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May 4, 2007 Part B Medicare Bulletin

Posted May 4, 2007

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Services Not Provided Within United States

Provider Types Affected
Physicians, suppliers, and providers who submit claims to Medicare carriers, fiscal intermediaries (FIs), and A/B Medicare Administrative Contractors (A/B MACs).

Key Points
CR5427 clarifies that payment may not be made for a medical service (or a portion of it) that was subcontracted to another provider or supplier located outside the United States.

Take Note: Payment may not be made for a medical service (or a portion of it) that was subcontracted to another provider or supplier located outside the United States. For example, if a radiologist who practices in India analyzes imaging tests that were performed on a beneficiary in the United States, Medicare would not pay the radiologist or the U.S. facility that performed the imaging test for any of the services that were performed by the radiologist in India.

Background
This article and related Change Request (CR) 5427 outlines the limited items and services that are reimbursable by Medicare outside the United States according to Section 1862(a)(4) of the Social Security Act.

The law specifies the following exceptions to the "foreign" exclusion:


Additional Information
CR5427 is the official instruction 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/R66BP.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.

NOTE: The previously published CR3781 http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3781.pdf also provides information and instructions about services not provided within the United States by defining "United States" for the purposes of the Social Security Act (Section 1814 (f) along with the parameters of this Medicare rule.

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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2007 Payment Allowance Limits for Medicare part B Not Otherwise Classified (NOC) Drugs April 2007 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing File

2007 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs April 2007 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing File

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April 2007 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing File, Effective April 1, 2007, and Revisions to the January 2007 Quarterly ASP Medicare Part B Drug Pricing Files

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
This article is based on Change Request (CR) 5517 which informs Medicare contractors to download the April 2007 Average Sales Price (ASP) drug pricing file for Medicare Part B drugs as well as the revised January 2007 ASP files.

Background
The Medicare Modernization Act of 2003 (MMA; Section 303(c)) revised the payment methodology for Part B covered drugs that are not paid on a cost or prospective payment basis. Starting January 1, 2005, many of the drugs and biologicals not paid on a cost or prospective payment basis are paid based on the average sales price (ASP) methodology, and pricing for compounded drugs is performed by the local Medicare contractor. Additionally, beginning in 2006, all ESRD drugs furnished by both independent and hospital-based ESRD facilities, as well as specified covered outpatient drugs, and drugs and biologicals with pass-through status under the OPPS, will be paid based on the ASP methodology.

The ASP methodology is based on quarterly data submitted to the Centers for Medicare & Medicaid Services (CMS) by manufacturers, and CMS supplies Medicare contractors (carriers, DMERCs, DME MACs, FIs, A/B MACs, and/or RHHIs) with the ASP drug pricing files for Medicare Part B drugs on a quarterly basis.

For 2007, a separate fee of $0.152 per International Unit (I.U.) of blood clotting factor furnished is payable when a separate payment for the blood clotting factor is made. The furnishing fee will be included in the payment amounts on the quarterly ASP pricing files. Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
ASP Methodology

Beginning January 1, 2005, the payment allowance limits for Medicare Part B drugs and biologicals that are not paid on a cost or prospective payment basis are 106 percent (106%) of the ASP.
Beginning January 1, 2006, payment allowance limits are paid based on 106 percent (106%) of the ASP for the following:

Exceptions are summarized as follows:


On or after March 19, 2007, the revised January 2007 and April 2007 ASP files and ASP Not Otherwise Classified (NOC) files will be available for retrieval from the CMS ASP Web page, and the payment limits included in the revised ASP and NOC payment files supersede the payment limits for these codes in any publication published prior to this document. The CMS ASP Web page is located at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/ on the CMS site. The revised files are applicable to claims based on dates of service as shown in the following table:

Payment Allowance Limit Revision Date Applicable Dates of Services
January 2007 January 1, 2007 through March 31, 2007
April 2007 April 1, 2007 through June 30, 2007

NOTE: The absence or presence of a Healthcare Common Procedure Coding System (HCPCS) code, and its associated payment limit, does not indicate Medicare coverage of the drug or biological. Similarly, the inclusion of a payment limit within a specific column does not indicate Medicare coverage of the drug in that specific category. The local Medicare contractor processing the claim will make these determinations.

Drugs Furnished During Filling or Refilling an Implantable Pump or Reservoir
Physicians (or a practitioner described in the Social Security Act (Section 1842(b) (18) (C);
http://www.ssa.gov/OP_Home/ssact/title18/1842.htm) may be paid for filling or refilling an implantable pump or reservoir when it is medically necessary for the physician (or other practitioner) to perform the service. Medicare contractors must find the use of the implantable pump or reservoir medically reasonable and necessary in order to allow payment for the professional service to fill or refill the implantable pump or reservoir and to allow payment for drugs furnished incident to the professional service.


If a physician (or other practitioner) is prescribing medication for a patient with an implantable pump, a nurse may refill the pump if the medication administered is accepted as a safe and effective treatment of the patient's illness or injury; there is a medical reason that the medication cannot be taken orally; and the skills of the nurse are needed to infuse the medication safely and effectively. Payment for drugs furnished incident to the filling or refilling of an implantable pump or reservoir is determined under the ASP methodology as described above.

Additional Information
For complete details, please see the official instruction issued to your carriers, DMERCs, DME MACs, FIs, A/B MACs, and/or RHHIs regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1204CP.pdf on the CMS Web site.

If you have any questions, please contact your carriers, DMERCs, DME MACs, FIs, A/B MACs, and/or RHHIs 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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April Quarterly Update for 2007 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule

Note: This article was revised on March 16, 2007, to show the correct effective date of January 1, 2007 above. 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 DMEPOS provided to Medicare beneficiaries.

Provider Action Needed
This article is based on Change Request (CR) 5537, which provides the April 2007quarterly update to the DMEPOS fee schedules in order to implement fee schedule amounts for new codes and to revise any fee schedule amounts for existing codes that were calculated in error. Be sure billing staff are aware of these changes.

Background
The DMEPOS fee schedules are updated on a quarterly basis in order to implement fee schedule amounts for new codes and to revise any fee schedule amounts for existing codes that were calculated in error. The quarterly updates process for the DMEPOS fee schedule is located in the Medicare Claims Processing Manual (Publication 100-04), Chapter 23, Section 60;
http://www.cms.hhs.gov/manuals/downloads/clm104c23.pdf).

CR 5537 provides specific instructions regarding the April quarterly update for the 2007 DMEPOS fee schedule. Payment on a fee schedule basis is required for durable medical equipment (DME), prosthetic devices, orthotics, prosthetics, and surgical dressings by the Social Security Act (Sections 1834(a), (h), and (i)). Payment on a fee schedule basis is required for parenteral and enteral nutrition (PEN) by regulations contained in Title 42 of the Code of Federal Regulations (42 CFR 414.102).

Key Changes
The following are key changes in the April 2007 quarterly update of the DMEPOS fee schedule:

L8690 and L8691
The A/B MACs, Local Carriers, and FIs will adjust previously processed claims for L8690 (Auditory Osseointegrated Device, Includes All Internal and External Components) and L8691 (Auditory Osseointegrated Device, External Sound Processor, Replacement), with dates of service on or after January 1, 2007, if you resubmit such claims as adjustments.

Code E1002 (Wheelchair accessory, Power Seating System, Tilt Only)
Code E1002 was added to the Healthcare Common Procedure Coding System (HCPCS) effective January 1, 2004. The fee schedule amounts that were calculated and implemented for this code included systems with tilts less than 45 degrees from horizontal. As described in the November 2006 Policy Article for Wheelchair Options/Accessories, power tilt seating systems (falling under code E1002) must have the ability to tilt to greater than or equal to 45 degrees from horizontal. Therefore as part of this quarterly update, the fee schedule amounts for code E1002 are being revised in order to remove pricing information for power seating systems with tilts less than 45 degrees.

The DME MACs, and DMERCs will adjust previously processed claims for code E1002 with dates of service on or after January 1, 2007, if they are resubmitted as adjustments.

Code E2377 (Power Wheelchair Accessory, Expandable Controller, Including All Related Electronics and Mounting Hardware, Upgrade Provided at Initial Issue)
Code E2377 was added to the HCPCS effective January 1, 2007, for use in paying claims for upgraded expandable controllers and mounting hardware provided at initial issue. The fee schedule amounts for code E2377 do not include payment for the proportional joystick and electronics/cables/junction boxes necessary to upgrade from a non-expandable controller. Suppliers need to submit claims for the upgraded proportional joysticks and electronics provided at initial issue for dates of service on or after January 1, 2007, using HCPCS code E2399.

Furher Changes for Power Wheelchairs
CMS is in the process of making refinements to the fee schedule amounts for several HCPCS codes for power wheelchairs to be implemented as part of the April quarterly update for the 2007 DMEPOS fee schedule. Additional instructions regarding these changes will be issued in the near future under separate cover.

Additional Information
The official instruction, CR 5537, issued to your carrier, intermediary, RHHI, A/B MAC, DMERC, or DME MAC regarding this change may be viewed at
http://www.cms.hhs.gov/Transmittals/downloads/R1203CP.pdf on the CMS Web site.

If you have any questions, please contact your Medicare carrier, intermediary, 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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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 many 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).

Another situation where this occurs is with diagnostic tests, mainly labs and x-rays. The CERT contractor or Medicare asks the provider rendering the service – the lab or radiology practice – for the information. They may not have the diagnostic information from the primary/ordering physician, so their claim may be denied. It would be advantageous for all if primary/ordering physicians make certain to provide the diagnostic facility with the clinical information so the billing and documentation can be complete and the providers can be paid appropriately.

If you fail to submit the requested information in a timely fashion, the claim is deemed to be an error and a refund of the overpayment will be requested from 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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Change in the Amount in Controversy Requirement for Federal District Court Appeals

If you have questions regarding the plan of a specific Medicare patient enrolled in a Medicare Advantage (MA) plan, you may wish to contact that plan. A plan directory and MA claims processing contact directory are available at http://www.cms.hhs.gov/MCRAdvPartDEnrolData/ on the Centers for Medicare & Medicaid Services (CMS) Web site. CMS updates this site on a monthly basis.

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
This article is based on Change Request (CR) 5518 which notifies Medicare contractors of an increase in the Amount in Controversy Required to sustain Federal District Court appeal rights beginning January 1, 2007.

Background
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 provides for an annual reevaluation, beginning in 2005, of the dollar amount in controversy required for an Administrative Law Judge (ALJ) hearing or Federal District Court review. Therefore, CR5518 updates the Medicare Claims Processing Manual (Pub. 100-04, Chapter 29, Sections 330.1 and 345.1) to announce the Amount in Controversy Requirements for ALJ or Federal District CourtAppeals during 2007.

The amount remaining in controversy requirement for ALJ hearing requests made before January 1, 2006 was $100. The amount in controversy requirement increased to $110 for requests made on or after January 1, 2006. CR 5518 announces that for ALJ hearing requests made on or after January 1, 2007, the amount that must remain in controversy did not change and remains at $110.

The amount remaining in controversy requirement for Federal District Court review prior to January 1, 2006, was $1,000. That amount increased to $1,090 on or after January 1, 2006.CR 5518 announces that for Federal District Court review requests made on or after January 1, 2007, the amount that must remain in controversy is increased to $1,130.

Additional Information
The official instruction, CR 5518, issued to your carrier, intermediary, RHHI, A/B MAC, DMERC, or DME MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1211CP.pdf on the CMS Web site.

If you have any questions, please contact your Medicare carrier, intermediary, 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.

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

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

Provider Action Needed
This article and related Change Request (CR) 5514 announces the changes that will be included in the April, 2007 release of the edit module for clinical diagnostic laboratory National Coverage Determinations (NCDs). You may want to assure your billing staff is aware of these changes.

Background
The NCDs for clinical diagnostic laboratory services were developed by the laboratory negotiated rulemaking committee and published as a final rule on November 23, 2001. Subsequently, the Centers for Medicare & Medicaid Services (CMS) contracted for nationally uniform software to be developed and incorporated into its claims processing systems so that laboratory claims subject to one of the 23 NCDs can be processed uniformly throughout the nation effective April 1, 2003. The laboratory edit module for the NCDs is updated quarterly (as necessary) to reflect coding updates and substantive changes to the NCDs developed through the NCD process. (See the Medicare Claims Processing Manual (Publication 100-04), Chapter 16, Section 120.2., available at http://www.cms.hhs.gov/manuals/downloads/clm104c16.pdf on the CMS Web site.)

These updating changes are a result of coding analysis decisions developed under the procedures for maintenance of codes in the negotiated NCDs, and biannual updates of the ICD-9-CM codes. In addition, many of the listed changes may correct Current Procedural Terminology (CPT) codes to reflect the current CPT update.

CR5514 informs your Medicare carrier, FI, or A/B MAC about changes to the laboratory edit module and changes in laboratory NCD code lists effective for services furnished on or after April 1, 2007.
Key Point of CR5514

Effective for dates of service on or after April 1, 2007:


Additional Information
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.

To see the official instruction (CR5514) issued to your Medicare carrier, FI, or A/B MAC, go to http://www.cms.hhs.gov/Transmittals/downloads/R1200CP.pdf on the CMS Web site.

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Colorectal Cancer: Preventable, Treatable, and Beatable —Medicare Coverage and Billing for Colorectal Cancer Screening

Provider Types Affected
All Medicare fee-for-service (FFS) physicians, nurse practitioners, physician assistants, clinical nurse specialists, outpatient hospital departments, and community surgical centers who furnish or provide referrals for and /or file claims for Medicare-covered colorectal cancer screening services.

Provider Action Needed

STOP – Impact to You
March is National Colorectal Cancer Awareness Month. The Centers for Medicare & Medicaid Services (CMS) would like to remind providers to encourage their eligible patients, age 50 and older, to get screened for colorectal cancer. This Special Edition MLN Matters article highlights coverage changes that became effective January 1, 2007, and reviews Medicare coverage and billing processes for colorectal cancer screening.

Caution – What You Need to Know
Medicare has covered colorectal cancer screening since 1998, but the benefit is underused. Claims data from 1998-2002 indicate that less than half of Medicare beneficiaries had any screening test during this five-year period, and less than one-third were tested according to recommended intervals.

Go – What You Need to Do
Be sure your staff is aware of this coverage and the CMS urges physicians to encourage their patients to take advantage of this important coverage.

Background
Colorectal cancer is the second leading cause of cancer death in the U.S., and the third most common type of cancer. In 2006, colorectal cancer was expected to account for 55,170 deaths and 148,610 new cases. Colorectal cancer primarily affects men and women ages 50 and older, and risk increases with age. If detected early, colorectal cancer can be treated and cured.

In January 1998, Medicare began covering colorectal cancer screening. The data currently available (1998- 2002) indicate the Medicare colorectal cancer screening benefit is underused. Less than half of enrollees had any colorectal cancer test during the five-year period and less than one-third were tested according to recommended intervals.

The U.S. Preventive Services Task Force (USPSTF) evaluates the clinical merits of preventive measures, and strongly recommends ("A" rating) that clinicians screen men and women ages 50 and older for colorectal cancer. The choice of screening strategy should be based on patient preferences, medical contraindications, patient adherence, and resources for testing and follow-up. There are insufficient data to determine which screening strategy is best in terms of the balance of benefits and potential harms or cost-effectiveness. Studies reviewed by the USPSTF indicate that colorectal cancer screening is likely to be cost-effective (less than $30,000 per additional year of life gained) regardless of the strategy chosen. To read the full recommendation, go to the following link: http://www.ahrq.gov/clinic/uspstf/uspscolo.htm on the Web.

The Partnership for Prevention conducted a systematic assessment of the clinical preventive services recommended by the USPSTF to help decision-makers identify those services that provide the most value based on 2 criteria--burden of disease prevented and cost-effectiveness. Screening adults for colorectal cancer screening was among the services considered to be of the greatest value. To read about the ranking of clinical preventive services, go to the following link: http://prevent.org/content/view/46/96/ on the Web.

Risk Factors
Beneficiaries are considered to be at high risk for colorectal cancer if they have any of the following:

Coverage Information
Medicare covers the following colorectal cancer screening tests and procedures:

Note: In 2006, and effective for services provided January 1, 2007, and later, CMS adopted the more specific CPT code 82270 (patient was provided 3 single cards or single triple card for consecutive collection) and discontinued the G code G0107 (FOBT, 1-3 simultaneous determinations) to encourage quality colorectal cancer screening practices. Two studies published in January 2005 in the Annals of Internal Medicine suggested that the office-based single sample screening fecal occult blood test is of limited value, and that many physicians are not following practice guidelines for screening and follow-up.


A screening barium enema must be ordered in writing and collected by a doctor of medicine or osteopathy once it is determined that it is the appropriate screening method for a beneficiary. A double contrast barium enema is preferable, but the physician may order a single contrast barium enema if it is more appropriate for the beneficiary.

The beneficiary is liable for paying 20% of the Medicare-approved amount (the coinsurance) for screening flexible sigmoidoscopy, screening colonoscopy, and screening barium enema. See "2007 Changes" for changes to coinsurance amount.

2007 Changes

In addition, G0107 (FOBT, 1-3 simultaneous determinations) has been discontinued. CPT code 82270 (patient was provided 3 single cards or single triple card for consecutive collection) has been adopted to encourage quality colorectal cancer screening.

How to Bill Medicare
The following Healthcare Common Procedure Coding System/Current Procedure Terminology (HCPCS/CPT) codes should be used to bill for colorectal cancer screening services:

HCPCS/CPT Code Code Description
G0104 Colon cancer screening; flexible sigmoidoscopy
G0105* Colon cancer screening; colonoscopy on indiviual at high risk
G0106 Colon cancer screening; barium enema as an alternative to G0104
82270 Colon cancer screening; FOBT, patient was provided 3 single cards or single triple card for consecutive collection
G0120 Colon cancer screening; barium enema as an alternative to G0105
G0121 colon cancer screening; colonoscop for individuals not meeting criteria for high risk.
G0122** Colon cancer screening; barium emena (non-covered)
G0328 Colon cancer screening; fecal occult blood test, immunoassay

* When billing for the "high risk" beneficiary, the screening diagnosis code on the claim must reflect at least one of the high risk conditions mentioned previously. Examples of diagnostic codes are in the colorectal cancer screening chapter of the Guide to Preventive Services. This guide is available at: http://www.cms.hhs.gov/MLNProducts/downloads/PSGUID.pdf on the CMS Web site.
**Medicare covers colorectal barium enemas only in lieu of covered screening flexible sigmoidoscopies (G0104) or covered screening colonoscopies (G0105). However, there may be instances when the beneficiary has elected to receive the barium enema for colorectal cancer screening other than specifically for these purposes. In such situations, the beneficiary may require a formal denial of the service from Medicare in order to bill a supplemental insurer who may cover the service. These non-covered barium enemas are to be identified by G0122 (colorectal cancer screening; barium enema). Code G0122 should not be used for covered barium enema services, that is, those rendered in place of the covered screening colonoscopy or covered flexible sigmoidoscopy. The beneficiary is liable for payment of the non-covered barium enema.

If billing Carriers, the appropriate HCPCS and corresponding diagnosis codes must be provided on Form CMS-1500 (or the HIPAA 837 Professional electronic claim record).
If billing Intermediaries, the appropriate HCPCS, revenue, and corresponding diagnosis codes must be provided on Form CMS-1450 (or the HIPAA Institutional electronic claim record). Information on the type of bill and associated revenue code is also provided in the colorectal cancer screening chapter of the Guide to Preventive Services. Once again, this guide is available at: http://www.cms.hhs.gov/MLNProducts/downloads/PSGUID.pdf on the CMS Web site.
Reimbursement information is also provided in this guide.

Additional Information

For products to share with your Medicare patients, visit http://www.medicare.gov on the Web.
Medicare beneficiaries can obtain information about Medicare preventive benefits at http://www.medicare.gov/ and then click on "Preventive Services." They can also call 1.800.MEDICARE (1.800.633.4227). TTY users should call 1.877.486.2048.

For more information about National Colorectal Cancer Awareness Month, please visit http://www.crfa.org/colorectal/ on the Web.

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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Common Billing Errors to Avoid When Billing Medicare Carriers

Provider Types Affected
Physicians and providers billing Medicare carriers for services provided to Medicare beneficiaries

Provider Action Needed
This special edition article includes some general information regarding the most frequent errors that are found in claims submitted to Medicare carriers. The article is intended to help you correctly complete your Medicare claims so they will not be denied, rejected, or delayed because of incorrect or incomplete information.

Background
The Administrative Simplification Compliance Act and its implementing regulation (42 CFR 44.32,
http://www.gpoaccess.gov/cfr/retrieve.html) require that all initial claims for reimbursement under Medicare be submitted electronically as of October 16, 2003 (except from small providers with limited exceptions).


All Medicare providers, except for small providers defined in regulation, must bill Medicare electronically. A "small provider" is defined in the Federal Register (42 CFR 424.32(d)(1)(vii),
http://www.gpoaccess.gov/cfr/retrieve.html). To simplify, Medicare will consider all physicians, practitioners, facilities, or suppliers with fewer than 10 full time employees (FTEs) that bill a Medicare carrier or DMERC to be small. Providers that qualify as "small" automatically qualify for waiver of the requirement that their claims be submitted to Medicare electronically. Those providers are encouraged to submit their claims to Medicare electronically, but are not required to do so under the law. Small providers may elect to submit some of their claims to Medicare electronically, but not others. Submission of some claims electronically does not negate their small provider status nor obligate them to submit all of their claims electronically.

Common Billing Errors
The following list includes common billing errors that you should avoid when submitting your claims to Medicare carriers:

Nursing Home or Skilled Nursing Facility Address - For a facility such as a nursing home or skilled nursing facility, it is preferred that a street name and number be supplied. In some cases, this information is not available, but if it is, please use it. Please verify the accuracy of your address before you send this information.

Apartment Complex - An apartment complex (words such as apartments, towers, or complex indicate such) should contain a street address and an apartment number. Again, this information is not always available, but should always be used when it exists.

Development Center/Trailer Park - If a development center or trailer park is given, it should contain the street address and number, if that information is part of the complete address.
"No Street Address" (NSA) - NSA (No Street Address) is not acceptable. This is not a deliverable address.

Changes to Provider Address - Please notify your carrier via a CMS-855 form of any address changes for your office practice.

E. Diagnosis and Procedure Codes
Make sure you keep current with valid diagnosis and procedure codes. HIPAA requires that Medicare conform to these standard code sets and reported codes must be valid as of the date of service. Remember that Medicare can no longer allow a grace period for using deleted codes.

Additional Information
Medicare Claims Processing Manual
The Medicare Claims Processing Manual (Publication 100-04) contains detailed instructions on Medicare's claims processes and detailed information on preparation and submission of claims. This manual is available at http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage on the CMS Web site.

MLN Matters
MLN Matters is a series of articles that CMS prepares especially for providers. These articles provide information on new and/or deleted procedure and diagnosis codes, changes to the Medicare Physician Fee Schedule and other changes that impact physicians and providers. These articles are available at http://www.cms.hhs.gov/MLNMattersArticles/ on the CMS Web site.

Listservs
Listservs are electronic mailing lists that CMS uses to get new information into the hands of physicians and providers as quickly as possible. To get your Medicare news as it happens, join the appropriate listserv(s) at http://www.cms.hhs.gov/apps/mailinglists/ on the CMS Web site.

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

Flu Shot Reminder
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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Competitive Acquisition Program (CAP) for Part B Drugs

Provider Types Affected
Approved CAP vendors billing the designated carrier

Background
This article and related Change Request (CR) 5546 provide additional details, information, and instructions for the implementation of the CAP as outlined in MLN articles 4064, 4309, 5079, 5332 and CR4306. (The Web addresses for these articles are listed in the Additional Information section of this article.)

Key Points of CR5546
The following are the key points listed in the revised Chapter 17, Section 100 of the Medicare Claims Processing Manual, which is attached to CR5546:

OLD RULES


NEW RULES


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

For complete details regarding this CR, please see the official instruction (CR5546) issued to your Medicare carrier. This instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1207CP.pdf on the CMS Web site.

The following addresses link to the MLN articles listed in the Background section of this article. The articles can be accessed by visiting:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4064.pdf for article MM4064on the CMS Web site; http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5332.pdf for article MM5332 on the CMS Web site; http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5079.pdf on the CMS Web site for article MM5079; and http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4309.pdf on the CMS Web site for article MM4309.

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Correction to CR5404: New Waived Tests

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

Provider Action Needed

Stop – Impact to You
Change Request (CR) 5482, from which this article is taken, corrects information provided in CR 5404 (released November 24, 2006).

Caution – What You Need to Know
CR 5404, which informed carriers and A/B MACS about new waived tests approved by the Food and Drug Administration (FDA) under Clinical Laboratory Improvement Amendments of 1988 (CLIA), contained an incorrect Current Procedural Terminology (CPT) code for the Gryphus Diagnostics BVBlue test. The correct code for this test is 87999QW (Unlisted microbiology procedure).

Go – What You Need to Do
You should ensure that your billing staffs are made aware of this CPT code correction, and bill accordingly.

Background
CR 5404, which informed carriers and A/B MACS of new waived tests approved by the Food and Drug Administration (FDA) under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), contained an incorrect CPT for the Gryphus Diagnostics BVBlue test. In both the table in the background section of the Recurring Update Notification attachment and in the waived test list attachment, CR 5404 listed the CPT code for the Gryphus Diagnostics BVBlue as CPT Code: 87899QW.


The CPT code 87899 is for infectious agent activity detection tests by immunoassay with direct optical observation; not otherwise specified. In contrast, the Gryphus Diagnostics BVBlue test is an enzyme activity test that detects sialidase activity in vaginal fluid specimens and is not an immunoassay test. The code in this table and in the waived test list attachment should have been 87999QW (Unlisted microbiology procedure). See the table below for the correct codes.
Note: All the other information in CR 5404 remains the same.

Table 1

CPT Code/Modifier Effective Date Description
82274QW
G0328QW		 June 15, 2006 immunostics, Inc., hema-screen Specific Immunochemical Fecal Occult Blood Test
87999QW June 30, 2006 Gryphus Diagnostics BVBlue
83655QW September 18, 2006 ESA Biosciences LeadCare II Blood Lead Testing System (whole blood)

CPT Codes for FDA Approved New Waived Tests
You should remember that the CLIA regulations require a facility to be appropriately certified for each test performed, and that laboratory claims are currently edited at the CLIA certificate level.
Note: Carriers and A/B MACs will not search their files to correct affected claims processed prior to the implementation date of this change, but will adjust any claims that you bring to their attention.

Additional Information
You can find the official instruction, CR 5482, issued to your carrier or A/B MAC by visiting http://www.cms.hhs.gov/Transmittals/downloads/R1197CP.pdf on the CMS Web site.

The MLN Matters article, MM5404, related to CR5404 may be found at http://www.cms.hhs.gov/MLNMAttersArticles/downloads/MM5404.pdf on the CMS Web site.

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

Flu Shot Reminder
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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Covered Indications for Chemotherapy Drugs and their Adjuncts

Labeled and Off-labeled Indications were based on the FDA Labeled Indications, the February 2007 issue of the Association of Community Cancer Centers Compendia Based Drug Bulletin and approved indications per the Carrier Medical Directors. Diagnoses other than those listed below may be covered, if the carrier receives information that would support the medical efficacy of the drug for that condition.

Note: The following drugs have Local Coverage Decisions. Please visit the CIGNA Government Services Web site for Coverage information http://www.cignamedicare.com/partb/index.html . Once you are in the Web site, click on the Medical Review drop down box/Medical Review Policies and then choose the appropriate state.

Abarelix J0128
185
See NCD – 100-19
Aldesluekin J9015
172.0-172.9, 189.0, 189.1, 200.00 to 200.88, 202.00 to 202.98, 205.00 to 205.11
Alemtuzumab J9010
204.10, 204.11
Arsenic Trioxide J9017
205.00, 205.20, and 238.71 to 238.79
Asparaginase J9020
172.0–172.9, 200.00 to 202.98, 204.00-204.11, 205.00 to 208.01
Bacillus Calmette-Guerin J9031
188.0-188.9, 233.7, 233.9
Bevacizumab J9035
153.0-154.8, 162.0-162.9, 174.0-175.9, 362.52
Bleomycin J9040
140.0 to 150.9, 157.0-157.9, 160.0–161.9, 170.0 to 173.9, 176.0–176.9, 180.0–180.9, 182.0, 183.0, 183.9, 184.4, 186.0 to 187.4, 188.0 to 189.1, 189.3, 193, 195.0, 197.2, 197.6, 198.5, 200.00 to 202.98, 236.1.
Bortezomib (Velcade) J9041
202.80 to 202.88, 203.00 to 203.01
Carboplatin J9045
140.0 to 151.9, 153.9, 154.2, 154.3, 155.0-155.2, 156.0 to 158.9, 160.0 to 165.9, 170.0 to 199.1, 200.00 to 204.91, 236.1
Carmustine J9050
151.0–151.9, 153.0 to 155.2, 162.2-162.9, 170.0-170.9, 172.0 to 175.9, 191.0-191.9, 200.00 to 203.81, 273.3
Cetuximab J9055
140.0 to 149.9, 153.0 to 154.8, 160.0 to 161.9, 195.0
Cisplatin J9060 & J9062
140.0 to 151.9, 153.9, 154.2-154.3,155.0- 155.2, 156.0 to 158.9, 160.0 to 165.9, 170.0 to 199.1, 200.00 to 204.91, 236.1
Cladribine J9065
200.00 to 202.98, 204.10, 204.11, 273.3
Cyclophosphamide J9070, J9080, J9090, J9091, J9092
Cyclophosphamide, Lyophilized J9093 to J9097
140.0 to 149.9, 153.0 to 154.8, 157.0-157.9, 160.0 to 165.9, 170.0 to 175.9, 180.0 to 195.0, 198.5, 200.00 to 204.11, 205.00 to 208.01, 236.1, 273.2, 273.3, 273.9, 282.9, 283.0, 287.30 to 287.5, 340, 446.0, 446.20, 446.4, 446.5, 447.6, 515, 517.2, 583.81, 695.4, 710.0 to 710.4, 710.9, 714.0 to 714.9
Cytarabine J9100 & J9110
198.4, 200.00 to 202.98, 204.00, 204.01, 204.11, 205.00 to 207.01, 238.71 to 238.79
Cytarabine Liposome Injection J9098
198.4
Dacarbazine J9130 & J9140
157.0 – 157.9, 160.0 to 194.9, 201.00-201.98
Dactinomycin J9120
170.0 to 172.9, 174.0 to 176.9, 181, 182.0, 183.0-183.9, 186.0-186.9, 189.0, 198.5, 204.00, 204.01, 204.11, 236.1
Daunorubicin J9150
160.0 to 194.9, 200.00-200.88, 202.00-202.98, 204.00, 204.01, 204.11, 205.00 to 208.01
Daunorubicin Citrate, Liposomal J9151
174.0 to 175.9, 176.0-176.9, 182.0, 182.9
Decitabine J0894
238.71-238.79
Denileukin Difitox J9160
173.0-173.9, 200.00-200.88, 202.00-202.98
Dexrazoxane Hydrochloride J1190
174.0 to 175.9, 995.20, 995.27, 995.29.
Diethylstillbestrol J9165
174.0 to 175.9, 185
Docetaxel (Taxotere) J9170
140.0 to 151.9, 157.0-157.9, 160.0 to 162.9, 171.0-171.9, 174.0 to 175.9, 179, 183.0-183.9, 185, 188.0-188.9, 195.0
Doxorubicin J9000
140.0 to 199.1, 200.00 to 204.11, 205.00 to 208.01, 236.1, 259.2
Epirubicin Hydrochloride J9178
150.0 to 151.9, 162.2-162.9, 171.0-171.9, 174.0 to 175.9, 183.0-183.9, 200.00 to 202.98
Etoposide J9181, J9182
151.0-151.9, 155.0, 155.2, 160.0-160.9, 162.0-162.9, 164.0-164.9, 170.0 to 171.9, 173.0 to 176.9, 181, 182.0 to -183.9, 184.0, 186.0-186.9, 188.0 to 189.9, 190.5, 191.0-191.9, 194.0 to 195.8, 198.5, 199.0-199.1, 200.00 to 207.01, 236.1
Floxuridine J9200
140.0 to 149.9, 151.0-151.9, 153.0 to 154.8, 155.0, 155.2, 156.0-156.9, 161.0-161.9, 174.0 to 175.9, 180.0-180.9, 183.0-183.9, 185, 188.0 to 189.1, 189.3, 191.0-191.9, 195.0, 204.00-204.11, 205.00 to 208.01
Fludarabine Phosphate J9185
173.0-173.9, 200.00 to 202.98, 204.10, 204.11, 204.90-204.91, 205.00 to 208.01, 273.0-273.3
Fluorouracil J9190
140.0 to 199.1, 259.2
Fulvestrant J9395
174.0 to 175.9
Gallium Nitrate J1457
Primary ICD-9 for the malignancy plus 275.42 as Secondary DX
Gemcitabine J9201
156.0-156.9, 157.0 to 158.9, 162.2-162.9, 164.2, 164.3, 164.8, 164.9, 174.0 to 175.9, 179, 181, 183.0-183.9, 186.0-186.9, 188.0-188.9, 194.4, 200.00 to 202.98
Gemtuzumab Ozogamicin J9300
205.00 to 207.11
Granisetron Hcl. J1626
787.01, 787.03, 995.20, 995.29 Anti-emetic (chemotherapy-induced)
Idarubicin J9211
204.00-204.11, 205.00-208.01, 238.71-238.79
Ifosfamide J9208
140.0 to 149.9, 157.0-157.9, 160.0-161.9, 162.2-162.9, 164.0, 164.2 – 164.3, 164.8 -164.9, 170.0 to 171.9, 174.0 to 175.9, 180.0 to 183.9, 186.0-186.9, 188.0 to 189.0, 194.0-194.9, 195.0, 198.5, 200.00 to 202.98, 204.00 to 207.81
Interferon Alpha-1 J9212, Interferon Alpha-2A J9213, Interferon Alpha-2B J9214, Interferon Alpha-N3 J9215, Interferon Gamma
1-B J9216
042, 070.51, 070.54, 078.11, 140.0 to 149.8, 150.0-150.9, 153.0 to 154.9, 157.0-157.9, 160.0-161.9, 170.0-170.9, 172.0 to 173.9, 176.0-176.9, 180.0-180.9, 183.0-183.9, 188.0 to 189.3, 191.0-191.9, 195.0, 196.9, 198.5, 200.00-200.88, 202.00 to 204.11, 205.00-205.11, 233.7, 238.4, 238.71 – 238.79, 259.2, 287.30-28739, 289.0-289.9, 571.40-571.49, 757.33
Irinotecan Hcl. J9206
150.0-152.9, 153.0 to 154.8, 155.1, 159, 162.0-162.9, 180.0-180.9, 183.0-183.9
Leucovorin Calcium J0640
140.0 to 149.9, 151.0-151.9, 153.0 to 154.8, 160.0-162.9, 170.0-170.9, 174.0 to 175.9, 181, 186.9, 195.0, 198.5, 200.00 to 202.98, 236.1
Leuprolide Acetate Depot J1950
3.75 mg/one month dose or 11.25 mg/ 3 month dose covered for the following: 157.0-157.9, 174.0-175.9, 182.0, 233.4, 617.3, 620.8, 621.2
Mechlorethamine J9230
162.2-162.9, 164.1, 197.2, 197.6, 200.00 to 202.98, 204.10, 204.11, 205.10, 205.11
Melphalan J9245
170.0 to 172.9, 174.0 to 175.9, 182.0 to 183..9, 185, 186.0-186.9, 193, 198.5, 201.00-201.98, 203.00-203.81, 205.10, 205.11, 273.3
Mesna J9209
595.82, 995.20, 995.29
Methotrexate J9250 & J9260
099.3, 140.0 to 151.9, 153.0 to 154.8, 155.0, 155.2, 157.0-157.9, 160.0-162.99, 170.0 to 171.9, 173.0 to 175.9, 180.0-180.9, 181, 183.0-183.9, 185 to 187.4, 187.8, 188.0-188.9, 189.0, 189.1, 191.0-191.9, 192.1, 192.3, 195.0, 198.4, 198.5, 200.00 to 203.81, 204.00, 204.20, 204.80, 205.00 to 207.01, 236.1, 446.4, 446.5, 447.6, 696.0, 696.1, 710.0, 710.3, 710.4, 710.8, 714.0-714.9, 716.00-716.99, 720.0, 725
Mitomycin J9280, J9290, & J9291
140.0 to 151.9, 153.0 to 154.8, 156.0 to 157.9, 160.0-161.9, 162.0-162.9, 174.0 to 175.9, 180.0-180.9, 185, 188.0- 188.9, 189.3, 195.0, 199.1, 200.00 to 202.08, 205.10, 205.11, 233.7
Mitoxantrone J9293
155.0-155.2, 174.0 to 175.9, 183.0-183.9, 185, 188.0-188.9, 200.00 to 204.11, 205.00 to 208.01, 340
Nelabarine J9261
200.10-200.18, 204.00-20401
Octreotide Acetate for Injectable Suspension J2352
140.0 to 199.1, 253.0, 259.2, 787.91
Ondansetron Hcl. J2405
787.01, 787.02, 787.03, 995.20, 995.29 Anti-emetic (chemotherapy-induced)
Oprelvekin J2355
140.0 to 202.98, 287.4, 287.5
Oxaliplatin J9263
151.0-151.9, 153.0-154.8
Paclitaxel J9265
140.0 to 151.9, 158.8-158.9, 160.0 to 162.9, 174.0 to 176.9, 180.0-180.9, 182.0 to 183.9, 185, 186.0-186.9, 188.0-188.9, 189.3, 195.0-195.8, 197.6, 198.81 to 200.88, 202.00-202.98
Paclitaxel Protein Bound J9264
174.0 to 175.9
Palonosetron Hydrochloride J2469
787.01, 787.02, 787.03, 995.20 Anti-emetic (chemotherapy-induced)
Panitumumab Injection J9999
153.0-154.8
Pamidronate Disodium J2430
174.0 to 175.9, 198.5, 203.00, 275.42, 731.0
Pegaspargase J9266
204.00
Pemetrexed J9305
162.0 – 163.9
Pentostatin J9268
173.0-173.9, 200.00-200.08, 202.00-202.98, 204.00-204.11, 204.90-204.91
Plicamycin J9270
186.0-186.9, 275.40-275.49, 731.0-731.8
Porfimer Sodium J9600
150.0-150.9, 162.2-162.9, 530.85
Streptozocin J9320
152.0-154.8, 157.0-157.9, 162.2-162.9, 183.0, 259.2
Teniposide Q2017
160.0-160.9, 194.0, 200.00-200.88, 202.00-202.98, 204.00
Thiotepa J9340
164.1, 174.0 to 175.9,183.0-183.9, 188.0-188.9, 189.3, 197.2, 197.6, 198.4, 200.00 to 202.98, 238.71-238.79, 714.0-714.2
Thyrotropin J3240
193
Topotecan Hcl. J9350
162.2-162.9, 180.0-180.9, 183.0-183.9, 205.10, 205.11, 238.71-238.79
Trastuzumab J9355
174.0 to 175.9, 198.2, 198.81, 233.0
Trimetrexate Glucoronate J3305
153.0 to 154.8
Valrubicin J9357
188.0-188.9, 233.7
Vinblastine Sulfate J9360
140.0 to 149.9, 153.0-153.9, 160.0 to 194.9, 195.0, 200.00 to 202.98, 205.10, 205.11, 236.1, 287.31
Vincristine Sulfate J9370, J9375, & J9380
140.0 to 149.9, 153.0 to 154.8, 155.0, 155.2, 157.0-157.9, 158.0, 160.0 to 194.9, 198.5, 200.00 to 204.11, 205.00 to 208.01, 236.1, 273.3, 287.30-287.31, 287.5
Vinorelbine Tartrate J9390
162.2-162.9, 174.0-175.9, 180.0-180.9, 183.0-183.9, 185

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CPT Code 77003

CIGNA Government Services acknowledges that an edit affecting CPT Code 77003 has resulted in denial of associated claims. The error has been identified and a change edit request has been submitted to correct this anomaly. The change should be effective no later than March 31, 2007, at which time you may resubmit your claims for reconsideration.

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Downloading Files from Stratus Mailboxes Using Wildcards (*)

During a recent audit of Stratus bulletin board system (BBS) user activity data, it was discovered that many of our users are using wildcards—data with an asterisk (*)—to download their files. Stratus is designed for the usage of wildcards, but the below guidelines should be followed:

Since CIGNA Government Services does not design or support automated scripts, all questions regarding scripting issues should be directed to the script programmer. However, we can answer questions about the above guidelines through our EDI departments:
NC 866.352.1608
TN/ID 866.520.4022

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Epoetin — LCD Revision

Effective April 1, 2007, CIGNA Government Services will remove coverage for ICD—9 285.22, the anemia of neoplastic disease, from the LCDs for Erythropoeitin analogs, Non—ESRD, for Tennessee, North Carolina, and Idaho for patients not on treatment. The policy change is in response to recently released information regarding potential adverse events.

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Extension for Acceptance of Form CMS—1500 (12—90)

Provider Types Affected
Physicians, non physician, practitioners, and suppliers who submit claims for their services using the Form CMS—1500 to Medicare contractors (carriers, Part A/B Medicare Administrative Contractors (A/B MACs), durable medical equipment regional carriers (DMERCs), and/or DME Medicare Administrative Contractors (DME/MACs)). Be aware that some of the new Form CMS—1500 (08—05) forms have been printed incorrectly. This article contains details on this issue.

Background
Form CMS—1500 is one of the basic forms prescribed by the Centers for Medicare & Medicaid Services (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 Form CMS—1500 (12—90) was revised in July of 2006 to accommodate the reporting of the National Provider Identifier (NPI).

Recently it came to the attention of CMS that there are incorrectly formatted versions of the revised form being sold by print vendors. After reviewing the situation, CMS determined that the source files received from the authorized forms designer were improperly formatted. This resulted in the sale of printed forms and negatives which do not comply with the form specifications.
Therefore, CMS has decided to extend the acceptance period of the Form CMS—1500 (12—90) version beyond the original April 1, 2007, deadline while this situation is resolved. The specific formatting issue involves top and bottom margins only, but may not be isolated to only top and/or bottom.

Key Points of CR5568


Additional Information
To see the official instruction (CR5568) issued to your Medicare carrier, A/B MAC, DME MAC, or DMERC, go to http://www.cms.hhs.gov/Transmittals/downloads/R1208CP.pdf on the CMS Web site.


To view the original communication from CMS regarding this issue, visit http://www.cms.hhs.gov/ElectronicBillingEDITrans/downloads/1500%20problems.pdf on the CMS site.


If you have questions, please contact your Medicare carrier, A/B MAC, DME MAC, or DMERC 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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Extracorporeal Photopheresis

Provider Types Affected
All providers who bill Medicare carriers, Fiscal Intermediaries (FI), or Part A/B Medicare Administrative Contractors (A/B MACs) for rendering extracorporeal photopheresis services

Provider Action Needed

STOP – Impact to You
For services provided on or after December 19, 2006, coverage for extracorporeal photopheresis is now expanded to include additional health conditions.

CAUTION – What You Need to Know
Change Request (CR) 5464, from which this article is taken, announces (effective December 19, 2006), the expansion of coverage of extracorporeal photopheresis to include patients with acute cardiac allograft rejection and chronic graft versus host disease whose disease is refractory to standard immunosuppressive drug treatment.

GO – What You Need to Do
Make sure that your billing staffs are aware of this expanded coverage for extracorporeal photopheresis, and bill accordingly.

Background
Extracorporeal photopheresis is a medical procedure in which a patient's white blood cells are exposed first to a drug called 8—methoxypsoralen (8—MOP) and then to an ultraviolet A (UVA) light. The procedure starts with the removal of the patient's blood, which is centrifuged to isolate the white blood cells. The drug is typically administered directly to the white blood cells after they have been removed from the patient (referred to as ex vivo administration), but the drug can alternatively be administered directly to the patient before the white blood cells are drawn. After UVA light exposure, the treated white blood cells are then re—infused into the patient.
Formerly, Medicare covered extracorporeal photopheresis only when used in the palliative treatment of the skin manifestations of cutaneous T—cell lymphoma that has not responded to other therapy. On April 6, 2006, a request for reconsideration of this national coverage determination (NCD) to allow additional indications initiated a national coverage analysis.

CR 5464 announces the NCD resulting from that analysis. It provides that CMS has reviewed the evidence and determined that extracorporeal photopheresis is reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act for patients with acute cardiac allograft rejection whose disease is refractory to standard immunosuppressive drug treatment, and for patients with chronic graft versus host disease whose disease is refractory to standard immunosuppressive drug treatment. Therefore, effective December 19, 2006, coverage has been expanded to include these conditions.

Billing Requirements for Extracorporeal Photopheresis
You should use Healthcare Common Procedure Coding System (HCPCS) procedure code 36522 (Photopheresis, extracorporeal) when submitting your outpatient or physician claims for this service under these expanded coverage guidelines. Effective for dates of service on or after December 19, 2006, Medicare contractors will pay hospital inpatient, including CAH, claims for extracorporeal photopheresis, based on the normal payment methodology for type of bills (TOBs) 11X, 13X or 85X, according to the expanded coverage conditions. Specifically, Medicare will accept claims for extracorporeal photopheresis:

Note: All other indications for extracorporeal photopheresis remain noncovered. Further, note that contractors will edit for an appropriate oncological and autoimmune disorder diagnosis prior to paying according to the NCD.

Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RAs) and Claim Adjustment Reason Code
Contractors will continue to use the appropriate existing messages that they have in place when denying claims submitted that do not meet the Medicare coverage criteria for extracorporeal photopheresis.
Contractors will deny claims when the service is not rendered to an inpatient or outpatient of a hospital, including CAHs, using the following codes:

Advance Beneficiary Notice and Hospital Issued Notice of Noncoverage Information

Additional Information
You can find the official instruction, CR 5464, issued to your carrier, FI or A/B MAC by visiting:

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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Faxing Documentation to the CERT Contractor

In order to provide documentation that supports the services that are billed and readily offer legible and complete records, providers can assist by reviewing the following problem situations related to imaging records from fax copies that are sent to the Comprehensive Error Rate Testing (CERT) Documentation Contractors: