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August 6, 2007 Part B Medicare Bulletin

Posted August 6, 2007

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Alefacept – Retired LCD

The Local Coverage Determination for alefacept has been retired for all three CIGNA Government Services states, effective July 15, 2007. The coverage will continue to be based on the FDA-approved indications and information in the package insert, and on the general principles expressed in the retired LCD. This drug should only be prescribed for appropriate patients with moderate to severe chronic plaque psoriasis, by clinicians experienced in its use.

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Appeals Transition - BIPA Section 521 Appeals

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, 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) 5460, which notifies Medicare contractors about their need to comply with changes to provisions in Chapter 29 of the Medicare Claims Processing Manual (Publication 100-04) that address the appointment of representatives, fraud and abuse, guidelines for writing appeals correspondence, and the disclosure of information.

Background
The Medicare claims appeals process was amended by the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act (BIPA) and the Medicare Prescription Drug Improvement and Modernization Act (MMA). The Social Security Act (Section 1869(c)), as amended by BIPA and MMA, requires changes to the Code of Federal Regulations (CFR; Title 42) regarding:

  • Appointment of representatives,
  • Fraud and abuse,
  • Guidelines for writing appeals correspondence, and • The disclosure of information.

Therefore, the Centers for Medicare & Medicaid Services (CMS) is revising provisions in Chapter 29 of the Medicare Claims Processing Manual that address these changes.

The purpose of CR5460 is to notify Medicare contractors about their need to comply with these revised Medicare Claims Processing Manual provisions, which are included as an attachment to CR5460.

Some of the key changes to the manual direct Medicare contractors to:

  • Follow the procedures that define who may be a representative and how a representative is
    appointed (via the CMS-1696 Appointment of Representative (AOR) form);
    • Do not accept an appointment if the contractor has evidence that the appointment should not be honored;
    • Send notice only to the representative when the contractor takes action or issues a redetermination [if there is an appointed representative];
    • Provide assistance in completing the CMS- 1696 form, as needed; and
    • Do not release beneficiary-specific information to a representative before the beneficiary or appellant and the prospective representative have completed and signed the CMS-1696 or other conforming written instrument.

Please note that the AOR applies to all services, claims and appeals submitted on behalf of the beneficiary for the duration of the AOR.

  • Follow the procedures that describe the process a beneficiary must use to assign their appeal rights to a provider (via the CMS-20031) Transfer of Appeal Rights form):
    • For each new appeal request, a form needs to be submitted, this form is valid for all levels of the appeal process including judicial review, even in the event of the death of the beneficiary;
    • If a provider furnishes the service, he/she would be a party to the initial determinations, only pro viders or suppliers who are not a party may accept assignment of appeal rights
      from a beneficiary. That is assignment of appeal rights applies only to providers and
      suppliers who are never a party to an appeal because they do not participate in Medicare and have not taken the claim on assignment; and
    • The provider or supplier who accepts the appeal rights to collect payment from the
      beneficiary for the item or service that is the subject of the appeal. The provider or supplier may collect any applicable deductible or coinsurance. The provider or supplier agrees to this waiver by completing and signing Section II of the Transfer of Appeal Rights form.
    • Provide redetermination letters that are understandable to beneficiaries.

Please note that an Assignment of Appeal Rights is valid for the duration of an appeal unless it is revoked by the beneficiary.

Additional Information
The official instruction, CR5460, issued to your Medicare contractor regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1274CP.pdf on the CMS Web site. The revised portions of the Medicare Claims Processing Manual are attached to that CR.

If you have any questions, please contact your Medicare contractor 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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Azacitidine (Vidaza) – Retired LCD

CIGNA Government Services has retired the LCD for azacitidine (Vidaza) for all three CIGNA Government Services state jurisdictions, effective August 1, 2007. Thereafter, drug will be covered for its FDA-approved, Compendia-listed indications only. CIGNA Government Services expects the general instructions in the retired LCD for use will be followed in the future, and that the drug will continue to be primarily used by physicians well experienced in its use. This will be followed on a post-pay basis.

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Bone Mass Measurements (BMMs)

Note: This article was revised June 4, 2007 to clarify the Medicare Summary Notices on page 3. Essentially, MSN 16.10 will be issued with a denied claim as well as either MSN 36.1 or MSN 36.2, depending on if an ABN was issued. All other information remains the same.

Provider Types Affected
Physicians, practitioners and hospitals that bill Medicare contractors (carriers, fiscal intermediaries (FIs), or Part A/B Medicare administrative contractors (A/B MACs) for BMM services

Provider Action Needed

STOP – Impact to You
Effective for dates of service on or after January 1, 2007, Medicare will pay for BMM services for dual-energy x-ray absorptiometry (CPT code 77080) when this procedure is used to monitor osteoporosis drug therapy. In addition, new CPT were assigned to BMMs.

CAUTION – What You Need to Know
Medicare edits will deny claims that are not consistent with revised BMM policy and providers may be liable for noncovered BMMs unless they have issued an advanced beneficiary notice (ABN) as required. This article explains the changes as a result of the CY2007 Physician Fee Schedule Final Rule.

GO – What You Need to Do
See the remainder of this article for important information regarding billing Medicare for BMMs.

Background
This article and related Change Request (CR) 5521 wants providers to know that on June 24, 1998, the Centers for Medicare & Medicaid Services (CMS) published an Interim Final Rule with Comment Period (IFC) in the Federal Register entitled "Medicare Coverage of and Payment for Bone Mass Measurements." This IFC implemented section 4106 of the BBA by establishing 42 CFR 410.31, Bone Mass Measurement: Conditions for Coverage and Frequency Standards. This new regulation defined BMM and individuals qualified to receive a BMM, established conditions for coverage under the "reasonable and necessary" provisions of 1862(a)(1)(A) of the Act, and established frequency standards governing when qualified individuals would be eligible for a BMM.

On December 1, 2006, CMS published the CY 2007 Physician Fee Schedule final rule, which included changes to 42 CFR 410.31. These changes can be found in Chapter 15, Section 80.5 of the Medicare Benefit Policy Manual. and in Chapter 13, Section 140 of the Medicare Claims Processing Manual. The revised manual sections are attached to CR5221. The Web address for viewing CR5221 is available in the "Additional Information" section at the end of this article.

Key Points
Listed is a summary of the revisions and additions to Chapter 13 of the Medicare Claims Processing Manual and Chapter 15 of the Medicare Benefit Policy Manual.

CHAPTER 13

Effective for dates of service on and after January 1, 2007, the CY 2007 Physician Fee Schedule final rule expanded the number of beneficiaries qualifying for BMM by reducing the dosage
requirement for glucocorticoid (steroid) therapy from 7.5 mg of prednisone per day to 5.0 mg.
It also changed the definition of BMM by removing coverage for a single-photon absorptiometry (SPA) as it is not considered reasonable and necessary under section 1862 (a)(1)(A) of the Act.

Note: Medicare will not cover single photon absorptiometry and procedure code 78350 will be denied (using MSN# 16.10) for services on or after January 1, 2007.

CHAPTER 15

NOTE: Since not every woman who has been prescribed estrogen replacement therapy (ERT) may be receiving an "adequate" dose of the therapy, the fact that a woman is receiving ERT should not preclude her treating physician or other qualified treating nonphysician practitioner from ordering a bone mass measurement for her. If a BMM is ordered for a woman following a careful evaluation of her medical need, however, it is expected that the ordering treating physician (or other qualified treating nonphysician practitioner) will document in her medical record why he or she believes that the woman is estrogen-deficient and at clinical risk for osteoporosis.

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR5521) issued to your Medicare carrier, FI or A/B MAC. That instruction consists of 3 transmittals, i.e.:

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.

A brochure outlining 'Bone Mass Measurements' is available at http://www.cms.hhs.gov/MLNProducts/downloads/bone_mass_06-08-05.pdf .

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Charges for Missed Appointments

National Provider Identifier (NPI) News – Medicare is now asking that submitters send a small number of claims using only the NPI. If no claims are rejected, the submitter can gradually increase the volume. Additional information can be found at the CMS NPI Web site at http://www.cms.hhs.gov/NationalProvIdentStand/.

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

Provider Action Needed

STOP – Impact to You
The Centers for Medicaid & Medicare Services (CMS) policy is to allow physicians and suppliers to charge Medicare beneficiaries for missed appointments. However, Medicare itself does not pay for missed appointments, so such charges should not be billed to Medicare.

CAUTION – What You Need to Know
Providers may not charge ONLY Medicare beneficiaries for missed appointments; they must also charge non-Medicare patients. The amount the physician/supplier charges Medicare beneficiaries for missed appointments must be the same as the amount that they charge non-Medicare patients.

GO – What You Need to Do
Make certain that your billing staff is aware that you may bill the beneficiary directly, that Medicare itself does not make any payments for missed appointments, and that Medicare should not be billed for these charges.

Background
According to Chapter 12, section 30.3.13 of the Medicare Claims Processing Manual, which is attached to CR5613, CMS policy allows physicians, providers, and suppliers to charge Medicare beneficiaries for missed appointments, provided that they do not discriminate against Medicare beneficiaries but also charge non-Medicare patients for missed appointments and the charges for Medicare and non-Medicare patient are the same. The charge for a missed appointment is not a charge for a service itself (to which the assignment and limiting charge provisions apply), but rather is a charge for a missed business opportunity. Therefore, if a physician's or supplier's missed appointment policy applies equally to all patients (Medicare and non-Medicare), then the Medicare law and regulations do not preclude the physician or supplier from charging the Medicare patient directly.

The other key points of CR5613 are:

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR5613) 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/R1279CP.pdf on the CMS Web site.

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

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Claims Processing Change for Services Submitted with Health Professional Shortage Area (HPSA) Modifiers QB or QU for Claims with Dates of Service On or After January 1, 2006

Provider Types Affected
Physicians submitting claims to Medicare Part A/B Medicare Administrative Contractors (A/B MACs), or carriers for services rendered to Medicare beneficiaries in health professional shortage areas.

Provider Action Needed

STOP – Impact to You
For dates of service on or after January 1, 2006, when a modifier is required to bill for the HPSA bonus, use the AQ modifier for physician services provided in HPSAs. Claims will be returned as unprocessable if submitted with the QB or QU modifiers, when submitted for dates of service on or after January 1, 2006.

CAUTION – What You Need to Know
Make certain that services eligible to receive a HPSA bonus for dates of service on or after January 1, 2006, are billed with the AQ modifier, when a modifier is required.

GO – What You Need to Do
Make certain that your billing staffs are aware of these changes.

Background
Under certain circumstances, it is necessary to include a modifier on a claim in order to receive a HPSA bonus payment. The QB and QU modifiers are the appropriate modifiers to be submitted for claims with dates of service prior to January 1, 2006. The AQ modifier is the appropriate modifier to be used for dates of service on or after January 1, 2006. Per direction from the Centers for Medicare & Medicaid Services (CMS), some Medicare contractors allow claims submitted with the QB and QU modifiers with dates of service on or after January 1, 2006 to be submitted and processed, though no bonus payment is made as the correct modifier has not been submitted. According to Health Insurance Portability and Accountability Act (HIPAA) regulations for transactions and code sets, as found in 45 Code of Federal Regulations (CFR) 160, providers must include valid codes and modifiers, as derived from the standard transaction code sets, on their incoming claims submitted to Medicare. Therefore, allowing claims with inappropriate modifiers to be accepted into the Medicare claims processing system constitutes a violation of the HIPAA standard transaction code sets.

In order to comply with HIPPA regulations and allow claims to be forwarded successfully to supplemental payers, as of October 1, 2007, Medicare will no longer accept claims submitted with the QB or QU modifiers for invalid dates of service. Claims must be submitted with the correct modifiers for the correct dates of service in order to be processed.

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR5629) issued to your Medicare carrier, or A/B MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1275CP.pdf on the CMS Web site.

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

Additional information on the HPSA bonus and the physician scarcity area bonus can be found at
http://www.cms.hhs.gov/HPSAPSAPhysicianBonuses/01_overview.asp on the CMS Web site.

The Guide for Using the HPSA/PSA Web Page can be viewed by going to http://www.cms.hhs.gov/HPSAPSAPhysicianBonuses/Downloads/instructions.pdf on the CMS Web site.

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Clarification of Manual Instruction Regarding Scope of Portable X-Ray Benefit

Provider Types Affected
Medicare providers who submit claims to Medicare contractors (Fiscal intermediaries (FIs), Part A/B Medicare Administrative Contractors (A/B MACs), carriers) for services rendered to Medicare beneficiaries for portable x-rays.

Provider Action Needed

STOP – Impact to You
Currently, the Medicare Benefit Policy Manual, Publication 100-02, chapter 15, section 80.4.3, relating to the scope of portable x-ray benefit is not completely consistent with regulations at 42 CFR 410.32(c)(3)(i). The manual section states that "skeletal films involving arms and legs" are covered services under the portable x-ray benefit.

CAUTION – What You Need to Know
In order to make certain the manual conforms to the regulations, the Centers for Medicare & Medicaid Services (CMS) is revising the manual to state that the benefit includes "skeletal films involving extremities". Although, the language differences are slight, the use of "extremities" in the regulation instead of "arms and legs" delineates coverage beyond 'arms and legs' to the hands, feet, toes, fingers, wrist and ankle. Language is also being added to include the coverage of diagnostic mammograms, when certain requirements are met.

GO – What You Need to Do
Make certain that your billing staffs are aware of these changes. Also, be aware that Medicare contractors will adjust claims previously processed incorrectly, if you bring those claims to their attention.

Background
CR5536 is the official document that announces these changes in Medicare processes. Attached to this document is the revised section of the Medicare Benefit Policy Manual section 80.4.3 - Scope of Portable X-Ray Benefit (Rev.71, Issued: 05-25-07, Effective: N/A; Implementation: July 2, 2007) the manual revision reads as follows and the bolded sections are new :

In order to avoid payment for services, which are inadequate or hazardous to the patient, the scope of the covered portable x-ray benefit is defined as:

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR5536) 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/R71BP.pdf on the CMS website.
If you have questions, please contact your Medicare carrier, FI or A/B MAC, at their toll-free number which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

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Clarification of the National Provider Identifier (NPI) Reporting Requirements for Ambulance Service Claims

National Provider Identifier (NPI) News – Medicare is now asking that submitters send a small number of claims using only the NPI. If no claims are rejected, the submitter can gradually increase the volume. Additional information can be found at the CMS NPI Web site at http://www.cms.hhs.gov/NationalProvIdentStand/.

Provider Types Affected
Providers and suppliers who bill Medicare carriers and Medicare Administrative Contractors (MACs) for ambulance services.

What You Need to Know
CR 5564, from which this article is taken, notifies carriers and Medicare Administrative Contractors (MACs) to not require you to include the ordering/referring physician's National Provider Identifier (NPI) on your claims for ambulance services.

You should make sure that your billing staffs are aware of this exception.

Background
Section 1833(q) of the Social Security Act (the Act), requires that the ordering/referring physician's name be provided on all claims for Medicare covered services and items resulting from a physician's order or referral. In addition, when the NPI reporting requirements go into effect according to the Medicare fee-for-service NPI contingency plan, the ordering/referring physician's NPI will also be required on these claims; except, however, on claims for ambulance services (as explained in the paragraphs below). (See MLN Matters article, MM5595, available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5595.pdf on the CMS Web site for details about the NPI contingency plan.)

The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandate the adoption of a standard unique health identifier for each health care provider. In response to this mandate, the Centers for Medicare and Medicaid Services (CMS) in the National Provider Identifier (NPI) final rule (published on January 23, 2004) established the NPI as this standard.
Although providers/suppliers may begin reporting the NPI as early as January 1, 2007, all health care providers covered under HIPAA must comply with the requirements of the NPI final rule in accordance with Medicare's NPI contingency plan. At the appropriate date, Medicare will reject claims in which the appropriate name and NPI are not entered in the required fields of the Form CMS-1500 paper claim format, version 08-05 (fields 17 and 17B, respectively), and the ANSI X12 837-P electronic claim format, version 4010A (NM1 segment of the 2310A and/or 2420E loop, respectively).

However, ambulance services (particularly transports provided in response to a 911 or 911-equivalent emergency call) are often ordered by someone other than a physician. In these situations, the name and the NPI of the ordering/referring physician are not available. Thus, CMS does not feel that it is appropriate to require that this information be submitted on the claim form. Therefore, CR 5564, from which this article is taken, instructs carriers and the Medicare Administrative Contractors (MACs) that the ordering/referring physician's NPI is not required on claims for ambulance services.

Additional Information
You can find the official instruction, CR 5564, issued to your carrier or MAC by visiting http://www.cms.hhs.gov/Transmittals/downloads/R1251CP.pdf on the CMS Web site.

If you have any questions, please contact your 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.

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Comprehensive Error Rate Testing (CERT) Report

The May 2007 Comprehensive Error Rate Testing (CERT) Report was published on May 15, 2007, on the CERT Web site, www.cms.hhs.gov/cert/ indicating that the national paid claims error rate for this reporting period is 4.2%, which equates to $10.4B.

Services incorrectly coded stood out as one of the top reasons for CERT errors. Specifically, the majority of these incorrectly coded claims relate to incorrectly coded Evaluation and Management (E&M) services in which the level of E&M service billed is not supported by the documentation submitted pertaining to the patient's condition and the key components of the E&M service.

This high rate of incorrectly coded Evaluation and Management (E&M) services generally implies that providers may be in need of education or review on how to properly code an Evaluation and Management (E&M) visit. Selecting the appropriate Evaluation and Management (E&M) code should be based upon medical necessity and the content of the service provided to the patient which needs to be supported by documentation in the patient's medical record.

It is important to remember:

  1. Documentation of the key components – the History, Physical Exam, and Medical Decision
    Making – should support the level of the E&M service billed.
  2. Per the Medicare Claims Processing Manual, Chapter 12, the selection of the level of Evaluation and Management service may be based on the duration of Coordination of Care and/or
    Counseling. When counseling and/or coordination of care dominates (more than 50 percent) the face- to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. The physician must document time
    spent with the patient in conjunction with the medical decision-making involved and a
    description of the coordination of care or counseling provided. Documentation must be in
    sufficient detail to support the claim.
  3. All billed E&M services must be based only on activities that are reasonable and necessary for the
    diagnosis or treatment of illness or injury (SSA 1862(a) (1) (A). ". . . Documentation of History, Physical Examinations, and Medical Decision Making should not be performed or billed at levels greater than needed for the patient's condition."
  4. As documented in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.1, "Medical
    necessity of a service is the overarching criterion for payment in addition to the individual
    requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of Evaluation and Management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record."

It Is Important To Note:

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Covered Indications for Chemotherapy Drugs and their Adjuncts

Spring 2007 Update
(Updates to ICD-9 Covered Indications are in Bold Numbers)

Labeled and Off-labeled Indications were based on the FDA Labeled Indications, the Spring 2007 Update 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.

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
 160.0-160.9, 170.0-170.9, 189.0, 194.0, 200.00- 200.88, 202.00-202.98, 204.00-204.91, 205.00 -205.11
Daunorubicin Citrate, Liposomal J9151
 176.0-176.9
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 157.9, 160.0-162.9, 164.0, 164.8, 170.0- 171.9, 174.0-176.9, 180.0-180.9, 181, 182.0, 183.0, 183.9, 185, 186.0, 186.9, 188.0-188.9, 189.0, 190.5, 193, 194.0, 195.0, 198.5, 200.00 to 204.11, 205.00-20501, 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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Implementation of the Carrier Jurisdictional Pricing Rules for All Purchased Diagnostic Service Claims

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.

Note: This article was revised on June 13, 2007, to delete an unnecessary note from page 2 regarding current processes and to add a bullet point (in italics) on page 3. All other information remains the same.
Provider Types Affected
Physicians, laboratories, and Independent Diagnostic Testing Facilities (IDTFs) who bill carriers/Medicare Administrative Contractors (MAC) for purchased diagnostic services.

Provider Action Needed
CR 5543, from which this article is taken, replaces the temporary physician billing instructions specified in CR 3630 (issued on December 23, 2004) with new billing procedures that (effective October 1, 2007) allow all physicians and suppliers to receive the correct payment amount for all purchased diagnostic services, including those performed outside of their local carrier's/Medicare Administrative Contractor's (MAC) jurisdiction.

Background
Through CR 3481, the Centers for Medicare and Medicaid Services (CMS), on April 1, 2005, implemented a Medicare Physician Fee Schedule (MPFS) national abstract file containing the Healthcare Common Procedural Coding System (HCPCS) codes, billable as a purchased diagnostic test/interpretation, for every locality throughout the country. With this file's implementation, CMS changed the carrier jurisdictional pricing rules for purchased diagnostic tests/interpretations to allow suppliers (including laboratories, physicians, and independent diagnostic testing facilities) to bill their local carrier/MAC for these services and receive the correct payment amount, regardless of the location where the service was performed. (See CR 3481, issued on October 29, 2004)

Note: Carrier jurisdictional pricing rules for all other services payable under the MPFS have remained in effect.

However, CMS delayed implementation of the CR3481's billing instructions for physicians, because of a previously noted potential problem with reporting the locality data in physician claims for such services performed outside of the local carrier's jurisdiction. Rather, through CR 3630, CMS implemented a temporary change in the carrier jurisdictional pricing rules for purchased diagnostic services to allow physicians providing out-of-jurisdiction diagnostic tests/interpretations to bill their local carrier for these services and receive the local rate.

CR 5543, from which this article is taken, replaces the temporary physician billing instructions specified in CR 3630 with new billing procedures to allow all physicians and suppliers to receive the correct payment amount for all purchased diagnostic services (based on the ZIP code of the location where the service was rendered, in accordance with the carrier jurisdictional pricing rules), including those performed outside of the local carrier's jurisdiction, effective for claims with dates of service on or after October 1, 2007.

CR 5543's key points include:

Additional Information
You can find the official instruction, CR5543, issued to your carrier or A/B MAC by visiting http://www.cms.hhs.gov/Transmittals/downloads/R1250CP.pdf on the CMS Web site.

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

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Important Information for Providers/Suppliers Regarding National Plan and Provider Enumeration System (NPPES) Errors, Using the NPI on Medicare Claims and 835 Remittance Advice Changes

National Provider Identifier (NPI) News – Medicare is now asking that submitters send a small number of claims using only the NPI. If no claims are rejected, the submitter can gradually increase the volume. Additional information can be found at the CMS NPI Web site at http://www.cms.hhs.gov/NationalProvIdentStand/.

Provider Types Affected
Physicians, providers, and suppliers who submit claims to Medicare fee-for-service contractors (Carriers, Fiscal Intermediaries (FIs), including Regional Home Health Intermediaries (RHHIs), Part A/B Medicare Administrative Contractors (A/B MACs), and Durable Medical Equipment Medicare Administrative Contractors (DME MACs))

Provider Action Needed

STOP – Impact to You
Certain information you enter into the National Plan and Provider Enumeration System (NPPES) in order to obtain and maintain your National Provider Identifier (NPI) is used by Medicare in processing claims.

CAUTION – What You Need to Know
If the information you entered in NPPES is not correct, your claims may reject. It is important to verify that information was entered correctly. Other guidance in this article will also help assure your claims are processed timely and correctly.

GO – What You Need to Do
The Centers for Medicare & Medicaid Services (CMS) recommends that physicians, providers, and suppliers validate their NPPES data and be sure their staff are aware of the key elements that need to be correct as explained in this article. Also, you may want to be sure your staff are aware of the important billing tips in this article.

Background
As Medicare begins to implement the NPI into its systems, several enumeration and billing errors have been identified that may result in claim rejections.

Common Enumeration Errors in NPPES
Below are some of the more frequent errors providers have been making when applying for NPIs:

Dos and Don'ts When Reporting "Other Provider Identification Numbers" in NPPES

If Medicare providers/suppliers determine that they should make changes to their NPPES records, they may do so by going to NPPES at https://nppes.cms.hhs.gov/ at any time and updating their information. Or, if they prefer, they may send updates on the paper NPI Application/Update Form (CMS-10114). Forms may be requested by calling the NPI Enumerator at their toll-free number, which is 1.800.465.3203, TTY 1.800.692.2326. The revised CMS-10114 is to be used beginning July 10, 2007. These forms can be obtained from the Enumerator, as outlined above, or you may download the form from the CMS Forms page at http://www.cms.hhs.gov/cmsforms on the Web.

CMS recommends that Medicare providers/suppliers make a copy of their NPPES information by doing a "print screen" of their NPPES record or make a photocopy of the completed paper NPI Application/Update form and keep it on hand for reference if they encounter problems.

Common Error in Reporting Change of Ownership to Medicare
Delays in reporting Change of Ownership: Whenever there is a change of ownership, the provider is responsible for reporting that change to the appropriate Medicare contractor within 30 days. Providers are supposed to report that change on the CMS-855.

How to Use Your NPI When Billing Medicare Part A (Institutional) Claims to a Fiscal Intermediary (FI) or A/B MAC

For providers who submit electronic Part A institutional claims to Medicare FIs or A/B MACs, a high volume of claims have been received where the NPI/legacy identifier combinations cannot be validated by the Medicare NPI crosswalk.

Failure to properly submit the NPI in the correct loops may cause the claim to reject. Organization providers should utilize their NPI in the 2010AA or 2010AB loop. The attending, operating or other physicians should be identified in the 2310A, B and C loops respectively. If 2420A loop is used, the Attending Physician NPI must be submitted.

Below is a guide to use when submitting primary NPI's:

Name/Loop Legacy Information NPI Information
Billing Provider 2010AA Loop OSCAR Provider NPI
Pay to Provider 2010AB Loop OSCAR Provider NPI
Attending Physician 2310A Loop PIN, UPIN Physician NPI
Operating Physician 2310 B Loop PIN, UPIN Physician NPI
Other Physician 21310C PIN, UPIN Physician NPI
Attending Physician 2420A PIN, UPIN Physician NPI

Some Medicare FIs and A/B MACs have developed front-end reason codes that will return claims to the providers when the NPI and Legacy combination submitted does not match the NPI crosswalk.

If a reject or RTP (Return to Provider) is received, providers are encouraged to verify that their NPI/Legacy combination is valid in NPPES first at https://nppes.cms.hhs.gov/ .

The following is a listing of Front-end Processing Reason Codes:

Code Desription
32000 This claim bas been rejected because the intermediary has no record of the Medicare provider number submitted.
32102 The claim contains an NPI but the first digit of the NPI is not equal to "1", "2", "3","4" or the 10th digit of the NPI does not follow the check digit validation routine. Please verify billing and, if appropriate, correct.
32103 NPI/OSCAR pair on the claim is not present in the Medicare NPI Crosswalk File.
This edit applies to the NPI associated with the OSCAR number. Please verify provider billing number and, if appropriate, please correct either NPPES or your CMS-855 information.

Please verify all of your information in NPPES. You should validate that the NPI/OSCAR pair you are using on the claim reflects the OSCAR number that you reported to NPPES. You may view/correct your NPPES information by going to https://nppes.cms.hhs.gov

If your NPPES information is correct, and you have included all Medicare legacy identifiers (OSCARS) in NPPES, but you are still experiencing problems with your claims that contain a valid NPI, you may need to submit a Medicare enrollment application (i.e. – the CMS 855). Please contact your contractor prior to submitting a CMS-855 form.
32104 The NPI and the legacy (OSCAR) number are present on the claim and the NPI is present int he Crosswalk File, but the associated legacy (OSCAR) number in the Crosswalk file does not match the legacy (OSCAR) number on the claim.
**Online providers – press PF9 to store the claim.
**Other providers – return to the intermediary.
32105

The NPI is present in the Crosswalk file but the NPI corresponds to more than one legacy (OSCAR) number.

Enter the OSCAR number associated with the NPI submitted. Please verify billing number and, if appropriate, correct.
***Online providers – Press PF9 to store the claim.
***Other Providers – Return to the intermediary.

32107 The NPI for the attending physician on the claim is not present in the Crosswalk File. Please verify billing number and, if appropriate, correct.
***Online providers - Press :F9 to store the claim.
*** Other providers - Return to the intermediary.
32108 The attending physisian's MPI and UPIN are present on the calim and the attending physician's MPI is present in the Crosswalk File, but the attending phsyciain's UPIN in the Crosswalk File does not match the attending physician's UPIN on the claim. Please verify the UPIN and, if appropriate, correct.
*** Online providers - Press PF9 to store the claim.
***Other providers - Return to intermediary.
32109 The operating physician's NPI on the claim is not present in the Crosswalk File. Please verify billing numebr and, if appropriate, correct.
***Online providers - Press PF9 to store the claim.
***Other providers - Return to the intermediary.
32110 The operating physician's NPI and UPIN are present on the claim and the operating physician's NPI is present int he Crosswalk File, but th eoperating physician's UPIN in the Crosswalk File does not match the operating physician's UPIN on the claim. Please verify the UPIN and, if appropriate, correct.
***Online provides - Pres sPF9 to store the claim.
***Other providers - Return to the intermediary.
32111 The other physician NPI on the claim is not presetn in the Crosswalk File. Please verify the billing number and, if appropriate, correct.
*** Online providers - Press PF9 to store the claim.
*** Other providers - Return to the intermediary.
32112 The other physician's NPI and UPIN are present on the claim and the other phsycian's NPI is present in the Crosswalk File, but th eother physciain's UPIN in the Crosswalk File does not match the other physician's UPIN on the claim.
Please verify the UPIN and, if appropriate, correct.
*** Online providers - Press PF9 to store the claim
***Other providers - Return the intermediary.
32113 The taxonomy code is required when the NPI is present in the Crosswalk File and the NPI corresponds to more than one legacy (OSCAR) number.
Please verify the billing number and, if approprite, correct.
***Online providers - Press PF9 to store the claim.
***Other providrs - Return to the intermediary.

If your FI or A/B MAC is using the MEDATRAN claims translator, below is a list of EDI Inbound Reject codes you may receive:

Edit Number Loop Edit Description
99 2010AA The NPI/Legacy combination does not match the NPI crosswalk.
99 2010AB The NPI/Legacy combination does not match the NPI crosswalk.
99 2310A,B, C The NPI/Legacy combination does not match the NPI crosswalk.
99 2420A The NPI/Legacy combination does not match the NPI crosswalk.

How to Use Your NPI When Billing Medicare Part B (Professional) Claims to Carriers and A/B MACs
For providers who submit electronic professional claims to Medicare Part B carriers and A/B MACs, CMS test data indicates that a high volume of claims have been received where the NPI/legacy identifier combinations cannot be validated by the Medicare NPI crosswalk.

Even if you have validated your NPPES data, failure to properly submit the NPI in the correct loops may cause the claim to reject. Group providers should utilize the materials for a full and accurate statement of their contents.

GROUP NPI in the 2010AA or 2010AB loop. The INDIVIDUAL or MEMBER OF GROUP NPI should only be submitted in the 2310B or 2420A loops.

Below is a guide to use when submitting primary NPI's:

Name/Loop Legacy Information NPI Information
Billing Provider 2010AA Loop Group PIN Individual PIN Group NPI
Individual NPI
Pay to Provider 2010AB Loop (this should only be submitted if different from Billing Provider) Group PIN Individual PIN Group NPI
Individual NPI
Rendering Provider 2310B Loop (this should only be submitted if a group practice) Individual/Member of Group PIN Individual/Member of Group NPI
Rendering provider 2420A Loop (this should only be submitted if a group practice) Individual/Member of Group PIN Individual/Member of Group NPI

Some carriers and A/B MACs will return the informational messages or edits below when the NPI and legacy identifier combination submitted doe snot match the NPI crosswalk. As of the date of this article calims with NPI/legacy identifiers are not rejecting because Part B contractors (except CIGNA Tennessee and Idaho), have "crosswalk bypass" logic in their system that will allow invalid pairs to process on the legacy number. The information edits you are receiving are a warning that your claims will reject whe the logic is remoed. Provides are encouraged to verify that the NPI/legacy identifier combination is valid on NPPES at https://nppes.cms.hhs.gov prior to submission of Medicare claims.

Following is a listing of the edits you may receive when billing Professional Part B claims:

Edit Number Loop Edit Description
M340 2010AA The NPI/Legacy combination does not match the NPI crosswalk.
M341 2010AB The NPI/Legacy combination does not match the NPI crosswalk
M343 2310B The NPI/Legacy combination does not match the NPI crosswalk
M347 2420A The NPI/Legacy combination does ot match the NPI crosswalk

Important Reminders Regarding 835 Remittance Advice Changes Effective July 2, 2007 for DME suppliers Submitting Claim to DME MACS Only.

DME suppliers are reminded that important changes will occur on your electronic remittance advice and your standard paper remittance actions, effective July 2, 2007. As of that date when you have submitted an NPI on your claim, your DME MAC will report on the 835 (or via the Medicare Remit Easy Print (MREP) Software) as follows:

When you do not report your NPI, but report your legacy National Supplier Clearinghouse (NSC) number on a claim, Medicare will continue to report legacy numbers in generating your remittance advice. Further information regarding the remittance changes may be found in CR5452, which is at http://www.cms.hhs.gov/Transmittals/downloads/R1241CP.pdf or in the related MLN Matters article, MM5452, at materials for a full and accurate statement of their contents. http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5452.pdf on the CMS Web site.

Important NOTE: The 835 Remittance Advice changes listed above will be effective for other providers submitting Part A Institutional claims and Part B Professional claims, at a later date. Medicare will notify submitters when a date is determined.

Additional Information
You may also want to review MLN Matters article SE0679, which has additional information on the overall NPI activity. This article is at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0679.pdf on the CMS Web site. Important information regarding current NPI implementation contingency plan is in article MM5595, which is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5595.pdf.

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.

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Intravenous Immune Globulin – LCD Revision

The LCDs for Intravenous Immune Globulin in all three CIGNA Government Services states will be revised per CMS change request 5635 to reflect the following changes:

Effective 06/30/2007 code J1567 will not be payable by Medicare.
Effective 07/01/2007, use one of the following codes as appropriate in place of J1567:

Q4087 Octagam Injection (IVIG, non-lyophilized (e.g. liquid), 500 mg)
Q4088 Gammagard Liquid Injection (IVIG, non-lyophilized (e.g. liquid), 500 mg)
Q4091 Flebogamma Injection (IVIG, non-lyophilized (e.g. liquid), 500 mg)
Q4092 Gammunex Injection (IVIG, non-lyophilized (e.g. liquid), 500 mg)

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Join CIGNA Government Services ListServ

By joining the CIGNA Government Services electronic mailing list, you can get immediate updates on all Medicare information, including: Medicare publications, important updates, workshops, and medical review information. To join the ListServ follow this link: http://www.cignagovernmentservices.com/medicare_dynamic/mailer/reminder.asp

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

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.

Note: This article was revised on June 25, 2007, to delete references in the title and elsewhere to a revised October 2006 ASP file. All other information is the same.

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

Provider Action Needed
This article is based on Change Request (CR) 5646 which informs Medicare providers of the availability of the July 2007 Average Sales Price (ASP) drug pricing file for Medicare Part B drugs as well as the revised January 2007 and April 2007 ASP files. Providers should make certain that your billing staffs are aware of these changes.

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. CMS also posts these files to its Web site at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/.

As announced in late 2006, after carefully examining Section 1847A of the Social Security Act, as added by the Medicare Modernization Act of 2003, CMS has been working further to ensure that more accurate and, as appropriate, separate payment is made for single source drugs and biologicals under Section 1847A. As part of this effort, CMS reviewed how the terms "single source drug," "multiple source drug," and "biological product" are operationalized in the context of payment under section 1847A. For the purposes of identifying "single source drugs" and "biological products" subject to payment under section 1847A, generally CMS (and its contractors) will utilize a multi-step process. CMS will consider:

For a biological product (as evidenced by a new FDA Biologic License Application or other relevant FDA approval) or a single source drug (that is, not a drug for which there are two or more drug products that are rated as therapeutically equivalent in the most recent FDA Orange Book) first sold in the United States after October 1, 2003, the payment limit under Section 1847A for that biological product or single source drug will be based on the pricing information for products produced or distributed under the applicable FDA approval. As appropriate, a unique HCPCS code will be assigned to facilitate separate payment. Separate payment may also be operationalized through use of existing specific HCPCS codes or "not otherwise classified" HCPCS codes.

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.

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:

On or after June 19, 2007, revised January 2007 and April 2007 ASP payment files and the July 2007 ASP file will be available for retrieval from the CMS ASP Web page. 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 Web 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 Service
July 2007 July 1, 2007 through September 30, 2007
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 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 shall 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. Note that pricing for compounded drugs is done by your local Medicare contractor.

Additional Information
The official instruction (CR5646) issued to your Medicare carrier, FI, A/B MAC, DME MAC, DMERC, or RHHI is available at http://www.cms.hhs.gov/Transmittals/downloads/R1270CP.pdf on the CMS Web site.
If you have questions, please contact your Medicare carrier, FI or 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.

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

The Centers for Medicare & Medicaid Services (CMS) is now soliciting bids for the first round of the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program. All bids are due by 9:00 p.m. prevailing Eastern Time on July 13, 2007. The contract period for mail order diabetic supplies is April 1, 2008 – December 31, 2009. The contract period for all other first round product categories is April 1, 2008 – March 31, 2011. Suppliers must be accredited or have pending accreditation to submit a bid and will need to be accredited to be awarded a contract. The accreditation deadline for the first round of competitive bidding is August 31, 2007. Suppliers should apply for accreditation immediately to allow adequate time to process their applications. Suppliers interested in bidding must first register and receive a User ID and Password before they can access the internet-based bid submission system. Suppliers should register immediately to avoid a delay in being able to submit bids. The registration deadline is June 30, 2007. For more information on the program as well as bidding and accreditation information, please visit
http://www.dmecompetitivebid.com or http://www.cms.hhs.gov/CompetitiveAcqforDMEPOS.

Note: This article was revised on June 19, 2007, to clarify that the modifier that should not be used with HCPCS codes E0691, E0692, E0693, and E0694 for dates of service on or after January 1, 2005, is the KF modifier. All other information remains the same.

Provider Types Affected
Providers and suppliers submitting claims to Medicare contractors (carriers, DME 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) 5641, which provides the July 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 or that may no longer be paid under the fee schedule. Be sure billing staff are aware of these changes.

Background
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 on the CMS Web site.
CR 5641 provides specific instructions regarding the July 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 Points
The following are key changes in the July 2007 quarterly update of the DMEPOS fee schedule including the Healthcare Common Procedure Coding System (HCPCS) codes:


Also, after consulting with the Food and Drug Administration, the Centers for Medicare & Medicaid Services (CMS) determined that ultraviolet light therapy systems are classified as class II devices and are not class III devices. Thus, suppliers should not submit the class III "KF" modifier with claims for HCPCS codes E0691, E0692, E0693 and E0694 with dates of service on or after January 1, 2005. CMS is removing HCPCS codes E0691, E0692, E0693, and E0694, billed with the KF modifier, from the fee schedule, effective July 1, 2007 and as of that date, Medicare contractors will reject claims for HCPCS codes E0691, E0692, E0693, and E0694, which contain the KF modifier and a date of service on or after January 1, 2005. Medicare contractors will adjust previously processed claims for E0691, E0692, E0693 and E0694 with dates of service on or after January 1, 2007, if suppliers resubmit the claims as adjustments.

The HCPCS Quarterly Update public use file, containing the long and short descriptors for all new codes, is available for downloading at: www.cms.hhs.gov/HCPCSReleaseCodeSets/02_HCPCS_Quarterly_Update.asp.

Additional Information
If you have questions, please contact your Medicare A/B MAC, FI, DMERC, DME MAC, RHHI or carrier at their toll-free number which may be found at:
http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.
For complete details regarding this Change Request (CR) please see the official instruction (CR5641) issued to your Medicare A/B MAC, FI, DMERC, DME MAC, RHHI or carrier. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1263CP.pdf on the CMS Web site.

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July, 2007 Quarterly Update to the HCPCS Codes for Albuterol, Levalbuterol, and Reclast®

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.

Provider Types Affected
Physicians, providers, and suppliers who bill Medicare contractors (carriers, fiscal intermediaries (FI)(including Regional Home Health Intermediaries (RHHI)), Medicare Administrative Contractors (A/B MAC) and Durable Medical Equipment Medicare Administrative Contractors (DME MAC)) for providing Albuterol, Levalbuterol, Reclast®, and Zometa® to Medicare beneficiaries.

What Providers Need to Know
CR 5645, from which this article is taken, implements the July 2007 quarterly update to the HCPCS Codes for Albuterol, Levalbuterol, and Reclast®.

Effective for dates of service on or after July 1, 2007, the following HCPCS codes are no longer payable by Medicare: J7611, J7612, J7613, and J7614; and the following are payable by Medicare: Q4093, Q4094, and Q4095. Code J3487 continues in use for Zometa®.

You should make sure that your billing staffs are aware of these HCPCS code changes.

Background
CR 5645, from which this article is taken, implements the July, 2007 quarterly update to the HCPCS Codes for Albuterol, Levalbuterol, and Reclast®.

Effective July 1, 2007, the Health Care Procedure Code System (HCPCS) codes in table 1 will no longer be payable for Medicare.

Table 1
HCPCS Codes Not Payable for Dates of Service on or after July 1, 2007

HCPCS Code Short Description Long Description
J7611 Albuterol non-comp con Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 1 mg
J7612 Levalbuterol non-comp con Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 0.5 mg
J7613 Albuterol non-comp unit Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg
J7614 Levalbuterol non-comp unit Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 0.5 mg

In place of the Table 1 codes, the HCPCS codes displayed in Table 2 will be payable, effective July 1, 2007.

Table 2

HCPCS Code Short Description Long Description
Q4093 Albuterol inh non-comp con Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, per 1 mg (Albuterol) or per 0.5 mg (Levalbuterol)
Q4094 Albuterol inh non-comp u d
Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, per 1 mg (Albuterol) or per 0.5 mg (Levalbuterol)

HCPCS Codes Payable for Services on or After July 1, 2007
In addition, a new code, Q4095 (in Table 3) will be effective July 1, 2007, for Reclast®.

Table 3

HCPCS Code Short Description Long Description
Q4095 Reclast injection Injection zoledronic acid (Reclast), 1 mg

Also, please note the following:

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Bone Mass Measurements - LCD Revision

The LCDs for Bone Mass Measurement have been revised per CMS change request 5521. Please refer to the CIGNA Government Services Web site at
http://www.cignagovernmentservices.com to view the policy and http://www.cms.hhs.gov/MLNMattersArticles/downloads/mm5521.pdf to review the MLN Matters Article.

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Medical Review Frequently Asked Questions

The following represent a variety of questions the Medical Review department has received. CIGNA Government Services will address at least quarterly "Frequently Asked Questions" related to coverage and local medical review policy issues. Providers may submit questions to the Web site at http://www.cignagovernmentservices.com/medicare_dynamic/customer_service/index.html

1. Guidelines for X-Stop Device
Question: What are the criteria for coverage of this procedure?

Answer: This procedure is covered for patients ages 50 and above who have a diagnosis of lumbar stenosis and have undergone six months' of nonoperative treatment without improvement. The first level would be billed for using CPT code 0171T. If medically necessary for the individual patient, one additional level may be paid using code 0172T. These claims are carrier-priced; and therefore, each claim is considered on a case-by-case basis. Therefore, if on initial claim submission, if the patient has met the age and diagnosis criteria, providers will be sent a request for documentation to determine if the other criteria have been met.

2. Guidelines for physician supervised weight loss prior to Bariatric surgery
Question: What documentation is required to be in the chart of patients undergoing weight loss surgery to show they have participated in a supervised weight loss program?

Answer: We would expect that the medical record reflect at least three failed attempts to lose weight on a supervised non-surgical weight loss program of which one of these attempts having been a physician directed program for at least 6 consecutive months (with corresponding monthly notes that included the assessments as follows and as itemized in the each state's local coverage decision):
-Vital signs to include weight
- Current dietary program
- Physical activity/exercise program
- Behavioral interventions
- Consideration of or use of pharmacotherapy with FDA-approved medication, if appropriate

We'd expect that the physician directed program would have recently preceded (i.e. no more than 12-18 months before) the referral to surgical treatment. Please closely review the policy for all requirements:

TN policy:
http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=24057&lcd_version=5&show=all

NC policy:
http://www.cms.hhs.gov/MCD/viewlcd.asp?lcd_id=23540&lcd_version=3&basket=lcd%3A23540%3A3%3ABariatric+Surgery+%28Surgical+Management+of+Morbid+Obesity%29%3ACarrier%3ACIGNA+Government+Services+%2805535%29%3A

ID policy:
http://www.cms.hhs.gov/MCD/viewlcd.asp?lcd_id=24055&lcd_version=6&show=all

3. Therapy recertification & MD visits
Question: Does the patient have to see the doctor every 30 days in order to continue therapy?

Answer: CMS Publication 100-2, the Medicare Benefit Policy Manual, Chapter 15, Section 220.1.3, subsection C, addresses this question under "Physician/NPP options for Certification." It states: (via this link: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf)

"Physicians/NPPs (non-physician practitioners) may require that the patient make a visit for an examination if, in the professional's judgment, the visit is needed prior to certifying the plan. Physicians/NPPs should indicate their requirement for visits, preferably on an order preceding the treatment, or on the plan of care. Physicians/NPPs should not sign a certification if they require a visit and a visit was not made. However, Medicare does not require a visit unless the National Coverage Determination (NCD) for a particular treatment requires it (e.g., see Pub. 100-03, §270.1 - Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds)."

4. Update on Shingles Vaccination (previously published 092906)
Question: Does Medicare cover Zostavax and its administration?

Answer: Effective January 1, 2007, physicians administering a Part D vaccine should bill to their Part B carrier HCPCS code G0377. Medicare will not pay for the vaccine itself. If the beneficiary is enrolled in Part D, payment for the Part D covered vaccine is made solely by the participating Prescription Drug Plan.
As of January 1, 2008, HCPCS code G0377 can no longer be billed to Part B. At that time, providers will need to bill the patient for the vaccine and its administration, and the patient will need to submit the claim to the Part D plan for reimbursement.

For additional information see the attached CMS articles:


Previous FAQ (question #1 September 2007 issue):http://www.cignamedicare.com/articles/Sept06/Cope4869.html

5. Update on sodium hyaluronates (previously published 060106)
Question: Does Medicare cover viscosupplementation treatment of the knee?

Answer: The following link is to an article from January 12, 2007 publishing the most recent guidelines for these services: http://www.cignamedicare.com/articles/Jan07/cope5205.html

Four interim Q codes are in effect for these products as of January 1, 2007, i.e. Q4083 (Hyalgan/supartz injection per does), Q4084 (Synvisc injection per dose), Q4085 (Euflexxa injection per dose), and Q4086 (Orthovisc injection per dose). These replace HCPCS codes J7317 and J7320 referenced in the June 2006 issue of "Frequently Asked Questions." The remainder of the 011207 article details covered diagnoses, guidelines for repeat use, and guidelines for billing an evaluation and management service the same date as the joint injection of one of these drugs.

For additional information see the attached CMS article: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5459.pdf
Previous FAQ (question #6 June 2006 issue):
http://www.cignamedicare.com/articles/June06/cope4333C.html

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Medicare Contractor Annual Update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)

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.

Provider Types Affected
Physicians, suppliers, and providers billing Medicare contractors (carriers, Medicare administrative Contractors (A/B MACs), durable medical equipment administrative contractors (DMACs), and fiscal intermediaries (FIs) including regional home health intermediaries (RHHIs))

What Providers Need to Know
CR 5643, from which this article is taken, reminds the Medicare contractors and providers that the annual ICD-9-CM update will be effective for dates of service on and after October 1, 2007 (for institutional providers, effective for discharges on or after October 1, 2007).

You can see the new, revised, and discontinued ICD-9-CM diagnosis codes on the CMS Web site at
http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/07_summarytables.asp#TopOfPage, or at the National Center for Health Statistics (NCHS) Web site at http://www.cdc.gov/nchs/icd9.htm in June of each year.

Background
ICD-9- CM codes, became mandatory as follows:

The ICD-9-CM codes are updated annually as stated in the Medicare Claims Processing Manual, Chapter 23 (Fee Schedule Administration and Coding Requirements), Section 10.2 (Relationship of ICD-9-CM Codes and Date of Service).

CMS issued CR 5643 as a reminder that the annual ICD-9-CM coding update will be effective for dates of service on or after October 1, 2007 (for institutional providers, effective for discharges on or after October 1, 2007).

You should remember that an ICD-9-CM code is required for all professional claims (including those
from physicians, non-physician practitioners, independent clinical diagnostic laboratories, occupational and physical therapists, independent diagnostic testing facilities, audiologist, ambulatory surgical centers (ASCs)), and for all institutional claims; but is not required for ambulance supplier claims.

Additional Information
You can find the official instruction, CR5643, issued to your Medicare contractor by visiting
http://www.cms.hhs.gov/Transmittals/downloads/R1269CP.pdf on the CMS Web site. As mentioned, you can find the new, revised, and discontinued ICD-9-CM diagnosis codes on the CMS Web site at
http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/07_summarytables.asp#TopOfPage, or at the

National Center for Health Statistics (NCHS) Web site at
http://www.cdc.gov/nchs/icd9.htm, in June of each year. The annual ICD-9-CM code changes are also included in a CD-ROM, which you can purchase for $25.00 from the Government Printing Office (GPO), stock number 017-022-01573-1.

To learn more about ICD-9-CM codes, you might want to read Medicare Claims Processing Manual, Chapter 23 (Fee Schedule Administration and Coding Requirements), Section 10.2 (Relationship of ICD-9-CM Codes and Date of Service); or look at the information provided at http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/01_overview.asp#TopOfPage on the CMS Web site.

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

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Medicare Payment for Ambulance Transports

If you treat a Medicare Advantage enrolled beneficiary and you have questions about their Medicare Advantage 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 CMS Web site. CMS updates this site on a monthly basis.

Provider Types Affected
Providers, physicians, and suppliers who bill Medicare fiscal intermediaries (FIs), carriers, and A/B Medicare Administrative Contractors (MAC) for ambulance services or who initiate ambulance transports for their Medicare patients.

Provider Action Needed

STOP – Impact to You
According to a recent study conducted by the Office of the Inspector General (OIG), "Medicare Payments for Ambulance Transports," during the calendar year 2002, twenty-five percent of ambulance transports did not meet Medicare's program requirements. This resulted in an estimated $402 million of improper payments. In two out of three cases, third-party providers (most likely not the patient) who requested transports may not have been aware of Medicare's requirements for ambulance transports.

CAUTION – What You Need to Know
Liability for overpayment resulting from a denied ambulance transport claim depends on the type of denial. A denial due to coverage reasons (such as when other forms of transportation are not contraindicated) may result in a liability to the Medicare beneficiary unless he or she lacks constructive knowledge that the service is not covered. Claims denied due to level of service requirements are often down-coded to a lower level of ambulance service. In this case, the ambulance supplier is generally liable in the event of an overpayment.

GO – What You Need to Do
Please refer to the Background and Additional Information sections of this article and make certain that, if there are other payers, these situations are identified. It is important to know whether the use of an ambulance transport for your patient would be covered by Medicare, and if so, what level of service would be covered. Please refer to the Background section of this Special Edition article for information about payment and level of service requirements for ambulance transports.

Background
Some key provisions of the OIG Report are as follows:

Medicare Coverage of Ambulance Transports
When evaluating coverage of ambulance transport services, two separate questions are considered:

  1. Would the patient's health at the time of the service be jeopardized if an ambulance service was not used? If so, Medicare will cover the ambulance service whether it is emergency or non-emergency use of the transport. If not, the Centers for Medicare & Medicaid Services (CMS) will deny the transport claim. Additionally, Medicare does not cover non-ambulance transports.
  2. Once coverage requirements are met, Medicare asks the following question: What level of service (determined by medical necessity) is appropriate with regard to the diagnosis and treatment of the patient's illness or injury? If the incorrect level of service is billed and subsequently denied, Medicare will usually reimburse at a lower rate reflecting the lower level of services judged appropriate.

Levels of ambulance service are differentiated by the equipment and supplies carried in the transport and by the qualifications and training of the crew. They include:

  1. Basic life support
  2. Advanced life support
  3. Specialty care transport
  4. Air transport – fixed wing and rotary wing

Emergency Ambulance Transport
An emergency transport is one provided after the sudden onset of a medical condition that manifests itself with acute symptoms of such severity that he absence of immediate medical attention could reasonably be expected to:

Symptoms or conditions that may warrant an emergency ambulance transport include, but are not limited to:

Non-Emergency Ambulance Transports
Non-emergency ambulance transportation is appropriate with a patient who is bed-confined AND
his/her condition is such that other methods of transportation are contraindicated; OR if the patient's condition, regardless of bed-confinement, is such that transportation by ambulance is medically required (patient poses a danger to him or herself or to others). Bed-confinement alone is neither sufficient nor necessary to determine the coverage for Medicare benefits. To be considered bed-confined, the patient must be unable to do all three of the following:

Documentation Requirements
Ambulance suppliers are not required to submit documentation in addition to the uniform Medicare billing form CMS-1500 submitted by independent ambulance suppliers to Medicare carriers or A/B MACs or the UB-04 (form CMS-1450) billed to FIs or A/B MACs by ambulance suppliers that are owned by or affiliated with a Medicare Part A provider such as a hospital.

However, ambulance suppliers are required to retain documentation that contains information about the personnel involved in the transport and the patient's condition and to be made available to Medicare FIs, carriers, and A/B MACs upon request. Ambulance suppliers are also required to obtain a Physician Certification Statement (PCS) for non-emergency transports. The PCS states the reason(s) a patient requires non-emergency transportation by ambulance. It is effective for 60 days from the date it is signed. The PCS, or proof of the supplier's attempt to obtain it, is required within 48 hours after provision of the ambulance service. The "trip ticket" is documentation used in emergency transports and contains the date, mileage, crew, origin, destination, type and level of ambulance service provided, patient condition, the type of service, and supplies provided to the patient while in transport.

How to Avoid Improper Billing

Additional Information
SE0724 is based on the January 2006 U.S. Department of Health and Human Services (HHS) OIG report, Medicare Payments for Ambulance Transports, which is located at http://oig.hhs.gov/oei/reports/oei-05-02-00590.pdf on the OIG HHS Web site.

CR 5422, dated February 23, 2007, "Ambulance Fee Schedule – Medical Conditions List – Manualization
Revisions," is located at http://www.cms.hhs.gov/transmittals/downloads/R1185CP.pdf on the CMS Web site.

If you have questions, please contact your local Medicare contractor at their toll-free number, which may be found in the Provider Call Center Toll-Free Numbers Directory. The directory is available in the "Downloads" Section of the Medicare Learning Network Contact Us Page located at http://www.cms.hhs.gov/MLNGenInfo/30_contactus.asp on the CMS Web site.


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Medigap Claim-Based Crossover Moves to a Consolidated, Standardized Process

Dear Medigap Insurer:
This announcement is to inform you that, effective October 1, 2007, the Centers for Medicare & Medicaid Services (CMS) will transfer the mandatory Medicare supplemental (Medigap) insurance claim-based crossover process from its Medicare contractors to the national Coordination of Benefits Contractor (COBC). The definition of a "Medicare supplemental (Medigap) policy" is found at §1882(g)(1) of the Social Security Act, the text of which is being attached for your reference. The Medigap crossover process is mandated by §1842(h)(3)(B) of Title XVIII of the Social Security Act and is activated when 1) a participating Medicare provider includes a specific identifier on the beneficiary's claim and 2) the beneficiary assigns payment rights to that provider.

What Does This Mean to You?
The CMS is expecting your organization to contact the COBC during June 2007 regarding your need to sign a national Coordination of Benefits Agreement (COBA) that will enable you to continue receiving Medigap claim-based crossover claims. You may reach the COBC for this purpose by dialing 1.646.458.6740. The executed COBA will address claim transfer protocols, the frequency of the claim transfers (available options include daily, weekly, bi-weekly, or monthly), and the standard crossover fee. After your organization has signed the COBA, you will be assigned a new 5-byte COBA Medigap claim-based identifier. All participating providers will then have access to the Medigap insurer's new COBA Medigap claim-based identifier prior to October 1, 2007, and will be required to include this new identifier on your policy or certificate holders' incoming Medicare claims to successfully trigger mandatory Medigap claim-based crossovers.

With the transition of the Medigap claim-based crossover process to the COBC, Medigap insurers will enjoy the benefit of only needing to interact with one entity when they have questions or concerns. In addition, the Medigap insurers will now receive their claims and invoices from a single entity rather than individually from numerous Medicare contractors across the nation.

Effective October 1, 2007, CMS will discontinue the use of all non-standard claim formats, including National Standard Format (NSF) and paper claims. As "covered entities" under the final Health Insurance Portability and Accountability Act (HIPAA) transactions and code sets rule, Medigap insurers must be able to accept the standard HIPAA American National Standards Institute (ANSI) X12-N 837 professional coordination of benefits (COB) version 4010-A1 claim. In addition, your organization should be able to accept National Council for Prescription Drug Programs (NCPDP) version 5.1 batch standard 1.1 Part B drug claims. However, CMS is not mandating receipt of NCPDP batch standard claims at this time. CMS will advise your organization when acceptance of these claims is required. Therefore, effective October 1, 2007, your organization will receive Part B physician and supplier claims in the HIPAA ANSI X12-N 837 professional claim (with receipt of NCPDP batch standard claims to follow in the future). In accordance with volume 55, number 225 of the November 21, 1990, Federal Register Notice, CMS will exclude non-assigned, fully paid original and fully paid adjustment claims, fully denied original and fully denied adjustment claims, and non-monetary adjustment claims from its national COBA Medigap claim-based crossover process with your organization..

Medigap insurers will continue to receive their crossover claims from their associated Medicare contractors at their currently designated frequency and in their currently designated claims format during the interim period from June 1 to September 30, 2007. Until October 1, 2007, the only change to the current Medigap claim-based process is that the Medigap insurer will be replacing its current identifier that initiates claim-based crossover to the 5-byte COBA Medigap claim-based identifier for processing purposes. This change will occur shortly after execution of the COBA.

What Can My Organization Do to Be Prepared for the October 1, 2007, Change?
Since your organization will no longer receive Medigap claim-based crossovers from CMS' Medicare contractors effective October 1, 2007, CMS strongly encourages all Medigap insurers that are currently receiving their crossovers via this methodology to act now and contact the COBC at 1-646-458.6740 to obtain more information about signing the national Coordination of Benefits Agreement (COBA). Your COBA will need to be signed during the months from June to August 2007, to allow your organization sufficient time for testing with the COBC in advance of the October 1, 2007, implementation. In addition, since Medicare will exclusively be crossing claims over to your organization in the standard HIPAA ANSI X12-N 837 professional claim format effective October 1, 2007, your organization may need to consider planning now to contract with an outside vendor that is able to accept the standard HIPAA claims format on your behalf.

Upon receipt of your COBA Medigap claim-based identifier, your organization should initiate provider and member education on the use of the new identifier. CMS recommends that, in accordance with §1882(c)(3)(C) of the Social Security Act, you consider issuing new cards to your Medigap policy and certificate holders that inform them of the new COBA Medigap claim-based ID for your organization. This will assist your policy or certificate holders with ensuring that their providers include the correct number on their incoming claims to Medicare. In addition, Medicare will be conducting extensive provider education concerning the new COBA Medigap crossover process through its Medicare contractor provider communication channels and Web sites.

If your organization currently provides an eligibility file to initiate COBA Medigap crossovers, you may simply add all policy or certificate holders to your COBA eligibility file and maintain your current COBA identifier. In addition, please contact your COBC EDI or CMS representative for information on discontinuing your current Medigap claim-based crossover contract(s) with the Medicare contractor(s) if applicable.

What Other Details Should My Organization Know?
Effective with claims received after your COBA has been executed, your previously assigned Other Carrier Name and Address (OCNA) or N-key Medigap identifier will no longer be accepted on participating provider claims as a basis for triggering the crossing over of adjudicated claims to your organization. Also, unless your organization has executed a COBA with the COBC prior to October 1, 2007, your organization will be unprepared to test the new process with the COBC and, consequently, will be unable to receive production claim-based crossover claims following the implementation of the new process on October 1, 2007.

Starting October 1, 2007, claims will exclusively be selected for crossover to your organization through the new COBA Medigap claim-based crossover process. CMS' Medicare contractors will cease crossing claims directly to your organization. In addition, all current Medigap claim-based crossover recipients are advised that CMS' Medicare contractors will automatically terminate any existing crossover agreements with your organization no later than October 31, 2007, following your receipt of the final or residual claims that were tagged for crossover directly from the Medicare contractors prior to October 1, 2007.
If your organization has already signed a COBA with the COBC to participate in the eligibility file-based crossover process but you wish to continue receipt of claim-based crossovers for a portion of your policy or certificate holders, your organization will need to sign a new COBA (base agreement and attachment) to address your receipt of claims via the COBA Medigap claim-based crossover process.

The CMS and its COBC look forward to working with your organization to ensure a smooth transition from your current Medigap claim-based crossover process to the consolidated COBA Medigap claim-based crossover process.

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Notifying Affected Parties Regarding Changes to the Mandatory Medigap ("Claim-Based") Crossover Process

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 June 26, 2007, to reflect a corrected Web address on page 3 as noted when CR5662 was re-issued on June 26. All other information remains the same.

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

What Providers Need to Know
CR 5662, from which this article is taken, outlines the processes that Part B carriers, Medicare Administrative Contractors (MACs) responsible for Part B claims processing, and Durable Medical Equipment Medicare Administrative Contractors (DMACs) shall follow in notifying affected parties that the mandatory Medigap (claim-based) crossover process is being transitioned to the Coordination of Benefits Contractor (COBC) effective October 1, 2007

Background
The Centers for Medicare & Medicaid Services (CMS) has decided that, effective October 1, 2007, all mandatory Medigap ("claim-based") crossovers will now be accomplished through its Coordination of Benefits Contractor (COBC). Further, CMS has decided that, in accordance with Public Law 104-191 and 45 Code of Federal Regulations (CFR) 160, it will only transmit claims to Medigap claim-based crossover recipients in the Health Insurance Portability and Accountability Act (HIPAA) American National Standards Institute (ANSI) X12-N 837 professional (version 4010A1) coordination of benefits (COB) claim format or in the National Council for Prescription Drug Programs (NCPDP) version 5.1 batch standard 1.1 format. (NOTE: The systematic requirements relating to this transition were communicated via change request (CR) 5601, as reflected in MLN Matters article MM5601 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5601.pdf on the CMS Web site.)

Starting with June 2007, CMS' COBC will gradually begin to assign new Medigap claim-based COBA identifiers (range 55000 to 59999) to Medigap insurers that have not voluntarily moved to the COBA eligibility file-based crossover process. CMS anticipates that the COBC will complete the execution of crossover agreements with Medigap claim-based insurers and assign new COBA Medigap claim-based identifiers to these entities by August 31, 2007. As the COBC assigns a new COBA Medigap claim-based ID to a Medigap claim-based crossover recipient, CMS will alert all Part B contractors, including MACs, and DMACs via e-mail of this action on a weekly basis. The CMS alert will include the following information: affected entity's name; the entity's multiple formerly contractor-assigned Other Carrier Name and Address (OCNA) or N-key identifiers; and its newly assigned COBA Medigap claim-based ID. Upon receipt of the CMS alert, the affected contractors shall manually add the newly assigned COBA Medigap claim-based ID to their existing insurer screens or tables to replace the formerly assigned OCNA or N-key identifier. Contractors shall also maintain a link to the COB Web site (http://www.cms.hhs.gov/COBAgreement) for purposes of receiving updates to the COBA Medigap claim-based ID listing.

The affected contractors shall post CMS' Medigap claim-based crossover transition announcement in its entirety on their Web sites that are accessed by the public and insurers. These contractors shall also mail the CMS announcement on a one-time basis to their electronic Medigap claim-based crossover recipients and shall also notify their paper claim recipients through information included with their next scheduled claim mailings.

Providers should note the following: Effective October 1, 2007, the COBC will assume responsibility for the Medigap claim-based crossover, which is driven by information that participating providers enter on the incoming claim. The primary change for providers resulting from this transition will be that they will need to include a new Medigap identifier, even in advance of October 1, 2007, on their incoming Medicare claims to trigger crossovers to Medigap insurers. During June through August 2007, CMS will assign each Medigap insurer that does not provide an eligibility file to the COBC to identify all of its covered policy or certificate holders for crossover purposes a new 5-digit COBA Medigap claim-based identifier (ID). Providers may reference a weekly updated listing of the newly assigned COBA Medigap claim-based IDs for Medicare billing purposes at the following Web site: http://www.cms.hhs.gov/COBAgreement/Downloads/Medigap Claim-based COBA IDs for Billing Purpose.pdf. Once the COBC has assigned a new COBA Medigap claim-based ID to a Medigap insurer, participating providers that wish to trigger crossovers to Medigap insurers will be required to include that new identifier, as found on the CMS COB Web site, on their incoming Medicare claims. Failure to do so will result in their claims not being successfully crossed over to the Medigap insurer. If the older contractor-assigned number is included on the claim, Medicare will include the standard MA19 message—'Information was not sent to the Medigap insurer due to incorrect/invalid information you submitted concerning the insurer. Please verify your information and submit your secondary claim directly to that insurer.'—on the provider's electronic remittance advice (ERA) or other production remittance advice for the associated claim(s). Participating providers that are permitted under Administrative Simplification Compliance Act (ASCA) to bill Medicare on paper should include the newly assigned 5-digit COBA Medigap claim-based ID within block 9-D of the CMS-1500 claim form. Providers that are required to bill Medicare electronically using the Health Insurance Portability and Accountability Act (HIPAA) American National Standards Institute (ANSI) X12-N 837 professional claim shall include the newly assigned 5-byte only COBA Medigap claim-based ID (range=55000 to 59999) left-justified in field NM109 of the NM1 segment within the 2330B loop and followed by spaces. (See important note that follows regarding the submission of claims to DMACs.)

Retail pharmacies that bill National Council for Prescription Drug Programs (NCPDP) batch claims to Medicare shall include the newly assigned Medigap identifier left-justified within field 301-C1 of the T04 segment of their incoming NCPDP claims and followed by spaces. IMPORTANT: For all of the claim submission situations discussed above, suppliers (including retail pharmacies) that bill DMACs must include an accompanying 4-byte "Z001" identifier with the newly assigned COBA Medigap claim-based crossover ID (for example, 55000Z001) when seeking to trigger Medigap claim-based crossovers during the interim transitional period, which runs from June through September 30, 2007.

Providers should notify their clearinghouses and billing vendors of the impending changes to the existing Medigap claim-based crossover process as soon as possible.

Additional Information
You can find the official instruction, CR5662, issued to your carrier, MAC, or DMAC by visiting
http://www.cms.hhs.gov/Transmittals/downloads/R283OTN.pdf on the CMS Web site.
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

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October Quarterly Update to 2007 Annual Update of HCPCS codes Used for Skilled Nuring Facility (SNF) Consoliated Billing (CB) Enforcements

National Provider Identifier (NPI) NEWS – Medicare is now asking that submitters send a small number of claims using only the NPI. If no claims are rejected, the submitter can gradually increase the volume. Additional information can be found at the CMS NPI Web site at http://www.cms.hhs.gov/NationalProvIdentStand/.

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

What Providers Need to Know

Background
Periodically, the Centers for Medicaid & Medicare Services (CMS) updates the lists of HCPCS codes (for FIs carriers and DME/MACs) that are subject to the consolidated billing provision of the SNF PPS. This particular update, however, applies to providers who bill for NTIOLs furnished in ASCs as well as providers billing Medicare FIs for Major Category IV. A. Mammography Screening. The mammography codes for screening and diagnostic mammography services that are no longer valid as of January 1, 2007 are:

In addition, Medicare edits allow the payment of the $50 additional fee for Category 3 NTIOLs for dates of service prior to January 1, 2007, when billed with HCPCS code Q1003. (See MM4361 for additional information about NTIOLs and Q1003 and the article may be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4361.pdf on the CMS Web site.)

Remember that:

Additional Information
To see the official instruction (CR5636) issued to your Medicare carrier, FI or A/B MAC, go to http://www.cms.hhs.gov/Transmittals/downloads/R1266CP.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.

Also, MM3901 is the article that announced the cessation of the additional $50 payment for NTIOLs for codes Q1001 and Q1002 and that article may be viewed at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3901.pdf on the CMS Web site.

You can find more information about the new 2007 mammography CPT codes by going to CR5327, located at http://www.cms.hhs.gov/Transmittals/downloads/R1070CP.pdf on the CMS Web site. There, as an attachment to that CR, you will find revised Chapter 18 (Preventive and Screening Services), Section 20 (Mammography Services) of the Medicare Claims Processing Manual (100-04),

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Quarterly Update to Medically Unlikely Edits (MUEs), Version 1.2, Effective July 1, 2007

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 June 12, 2007, to reflect the changes made to CR5603 on that date.

The CR release date, transmittal number and Web address for accessing CR5603 were changed. All other information remains the same.

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), DME Medicare Administrative contractors (DME/MACs), durable medical equipment regional carriers (DMERCs), and/or regional home health intermediaries (RHHIs)).

Background
In order to lower the Medicare fee-for-service paid claims error rate, the Centers for Medicare & Medicaid Services (CMS) established units of service edits referred to below as MUEs. The National Correct Coding Initiative (NCCI) contractor develops and maintains MUEs. Key points of CR5603 are as follows:

Additional Information
To see the official instruction (CR5603) 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/R1265CP.pdf on the CMS Web site.
If you have questions, please contact your Medicare carrier, FI or A/B MAC, DME MAC, 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.

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Revised HCPCS Codes Relating to Immune Globulin

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 for eligible professionals by CMS. CMS has titled the statutory program the Physician Quality Reporting Initiative. For more information, visit http://www.cms.hhs.gov/pqri on the CMS Web site.

Note: This article was corrected on June 20, 2007, to show the correct HCPCS code for Flebogamma Injection in Table 1 of page 2 is Q4091. All other information remains the same.

Provider Types Affected
Physicians, providers and suppliers who bill Medicare contractors (carriers; Fiscal Intermediaries (FI), including Regional Home Health intermediaries (RHHIs); Medicare Administrative Contractors (A/B MACs); and Durable Medical Equipment Medicare Administrative Contractors (DME MACs)) for Immune Globulin

What You Need to Know
CR 5635, from which this article is taken, implements HCPCS coding changes for Immune Globulin. On and after July 1, 2007:

Background
CR 5635, from which this article is taken, implements HCPCS Coding Changes for Immune Globulin, Effective for services on or after July 1, 2007. See Table 1, below, for details.

Table 1
HCPCS Code Changes for Immune Globulin
Effective July 1, 2007

HCPCS Code Short Description Long Description
Status: not Payable by Medicare on or after July 1, 2007
J1567 Immune globulin, liquid Injection immune globulin, intravenous, non-lyophilized (e.g. liquid), 500 mg
Status: Payable for services on or after July 1, 2007
Q4087 Octagam Injection Injection, immune globulin (Octagam), intravenous non-lyophilized (e.g. liquid), 500 mg
Q4088 Gammagard Liquid Injection Injection immune globulin (Gammagard liquid), intravenous, non-lyophilized (e.g. liquid), 500 mg
Q4091 Flebogamma Injection Injection, immune globulin (Flebogamma), intravenous, non-lyophilized (e.g. liquid), 500 mg
Q4092 Gamunex Injection Injection, immune globulin (Gamunex), intraveous, non-lyophilized (e.g., liquid), 500 mg
Status: New/Payable for services on or after July 1, 2007
Q4089* rhophylac injection Injection, Rho(D) immune globulin (human), (Rhophylac), intramuscular or intravenous, 100iu
Q4090^ HepaGam B injection Injection, hepatitis B immune globulin (HepaGam B), intramuscular, 0.5ml

*Currently, Rhophylac® is the only product that should be billed using code Q4089. If other products under the FDA approval for Rhophylac® become available, code Q4089 would be used to bill for such products.
^Currently, HepaGam BTM, when given intramuscularly, is the only product that should be billed using code Q4090. If other products under the FDA's approval for HepaGam BTM IM become available, code Q4090 would be used to bill for such products. HepaGam BTM when given intravenously should be billed using an appropriate Not Otherwise Classified code in the absence of a specific HCPCS code.

Additional Information
You can find the official instruction issued to your Medicare contractor about the revised HCPCS codes relating to Immune Globulin by going to CR5635, located at http://www.cms.hhs.gov/Transmittals/downloads/R1261CP.pdf on the CMS Web site.

Payment limits for the new Q codes will be included in the July 2007 quarterly Average Sales Price payment file, which will be posted at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01a_2007aspfiles.asp#TopOfPage.

In addition, more information regarding the Outpatient Prospective Payment System (OPPS) and the new Q codes in the July update of OPPS Addendum A and Addendum B on the hospital outpatient Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS/AU/list.asp#TopOfPage.
You might also want to look at CR 5428 (Medicare Payment for Pre-administration-Related Services Associated with IVIG Administration—Payment Extended through CY 2007). The MLN Matters article (MM5428) associated with that CR is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5428.pdf on the CMS Web site.

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

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Revision to Internet Only Manual (IOM) Pub 100-04, Chapter 12, Section 90.4 Billing and Payment in a Health Professional Shortage Area (HPSA)

News Flash – PQRI Tool Kit Available
The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that the 2007 Physician Quality Reporting Initiative (PQRI) Tool Kit is now available. To access the Tool Kit, visit the PQRI Web page at http://www.cms.hhs.gov/PQRI on the CMS Web site, then go to the PQRI Tool Kit section. To access all of the other resources you need to assist in successful reporting, go to the Educational Resources section of the previously mentioned Web site.

Provider Types Affected
Physicians who bill Medicare carriers and Medicare Administrative Contractors (A/B MACs) for services rendered in HPSAs.

What Physicians Need to Know
CR 5625, from which this article is taken, informs carriers and A/B MACs that they no longer have to maintain a separate Web site of HPSA designated areas for you to use concerning claims for the HPSA bonus payment. Rather, your contractor's Web site will have links to a Center for Medicare and Medicaid Services (CMS) Web site (http://www.cms.hhs.gov/hpsapsaphysicianbonuses/) and a Health Resources and Services Administration (HRSA) Web site (http://www.bhpr.hrsa.gov/shortage/). These sites will be available to help you when filing HPSA bonus payment claims.

You should make sure that your billing staffs are aware of these changes.

Background
CMS is simplifying the process of determining designations that are eligible to receive the Health Professional Shortage Area (HPSA) bonus payment; in order to ensure a more accurate method of 1) paying claims in areas that are designated for the HPSA bonus payment, and 2) reducing the risk of overpayments in area that are not designated as HPSA bonus payment areas.

To reflect these changes, Medicare Claims Processing Manual (100-04) Chapter 12 (Physician/Practitioner Billing), Section 90.4 (Billing and Payment in a Health Professional Shortage Area (HPSA)) is being updated; and CR 5625, from which this article is taken, revises how Medicare contractors will disseminate information about HPSA bonus payment to the provider community.
Per these revisions, carriers will no longer maintain an updated Web site of HPSA designations for physicians to use when filing HPSA bonus payment claims. The carriers, instead, will be required to provide two direct links for you to use when filing HPSA bonus payment claims. Those links are:

You should be aware that CMS will continue to automatically pay a bonus for those ZIP codes that are considered to fully fall in the county based on a determination of dominance made by the United States Postal Service (USPS) and for those ZIP codes that fully fall within a partial county HPSA (effective for services rendered on or after the date of designation by HRSA)

However, for those ZIP codes that do not fully fall within a full county HPSA or fully within a non full county HPSA, you must continue to enter the AQ modifier on the claim in order to receive the bonus.

Additional Information
You can find the official instruction, CR5625, issued to your carrier or A/B MAC by visiting http://www.cms.hhs.gov/Transmittals/downloads/R1273CP.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

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The NPI is Here. The NPI is Now. Are you Using It? New MLN Matters Article Available!


A new Special Edition MLN Matters article is now posted on the CMS Web site with important information for Medicare providers and suppliers. Some of the topics include:

You can view this article by visiting http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0725.pdf on the CMS Web site.

June 14, 2007 NPI Data Dissemination Roundtable Transcript Available Now

The transcript for the 6/14/2007 NPI Data Dissemination Roundtable can be found at http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/6-14NPITranscript.pdf on the CMS Web site.

Not sure what an NPI is and how you can get it, share it and use it? As always, more information and education on the NPI can be found at the CMS NPI Webpage located at www.cms.hhs.gov/NationalProvIdentStand on the CMS Web site. Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1.800.465.3203.

Getting an NPI is free - not having one can be costly.

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Update of Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) and Enhancement of Medicare Remit Easy Print (MREP)

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 who submit claims to Medicare contractors (carriers, fiscal intermediaries (FIs), regional home health intermediaries (RHHIs), Part A/B Medicare Administrative Contractors (A/B MACs), durable medical equipment regional carriers (DMERCs) and DME Medicare Administrative Contractors (DME MACs)) for services.

Provider Action Needed
This article is based on Change Request (CR) 5634 which instructs Medicare contractors that a Remittance Advice Remark Code (RARC) must be used with Claim Adjustment Reason Codes (CARCs) 16, 17, 96, 125, and A1. CR5634 also instructs that updated Medicare Remit Easy Print (MREP) software will be provided which incorporates enhancements approved by the Centers for Medicaid & Medicaid Services (CMS) and the currently valid Claim Adjustment Reason and and Remittance Advice Remark Codes.

Background
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 instructs health plans to be able to conduct standard electronic transactions (submission of claims, claims inquiries, electronic remittance advice, etc.) adopted under HIPAA using valid standard codes. The American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X12 transactions are part of the Transactions and Code Sets Rule selected by HIPAA, and the ANSI X12 subcommittee 'N' covers standards in the insurance industry, including health insurance (hence these are X12N standards). The ANSI ASC X12N transaction number 835 (ANSI ASC X12N-835) is the ANSI standard electronic remittance advice (ERA) transaction that provides payment information on a submitted claim.

Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) Update
As a reminder, Medicare policy states that:

When the payment differs from the amount being billed, Payers communicate the reason for any adjustment using:

The following table includes Group codes currently being used by CMS:

Group Code Definition
CO Contractual Obligation (Provider is financially responsible).
PR Patient responsibility (Provider can collect the amount from patient)
OA Other Adjustment (Gernerally used to report bundling/unbundling situation, predetermination of benefits, and secondary payments)
CR Correction (Used with reversal and correction)

The ANSI ASC X12N-835 Implementation Guide (version 004010A1) requires CARCs (if needed) but does not require use of RARCs. A HIPAA compliant version of the Implementation Guide for transaction 835 (Health Care Claim Payment & Remittance Advice) is available at: http://www.wpc-edi.com/HIPAA.
The code committee that maintains the CARC code set recently modified five CARCs (16, 17, 96, 125, and A1). These CARCs were selected for modification because they were very generic, and they were used most frequently. Of these 5 CARCs, the following 4 now require the use of at least one appropriate RARC, and they are effective April 1, 2007:

CARC Definition
16 Claim/service lacks information which is needed for adjudicaiton. Additional information is supplied using remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark code or NCPDP Reject Reason Code
17 Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one Remark Code must be provided (may be comprised of either the Remittance advice Remark Code or NCPC Reject Reason Code.)
96 Non-covered charge(s). This change to be effective 4/1/2007: At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code
125 Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks code whenever appropriate. This chang eto be effective 4/1/2007: At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)

The remaining 1 CARC (which follows) also requires at least one RARC, but it is effective June 1, 2007.

CARC Definition
A1 Claim denied charges

CMS instructed your Medicare contractor(s) to analyze their current use of RARCs with CARCs 16, 17, 96, and 125, and determine if any existing RARCs (that are not currently being used) may be appropriate to explain an adjustment. Your Medicare contractor(s) may start using any of the currently existing RARCs with CARCs 16, 17, 96, 125, and A1.

Note: The most current list of RARCs can be found at: http://www.wpc-edi.com/codes.
In addition, the committee that maintains reason codes approved the following CARC effective February 28, 2007:

CARC Definition
204 This service/equipment/drug is not covered under the patient's current benefit plan

Your Medicare contractor(s) may use CARC 204 instead of CARC 96 and an appropriate remark code, e.g., N130.

NARC Definition
N130 Consult plan benefit documents for information about restrictions for this service

RARC N130 will be used with CARC 96 as a default combination to be reported on all DME claims if:

Medicare Remit Easy Print (MREP) Enhancement
CMS developed Medicare Remit Easy Print (MREP) software that gives providers a tool to read and print an electronic remittance advice (RA) in a human readable format. Providers who use the MREP software have the ability to print paper documentation that can be used to reconcile accounts receivable, as well as create document(s) that can be included with claims submissions to secondary/tertiary payers for Coordination of Benefits. Information regarding MREP and instructions on obtaining MREP are available through your Medicare contractor.

In a continuing effort to improve MREP, CMS established a process to receive suggestions to enhance the functionality and effectiveness of MREP from providers, contractors, and CMS staff. The next updated version of MREP that incorporates improvements approved by CMS will be available in July 2007. Note that the timeline for the annual MREP enhancement update has changed from October to July.

Additional Information
The official instruction, CR5634, issued to your carrier, FI, RHHI, A/B MAC, or DME MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1267CP.pdf on the CMS Web site.

If you have any questions, please contact your Medicare carrier, FI, RHHI, A/B MAC, 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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Update to the 2007 Medicare Physician Fee Schedule Database (MPFSDB)

Medicare Fee-For-Service (FFS) Contingency Plan Announced!
Effective May 23, 2007, Medicare FFS is establishing a contingency plan for implementing the National Provider Identifier (NPI). In this plan, as soon as Medicare considers the number of claims submitted with an NPI for primary providers (Billing, pay-to and rendering providers) is sufficient, Medicare (after advance notification to providers) will begin rejecting claims without an NPI for primary providers, perhaps as early as July 1, 2007. For more information on this contingency plan, please visit the NPI dedicated Web site at http://www.cms.hhs.gov/nationalprovidentstand/.
Note: This article was changed on July 9, 2007, to reference MM5635. MM5635 implemented HCPCS coding changes for Immune Globulin. On and after July 1, 2007, HCPCS code J1567 (injection, immune globulin, intravenous, non-lyophilized (e.g. liquid), 500 mg) will no longer be payable by Medicare. There is a reference to J1567 on page 3 of this article. To view the new HCPCS codes for Immune Globulin, please go to http://www.cms.hhs.gov/MLNMattersArticles/downloads/mm5635.pdf on the CMS Web site.

Provider Types Affected
Physicians and providers who submit claims to Medicare contractors (Fiscal intermediaries (FIs), Part A/B Medicare Administrative Contractors (A/B MACs), carriers) for services rendered to Medicare beneficiaries that are paid based on the MPFSDB.

Provider Action Needed

STOP – Impact to You
Payment files for the MPFS were issued based on the December 1, 2006 Medicare Physician Fee Schedule Final Rule. CR5614, amends those files and includes new/revised codes for the Physician Quality Reporting Initiative (PQRI)

CAUTION – What You Need to Know
Physicians and providers may want to pay particular attention to Attachment 1 of CR5614 that identifies the changes included in the July Update to the 2007 MPFSDB—the highlights of attachment 1 are:

GO – What You Need to Do
Make certain that your billing staffs are aware of these changes.

Background
Section 1848 (c)(4) of the Social Security Act provides for the establishment of the policies needed in order to implement relative values for physicians' services. CR 5614 is the official document that announces these changes in the Medicare schedule. Rather than duplicate all the additions, deletions and changes in this article, the Centers for Medicare & Medicaid Services (CMS) directs you to CR5614, which contains lengthy lists of these items. CR5614 is available at http://www.cms.hhs.gov/Transmittals/downloads/R1258CP.pdf on the CMS Web site.

As mentioned above, the key portion of CR5614 is Attachment 1, which includes the following information:

Also, attachment 3 (which is informational only) states that the Performance Payment Indicator has been changed to '1' for the extensive list of carrier priced codes identified in attachment 3.

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR5614) 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/R1258CP.pdf on the CMS Web site.

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

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Vagus Nerve Stimulation (VNS) for Resistant Depression

If you treat a Medicare Advantage enrolled beneficiary and you have questions about their Medicare Advantage 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 CMS Web site. CMS updates this site on a monthly basis.

Provider Types Affected
Physicians, hospitals, and other providers who bill Medicare carriers, fiscal intermediaries (FI), and Medicare Administrative Contractors (A/B MAC) for vagus nerve stimulation procedures.

Provider Action Needed
CR 5612, from which this article is taken, announces that CMS is issuing a national (non) coverage determination (NCD) stating that vagus nerve stimulation (VNS) is not reasonable and necessary for the treatment of resistant depression.

Therefore, effective May 4, 2007, CMS will deny VNS claims when resistant depression is the indication for the procedure.

Background
Vagus Nerve Stimulation (VNS) utilizes a battery-powered pulse generator (similar to a pacemaker), that is surgically implanted under the skin of the left chest and an electrical lead (wire) connected from the generator to the left vagus nerve; through which electrical signals are sent to the brain.
In 1999, the Centers for Medicare & Medicaid Services (CMS) issued a national coverage determination (NCD) that (effective for services performed on or after July 1, 1999) VNS is reasonable and necessary for patients with medically refractory partial onset seizures when surgery is not recommended or has failed.

On August 7, 2006, a formal request to reconsider resistant depression as an additional indication initiated a national coverage analysis, and CR 5612, from which this article is taken, communicates the findings of that analysis. Specifically in CR5612, CMS announces that it has reviewed the evidence and has concluded that vagus nerve stimulation (VNS) is not reasonable and necessary for the treatment of resistant depression under §1862(a)(1)(A) of the Social Security Act, and has issued a national noncoverage determination for this indication.

Therefore, effective May 4, 2007, CMS will deny or reject, as appropriate, VNS claims for resistant depression, as specified in the Medicare National Coverage Determinations Manual, Chapter 1, Part 2 (Sections 90 – 160.25 (Coverage Determinations)), Section 160.18 (Vagus Nerve Stimulation (VNS), Subsection C (Nationally Non-Covered Indications).

CR5612 contains some specifics about VNS coverage that you should be aware of:

Finally, you should remember that this addition/revision of section 160.18 of the Medicare National Coverage Determination Manual is a national coverage determination (NCD). NCDs are binding on all carriers, fiscal intermediaries, quality improvement organizations, qualified independent contractors, the Medicare Appeals Council, and administrative law judges (ALJs) (see 42 CFR section 405.1060(a)(4) (2005)). An NCD that expands coverage is also binding on a Medicare advantage organization. In addition, an ALJ may not review an NCD. (See section 1869(f)(1)(A)(i) of the Social Security Act.)

Additional Information
You can find the official instruction issued to your carrier, FI, or A/B MAC about the VNS NCD by looking at the two transmittals for CR5612. The first transmittal is at http://www.cms.hhs.gov/Transmittals/downloads/R70NCD.pdf on the CMS Web site. That transmittal contains the amended Medicare National Coverage Determinations Manual, Chapter 1, Part 2 (Sections 90 – 160.25 – Coverage Determinations), Section 160.18 (Vagus Nerve Stimulation (VNS), Subsection C (Nationally Non-Covered Indications). The second transmittal is at http://www.cms.hhs.gov/Transmittals/downloads/R1271CP.pdf and it contains the amended Medicare Claims Processing Manual, Chapter 32 (Billing Requirements for Special Services), Section 200 (Billing Requirements for Vagus Nerve Stimulation (VNS).

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

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Zoledronic Acid (Zometa and Reclast) – Retired LCD's

The CIGNA Government Services LCDs for zoledronic acid in Idaho, North Carolina, and Tennessee are retired, effective July 1, 2007. These agents, Zometa and Reclast, will henceforth be covered for their FDA-approved indications. The off-label use of IV zoledronic acid (Zometa) for osteoporosis may still be covered on an individual case basis when there is a valid medical reason why a patient cannot tolerate/make use of oral bisphosphonates, and this is well documented in the medical record. This will be subject to post-pay review.


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