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September 4, 2007 Part B Medicare Bulletin

Posted September 4, 2007

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Additional Common Working File (CWF) Editing for Skilled Nursing Facility (SNF) Consolidated Billing (CB)

News Flash — 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/.

Note: This article was revised on July 17, 2007, to reflect a correction made to CR5624. The implementation date was changed to January 7, 2008. All other information remains the same.

Provider Types Affected
Physicians, providers, and suppliers who bill Medicare carriers, Medicare Administrative Contractors (A/B MAC), or Durable Medical Equipment Medicare Administrative Contractors (DME MAC) for services provided to Medicare beneficiaries in SNF stays.

What Providers Need to Know
Effective for dates of service on or after April 1, 2001, CR 5624, from which this article is taken, instructs Medicare carriers, A/B MACs, and DME MACs to bypass certain current SNF consolidated billing (CB) Part B and Part B/DMEMAC edits in order to enable the identification of periods when SNF CB edits should not be applied.

Background
CR 5624 instructs Medicare carriers, A/B MACs, and DME MACs (effective April 1, 2001) to bypass SNF CB Part B and Part B/DMEMAC edits when certain inpatient claims are present on Medicare’s history.

These revisions will allow Medicare SNF CB editing to take into account periods of SNF stays that are non-covered by Medicare Part A when services should be payable outside of CB by the Medicare Part B contractor.

Note: CR 5624 does not change the policy for SNF CB. It adjusts Medicare’s claims systems to be in line with current policy.

Medicare contractors (carrier, A/B MAC, or DME MAC) will re-open and re-process inappropriately denied claims for dates of service on or after April 1, 2001 through January 1, 2008, when you bring such claims to their attention. You should contact your Medicare contractor to have claims re-processed that you feel were erroneously subject to these consolidated billing edits, and denied. The change will be implemented on January 7, 2008, and claims will be processed correctly as of that date.

Additional Information
You can find the official instruction, CR5624, issued to your carrier, A/B MAC, or DME MAC on the CMS Web site at http://www.cms.hhs.gov/Transmittals/downloads/R1289CP.pdf. As an attachment to CR5624, you will find updated Medicare Claims Processing Manual (100-04), Chapter 6 (SNF Inpatient Part A Billing), Sections 110.2.2 (A/B Crossover Edits), 110.2.4 (Edit for Ambulance Services), and 110.2.5 (Edit for Clinical Social Workers (CSWs)).

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

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Adjustment of Gastric Band after Laparoscopic Gastric Banding Procedure

Effective September 1, 2007 for all three CGS states — Laparoscopic placement of an adjustable gastric band is a covered procedure for morbid obesity, when appropriate under the Medicare national coverage determination and local policy (see CMS IOM and CGS jurisdiction Web sites). Open placement of adjustable gastric band is not a covered procedure, and adjustments of bands placed by an open procedure would not be covered services.

There is no specific CPT code for the “adjustment” of the band by injection or withdrawal of saline. This should not be billed during the 90 day global period after the procedure, as it is included in the primary procedure and not separately payable during the global period. After that time, this adjustment should be billed with CPT 43999, with the statement “Adjustment of gastric band” in Item 19 of the CMS–1500 claim form, or the electronic equivalent.

An E&M service and an adjustment of gastric band will only be allowed if a significant separately identifiable and medically necessary service is provided, in addition to the evaluation and adjustment of the gastric band. Modifier -25 should be appended to the E&M code to indicate this.

It is not appropriate to bill CPT 43771 for this adjustment service when saline is injected or withdrawn.

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Aquatic Therapy

A recent review by our Program Safeguard Contractor found several concerns regarding the practice and documentation regarding the use of aquatic therapy. As with all Medicare services, aquatic therapy must be medically reasonable and necessary in order for the provider to receive payment. Therein the documentation must be detailed so that a reviewer is able to determine such necessity. This article is to alert our providers to the documentation expected and that absence of same will result in a denial of the claim.

The PSC review highlighted the following areas of weakness:

  • Therapy services were provided to beneficiaries with no identified need for the use of this type of therapy. There was little evidence to support the need for use of a water–based environment (i.e. buoyancy for un- weighting joints, resistance, and/or loss of motion).
  • Services were provided for excessive durations of time per treatment session. In some cases aquatic therapy was rendered in excess of one hour.
  • Aquatic therapy services continued for long periods of time (several months) in the absence of
    documented functional gains.
  • Services were repetitive in nature and appeared to be for conditioning and overall fitness or maintenance.
  • There was little evidence of transitioning the aquatic exercise program to a land-based exercise program to improve functional performance with every day activities. The programs provided in the pool setting were rendered in a group environment yet individual therapy was billed.

Based on these findings, the PSC initiated several investigations. As such CIGNA Government Services will make aquatic therapy a major area in our strategic medical review plan. By providing to you this information, CIGNA Government Services is expecting you to review your practices regarding this treatment modality and make any necessary adjustments to your practice and documentation or aquatic therapy.

In addition, CIGNA Government Services realizes that maintaining a pool is expensive and that some providers will elect to use external pool facilities. For example, a therapist in private practice may furnish aquatic therapy in a community center pool. The practice would have to rent or lease the pool for those hours, and the use of the pool during that time would have to be restricted to the therapist’s patients, in order to recognize the pool as part of the therapist’s own practice office during those hours. One must also bill the appropriate code for individual or group therapy. Individual therapy is considered on-on-one for the entire duration of the therapy session.

For more information please refer to the CMS Internet Only Manuals and particularly the Medicare Benefit Policy Manual 100-02 Chapter 15 Section 220 and 230. The following link may be used to reach this manual. http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf

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.

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Clarification About the Medical Privacy of Protected Health Information

News Flash – The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that reporting for the 2007 PQRI on claims for dates of service as of July 1, 2007, has begun. Eligible professionals can now start participating in the PQRI by simply reporting the appropriate quality measure data on claims submitted to their Medicare claims processing contractor. Remember, all your informational needs can be met by visiting the PQRI Web site at http://www.cms.hhs.gov/PQRI. Here you will find educational resources, including the PQRI Tool Kit, and links to our most Frequently Asked Questions (FAQs).

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

Provider Action Needed
The purpose of this Special Edition (SE) article, SE0726, is be sure that heath care providers are aware of the helpful guidance and technical assistance materials the U.S. Department of Health and Human Services (HHS) has published to clarify the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), specifically, the educational material below. Remind individuals within your organization of:

HHS Privacy Guidance
HHS’ educational materials include a letter to healthcare providers with the following examples to clarify the Privacy Rule:

HIPAA does not require patients to sign consent forms before doctors, hospitals, or ambulances can share information for treatment purposes:
Providers can freely share information with other providers where treatment is concerned, without getting a signed patient authorization or jumping through other hoops. Clear guidance on this topic can be found in a number of places:

HIPAA does not require providers to eliminate all incidental disclosures:

HIPAA does not cut off all communications between providers and the families and friends of patients:

HIPAA does not stop calls or visits to hospitals by family, friends, clergy or anyone else:

HIPAA does not prevent child abuse reporting:
Doctors may continue to report child abuse or neglect to appropriate government authorities. See the explanation in the FAQs on this topic, which can be found, for instance, by searching on the term “child abuse;” or review the fact sheet on “Public Health” that can be reviewed at http://www.hhs.gov/ocr/hipaa/guidelines/publichealth.pdf on the HHS Web site.

HIPAA is not anti-electronic:
Doctors can continue to use e-mail, the telephone, or fax machines to communicate with patients, providers, and others using common sense, appropriate safeguards to protect patient privacy just as many were doing before the Privacy Rule went into effect. A helpful discussion on this topic can be found at http://www.hhs.gov/hipaafaq/providers/smaller/482.html on the HHS Web site.

Additional Information
The HHS complete listing of all HIPAA medical privacy resources is available at http://www.hhs.gov/ocr/hipaa/ on the HHS Web site.

For a full list of educational materials, visit http://www.hhs.gov/ocr/hipaa/assist.html on the HHS Web site.

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Correct Reporting of Diagnosis Codes on Screening Mammography Claims

This article was revised on July 27, 2007 to add a reference to CR5377. MM5050 erroneously removed TOB 12X as an applicable TOB for diagnostic mammography services (page 1) supplied to Medicare inpatients and billable under Medicare Part B. CR5377 announced that effective April 1, 2007, TOB 12X is acceptable by FIs and A/B MACS as an appropriate bill type for such services.

Provider Types Affected
All providers billing Medicare carriers and fiscal intermediaries (FIs) for screening mammography claims

Providers Action Needed
This article and Change Request (CR) 5050 provide specific information regarding the reporting of diagnostic codes on screening mammography claims. The following are the instructions:

In addition, CR5050 updates Chapter 18, Section 20.4 of the Medicare Claims Processing Manual for FI processed claims as follows:

Background
The Centers for Medicare & Medicaid Services (CMS) is clarifying its reporting requirements to allow other diagnosis codes and a screening mammography submitted on the same claim.

Currently, providers are required to report screening mammography diagnosis codes V76.11 or V76.12 as the primary diagnosis whenever a screening mammography is billed, regardless of whether other services are reported on the same claim. This CR adjusts that requirement.

Implementation
The implementation date for this instruction is October 2, 2006.

Additional Information
The official instructions issued to your Medicare carrier and intermediary regarding this change can be found at http://www.cms.hhs.gov/Transmittals/downloads/R916CP.pdf on the CMS Web site. The revised Section 20.4 of Chapter 18 of the Medicare Claims Processing Manual is attached to CR5050.

To view the instruction (CR5377) that reversed the removal of TOB 12x, visit http://www.cms.hhs.gov/Transmittals/downloads/R1117CP.pdf on the CMS Web site. The related MLN Matters article maybe found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5377.pdf on the CMS Web site.

If you have questions, please contact your Medicare intermediary 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.

 

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Cryosurgery of the Prostate Gland, Appropriate Billing

For claims with dates of service on or after July 1, 1999, Medicare covers cryosurgery of the prostate gland as primary treatment for patients with clinically localized prostate cancer, stages T1-T3.

When billing for this procedure for patients meeting criteria, please note stage (T1, T2, or T3) in Box 19 of CMS-1500 or electronic equivalent. Claims not having this notation will be subject to denial.

For claims with dates of service on or after July 1, 2001, Medicare covers salvage therapy for patients meeting the following requirements:

Please put one (or more) of the above indicators numbered 1 - 3 in Box 19 or electronic equivalent when billing for this procedure. Claims lacking this documentation will be subject to denial.

NOTE: Medicare does not cover cryosurgery of the prostate gland performed as salvage therapy after failure of other therapies as the primary treatment. Cryosurgery as salvage is only covered after the failure of a trial of radiation therapy, under the above conditions.

CPT Code: 55873 (90-day global)

ICD-9-CM: 185 (Malignant neoplasm of prostate)

CMS National Coverage Determination 230.9 (CMS IOM, Pub 100-3, NCDs, Ch 1, sect 230.9)
Effective 10-1-07

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Electronic Funds Transfer Standardizations and Revisions to the Medicare Claims Processing Manual (Chapter 24)

News Flash — 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, 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

STOP – Impact to You
This article is based on Change Request (CR) 5586 which revises the Medicare Claims Processing Manual, , Chapter 24 (General Electronic Data Interchange (EDI) and EDI Support Requirements, Electronic Claims and Coordination of Benefits Requirements, Mandatory Electronic Filing of Medicare Claims).

CAUTION – What You Need to Know
Effective July 1, 2007, your Medicare contractor will conduct Administrative Simplification Compliance Act (ASCA) reviews annually of at least 20% of providers submitting CMS-1500 paper claims who were not already reviewed in the past 2 years and found to have fewer than 10 FTEs employed by the practice. In addition, contractors will insure that the addenda record is sent with the Medicare claim payment when an ACH format is used to transmit an EFT payment to a financial institution but the remittance advice is separately transmitted to a provider. This will assist with reconciliation of the payment and the information that explains the payment. The EFT format will be the National Automated Clearinghouse Association (NACHA) format CCP - Cash Concentration/Disbursement plus Addenda (CCD+) (ACH) as mentioned in the X12N 835 version 004010A1 implementation guide.

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

Background
Change Request (CR) 5586 provides the following revisions to the Medicare Claims Processing Manual (Chapter 24, Sections 40.7 and Section 90.5.3) regarding electronic funds transfer (EFT) and the identification of providers to be reviewed.

Contractor Roles in Administrative Simplification Compliance Act (ASCA) Reviews and Identification of Providers to be Reviewed
Each carrier, DME MAC and B MAC (not FIs or RHHIs at this time) conducts an ASCA review annually of 20% of those providers still submitting CMS-1500 paper claims. Medicare contractors will not select a provider for a quarterly review if:

Electronic Funds Transfer (EFT)
Although EFT is not mandated by the Health Insurance Portability and Accountability Act (HIPAA), EFT is the required method of Medicare payment for all providers entering the Medicare program for the first time and any existing providers, not currently receiving payments by EFT, who are submitting a change to their existing enrollment data. Providers must submit a signed copy of Form CMS-588 (Electronic Funds Transfer Authorization Agreement) to their Carriers, DME MACs, A/B MACs, FIs, and/or RHHIs. For changes of information, DME MACs will verify the authorized official on the CMS-855 form. In addition, Medicare contractors will not approve any requests to change the payment method from EFT to check.

Carriers, DME MACs, A/B MACs, FIs and RHHIs must use a transmission format that is both economical and compatible with the servicing bank. If the money is traveling separately from an X12 835 transaction, then the NACHA format CCP (Cash Concentration/Disbursement plus Addenda –CCD+) is used to make sure that the addenda record is sent with the EFT, because providers need the addenda record to re-associate dollars with data. Carriers, DME MACs, A/B MACs, FIs, and RHHIs must:

Note: Medicare contractors will not approve any requests to change payment method from EFT to check.

Additional Information
The official instruction, CR5586, issued to your carrier, intermediary, RHHI, A/B MAC, or DME MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1284CP.pdf on the CMS Web site.

If you have any questions, please contact your Medicare carrier, intermediary, 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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Health Care Provider Taxonomy Code Set

Under HIPAA, code sets that characterize a general administrative situation, rather than a medical condition or service, are referred to as non-clinical or non- medical code sets. The Provider Taxonomy code set is an external non-medical data code set designed for use in classifying health care providers according to provider type or practitioner specialty in an electronic environment, specifically within the American National Standards Institute (ANSI) Accredited Standards Committee (ASC) health care transaction.

The Health Care Provider Taxonomy Code (HPTC) is not required. However, if a HPTC is submitted it must be valid data from that code set. The HPTC is a named code set in the 837 professional implementation guide, thus carriers must validate the inbound taxonomy codes against their internal HPTC tables.

The HPTCs are updated twice per year, in April and October. The summary of changes is noted in the table below:

TYPE OF CHANGE PROVIDER TAXONOMY VALUE CODE
Additions • 207QB0002X
• 207RB0002X
• 207RT0003X
• 207VB0002X
• 207ZC0006X
• 2080T0004X
• 2081N0008X
• 2084B0002X
• 2084N0008X
• 102X00000X
• 172V00000X
• 246ZC0007X
• 252Y00000X
• 273100000X
• 333300000X
Revisions Please view the revised HPTC code list located on the Washington Publishing Company Web site listed below.

The HPTC code list is available in two forms from the Washington Publishing Company:
http://www.wpc-edi.com/codes/taxonomy

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Important Guidance on the New CMS-1500 and UB-04 Forms

National Provider Identifier (NPI) News – During this testing and implementation phase for the NPI, providers should pay close attention to information from health plans and clearinghouses to understand how claims are being processed and what providers should be doing to assure no disruption in payment. Providers should also ensure that the information they are submitting on a claim is what is being transmitted to each health plan by the billing vendors or clearinghouses who may be submitting the claims on their behalf. Additional information can be found at http://www.cms.hhs.gov/NationalProvIdentStand/ on the CMS Web site.

Provider Types Affected
All providers using the new forms CMS-1500 or UB-04 to bill Medicare contractors (carriers, fiscal intermediaries (FI), or Medicare Administrative Contractors MACs)) for services provided to Medicare beneficiaries.

What You Need to Know
This MLN Matters article, SE0729, provides you valuable information about the new CMS-1500 and UB-04 forms.

Background
CMS Form 1500 Version 08-05
In 2006, the Centers for Medicare & Medicaid Services (CMS) introduced the revised Form CMS-1500 (08-05). This new version of the form, revised to accommodate the reporting of the National Provider Identifier (NPI), was developed through a collaborative effort headed up by the National Uniform Claim Committee (NUCC), which is chaired by the American Medical Association (AMA), in consultation with the CMS.

The committee includes representation from key provider and payer organizations, as well as standards setting organizations, one healthcare vendor, and the National Uniform Billing Committee (NUBC). As such, the committee is intended to have an authoritative voice regarding national standard data content and data definitions for non-institutional health care claims in the United States.

Although CMS prefers that you submit all claims to Medicare electronically, the Administrative Simplification Compliance Act Public Law 107-105 (ASCA) and the implementing regulation at 42 CFR 424.32 provide for exceptions to the mandatory electronic claim submission requirement. Therefore, Medicare will receive, and process, paper claims (using the new [08-05] version of the CMS-1500 form) only from physicians and suppliers who are excluded from the mandatory electronic claims submission requirements.

CMS began accepting the revised form CMS-1500 in January 1, 2007, planning to discontinue the older version on April 1, 2007; however formatting issues forced CMS to extend this date to July 2, 2007. At that time, CMS began returning the 12-90 version of the form. While the Government Printing Office (GPO) is not yet in a position to accept and fill orders for the revised CMS-1500 form, CMS’ research indicates the form is widely available for purchase from print vendors.

For assistance in locating the form, you can contact the NUCC at http://www.nucc.org/, or you might consider using local print media directories to search for print vendors, contacting other providers to inquire on their source for the form, or searching for “CMS-1500 (08-05)” or “CMS-1500 08/05” on the internet to locate online print vendors. You should ask for samples before ordering to ensure that the formatting is correct.

Some important details in completing the new CMS-1500 form are as follow:

You can learn more about the new version of the CMS-1500 by reading MLN Matters article MM5060 (Additional Requirements Necessary to Implement the Revised Health Insurance Claim Form CMS-1500), released September 15, 2006. You can find that article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5060.pdf.

UB-04 Information
At its February 2005 meeting, the National Uniform Billing Committee (NUBC) approved the UB-04 (CMS-1450) as the replacement for the UB-92. The UB-04, the basic form that CMS prescribes for the Medicare program, incorporates the National Provider Identifier (NPI) taxonomy, and additional codes; and is only accepted from institutional providers that are excluded from the mandatory electronic claims submission requirements set forth in the Administrative Simplification Compliance Act, Public Law 107-105 (ASCA), and the implementing regulation at 42 CFR 424.32.

Effective March 1, 2007, institutional claim filers such as hospitals, SNFs, hospices, and others were to have begun using the UB-04, with a transitional period between March 1, 2007, and May 22, 2007 (during which time either the UB-92 or the UB-04 may have been used). On and after May 23, 2007: 1 The UB-92 has become no longer acceptable (even as an adjustment claim); and 2) All institutional paper claims must be submitted on the UB-04.

You should note that while most of the data usage descriptions and allowable data values have not changed on the UB-04, many UB-92 data locations have changed and, in addition, bill type processing will change. Some details of the form follow:

You can find more information about the UB-04 (Form CMS-1450) by reading MLN Matters article MM5072 (Uniform Billing (UB-04) Implementation – UB-92 Replacement), released November 3, 2006. You can find that article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5072.pdf . The CR, from which that article was taken, contains a copy of the UB-04 form (front and back) in PDF format, a crosswalk between the UB-04 and the UB-92, and the revised portion of the Medicare Claims Processing Manual, Chapter 25 (Completing and Processing the CMS 1450 Data Set), Sections 70 (Uniform Bill - Form CMS-1450 (UB-04)) and 71 (General Instructions for Completion of Form CMS-1450 (UB-04)). These sections contain very detailed instructions for
completing the form.

For assistance in obtaining UB-04s you can contact the NUBC at http://www.nubc.org/ .

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

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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 2310B Loop PIN, UPIN Physician NPI
Other Physician 2310C 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/ .

Code Description
32000 This claim has been rejected becasue the intermdeiary has no record of the Medicare provider number submitted.
32102 The claim contains an NPI but the first digist of the NPI is not equal to “1”,“2”,“3”, “4” or the 10th digist of the NPI does not follow the check digit validation routine. Please verify billing and, if appropriate, correct.
**Online provides — press PF9 to store the claim.
**Other providers — return to the intermediary.
32103 NPI/OSCAR pair on the calim is not present in the Medicare NPI Crosswalk File. This edit apples to the NPI assocated 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 shuld validate that the NPI/OSCAR pair you are using on the claim reflescts the OSCAR nuber that you reported ot 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 in the Crosswalk File, but the associated legacy (OSCAR) number in the Crosswalk file does not match the legacy (OSCAR) number on the claim.
Please verify billing number and, if appropriate, correct.
***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 PF9 to store the claim.
***Other providers – Return to the intermediary.
32108 The attending physician’s NPI and UPIN are present on the claim and the attending physician’s NPI is present in the Crosswalk File, but the attending physician’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 the intermediary.

32109 		The operating physician’s NPI on the claim is not present in the Crosswalk File.
Please verify billing number 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 in the Crosswalk File, but the operating 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 providers – Press PF9 to store the claim.
***Other providers – Return to the intermediary.

32111		 The other physician NPI on the claim is not present 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 physician’s NPI is present in the Crosswalk File, but the other physician’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 to the intermediary.
32113 The taxonomy code entered is invalid.
Or, a 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 appropriate, correct.
***Online providers – Press PF9 to store the claim.
***Other providers – 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/Legcy combincation does not match the NP 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 1010AA Loop

Group PIN
Individual PIN

Group NPI
Individual NPI

Pay to Provider 1010AB Loop (this should only be submitted if different from Billing Provider) Indivudual/Member of Group PIN Individual/member of Group NPI
Rendering Provider 2310B Loop (this should only be submittedif a group practice) Individual/Member of Group NPI Individual?Member of Group NPI
Rendering Provider 2420A Loop (this should only be submitted if a group practice Indvidual/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 does not match the NPI crosswalk. As of the date of this article, claims 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 informational edits you are receiving are a warning that your claims will reject when the logic is removed. Providers 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 combincation does ot match the NPI crosswalk
M343 3210B The NPI/LEgacy combincation does not match the NPI crosswalk
M347 2420A The NPI/Legacy combincaiton does nto match the NPI crosswalk

Important Reminders Regarding 835 Remittance Advice Changes Effective July 2, 2007, for DME Suppliers Submitting Claims 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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Important: Web Site Domain Name Change

Background:
Effective Monday, September 3, 2007, http://www.cignamedicare.com will no longer be a valid, alternate domain name for www.cignagovernmentservices.com.

As you may remember, in May 2005 we changed our name to CIGNA Government Services. Since that time, in an effort to better serve our customers, CIGNA Government Services has maintained the domain name www.cignamedicare.com. Visitors who used this address when visiting our site have been automatically redirected to http://www.cignagovernmentservices.com. Beginning Monday, September 3, 2007, this redirect function will be removed and visitors using the old domain name will no longer be able to reach our site using the old domain name.

What You Need to Do:
Keep in mind that http://www.cignamedicare.com will no longer be a valid domain name for CIGNA Government Services.

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

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

Note: This article was revised on July 18, 2007, to correct a typo in the sentence at the end of paragraph 1 on page 3 and to provide new Web addresses for accessing the Notices of Exclusion from Medicare Benefits. All other information remains the same.

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

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

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

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

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

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

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

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

An A-C IOL is intended to provide what is otherwise achieved by two separate items:

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

Benefits for Which Medicare Makes Payment Services for Which Medicare Does NOT pay - No Benefit Category
A conventional intraocular lens (IOL) implanted following cataract surgery. The asitgmatism- correcting funcitonality of an IOL implanted following cataract surgery.
Facility or physician services and supplies required to insert a conventional IOL following cataract surgery. Facility or physician services and resources required to insert and adjust an AC-IOL following cataract surgery that exceeds the services and resources furnished for insertion of a conventional IOL.
One pair of eyeglasses or contact lenses as a prosthetic device furnished after each cataract surgery with insertion of an IOL.

The surgical correction of cylindrical lenses of eyeglasses or contact lenses that may be required to compensate for imperfect vurvature of the cornes (astigmatism)

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

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

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

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

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

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

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

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

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

Physicians inserting an IOL or an A-C IOL in an office setting may bill code V2632 (posterior chamber intraocular lens) for the IOL or the A-C IOL, which is paid on a reasonable charge basis.

If appropriate, hospitals and physicians may use the proper CPT code(s) to bill Medicare for evaluation and management services usually associated with services following cataract extraction surgery, if appropriate.

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

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

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

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

 

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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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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.

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

National Provider Identifier (NPI) News – During this testing and implementation phase for the NPI, providers should pay close attention to information from health plans and clearinghouses to understand how claims are being processed and what providers should be doing to assure no disruption in payment. Providers should also ensure that the information they are submitting on a claim is what is being transmitted to each health plan by the billing vendors or clearinghouses who may be submitting the claims on their behalf. Additional information can be found at http://www.cms.hhs.gov/NationalProvIdentStand/ on the CMS Web site.

Provider Types Affected
Radiology suppliers, clinical diagnostic laboratories, and other providers billing Medicare carriers or Part A/B Medicare Administrative Contractors (A/B MACs) for the TC of radiology and pathology services provided to Medicare fee-for-service hospital inpatients.

Provider Action Needed

STOP – Impact to You
Previously the Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 5347 that established duplicate claims edits, which included consideration of the admission and discharge dates of a hospital stay in identifying duplicate claims for radiology and pathology services.

CAUTION – What You Need to Know
Effective with implementation of CR5675 on October 1, 2007, claims with dates of service on or after April 1, 2007, will be paid that provide radiology and pathology services to Medicare beneficiaries on the day of admission and the day of discharge during an inpatient hospital stay.

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

Background
This CR is being implemented to avoid denying claims that were legitimately provided to beneficiaries on the admission and discharge dates. The general rule is that the technical component (TC) of radiology services provided during an inpatient stay may be billed only by the admitting hospital. Radiology suppliers that render services to beneficiaries in an inpatient stay may not bill the Medicare carrier for the technical portion of the service.

Also, the TC of physician pathology services provided to a hospital inpatient may be billed only by the admitting hospital. Independent laboratories have been instructed that they may not bill for these services after December 31, 2007 per CR 5468 (Transmittal 1148, issued Jan 5, 2007). The exception is that imaging and pathology services performed on the admission date and discharge date by entities other than the admitting hospital are separately payable.

Also, note that carriers and A/B MACs will not reprocess claims already processed, but they will adjust previously processed claims if affected providers bring such claims to the attention of their carrier or A/B MAC.

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR5675) issued to your Medicare carrier or A/B MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1295CP.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.

CR 5347 implemented a process to prevent payments of the TC of radiology services furnished to an inpatient of a hospital by any entity other than the admitting hospital. This CR may be reviewed by clicking on http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5347.pdf on the CMS Web site.

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LCD for Bone Mass Measurements Revised

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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Medicare Payment for Preadministration-Related Services Associated with IVIG Administration—Payment Extended through CY 2007

Do you have your NPI? National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007. Every health care provider needs to get an NPI. Learn more about the NPI and how to apply for an NPI by visiting http://www.cms.hhs.gov/NationalProvIdentStand/ on the CMS Web site.

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. To view the new HCPCS codes, please go to http://www.cms.hhs.gov/MLNMattersArticles/downloads/mm5635.pdf on the CMS Web site.

Provider Types Affected
Physicians and hospitals that bill Medicare carriers, fiscal intermediaries (FIs), or Part A/B Medicare Administrative Contractors (A/B MACs) for Intravenous Immune Globulin (IVIG) administration.

Provider Action Needed

STOP – Impact to You
You may bill for preadministration-related services associated with Intravenous Immune Globulin (IVIG) administration (HCPCS code G0332) during calendar year 2007. The preadministration-related service must be billed on the same claim and have the same date of service, as the claim for the IVIG itself (codes J1566 and/or J1567) and the drug administration service. (See note above regarding J1567.)

CAUTION – What You Need to Know
CR 5428, from which this article was taken, extends payment of the preadministration-related service for IVIG through CY 2007 but only when submitted on the same claim as the IVIG and its administration.

GO – What You Need to Do
Make sure that your billing staff is aware that they must include your claim for the IVIG preadministation-related services on the same claim (and with the same date of service) as the IVIG and its administration.

Background
Under Section 1861(s)(1) and 1861(s)(2), Medicare Part B covers intravenous immune globulin (IVIG) administered by physicians in physician offices and by hospital outpatient departments. More specifically, when you administer IVIG to a Medicare beneficiary in the physician office or hospital outpatient department, Medicare makes separate payments to the physician or hospital for both the IVIG product itself and for its administration via intravenous infusion.

In addition, for 2006, CMS established a temporary preadministration-related service payment, for physicians and hospital outpatient departments that administer IVIG to Medicare beneficiaries, to cover the effort required to locate and acquire adequate IVIG product and to prepare for an infusion of IVIG during this current period where there may be potential market issues. CR 5428, from which this article was taken, announces the extension of this temporary payment for the IVIG preadministration-related service through CY 2007.

As a reminder, here are some important details that you should know:

Additional Information
You can find the official instruction, CR 5428, issued to your FI, carrier, or A/B MAC by visiting http://www.cms.hhs.gov/Transmittals/downloads/R1140CP.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 on the CMS Web site.

Flu Shot Reminder
As a respected source of health care information, patients trust their doctors’ recommendations. If you have Medicare patients who haven’t yet received their flu shot, help protect them by recommending an annual influenza and a one time pneumococcal vaccination. Medicare provides coverage for flu and pneumococcal vaccines and their administration. And don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot. Remember — Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’s Web site: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf .

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National Provider Identifier (NPI) Required to Enroll in Electronic Data Interchange (EDI), and Update of Telecommunication and Transmission Protocols for EDI

News Flash – The Centers for Medicare & Medicaid Services has announced the proposed rule that would establish new policies and payment rates for physicians and other providers who are paid under the Medicare physician fee schedule. Included in the proposed rule is important information directly related to 2008 PQRI. To view or download the proposed rule, visit, http://www.cms.hhs.gov/center/physician.asp, click on CMS-1385-P, then go to page 402 of the document.

Note: This article was revised on July 17, 2007, to reflect a new Web address in the Additional Information section for NPI information. All other information remains the same.

Provider Types Affected
Physicians and other providers who bill Medicare contractors (carriers, fiscal intermediaries (FI), including regional home health intermediaries (RHHI), Medicare Administrative Contractors (A/B MAC), or Durable Medical Equipment Medicare Administrative Contractors (DME MAC)) for services provided to Medicare Beneficiaries.

Provider Action Needed

STOP – Impact to You
If not already enrolled for use of electronic billing & other electronic data interchange (EDI) transactions, you will not be able to enroll to begin use if you have not yet obtained a National Provider Identifier (NPI).

CAUTION – What You Need to Know
CR 5637, from which this article is taken, announces that providers must obtain an NPI, as a condition for initial enrollment, for the use of EDI. Your Medicare contractor will not issue you an EDI access number and password until you obtain an NPI.

GO – What You Need to Do
If you have not already obtained your NPI, you should apply now. You can apply on line by going to
https://nppes.cms.hhs.gov/.

Background
Since May 2006, providers have been required to obtain a National Provider Identifier (NPI) prior to initial Medicare enrollment, or before updating their enrollment records, but were not required to have an NPI, as a condition for enrollment, in order to begin using electronic data interchange (EDI) transactions.

CR 5637, from which this article is taken, announces that (effective October 1, 2007) providers will need to obtain an NPI, as a condition for initial enrollment, for the use of EDI.

This is being implemented to further support efforts by the Centers for Medicare & Medicaid Services (CMS) to have all providers obtain NPIs as soon as possible. Moreover, as indicated in MLN Matters article MM5595 (http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5595.pdf), Medicare is monitoring claims to determine the level of NPI reporting. This is being done to determine when it will be reasonable for Medicare to begin rejecting claims that lack an NPI for billing, pay-to or rendering providers.

CR 5637 also updates EDI connectivity information in the Medicare Claims Processing Manual, Section 24 (General EDI and EDI Support Requirements, Electronic Claims and Coordination of Benefits Requirements, Mandatory Electronic Filing of Medicare Claims), Sections 20 (EDI Enrollment) and 30.3 (Telecommunications and Transmission Protocols) because some of the information in the manual is obsolete due to technology changes.

In summary, these changes are:

Additional Information
You can find more information about the requirement for an NPI in order to be able to use EDI transactions, by going to CR 5637, located at http: