads/R62NCD.pdf on the CMS Web site. In addition, there is a transmittal related to the Medicare Claims Processing Manual revision, which is at http://www.cms.hhs.gov/Transmittals/downloads/R1183CP.pdf on the CMS 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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Nerve Conduction Studies – LCD Retired

The LCD for Nerve Conduction Studies has been retired effective February 4, 2007 and replaced with Electrodiagnostic Testing: Nerve conduction studies (NCS) & Electromyography (EMG). Please refer to the CIGNA Government Services Web site at http://www.cignagovernmentservices.com to view the policy.

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Part C Plan Type Description Display on Medicare’s Common Working File (CWF)

Note: This article was revised on March 8, 2007, to reflect that the plan directory will be posted on the CMS Web site in mid-March of 2007. Originally, the article stated the directory would be posted as of March 1, 2007. All other information in the article remains the same.

Provider Types Affected
Physicians, providers, and suppliers who access Medicare beneficiary eligibility data through CWF eligibility screens (e.g. HUQA, HIQA, HIQH, ELGA, ELGB, ELGH).

Provider Action Needed
Be aware of the expanded list of MA Plan Type Descriptions that are being displayed by Medicare’s CWF system. Being aware of the MA plan type is crucial, especially for those beneficiaries who are enrolled in Private Fee-For-Service (PFFS) plans.

A plan directory, which will be quite descriptive, will soon be published that contains the list of all active Medicare contracts and their corresponding plan type. The directory will be in a table format and will be posted at the following URL in mid-March of 2007: http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/02_EnrollmentData.asp#TopOfPage

When you query Medicare regarding a beneficiary’s entitlement and eligibility, Medicare’s CWF system responds with information on the Medicare managed care contract number in which a beneficiary is enrolled, including the plan type description associated with the contract. Currently, CWF largely displays the label “HMO” for these contracts. In many cases, the “HMO” label is incorrect since the list of possible plan type values has grown far larger since the creation of the Medicare Advantage program.

For example, under the MA Part C program, Medicare beneficiaries can enroll in Private Fee-for-Service (PFFS) plans. PFFS plans are very different from the more traditional MA HMO type plan.

PFFS PLANS
PFFS plans generally have no plan specific provider network. Enrollees in a PFFS plan can obtain plan covered health care services from any Medicare FFS enrolled provider in the U.S. who is willing to furnish services to a PFFS plan beneficiary. It is important to note that a provider is not required to furnish health care services to enrollees of a PFFS plan.

In most cases, a PFFS enrollee will inform a provider before obtaining a service that they are enrolled in a PFFS plan. In addition, the PFFS enrollee will have an enrollment card provided by the PFFS plan identifying them as enrollees in a PFFS plan. The card will specify a phone number and/or a Web address where the provider can obtain the PFFS plan’s terms and conditions of participation.

At a minimum, the terms and conditions will specify:

A PFFS organization is required to make its terms and conditions of participation reasonably available to providers in the U.S. from whom its enrollees seek health care services. This generally means that the organization offering the PFFS plan will post its terms and conditions on a Web site and also make them available upon written or phoned request.

To be paid by a PFFS organization, the provider must send their bill to the address (or electronic address) provided in the PFFS plan’s terms and conditions of participation.

For more detailed information on PFFS plans as they relate to providers, see the “Provider Q&A” Downloadable document on http://www.cms.hhs.gov/PrivateFeeforServicePlans/.

Additional Information
If you have questions regarding the plan of a specific Medicare MA enrolled patient, you may wish to contact that plan.

To view the official instruction (CR5349) issued to your Medicare FI, carrier, MAC, DMERC or RHHI, visit http://www.cms.hhs.gov/Transmittals/downloads/R1175CP.pdf on the CMS Web site.


To review a related article that explains Medicare’s Common Working File (CWF) Part C (Medicare Advantage Managed Care) Data Exchange and Data Display Changes go to http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5118.pdf on the CMS Web site.

Flu Shot Reminder
It’s Not Too Late to Give and Get a Flu Shot!
The peak of flu season typically occurs between late December and March; however, flu season can last until May. Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a lifetime pneumococcal vaccination. Remember — influenza and pneumococcal vaccination and their administration are covered Part B benefits. Note that influenza and pneumococcal vaccines are NOT Part D covered drugs. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’ Web site:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf .

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Remicade (Infliximab) – Article Retired

The Article for Remicade (Infliximab) has been retired effective February 1, 2007 for Part B states Tennessee (A22854), North Carolina (A21649), and Idaho (A19916). Please refer to the CIGNA Government Services Web site at http://www.cignagovernmentservices.com to view the policy.

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Reminder – Medicare Provides Coverage of Prostate Cancer Screening for Eligible Medicare Beneficiaries

PQRI Information Available
A new CMS Web page dedicated to providing information on the Physician Quality Reporting Initiative (PQRI) is now available.

On December 20, 2006, the President signed the Tax Relief and Health Care Act of 2006 (TRHCA). Section 101 under Title I authorizes the establishment of a physician quality reporting system by CMS. CMS has titled the statutory program the Physician Quality Reporting Initiative. For more information, visit
http://www.cms.hhs.gov/pqri on the CMS Web site.

Provider Types Affected
All Medicare fee-for-service (FFS) physicians, providers, suppliers, and other health care professionals, who furnish or provide referrals for and/or file claims for Medicare-covered prostate cancer screening services.

Provider Action Needed
This article conveys no new policy that requires provider action. The article is for informational purposes only and serves as a reminder that Medicare provides coverage of certain prostate cancer screening tests subject to certain coverage, frequency, and payment limitations.

Introduction
Effective for services furnished on or after January 1, 2000, Medicare Part B covers annual preventive prostate cancer screening tests/procedures for the early detection of prostate cancer. The information in this Special Edition MLN Matters article reminds health care professionals about the coverage criteria, eligibility requirements, frequency parameters, and correct coding when billing for prostate cancer screening services so that you can talk with your Medicare patients about this preventive benefit and file claims properly for the screening service.

The Screening Services Defined

  1. Screening Digital Rectal Examination (DRE) Medicare defines a screening DRE as a clinical examination of an individual’s prostate for nodules or other abnormalities of the prostate. This screening must be performed by a doctor of medicine or osteopathy, physician assistant, nurse practitioner, clinical nurse specialist, or by a certified nurse midwife who is authorized under State law to perform the examination, fully knowledgeable about the beneficiary’s medical condition, and would be responsible for explaining the results of the examination to the beneficiary.
  2. Screening Prostate Specific Antigen (PSA) Tests Medicare defines a screening PSA as a test that measures the level of prostate specific antigen in an individual’s blood. This screening must be ordered by the beneficiary’s physician (doctor of medicine or osteopathy) or by the beneficiary’s physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife who is fully knowledgeable about the beneficiary’s medical condition, and would be responsible for explaining the results of the test to the beneficiary.

Coverage Information
Medicare Provides Coverage of the Following Prostate Cancer Screening Tests:

Eligibility and Frequency
Medicare provides coverage of an annual preventive prostate cancer screening PSA test and DRE once every 12 months for all male beneficiaries age 50 and older (coverage begins the day after the beneficiary’s 50th birthday), if at least 11 months have passed following the month in which the last Medicare-covered screening DRE or PSA test was performed for the early detection of prostate cancer.

Calculating Frequency
When calculating frequency, to determine the 11-month period, the count starts beginning with the month after the month in which a previous test/procedure was performed.

EXAMPLE: The beneficiary received a screening PSA test in January 2006. The count starts beginning February 2006. The beneficiary is eligible to receive another screening PSA test in January 2007 (the month after 11 months have passed).

Deductible and Coinsurance/Copayment

Claim Filing Information
The following Healthcare Common Procedure Coding System (HCPCS) codes and diagnosis code must be reported when filing claims for prostate cancer screening services:

HCPCS Codes Code Descriptors
G0102 Prostate cancer screening; digital rectal examination
G0103 Prostate cancer screening; prostate specific antigen test (PSA), total
Diagnosis Code Description
V76.44 Prostate cancer screening digital rectal examinations (DRE) and screening prostate specific antigen (PSA) blood tests must be billed using screening (“V”) code V76.44 (Special Screening for Malignant Neoplasms, Prostate).

IMPORTANT NOTE: When submitting claims for the annual preventive prostate cancer screening PSA test it is important to bill for a screening test, which is covered once every 12 months, and not for a diagnostic test.

Payment for Prostate Cancer Screening Services