CIGNA Government Services HomeDME MAC Jurisdiction C HomePart B Home

June 6, 2007 Part B Medicare Bulletin

Posted June 6, 2007

Send this page to a colleague

Table of Contents

PDF Documents
(Includes Base Topics)



Download your free copy of Acrobat Reader

Looking for archived issues of the Medicare Bulletin?

Back to the Top of the PageTop

Ambulance Fee Schedule - Ground Ambulance Services - Manualization Revision to the Specialty Care Transport (SCT) Definition

The Medicare Guide to Rural Health Services: Information for Providers, Suppliers, and Physicians (Second Edition), which provides rural information pertaining to rural health facility types, coverage and payment policies, and rural provisions under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and the Deficit Reduction Act of 2005 is now available in downloadable format at http://www.cms.hhs.gov/MLNProducts/downloads/MedicareRuralHealthGuide.pdf.

Provider Types Affected
Providers and suppliers submitting claims to Medicare contractors (Fiscal Intermediaries (FIs), Medicare Administrative Contractors (MACs) and carriers), for ambulance services to Medicare beneficiaries

Provider Action Needed
Providers and suppliers are reminded that the Centers for Medicare & Medicaid Services (CMS) expanded the interpretation of “interfacility” to include both hospitals and Skilled Nursing Facilities (SNFs) in the December 1, 2006 (71 FR 69716) final rule.

Background
In the February 27, 2002 Federal Register (67 FR 9100) a final rule was published with comment period entitled “Fee Schedule for Payment of Ambulance Services and Revisions to the Physician Certification Requirements for Coverage of Nonemergency Ambulance Services” that implemented the ambulance fee schedule. In that rule, CMS defined SCT at Section 414.605. In the December 1, 2006 (71 FR 69716) final rule, CMS expanded the definition of “interfacility” to include both hospitals and skilled nursing facilities (SNFs).

In addition, CMS further clarified the kinds of facilities included as origin or destination points for “interfacility” transport for Specialty Care Transport (SCT) purposes. Therefore, for purposes of SCT payment, CMS considers a “facility” to include:

  • Only a SNF or a hospital that participates in the Medicare program, or
  • A hospital-based facility that meets the requirements for provider-based status.

Medicare hospitals include, but are not limited to, rehabilitation hospitals, cancer hospitals, children’s hospitals, psychiatric hospitals, Critical Access Hospitals (CAHs), inpatient acute-care hospitals, and Sole Community Hospitals (SCHs).

Note: Contractors will not search their files to either retract payment for claims already paid or to retroactively pay claims. However, contractors will adjust claims brought to their attention.

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


For complete details regarding this Change Request (CR) please see the official instruction (CR5533) issued to your Medicare FI, Carrier or A/B MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R68BP.pdf on the CMS Web site.

Providers may review the Federal Regulations for the Ambulance Fee Schedule located at http://www.cms.hhs.gov/AmbulanceFeeSchedule/04_CFRAFS.asp#TopOfPage on the CMS Web site.

 

Back to the Top of the PageTop

New Durable Medical Equipment, Prosthetics, Orthotics & Supplies (DMEPOS) Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFS) for Claims Processing

The Medicare Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program Final Regulation is now available. CMS has also announced the first 10 metropolitan areas in which competition will occur as well as the first items to be competitively bid. Visit the CMS Web site at http://www.cms.hhs.gov/competitiveacqfordmepos/ to view the rule and get more information.

Provider Types Affected
Physicians (when ordering DMEPOS) and suppliers using CMNs and DIFs when billing to Medicare durable medical equipment regional carriers (DMERCs) or DME Medicare Administrative contractors (DME/MACs).

Provider Action Needed

STOP – Impact to You
The Centers for Medicaid & Medicare Services (CMS) has developed improved CMNs and DIFs that are consistent with current medical practices and conform to Medicare guidelines. Through this process, CMS revised several CMNs and replaced three CMNs with two DIFs. This information was previously communicated in MLN Matters article MM4296 (http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4296.pdf).

CAUTION – What You Need to Know
The transition period has been extended for claims with dates of service from October 1, 2006, through June 30, 2007. During this transition period claims for items requiring a CMN or DIF will be accepted with either the old or the new form. For dates of service on or after July 1, 2007, the old CMN/DIF forms will no longer be accepted.

GO – What You Need to Do
Be sure your staff is aware that the transition period for use of the new forms has been extended through June 30, 2007.

Background
CMNs provide a mechanism for suppliers of durable medical equipment, defined in 42 United States Code (U.S.C.) §1395x (n) and medical equipment and supplies defined in 42 U.S.C. §1395j (5), to demonstrate that the item they provide meets the minimal criteria for Medicare coverage.
CMNs contain section A through D. Sections A and C are completed by the supplier and Sections B and D are completed by the physician. A DME DIF is completed and signed by the supplier. It does not require a narrative description of equipment and cost or a physician signature. Contractors review the documentation provided on the CMNs and DIF.

Recap of MM4296 Information
As previously reported in MLN Matters article MM4296, the changes to the CMN forms have resulted in the following:

The following table identifies the old versions of the CMNs, which are acceptable for claims for services provided during the transition period from October 1, 2006, through June 30, 2007. (For services on or after July 1, 2007, the old forms will no longer be accepted.)

DMERC FORM CMS FORM ITEMS ADDRESSED

DMERC FORM CMS FORM ITEMS ADDRESSED
484.2 484 Home Oxygen Therapy
01.02A 841 Hospital Beds
01.02B 842 Suppport Surfaces
04.03B 846 Lymphedema Pumps (Pneumatic Compression Devices)
04.03C 847 Osteogenesis Stimulators
06.02B 848 Transutaneous Electrical Nerve Stimulators (TENS)
07.02A 849 Seat Lift Mechanisms
09.02 851 External Infusion Pumps
10.02A 852 Parenteral
10.02B 853 Enternal Nutrition
11.01 854 Ssection C Continuation Form

Newly Revised CMNs Accepted During Transition Period
The following table identifies the newly revised CMNs that will be accepted for services provided during the transition period for claims from October 1, 2006, through June 30, 2007. (These forms are available at http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp#TopOfPage.) For services on or after July 1, 2007, these forms will become effective for claims for items requiring a CMN.
Noteworthy changes include changing the title of CMS-484 from Home Oxygen Therapy to Oxygen. In addition, the title of CMS-846 was changed from Lymphedema Pumps to Pneumatic Compression Devices.

DME MAC FORM CMS FORM ITEMS ADDRESSED
484.03 484 Oxygen
04.04B 846 Pneumatic Compression Devices
04.04C 847 Osteogensis Stimulators
06.03B 848 Transcutaneous Electrical Nerve Stimulators (TENS)
07.03A 849 Seat Lift Mechanisms
11.02 854 Section C Continuation Form

New DIFs Accepted During Transition Period The following table identifies the new DIFs that will also be accepted during the transition period for claims for services provided from October 1, 2006, through June 30, 2007. (These forms are available at http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp#TopOfPage.) For services on or after July 1, 2007, the new forms will become effective for claims for items requiring a DIF.
Noteworthy changes include changing CMS-851 for Infusion Pumps to a CMS-10125, External Infusion Pump DIF.

In addition, CMS-852 for Parenteral Nutrition and CMS-853 for Enteral Nutrition were combined into a CMS-10126 Enteral and Parenteral Nutrition DIF.

DME MAC FORM CMS FORM ITEMS ADDRESSED
09.03 10125 External Infusion Pumps
10.03 10126 Enternal and Parenteral Nutrition

The use of the CMNs for hospital beds (CMS-841) and support surfaces (CMS-842) will be eliminated for claims with dates of service on or October 1, 2006.

CMNs Eliminated
The following table identifies the CMNs that will be eliminated for claims for services provided on or after October 1, 2006.

DME MAC FORM CMS FORM ITEMS ADDRESSED
01.02A 841 Hospital Beds
01.02B 842 Support Surfaces

Medicare is developing a crosswalk to link legacy supplier numbers (National Supplier Clearinghouse (NSC)) to the new National Provider Identifiers (NPI). Until that crosswalk is completed, DMERCs will require you to continue to submit your legacy/NSC number. If you choose to submit your NPI as of October 1, 2006, you must still report your legacy/NSC number until that crosswalk is operational. Similarly, treating physicians should report their UPIN (preceded by an “XX” qualifier) AND their NPI (preceded by a “1G” qualifier) until the crosswalk is operational. CMS will issue further instructions when the crosswalk approaches operational status.

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR5571) issued to your Medicare DME MAC, or DMERC. This instruction may be viewed by going to
http://www.cms.hhs.gov/Transmittals/downloads/R198PI.pdf on the CMS Web site.

If you have questions, please contact your Medicare 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.

For additional information about the new CMNs and DIFs, see the MLN Matters article MM4296, titled “New Durable Medical Equipment Prosthetic, Orthotics & Supplies (DMEPOS) Certificates of Medical Necessity (CMNs) and DME Medicare Administrative Contractor (MAC) Information Forms (DIFS) for Claims Processing” at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4296.pdf on the CMS Web site.

Back to the Top of the PageTop

Blood Brain Barrier Osmotic Disruption for Treatment of Brain Tumors

Physician Quality Reporting Initiative (PQRI) Measures and Specifications
The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that the 2007 Physician Quality Reporting Initiative (PQRI) Quality Measures and Specifications are now available. In addition to posting the 2007 PQRI Measures Specifications, CMS has also updated the list of 2007 PQRI measure statements and descriptions. To access both the measures and measure specifications documents, visit the PQRI Web page at http://www.cms.hhs.gov/PQRI on the CMS Web site. Once there, go to the Measures/Codes section of the page and scroll down to the Downloads section. Providers may want to test their systems to be certain that claims containing the codes associated with the measures will be processed. Please note that many of the quality codes are new and will be rejected by Medicare claims processing systems prior to the July 1, 2007 HCPCS update. CMS will be issuing further information about which measures may be used for testing systems prior to the July 1 start date.

Provider Types Affected
Physicians and providers submitting claims to Medicare contractors (Fiscal Intermediaries (FIs), Part Medicare Administrative Contractors (MACs) and carriers)

What Providers Need to Know
Effective for claims with dates of service on or after March 20, 2007, the use of osmotic blood brain barrier disruption is not considered reasonable and necessary when it is used as part of a treatment regimen for brain tumors in Medicare patients.

Background
This article and Change Request (CR) 5530 states that Medicare does not currently have a national coverage determination (NCD) for osmotic blood brain barrier disruption (BBBD) as part of a treatment regimen for brain tumors. The Centers for Medicare & Medicaid Services (CMS) accepted a formal request for non-coverage of BBBD used for this indication.

CMS determined that the use of osmotic blood brain barrier disruption is not reasonable and necessary when it is used as part of a treatment regimen for brain tumors.

Be aware that the BBBD process includes all items and services necessary to perform the procedure, including hospitalization, monitoring, and repeated imaging procedures.

This NCD does not alter in any manner the coverage of anti-cancer chemotherapy.

Additional Information
If you have questions, please contact your Medicare FI, carrier or 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.

CR5530 is the official instruction issued to your Medicare FI, Carrier or MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R67NCD.pdf on the CMS Web site.

Back to the Top of the PageTop


CERT Fact Sheet Comprehensive Error Rate Testing Program

Currently, CMS (Centers for Medicare & Medicaid Services) calculates a national paid claims error rate, a contractor specific error rate, and a provider compliance error rate (which measures how well providers prepared claims for submission).

The CMS methodology includes:

These changes must be done by completing the CMS 855I application (Individual) or CMS 855B application (Group or Organization) application to change your information. These forms and instructions can be found on our Web site at http://www.cignagovernmentservices.com under Provider Enrollment or on the CMS Web site at www.cms.hhs.gov. If you have additional questions after reviewing these resources, please call our Provider Enrollment Department at 866.520.4007 hours 9:00 am- 3:00 pm (CST).

Important Information
If you fail to submit the requested information in a timely fashion, an “error” is registered against both the Medicare contractor (CIGNA Government Services) and you as the Medicare provider. (At this point, the CERT review contractor has no choice but to register the claim submission as “erroneous” because there is insufficient supporting documentation to determine otherwise.) Treating these claims as errors will prompt the CERT reviewer to instruct CIGNA Government Services to send the providers overpayment letters. Also, these errors have a corresponding negative impact on the other error rates that are calculated under the CERT program.

More information can be found on the CIGNA Government Services Web site at:
http://www.cignamedicare.com/partb/index.html#New

If you have questions or need assistance you can reach your CERT Coordinator, Julene Mull, at 615.782.4591 or julene.mull@cigna.com

Back to the Top of the PageTop

Clarification of Bariatric Surgery Billing Requirements Issued in CR 5013

Physician Quality Reporting Initiative (PQRI) Measures and Specifications
The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that the 2007 Physician Quality Reporting Initiative (PQRI) Quality Measures and Specifications are now available. To access both the measures and measure specifications documents, visit the PQRI Web page at http://www.cms.hhs.gov/PQRI on the CMS Web site. Once there, go to the Measures/Codes section of the page and scroll down to the Downloads section. Please note that many of the quality codes are new and will be rejected by Medicare claims processing systems prior to the July 1, 2007 HCPCS update.

Note: This article was revised on May 4, 2007, to clarify the types of Medicare contractors that will deny certain claims as opposed to rejecting claims.

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

Provider Action Needed

STOP – Impact to You
This article is based on Change Request (CR) 5477 which clarifies the claims processing instructions contained in CR 5013 (Transmittals R931CP and R54NCD; titled Bariatric Surgery for Morbid Obesity).

CAUTION – What You Need to Know
On April 28, 2006, the Centers for Medicare & Medicaid Services (CMS) issued CR 5013 providing coverage for certain bariatric surgical procedures. CMS found that some claims not involving bariatric surgery are being denied in error while some covered bariatric surgery claims are being held rather than paid.

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

Background
On April 28, 2006, CMS issued CR 5013 (Transmittals R931CP and R54NCD, dated April 28, 2006) providing coverage for certain bariatric surgical procedures. This national coverage determination (NCD) is contained in section 100.1 of the Medicare NCD Manual.

It came to the attention of the CMS that this NCD is not being implemented uniformly, and CMS found that:

Some claims not involving bariatric surgery are being denied in error, and some covered bariatric surgery claims are being held rather than paid.

Therefore, CMS is issuing CR5477 to clarify the claims processing instructions contained in CR 5013.

Certain bariatric surgery procedures for treatment of co-morbidities associated with morbid obesity are considered reasonable and necessary under the Social Security Act (Section1862(a)(1)(A)) if the following conditions are satisfied:

  1. The Medicare beneficiary:
  1. The Procedure is performed in an approved facility listed at http://www.cms.hhs.gov/MedicareApprovedFacilitie/BSF/list.asp on the CMS Web site.

Note: The NCD itself has not changed and treatments for obesity alone are non-covered.
The following revisions to the Medicare Claims Processing Manual (Publication 100-04; Chapter 32) provide guidance for bariatric surgery claims payment:

ICD-9 Diagnosis Codes for BMI ≥35

ICD-9-CM CODE Descriptor
V85.35 Body Mass Index 35.0-35.98, adult
V85.36 Body Mass Index 36.0-36.9, adult
V85.37 Body Mass Index 37.0-37.9, adult
V85.38 Body Mass Index 38.0-38.9, adult
V85.39 Body Mass Index 39.0-39.9, adult
V85.4 Body Mass Index 40 and over, adult

Claims must be submitted to carriers or A/B MACs with the ICD-9-CM diagnosis code of 278.01 for morbid obesity and one of the appropriate Healthcare Common Procedure Coding System (HCPCS) codes as follows:

Medicare FIs and A/B MACS will accept bariatric surgery claims billed by institutional providers with and ICD-9-CM diagnosis code of 278.01 for morbid obesity and one of the following ICD-9-CM procedure codes:

Note: If ICD-9-CM diagnosis code 278.01 is present, but one of the listed ICD-9-CM procedure codes or HCPCS codes is not present, then the Medicare contractor will determine the claim is not for bariatric surgery and will process the claim accordingly. Also, if one of the ICD-9-cm procedure codes is present without ICD-9-CM diagnosis code 278.01, then the claim is not for bariatric surgery, and the contractor will process the claim accordingly. Also, to describe either laparoscopic or open biliopancreatic diversion with duodenal switch (BPD/DS), claims must contain all three of the following codes:

Claims submitted to FIs or A/B MACs must contain International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) procedure code reported as specified according to the following conditions:

Note: The term, “deny”, rather than “reject” is used because beneficiaries and providers are entitled to appeal rights.

Note: Carriers, FIs, or A/B MACs will use Claim Adjustment Reason Code 50 when denying/rejecting claims for noncovered bariatric surgery procedures, reason code 58 when payment is denied due to performing the surgery at an unapproved facility, and reason code 167 when denying the claim because the patient did not meet the conditions for coverage. Appeal rights will be afforded to all parties.


Additional Information
The official instruction, CR5477, issued to your carrier, FI, and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1233CP.pdf on the CMS Web site.

The manual revisions to the Medicare Claims Processing Manual (Pub. 100-04; Chapter 32) included as an attachment to CR5477: CR 5013, Transmittal R931CP and R54NCD, dated April 28, 2006, may be found at http://www.cms.hhs.gov/Transmittals/downloads/R931CP.pdf and
http://www.cms.hhs.gov/Transmittals/downloads/R54NCD.pdf) on the CMS Web site.

If you have any questions, please contact your carrier, FI, 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 on the CMS Web site.

Back to the Top of the PageTop

Clarification of MM5488 Article Regarding Coding on CMS-1500

Provider Types Affected
Physicians and providers submitting co-payment reimbursement claims to Medicare carriers and Part A/B Medicare Administrative Contractors (A/B MACs) for services provided to Medicare beneficiaries.


What You Need to Know
This special addition article (SE0716) clarifies MM5488 (Temporary Addition to the Administrative Simplification Compliance Act (ASCA) Exception List for Medicare Secondary Payer (MSP) Claims —Released March 9, 2007). MM5488 related to Change Request (CR) 5488, which informed Medicare carriers and A/B MACS that a temporary waiver to a requirement of the Administrative Simplification Compliance Act (ASCA) is being granted for the co-payments in MSP claims.
Specifically, SE 0716 notifies physicians and providers that your claims may be processed in error if you identify the primary payer’s primary payment in block 29 of the CMS form 1500. You must only identify and enter the beneficiary payment amount in this block.

Background
CR 5488 instructed CMS contractors (carriers and A/B MACs) who use the Medicare Multi-Carrier System (MCS) for claims processing, to grant a temporary ASCA waiver (until July 1, 2007) for Electronic Media Claim (EMC) MSP claims to allow processing of these claims for reimbursement of a beneficiary for co-payment paid to the provider when the primary payer is an employer Managed Care Organization (MCO).

Therefore, until July 1, 2007, carriers and A/B MACs will allow for co-payment reimbursement claims to be submitted on paper and to send reimbursement directly to the beneficiary.

In clarifying MM5488, this special addition article (SE0716) notifies physicians and providers, that in order for this temporary exception to be implemented, you must only identify the beneficiary payment amount in block 29 of the CMS form 1500. You must not identify the primary payer’s primary payment in this block, or your claims may be processed in error.

Additional Information
You might want to review CR 5488 at http://cms.hhs.gov/transmittals/downloads/R1194CP.pdf or MM5488 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5488.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

Back to the Top of the PageTop

Colony Stimulating Factors

The draft local coverage determination (LCD) for Colony Stimulating Factors has been released into its final version for Tennessee and North Carolina (L24841) and Idaho (L24589). The effective date of this LCD will be June 1, 2007 for all states. Please visit the CIGNA Government Services Web site at http://www.cignagovernmentservices.com draft table for your specific state.

Back to the Top of the PageTop

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

Revised errata sheets and downloadable versions (April 2007) of the Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals and the Facilitator’s Guide – Companion to Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals have been posted on the CMS Medicare Learning Network. To access these publications, visit www.cms.hhs.gov/MLNProducts/MPUB/list.asp.
Note: This article was revised on April 20, 2007, to show that important new information on this issue is available in MLN Matters article MM5468 (http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5468.pdf). In essence, according to MM5468, qualifying independent laboratories may continue to bill Medicare for the TC of physician pathology services furnished to Medicare patients of a covered hospital stay during calendar year 2007. Be sure to view MM5468 for details.

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

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

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

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

Key Points

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

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

For complete details regarding this CR, please see the official instruction issued to your Medicare FI, Carrier or A/B MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1221CP.pdf on the CMS Web site.

Back to the Top of the PageTop

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

As noted in Change Request (CR) 5537, the April Quarterly Update for 2007 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule implements fee schedule changes for several PMD HCPCS codes. Joint Signature Memorandum/Technical Direction Letter (JSM/TDL)-07308, issued on March 23, 2007, included instructions for implementation on April 2, 2007, of revised 2007 fee schedule amounts for codes K0822, K0825, K0835, K0838, K0848, K0850, K0851, K0859, and K0864. Only Louisiana and the United States Virgin Islands are affected by the revisions to the fee schedule amounts for code K0864.

This JSM/TDL advises that included in the aforementioned 2007 fee schedule changes noted in CR 5537 are revisions to codes K0829, K0839, K0855, K0863, and K0864. The revisions to the 2007 fee schedule amounts for codes K0829, K0839, K0855, K0863, and K0864 affect only Kansas. In addition to Kansas, Puerto Rico is also affected by the 2007 fee schedule amount revisions for code K0864. Instructions for retrieving the revised 2007 DMEPOS fee schedule file were provided in CR 5537.
Contractors must adjust previously processed claims for codes K0829, K0839, K0855, K0863, and K0864 with dates of service on or after January 1, 2007, if they are resubmitted as adjustments.

Back to the Top of the PageTop

Instructions for Implementing the Centers for Medicare & Medicaid (CMS) Ruling CMS 1536-R; Astigmatism-Correcting Intraocular Lens (A-C IOLs)

An Overview of Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Health Care Professionals educational video program, provides information on Medicare-covered preventive services, risk factors associated with various preventable diseases, and highlights the importance of prevention, detection, and early treatment of disease. The program is an excellent resource to help physicians, providers, suppliers, and other health care professionals learn more about preventive benefits covered by Medicare. Running approximately 75 minutes in length, the program is suitable for individual viewing or for use in conjunction with a conference or training session. To order your copy today, go to the Medicare Learning Network Product Ordering page at
http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=5 on the CMS Web site. Available in DVD or VHS format.

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

Provider Action Needed
This article is based on Change Request (CR) 5527 which discusses a recent Administrator Ruling from the Centers for Medicare & Medicaid Services (CMS) regarding astigmatism-correcting intraocular lenses (A-C IOLs) following cataract surgery (CMS-1536-R). The new policy is effective for dates of service on and after January 22, 2007. Physicians and providers need to be aware that effective January 22, 2007:

In addition, CMS reminds physicians that they can be reimbursed for the conventional or A-C IOL (V2632) only when the service is performed in a physician’s office. Also, when physicians perform cataract surgery in an ASC or hospital outpatient setting, the physician may only bill for the professional service because payment for the lens is bundled into the facility payment for the cataract extraction.

Background
The Centers for Medicare & Medicaid Services (CMS) Administrator rulings serve as 1) precedent final opinions and orders and 2) statements of policy and interpretation. The Administrator rulings provide clarification and interpretation of complex or ambiguous provisions of the law or regulations relating to Medicare, Medicaid, utilization and peer review by Quality Improvement Organizations, private health insurance, and related matters. These rulings also promote consistency in interpretation of policy and adjudication of disputes, and they are binding on all CMS components, Medicare contractors, the Provider Reimbursement Review Board, the Medicare Geographic Classification Review Board, and Administrative Law Judges who hear Medicare appeals.

CR5527 discusses a recent CMS Administrator Ruling concerning requirements for determining payment for insertion of intraocular lenses (IOLs) that replace beneficiaries’ natural lenses and correct pre-existing astigmatism following cataract surgery under the Social Security Act:

Note that CR5527 basically restates CMS policy provided in CR3927 (MLN Matters article MM3927), except that CR3927 focused on presbyopia-correcting IOLs and this article focuses on A-C IOLs.

Coverage Policy
In general, an item or service covered by Medicare must satisfy the following three basic requirements:

The Social Security Act specifically excludes eyeglasses and contact lenses from coverage, with an exception for one pair of eyeglasses or contact lenses covered as a prosthetic device furnished after each cataract surgery with insertion of an IOL. In addition, there is no Medicare benefit category to allow payment for the surgical correction of cylindrical lenses of eyeglasses or contact lenses that may be required to compensate for the imperfect curvature of the cornea (astigmatism).
An A-C IOL is intended to provide what is otherwise achieved by two separate items:

Although A-C IOLs may serve the same function as eyeglasses or contact lenses furnished following removal of a cataract, A-C IOLs are neither eyeglasses nor contact lenses. The following table is a summary of benefits for which Medicare makes payment, and services for which Medicare does not pay (no benefit category):

Benefits for Which Medicare Makes Payment Service for Which Medicare Does NOT Pay-No Benefit Category
A conventional intraocular lens (IOL) implanted following cataract surgery The asignatism-correcting functionality of an IOL implanted following cataract surgery.
Facility or physician services and suppies required to insert a conventional IOL following cataract surgery Facility or physician services and resources required to insert and adjust an AC-IOL following cataract surgery that exceeds the services and resources furnished for insertion of a conventional IOL.
One pair of eyeglasses or contact lenses as a prosthetic device furnished after each cataract surgery with insertion of an IOL. The surgical correction of cylindrical lenses of eyeglasses or contact lenses that may be required to compensate for inperfect curvature of the cornea (astignatism)

Eye examinations performed to determine the refractive state of the eyes specifically associated with insertion of an AC-IOL (including subsequent monitoring services), that exceed the one-time eye examination following cataract surgery with insertion of a conventional IOL.

Currently, there is one NTIOL class approved for special payment when furnished by an ASC, and this currently active NTIOL category for “Reduced Spherical Aberration” was established on February 27, 2006 and expires on February 26, 2011.


Effective for services furnished on or after January 22, 2007, CMS now recognizes the following as A-C IOLs:

Payment Policy for Facility Services and Supplies
The following applies to an IOL inserted following removal of a cataract in a hospital (on either an outpatient or inpatient basis) that is paid under 1) the hospital Outpatient Prospective Payment System (OPPS) or 2) the Inpatient Prospective Payment System (IPPS), respectively (or in a Medicare-approved ASC that is paid under the ASC fee schedule):

For an A-C IOL inserted subsequent to removal of a cataract in a hospital (on either an outpatient or inpatient basis) that is paid under the OPPS or the IPPS, respectively (or in a Medicare-approved ASC that is paid under the ASC fee schedule):

Payment Policy for Physician Services and Supplies For an IOL inserted following removal of a cataract in a physician’s office Medicare makes separate payment, based on reasonable charges, for an IOL inserted subsequent to extraction of a cataract that is performed at a physician’s office.

For an A-C IOL inserted following removal of a cataract in a physician’s office:


For an A-C IOL inserted following removal of a cataract in a hospital or ASC:


Coding
No new codes are being established at this time to identify an A-C IOL or procedures and services related to an A-C IOL, and hospitals, ASCs, and physicians should report one of the following CPT codes to bill Medicare for removal of a cataract with IOL insertion:


Physicians inserting an IOL or an A-C IOL in an office setting may bill code V2632 (posterior chamber intraocular lens) for the IOL or the A-C IOL, which is paid on a reasonable charge basis.
If appropriate, hospitals and physicians may use the proper CPT code(s) to bill Medicare for evaluation and management services usually associated with services following cataract extraction surgery, if appropriate.

Beneficiary Liability
When a beneficiary requests insertion of an A-C IOL instead of a conventional IOL following removal of a cataract and that procedure is performed, the beneficiary is responsible for payment of facility charges for services and supplies attributable to the astigmatism-correcting functionality of the A-C IOL:

Provider Notification Requirements
When a beneficiary requests insertion of an A-C IOL instead of a conventional IOL following removal of a cataract:

Additional Information
The official instruction, CR5527, issued to your Medicare carrier, intermediary, and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1228CP.pdf on the CMS Web site.

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

Back to the Top of the PageTop

Invalid Skilled Nursing Facility (SNF) Informational Unsolicited Responses (IURs) from Medicare’s Common Working File (CWF) System

Provider Types Affected
Physicians, suppliers, and providers who submit claims to Medicare contractors (fiscal intermediaries (FIs), carriers, Part A/B Medicare Administrative Contractors (A/B MACs), durable medical equipment (DME) regional carriers (DMERCs), DME Medicare Administrative contractors (DME/MACs), and/or regional home health intermediaries (RHHIs)).

Provider Action Needed

STOP – Impact to You
Medicare systems may have inadvertently rejected outpatient, Part B, and DME claims that overlapped periods of a SNF stay by a beneficiary, whose Medicare SNF benefits were exhausted and for whom a non-pay SNF claim was submitted to Medicare.

CAUTION – What You Need to Know
This problem may have affected some of your claims processed by Medicare from October 2, 2006 until January 29, 2007, when Medicare systems were fixed.

GO – What You Need to Do
You need not take any action as your Medicare contractor will take steps to adjust any claims affected and to reverse or stop any payment recovery actions. See the Background section for more details.

Background
Providers need to be aware that the Centers for Medicare & Medicaid Services (CMS) has identified an issue with processing outpatient, Part B, and DME claims for beneficiaries who are in a SNF, but whose Medicare coverage for the SNF stay has ended. In October of 2006 Change Request (CR) 4292 (Benefits Exhaust and No-Payment for Medicare FIs and SNFs) was implemented. CR4292 (see Additional Information section for the CMS Web site address of CR4292) mandated that providers submit ALL SNF non-pay claims after benefits were exhausted to allow CMS to track the beneficiary’s benefit period.

Medicare system changes relating to CR4292 caused outpatient, Part B, and DME paid claims that overlap non-pay SNF claims to be rejected. This is an error and your Medicare contractor will adjust claims or payment recovery actions resulting from this problem. The CWF coding change to fix this problem was effective and in production on January 29, 2007 and CWF will provide a list of claims to the applicable contractors to allow for corrections and payment to be made to providers.

Key Points
CMS has directed Medicare contractors to correct any claims that were adjusted as a result of the problem with implementation of CR4292.

Additional Information
For complete details regarding this CR please see the official instruction (CR5587) issued to your Medicare carrier, FI, A/B MAC, DME MAC, DMERC, or RHHI. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R274OTN.pdf on the CMS Web site.

If you have questions, please contact your Medicare carrier, FI, A/B MAC, DME MAC, DMERC, or RHHI, at their toll-free number which may be found at:
http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site. The MLN Matters article for CR4292, Benefits Exhaust and No-Payment for Medicare FIs and SNFs, can be viewed at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4292.pdf on the CMS Web site.

Back to the Top of the PageTop

LCD for Electrodiagnostic Testing: Nerve Conduction Studies (NCS) & Electromyography (EMG) Revised – Covered ICD-9 Diagnosis Codes Added

The LCDs for Electrodiagnostic Testing: Nerve Conduction Studies (NCS) & Electromyography (EMG) have been revised to add covered ICD-9 diagnosis codes 354.0, 729.5 and 782.0 to the lists of covered ICD-9 diagnosis codes for Group 5 (CPT© procedure codes 95903, 95934 and 95936). This additional coverage is retroactive to the original effective date for the LCDs, February 4, 2007. Please refer to the CIGNA Government Services Web site at http://www.cignagovernmentservices.com to view the policy.

Back to the Top of the PageTop

Measurement of Bone Density

The dosage eligibility requirement for steroid therapy has been reduced from 7.5mg to 5.0 mg of prednisone effective January 2, 2007. Please refer to the CIGNA Government Services Web site at http://www.cignagovernmentservices.com to view the policy.

Back to the Top of the PageTop

Medicare Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program Final Regulation

The Medicare Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program Final Regulation is now published at the Federal Register at http://www.cms.hhs.gov/CompetitiveAcqforDMEPOS/Downloads/CMS-1270-F.pdf
CMS has also announced the first 10 metropolitan areas in which competition will occur, as well as the first items to be competitively bid. Visit the CMS Web site at http://www.cms.hhs.gov/CompetitiveAcqforDMEPOS/ to view the rule and for additional information.

Back to the Top of the PageTop

Medicare Fee for Service (FFS) National Provider Identifier (NPI) Implementation Contingency Plan

Medicare Fee for Service (FFS) National Provider Identification (NPI) Implementation Contingency Plan

Back to the Top of the PageTop

Not Otherwise Classified Drugs And Unlisted Procedures

When billing for a Not Otherwise Classified Drug, the name of the drug and exact dosage administered must be entered in item 19 of the CMS–1500 claim form or as an attachment for paper claims. For claims submitted electronically, this information would be entered in the Loop 2300 Segment NTE field (the electronic equivalent of block 19 of the paper form). The allowed amount for the drug will be based on the information entered in these fields.

The actual number or quantity billed must be clearly indicated on the claim form. When multiple services are provided, enter the actual number provided. For claims reporting a service or pricing unit, the following example should be used to code the line item.

Example: A total of 300mgs was administered for Not Otherwise Classified drug code (NOC) J3490. Cimetidine Hydrochloride (Tagamet), 150 mgs. In this case, 150 mg equals 1 unit/service. Thus, 300 mgs equals 2 units/services. Item 19 should be completed with the Not Otherwise Classified drug billed and the actual dosage given - J3490 – Cimetidine Hydrochloride 300mgs.

Once the drug has been issued a specific procedure code, the assigned procedure code should be used and your number of services should be adjusted based on the description and the dosage of the assigned procedure code. If the miscellaneous code continues to be billed after a specific procedure code has been assigned, your claim may be denied as a billing error. This does not apply to the compounded drugs billed under J3490. Compounded drugs shall continue to be billed under J3490 and the purchase information included with the claim.

When billing for an “Unlisted Procedure Code” a concise description of an “unlisted procedure code” must be entered in item 19 of the CMS-1500 claim form or as an attachment for paper claims. For claims submitted electronically, this information would be entered in the Loop 2300 Segment NTE field (the electronic equivalent of block 19 of the paper form).

Claims will be returned as unprocessable if an “unlisted procedure code” or a Not Otherwise Classified Drug (NOC) code is indicated in item 24D, but an accompanying narrative is not present in item 19 or an attachment.

For claims submitted electronically, claims will be returned as unprocessable if an “unlisted procedure code” or a Not Otherwise Classified Drug (NOC) code is indicated in the Loop 2400 Segment SV101-2, but an accompanying narrative is not present in the Loop 2300 Segment NTE field.

Back to the Top of the PageTop

Part C Plan Type Display on the Medicare’s Common Working File (CWF) — CR5538 rescinds and fully replaces CR 5349

Provider Types Affected
Physicians, providers, and suppliers who access Medicare beneficiary eligibility data through CWF eligibility screens (e.g. HUQA, HIQA, HIQH, ELGA, ELGB, and 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 is quite descriptive, is now available at http://www.cms.hhs.gov/MCRAdvPartDEnrolData/.

Background
The CWF displays information on the Medicare Part C (now known as Medicare Advantage) contract number in which a beneficiary is enrolled, including the plan type description associated with the contract, and currently, CWF displays the label “HMO” for these contracts. In many of these cases, the “HMO” label is incorrect because the list of possible plan type descriptions has grown much larger since the creation of the Medicare Advantage (MA) programs.

This situation has especially become problematic for Medicare beneficiaries who are enrolled in MA Private Fee-for-Service (PFFS) contracts because PFFS contracts are labeled as “HMO” in CWF. Consequently, some providers are not recognizing that they can offer services to those beneficiaries enrolled in a MA PFFS contract.

To address this issue, the Health Plan Management System (HPMS) will modify the existing HMO address file exchange process with CWF in order to supply the list of available contract numbers and their corresponding plan type descriptions. With this new data, CWF can correctly display one of the following plan type descriptions: HMO, PPO, POS, Indemnity, or FFS Demo. The following table provides additional information to providers regarding these plan type descriptions:

Plan Type Descripton Brief Guidance on Treating Patient Additional Information
HMO Call plan for authorization Managed Care plan with a provider network. Limited or no out -of-network coverage witht he exception of emergency services
PPO You may treat the patient Has a network of providers. In return for higher cost sharing, members can go out of the plan network for all plan services, including supplemental benefits
POS You may treat the patient subject to plan rules. Contact the plan for details A limited out-of-network option offered by HMO plans. Contact plan for details
Indemnity You may treat the patient If this is a PFFS plan, you must follow the PFFS plan’s terms and conditions of payment. If this is a Medical Savings Account (MSA) plan, the member may pay you directly.

FFS Demo You may treat the patient. Beneficiaries remain in original Medicare and are entitled to all fee-for-service benefits. There are no changes to Medicare FFS billing instructions or claims processing.

Additional Information
The official instruction, CR5538, 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/R1219CP.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.

Back to the Top of the PageTop

Provider Education for Handling NPI Issues Related to Deceased Providers

Provider Education for Handling NPI Issues Related to Deceased Providers

Back to the Top of the PageTop

Removal and Destruction of Benign Skin Lesions — Important Reminder About Correct Billing

Providers are reminded that when billing for removal or destruction of benign skin lesions, correct modifier usage is required.


When coverage criteria described in the Local Coverage Determination (LCD) for Removal and Destruction of Benign Skin Lesions are met and documented in the patient’s medical record, modifier KX (Specific required documentation on file) must be appended to the procedure code(s) billed.

When lesion removal or destruction is for cosmetic purposes (e.g., at the request of the patient to improve appearance, or in the absence of a threat to health or function), modifier GY (Item/service statutorily excluded or does not meet definition of any Medicare benefit) must be appended to the procedure code(s) billed. Claims billed with modifier GY are denied as non-covered (coverage is statutorily excluded) and the patient is responsible for payment.

Claims billed for removal or destruction of benign skin lesions without either of the modifiers above may be denied as not reasonable and necessary. The provider is held liable unless a valid Advanced Beneficiary Notification (ABN) has been signed by the patient and is kept on file by the provider. When a valid ABN is on file, modifier GA (Waiver of liability statement on file) must be appended to the code(s) billed.

For additional information about these services, refer the LCD and related Article located at the CMS Web site, http://www.cms.hhs.gov/mcd/indexes.asp?clickon=index.

Back to the Top of the PageTop

Requirement for Providing Route of Administration Codes for Erythropoiesis Stimulating Agents (ESAs)

The Medicare Physician Fee Schedule Fact Sheet, which provides general information about the Medicare Physician Fee Schedule, is now available in print format. To place an order for the fact sheet, visit the Medicare Learning Network at http://www.cms.hhs.gov/mlngeninfo on the Centers for Medicare & Medicaid Services Web site and select “MLN Product Ordering Page” under the “Related Links inside CMS” Section.

Note: This article was revised on April 30, 2007, to replace one of the HCPCS codes on page 2 (Q4055) with J0886. All other information is the same.

Provider Types Affected
Physicians, providers, and suppliers who bill Medicare contractors (carriers, including durable medical equipment regional carriers (DMERCs) and DME Medicare administrative contractors (DME MACs), fiscal intermediaries (FIs),including regional home health intermediaries (RHHIs), and Medicare administrative contractors (MACs)) for providing ESA administration services to Medicare end stage renal disease (ESRD) beneficiaries.

What You Need to Know
CR 5480, from which this article is taken, instructs all providers and suppliers on the voluntary reporting of route of administration modifiers on claims for Erythropoiesis Stimulating Agents (ESAs) for ESRD beneficiaries. Route of administration modifiers were published and effective January 1, 2007, for reporting on Medicare claims submitted on or after February 1, 2007, for dates of service on or after January 1, 2007. Please see the background section for details.

Background
Current claims processing requirements do not allow you to report the method of administering Erythropoiesis Stimulating Agents (ESA) – such as epoetin alfa (EPO) and darbepoetin alfa (Aranesp) – to treat your end stage renal disease (ESRD) patients who are anemic. However, in order to study the efficacy of both intravenous administration and subcutaneous administration methods of ESA administration, the Centers for Medicare and Medicaid Services (CMS) will begin requesting you to voluntarily report modifiers, which will indicate the method of ESA administration.

Specifically, CR 5480, from which this article is taken, announces that, effective for claims submitted on or after February 1, 2007 (with dates of services on or after January 1, 2007), all providers and suppliers who bill for administering ESA to ESRD beneficiaries (Healthcare Common Procedure Coding System (HCPCS) codes Q4081, J0882, or J0886) are encouraged to include:

You should be aware that in the future, this reporting of the route of ESA administration will be a requirement, and additional instructions will be issued at that time. But until then, a claim for an ESA that does not report the route of administration will not be returned to the provider, and will be paid the same as a claim that does report the route of administration. Also, be aware that renal dialysis facilities whose claims include charges for ESA administration by both methods should report them in separate lines in order to identify the number of administrations provided by each method.

Additional Information
You can find more information about route of administration codes for Erythropoiesis Stimulating Agents (ESAs) by going to CR 5480, located at
http://www.cms.hhs.gov/Transmittals/downloads/R1212CP.pdf on the CMS Web site. As attachments to this CR, you will find updated Medicare Claims Processing Manual , Chapter 8 (Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims), Section 60.2.3.1 (Requirement for Providing Route of Administration Codes for Erythropoiesis Stimulating Agents (ESAs)); and Chapter 17 (Drugs and Biologicals), Section 80.11(Requirements for Providing Route of Administration Codes for Erythropoiesis Stimulating Agents (ESAs)).

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

Back to the Top of the PageTop

Revisions to Form CMS-1500 Submission Requirements

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
Physicians, non-physician practitioners, and suppliers who bill Medicare contractors (Part A/B Medicare Administrative Contractors (A/B MACS), carriers, durable medical equipment regional contractors (DMERCS) and DME Medicare Administrative Contractors (DME MACs) for their services using the Form CMS-1500.

Background
The Form CMS-1500 answers the needs of many health insurers. It is the basic form prescribed by the Centers for Medicare & Medicaid Services (CMS) for the Medicare and Medicaid programs for claims from physicians and suppliers. The language contained in the Medicare Claims Processing Manual, Chapter 26, regarding the Form CMS-1500 is being updated to reflect current processing guidelines and incorporate recent data collection decisions made by CMS.

Key Points
CR5489 makes the following updates to the CMS-1500 requirements:

In addition, language has been added regarding the completion of Item 25 (the provider of service or supplier federal tax identification number). Medicare providers are not required to complete this item for crossover claim purposes, since the Medicare contractor will retrieve the tax identification information from their internal provider file for inclusion on the Coordination of Benefits (COB) outbound claim. However, tax identification information is used in the determination of accurate National Provider Identification (NPI) reimbursement. Thus, reimbursement of claims submitted without tax identification information may be delayed.

Additional Information
CR5489 is the official instruction issued to your Medicare contractor. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1215CP.pdf on the CMS Web site. The revised Chapter 26, section 10.4, of the Medicare Claims Processing Manual is attached to CR5489.

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

Back to the Top of the PageTop

Update to Medicare Claims Processing Manual, Publication 100-04, Chapter 18, Section 60.1 Regarding Colorectal Screening Services

Provider Types Affected
Physicians, suppliers, and providers who submit claims for screening and diagnostic colorectal services to Medicare contractors (Fiscal intermediaries (FIs), carriers, Part A/B Medicare Administrative Contractors (A/B MACs).


Background
The Centers for Medicare & Medicaid Services (CMS) is aware that Chapter 18, Section 60.1 of the Medicare Claims Processing Manual (Publication 100-04) needed clarification regarding application of the annual Part B deductible for diagnostic colorectal services. Section 5113 of the Deficit Reduction Act (DRA) of 2005 waived the requirement for the annual Part B deductible for screening colorectal services, NOT diagnostic colorectal services. CR5541 clarifies that portion of the manual.

Key Points
The following are the key points of the revised portion of Chapter 18, Section 60.1 of the Medicare Claims Processing Manual, which is attached to CR5541 (the Web address for CR5541 is provided in the Additional Information section of this article).

Additional Information
You may see the official instruction (CR5541) issued to your Medicare carrier, FI, or A/B MAC by going to http://www.cms.hhs.gov/Transmittals/downloads/R1217CP.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.

Back to the Top of the PageTop


Ventricular Assist Devices (VADs)

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

Provider Action Needed

STOP – Impact to You
This article is based on Change Request (CR) 5516 which announces that, effective March 27, 2007, new facility criteria are established and hospitals must receive certification from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) under their Disease Specific Certification

Program for Ventricular Assist Devices (VADs). The new criteria apply to hospitals that implant VADs for the destination therapy indication.

CAUTION – What You Need to Know
Currently approved hospitals will have until March 27, 2009, to become certified by the JCAHO or they will be removed from the approved list.

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

Background
A VAD is an implantable device used to assist a damaged or weakened heart in pumping blood. These devices are used for support of blood circulation 1) post-cardiotomy, 2) as a bridge to a heart transplant, or 3) as destination therapy. Destination therapy is defined as use of a device as the end result of treatment (i.e., permanent transplantation), instead of a “bridge” to transplantation. Destination therapy is an indication for patients that are not heart transplant eligible, and therefore, they expect to require use of the VAD through the end of life.

Through a National Coverage Determination (NCD) Manual (Publication 100-03), Section 20.9, (“Artificial Hearts and Related Devices”) issued on October 14, 2003 (CR 2958, Transmittal 2; http://www.cms.hhs.gov/Transmittals/Downloads/R2NCD.pdf), Medicare began coverage of the destination therapy indication. The 2003 decision established hospital criteria and an application process through which hospitals were required to submit information to the Centers for Medicare & Medicaid Services (CMS). If approved, the hospital(s) were listed as an approved VAD destination therapy hospital on the CMS Web site (http://www.cms.hhs.gov/MedicareApprovedFacilitie/VAD/list.asp#TopOfPage). At that time, Medicare contractors were instructed to use this VAD Destination Therapy Facilities Web site to determine which hospitals in their area was Medicare approved for VADs as destination therapy.
CR 5516 announces that, effective March 27, 2007, new facility criteria are established. Included in the facility criteria are requirements that:


The VAD Destination Therapy Facilities Web site will be continuously updated by CMS to maintain a current list of approved facilities. Medicare contractors will continue to use this Web site to determine which hospitals are covered by Medicare when VADs are implanted as destination therapy.
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.


Additional Information
The official instruction, CR5516, issued to your carrier, intermediary, or A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R68NCD.pdf on the CMS Web site.

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

Back to the Top of the PageTop

Cryoplasty Considered Investigational

Cryoplasty is a new procedure that combines balloon angioplasty with cryogenics for the purpose of revascularization in peripheral artery disease while simultaneously treating to prevent re-stenosis.
At this time, CIGNA Government Services considers cryoplasty to be investigational and unproven. Cryoplasty must be billed with CPT® Code 37799. Do NOT bill using CPT® Codes 35470 through 35476.

Back to the Top of the PageTop

Use CPT Code 96549 for Blood Brain Osmotic Disruption Therapy for Brain Tumors

Effective March 20, 2007, CMS has promulgated National Coverage Determination 110.20, NCD for Blood Brain Barrier Osmotic DISRUPTION for Treatment of Brain Tumors” which states that the use of osmotic BBBD is not reasonable and necessary when it is used as part of a treatment regimen for brain tumors.

Providers that elect to file a claim for this procedure should report the procedure using CPT® code 96549, unlisted chemotherapy procedure.


An ISO 9001:2000 certified company

Home | About Us | Careers | Site Map | Disclaimer | Web Site Feedback | Contact Us


Centers for Medicare & Medicaid Services