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October 4, 2007 Part B Medicare Bulletin

Posted October 4, 2007

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2008 Annual Update of HCPCS Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) for the Common Working File (CWF), Medicare Carriers and Fiscal Intermediaries (FIs)

Provider Types Affected
Physicians, providers, and suppliers submitting claims to Medicare contractors (carriers, durable medical equipment Medicare Administrative Contractors (DME MACs), Part A/B Medicare Administrative Contractors (Part A/B MACs) and fiscal intermediaries (FIs)) for services provided to Medicare beneficiaries in SNFs.

Provider Action Needed

STOP – Impact to You
This article is based on Change Request (CR) 5696, which provides the 2008 annual update of HCPCS Codes for SNF CB and how the updates affect edits in Medicare claims processing systems.

CAUTION – What You Need to Know
CR5696 provides updates to HCPCS codes that will be used to revise CWF edits to allow carriers and FIs to make appropriate payments in accordance with policy for SNF CB in the Medicare Claims Processing Manual, Chapter 6, Section 110.4.1 for carriers and Chapter 6, Section 20.6 for FIs.

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

Background
Medicare’s claims processing systems currently have edits in place for claims received for beneficiaries in a Part A covered SNF stay as well as for beneficiaries in a non-covered stay. Changes to Healthcare Common Procedure Coding System (HCPCS) codes and Medicare Physician Fee Schedule designations are used to revise these edits to allow carriers, A/B MACs, DME MACs, and FIs to make appropriate payments in accordance with policy for SNF CB contained in the Medicare Claims Processing Manual. These edits only allow services that are excluded from CB to be separately paid by Medicare contractors.

Physicians and providers are advised that, by the first week in December 2007, new code files will be posted to the at http://www.cms.hhs.gov/SNFConsolidatedBilling/ on the CMS Web site. Institutional providers note that this site will include new Excel® and PDF format files.

Note: It is important and necessary for the provider community to view the “General Explanation of the Major Categories” PDF file located at the bottom of each year’s FI update listed at http://www.cms.hhs.gov/SNFConsolidatedBilling/ on the CMS Web site in order to understand the Major Categories including additional exclusions not driven by HCPCS codes.

Additional Information
The official instruction, CR5696, issued to your Medicare contractor regarding this change can be found at http://www.cms.hhs.gov/Transmittals/downloads/R1317CP.pdf on the CMS Web site.

If you have 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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Anesthesia Services Furnished by the Same Physician Providing the Medical and Surgical Service

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.

Note: This article was revised on August 28, 2007, to reflect changes made to CR5618 on August 27, 2007. CR5618 was modified to include the correct Medicare Summary Notice message number for notifying beneficiaries when they are not liable for payment. The CR transmittal number, release date, and the Web address for accessing CR5618 were also changed. All other information remains the same.

Provider Types Affected
Physicians and other practitioners who bill Medicare carriers and/or Medicare Administrative Contractors (A/B MACs) for anesthesia services provided in conjunction with the performance of medical/surgical services.

Provider Action Needed

STOP – Impact to You
Physicians who both perform, and provide moderate sedation for, medical/surgical services will be paid for the conscious sedation consistent with CPT guidelines. However, physicians who perform, and provide local or minimal sedation for, these procedures will not be paid separately for the sedation services.

CAUTION – What You Need to Know
The Medicare Claims Processing Manual (Publication 100-04) Chapter 12 (Physicians/Nonphysician Practitioners) Section 50A (General Payment) is being revised to be consistent with the pricing of the conscious sedation codes under the Medicare physician fee schedule payment system and CPT coding guidelines. In addition, a new section, 50L, explains the payment policy when the same physician performs both the medical/surgical service and the conscious sedation service, is added. Finally, Exhibit 1, that listed the base units by anesthesia code is deleted, because it is out of date and the material is communicated to carriers and Medicare Administrative Contractors (known as A/B MACs) annually via the HCPCS tape.

GO – What You Need to Do
Make sure that your billing staffs are aware of these new payment policies that address the same physician performing both the medical/surgical service and the conscious sedation service.

Background
The continuum of complexity in anesthesia services (from least intense to most intense) ranges from 1) local or topical anesthesia, 2) moderate (conscious) sedation, 3) regional anesthesia, to 4) general anesthesia. Moderate sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. It does not include minimal sedation, deep sedation, or monitored anesthesia care.

CR 5618, from which this article is taken announces the revision of the anesthesia policy in the Medicare Claims Processing Manual, Chapter 12 (Physicians/Nonphysician Practitioners), Section 50A (General Payment), to be consistent with the pricing of conscious sedation codes under the Medicare physician fee schedule and CPT coding guidelines. It further announces:

  1. The addition of a new Section (50L), that explains the payment policy if the same physician performs the medical/surgical service and the conscious sedation service; and
  2. The deletion of Exhibit 1, that lists the base units by anesthesia code because it is out of date and the material is communicated to the carriers annually via the HCPCS tape.

Currently, section 50A instructs carriers and MACs not to allow separate payment for the anesthesia service performed by the same physician who furnishes the medical or surgical services (for example, there is no separate payment allowed for a surgeon’s performance of a local or surgical anesthesia if the surgeon also performs the surgical procedure; or a psychiatrist’s performance of the anesthesia service associated with the electroconvulsive therapy if the psychiatrist performs the electroconvulsive therapy).

The revised policy is: If the physician performing the procedure also provides moderate sedation for the procedure, then payment may be made for conscious sedation consistent with CPT guidelines; however, if the physician performing the procedure provides local or minimal sedation for the procedure, then no separate payment is made for the local or minimal sedation service.

Carriers and A/B MACS will not allow payment for codes 99148-99150 if any of these codes are performed on the same day with a medical/surgical service listed in Appendix G of CPT and the service is provided in a non-facility setting. A facility is defined in Chapter 23 Addendum of the Medicare Claims Processing Manual as one with a place of service code of 21, 22, 23, 24, 26, 31, 34, 41, 42, 51, 52, 53, 56, or 61.

Prior to 2006, Medicare did not recognize separate payment if the same physician both performed the medical or surgical procedure and provided the anesthesia needed for the procedure. The final physician fee schedule published in the Federal Register on November 21, 2005, included newly created codes (99143 to 99150) for moderate (conscious) sedation, which the CPT added in 2006.

Note: These codes have been assigned a status indicator of “C” under the Medicare physician fee schedule designating that these services are carrier priced. CMS has not established relative value units for these services.

Three of these codes (99143, 99144, and 99145) describe the scenario in which the same physician performing the diagnostic or therapeutic procedure provides the moderate sedation, and an independent trained observer’s presence is required to assist in the monitoring of the patient’s level of consciousness and physiological status. The other three codes (99148, 99149, and 99150) describe the scenario in which the moderate sedation is provided by a physician other than the one performing the diagnostic or therapeutic procedure.

CR 5618 presents some specific points that you should be aware of:

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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Claim Status Category Code and Claim Status Code Update

Provider Types Affected
Physicians, providers, and suppliers who submit Health Care Claim Status Transactions to Medicare contractors (carriers, Medicare administrative contractors (A/B MACs), durable medical equipment Medicare administrative contractors (DME MACs), fiscal intermediaries (FIs), and regional home health intermediaries (RHHIs)).

Provider Action Needed

STOP – Impact to You
This article is based on Change Request (CR) 5687, which provides the January 2008 updates of the Claim Status Codes and Claim Status Category Codes for use by Medicare contractors (carriers, A/B MACs, DME MACs, FIs, and RHHIs).

CAUTION – What You Need to Know
Effective January 1, 2008, Medicare contractors are to use codes posted on July 9, 2007, at the
http://www.wpc-edi.com/codes Web site. Chapter 31 of the Medicare Claims Processing Manual, Section 20.7 - Health Care Claim Status Category Codes and Health Care Claims Status Codes for Use with the Health Care Claim Status Request and Response ASC X12N 276/277 discusses these codes in more detail. You may review section 20.7 at: http://www.cms.hhs.gov/manuals/downloads/clm104c31.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site.

GO – What You Need to Do
See the Background section of this article for further details.

Background
Under the Health Insurance Portability and Accountability Act (HIPAA), all payers (including Medicare) must use Claim Status Category and Claim Status codes approved by a recognized code set maintainer (instead of proprietary codes) to explain any status of a claim(s) sent in the Version 004010X093A1 Health Care Claim Status Request and Response transaction. These codes indicate the general category of a claim’s status (accepted, rejected, additional information requested, and so on).The national Code Maintenance Committee maintains the Claim Status Category and Claim Status codes.

The national Code Maintenance Committee meets at the beginning of each X12 trimester meeting (February, June, and October) and makes decisions about additions, modifications, and retirement of existing codes. The codes sets are available at http://www.wpc-edi.com/content/view/180/223/ . This page has previously been referenced by the following URL address: http://www.wpc-edi.com/codes. Included in the code lists are specific details, including the date when a code was added, changed, or deleted.

All code changes approved during the June 2007 committee meeting were posted on that site on July 9, 2007. One of the decisions made during this June meeting by this Maintenance Committee was to allow the industry more lead time for implementation of code changes. At least 6 months lead time will be allowed for industry implementation of all Claim Status-related code changes as well as Claim Adjustment Reason Code changes (the same committee maintains these code sets). As result, changes approved in June 2007 will be effective January 1, 2008.

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR5687) issued to your Medicare FI, carrier, DME MAC, RHHI or A/B MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1314CP.pdf on the CMS Web site.

If you have questions, please contact your Medicare FI, carrier, DME MAC, RHHI 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 Percutaneous Transluminal Angioplasty (PTA) Billing Requirements Issued in CR 3811

Note: This article was revised on August 30, 2007, to correct the link to MLN Matters article MM3811 on page 2. A link was also added in the Additional Information section to another PTA-related article, MM5022, which provided clarification of MM3811. All other information remains unchanged.

Provider Types Affected
Physicians, providers, and suppliers submitting claims to Medicare contractors (carriers, Fiscal Intermediaries (FIs), and/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) 5667, which adds ICD-9-CM diagnosis code 433.11, occlusion of the carotid artery with infarct, to the list of payable claims for PTA to ensure all eligible Medicare beneficiaries are covered.

Background
On March 17, 2005, the Centers for Medicare & Medicaid Services (CMS) issued a National Coverage Determination (NCD) providing Medicare coverage for Percutaneous Transluminal Angioplasty (PTA) of the carotid artery concurrent with placement of an FDA-approved carotid stent when beneficiaries are at high risk for carotid endarterectomy (CEA). (This was announced in CR 3811, effective March 17, 2005; see related MLN Matters article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3811.pdf.) The NCD provides coverage for patients with symptomatic carotid artery stenosis who meet the coverage criteria specified in the policy. As stated in the NCD,

Currently, there are no codes that distinguish between non-disabling and disabling strokes. In order to ensure that claims for all eligible patients can be paid, CR5667 adds the following International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code of 433.11 (Occlusion and stenosis of carotid artery, with cerebral infarction) to the list of payable claims for carotid artery stenting (CAS).

Patients who experience disabling strokes remain ineligible for coverage.

Note that Medicare contractors will not search their files to reprocess claims already processed. However, they will adjust such claims if you bring the claims to their attention. Also, since the Centers for Medicare & Medicaid Services (CMS) considers this an administrative error, your Medicare contractor will follow the guidelines in the Medicare Claims Processing Manual (Chapter 1, Section 70.7.1) for allowing an extension to the timely filing limits. In essence, this allows your contractor to accept claims with 433.11 outside the timely filing limitations, since such claims were not previously payable due to the administrative error. Medicare manuals are available at http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage on the CMS Web site.

CR5667 also advises providers that they can correctly bill covered bilateral carotid services by coding both 433.30 (Occlusion and stenosis of multiple and bilateral arteries, without mention of cerebral infarction) or 433.31 (Occlusion and stenosis of multiple and bilateral arteries, with cerebral infarction) and 433.10 (Occlusion and stenosis of carotid artery, without mention of cerebral infarction) or 433.11 in any order on the same claim. Providers would code 433.30 with 433.10 or 433.31 with 433.11 to identify the multiple and bilateral condition and 433.10 or 433.11 to specifically identify the carotid artery.

Claims submitted by physicians to carriers or MACs may also contain a CPT code of 37215 (Transcatheter placement of intravascular stent(s), cervical carotid artery, Percutaneous; with distal embolic protection), 0075T (Transcatheter placement of extracranial vertebral or intrathoracic carotid artery stent(s), including radiologic supervision and interpretation, percutaneous; initial vessel), or 0076T (Each additional vessel). Claims submitted by institutional providers to FIs or MACs should contain the appropriate procedure codes of 00.61 (Percutaneous angioplasty or atherectomy of precerebral (extracranial) vessels) and 00.63 (Percutaneous insertion of carotid artery stent(s)).

Additional Information
MM3489, Percutaneous Transluminal Angioplasty (PTA), can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3489.pdf on the CMS Web site.

MM3811, Expansion of Coverage for Percutaneous Transluminal Angioplasty (PTA), is located at
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3811.pdf on the CMS Web site.

MM5022, Clarification on Billing Requirements for Percutaneous Transluminal Angioplasty (PTA) Concurrent with the Placement of an FDA-approved Carotid Stent, is located at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5022.pdf on the CMS Web site.

The official instruction, CR5667, issued to your carrier, FI, and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1315CP.pdf on the CMS Web site.

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

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Comprehensive Error Rate Testing (CERT) Request for Documentation

The Centers for Medicare & Medicaid Services (CMS) established the Comprehensive Error Rate Testing (CERT) program to measure the accuracy of Medicare payments. The accuracy of these payments is established through a review of randomly selected claims submitted by health care providers along with supporting documentation obtained from the corresponding medical records. Participation in the CERT review is not optional; it is imperative that you respond to requests for medical record documentation from the CERT contractor. Although you have the same appeal rights with CIGNA Government Services as in any other situation, this could be an unnecessary, time-consuming process.

No response = no records = overpayment = taking money back

To obtain the appropriate documentation for the CERT review, refer to both the Bar Coded Sheet (lists needed records), and the Medical Records/Documentation Pull List (it shows the specific codes and rendering provider’s number).

If you receive a CERT records request letter, please note:

*EXCEPTION: Psychotherapy where counseling session notes contain confidential exchanges between the therapist and patient. However, psychiatric records, which are social/medical/administrative in nature, do not require special authorization, e.g., medication checks.

If you have questions concerning a request letter you have received, please contact the CERT Documentation Office at (301) 957.2380.

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Date of Service (DOS) for Laboratory Specimens

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

Provider Action Needed
This article is based on Change Request (CR) 5573
which implements revisions to the date of service (DOS) policy for tests performed on laboratory specimens, in accordance with updates to 42CFR414.510 that were published in the Federal Register on December 1, 2006. Remember when submitting claims that the general rule is that the date of service is the date the specimen is collected. Where a specimen is collected over a period that spans two calendar days, the date of service is the date the collection period ended.

Background
The general rule for the date of service (DOS) of a test performed on a laboratory specimen is the date that the specimen is collected. If a specimen is collected over a period that spans two calendar days, then the DOS must be the date that the collection period ended.

The current DOS policy allows an exception to the general rule for tests performed on an archived specimen. If a specimen was stored for more than 30 calendar days before testing (otherwise known as “an archived specimen”), the DOS of the test must be the date that the specimen was obtained from storage.


In the final physician fee schedule regulation published in the Federal Register on December 1, 2006
(http://www.access.gpo.gov/su_docs/fedreg/a061201c.html), the Centers for Medicare & Medicaid Services (CMS) revised the DOS policy for laboratory specimens to allow additional exceptions to the general rule and the DOS rule for tests performed on an archived specimen.

CR 5573 implements the revisions to the DOS policy for tests performed on laboratory specimens specified in the final rule, in accordance with the updates to 42 CFR §414.510 (http://a257.g.akamaitech.net/7/257/2422/01jan20061800/edocket.access.gpo.gov/2006/06-9086.htm).

As already mentioned, under the revised DOS policy for laboratory specimens, the General Rule is that the DOS of the test must be the date the specimen was collected. However, there is a variation: If a specimen is collected over a period that spans two calendar days, then the DOS must be the date the collection ended.

The following exceptions apply to the DOS policy for laboratory tests:

DOS for Tests Performed on Stored Specimens:
In the case of a test performed on a stored specimen, if a specimen was stored for less than or equal to 30 calendar days from the date it was collected, the DOS of the test must be the date the test was performed only if:

Note: If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have been archived, and the DOS of the test must be the date the specimen was obtained from storage.

DOS for Chemotherapy Sensitivity Tests Performed on Live Tissue:
In the case of a chemotherapy sensitivity test performed on live tissue, the DOS of the test must be the date the test was performed only if:

Note: For purposes of applying the above exception, a “chemotherapy sensitivity test” is defined as a test that requires a fresh tissue sample to test the sensitivity of tumor cells to various chemotherapeutic agents.

Additional Information
The official instruction, CR5573, issued to your carrier, FI, and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1319CP.pdf on the CMS Web site.

If you have any 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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Delete References to Required Reporting of the National Provider Identifier (NPI) on or after May 23, 2007 and Revise to a “When Effective” Date

News Flash – The 2nd Edition of The Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Health Care Professionals is now available in downloadable format from the Centers for Medicare & Medicaid Services, Medicare Learning Network (MLN). This comprehensive guide provides fee-for-services health care providers and suppliers with coverage, coding, billing, and reimbursement information for preventive services and screenings covered by Medicare. This guide gives clinicians and their staff the information they need to help them in recommending Medicare-covered preventive services and screenings that are right for their Medicare patients and provides information needed to effectively bill Medicare for services furnished. To view online, go to http://www.cms.hhs.gov/MLNProducts/downloads/mps_guide_Web-061305.pdf on the CMS Web site.

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

Provider Action Needed
This article is informational in nature and is based on Change Request (CR) 5678 which updates Chapter 80 of the Medicare Claims Processing Manual to delete references to the May 23, 2007 mandatory date for entry of the National Provider Identifier (NPI) on claims. The effective date for providers to use only the NPI on Medicare claims will be officially announced at a later date, as previously communicated to providers in the MLN Matters article corresponding to CR5595. That article is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5595.pdf on the CMS Web site.

Background
The National Provider Identifier (NPI) final rule, published in the Federal Register on January 23, 2004 (http://www.access.gpo.gov/su_docs/fedreg/a040123c.html; Health and Human Services Department Rules), established the standard for a unique identifier for each health care provider for use in health care transactions. Medicare contractors were to be required to enter NPI in certain items and fields of paper claim forms and electronic equivalents on or after May 23, 2007.

However, on April 2, 2007, the Department of Health and Human Services (DHHS) provided guidance regarding contingency planning for the implementation of the NPI. For some time after May 23, 2007, Medicare Fee for Service (FFS) will allow continued use of legacy numbers (Unique Physician Identification Numbers (UPINs) and Provider Identification Numbers (PINs)), as well as accepting transactions with only NPIs. The effective date for providers to use only the NPI only on claims and to cease entering UPINs and PINs will be officially announced at a later date, as previously communicated to providers in the MLN Matters article corresponding to CR5595. That article is available at
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5595.pdf on the CMS Web site. This article reflects CR5678, which simply amends Chapter 80 of the Medicare Claims Processing Manual to reflect that the use of the NPI will be mandated for Medicare FFS claims at a future date.

Additional Information
The official instruction, CR5678, issued to your carrier, A/B MAC, or DME MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1328CP.pdf on the CMS Web site.

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

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Important Notice Regarding Vaccine Administrations in 2008

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.

Note: This article was revised on August 3, 2007, to correct the G code for the administration of vaccinations for Part D on page 2. The G code referenced was G3077 and it should have been G0377. Also, a reference to a related article (SE0727) was added in the Additional Information section. All other information is unchanged.

Provider Types Affected
Physicians and other providers who bill Medicare carriers or Medicare Administrative Contractors (A/B MACs) for the administration of Part D-covered vaccines to Medicare beneficiaries.

What Providers Need to Know
This article (Special Edition (SE) 0723) provides 2008 payment guidance for the administration of Part D-covered vaccines. This is not new policy guidance, just a reminder of the policy for 2008. Remember that, effective January 1, 2008, physicians can no longer bill Medicare Part B for the administration of Medicare Part D-covered vaccines, using the special G code (G0377). Instead, you will need to bill the patient for the vaccine and its administration, and the patient will need to submit the claim to their Part D plan for reimbursement .

You should make sure that your billing staffs are aware of this Part D-covered vaccine administration guidance for 2008.

Background
Section 202(b) of the Tax Relief and Health Care Act of 2006 (TRHCA) established a permanent policy for payment by Medicare for administration of Part D-covered vaccines, beginning in 2008. Specifically, the policy states that, effective January 1, 2008, the administration of a Part D-covered vaccine is included in the definition of “covered Part D drug” under the Part D statute.

During 2007, in transition to this new policy, providers were permitted to bill Part B for the administration of a Part D vaccine using a special G code (G0377). SE0723 now reminds providers of the requirement that payment for the administration of Part D covered vaccines only during 2007.

Therefore, effective January 1, 2008, you can no longer bill the G code to Part B; rather you 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.

Important Note: This guidance does not affect Part B covered vaccines.

Additional Information
You might want to look at MLN Matters articles MM5486 (Payment by DME MACs and DMERCs for the Administration of Part D Vaccines), released December 29, 2006; and MM5459 (Emergency Update to the 2007 Medicare Physician Fee Schedule Database (MPFSDB)) released January 11, 2007. You can find these articles at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5486.pdf and http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5459.pdf, respectively.

You may also want to review SE0727 (Reimbursement for Vaccines and Vaccine Administration Under Medicare Part D), which may be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0727.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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Medicare’s Implementation of the National Provider Identifier (NPI): The Second in the Series of Special Edition MLN Matters Articles on NPI-Related Activities

This article was rescinded on August 9, 2007, due to a number of factors affecting NPI implementation, especially the contingency plan announced in MLN Matters article MM5595. For the latest NPI information, you can view all NPI related MLN Matters articles by going to http://www.cms.hhs.gov/NationalProvIdentStand/downloads/MMarticles_npi.pdf on the Centers for Medicare & Medicaid Services Web site.

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Microvolt T-Wave Alternans Testing (MTWA)

The CIGNA Government Services (CGS) Local Coverage Determination (LCD) for this test has been retired, effective September 15, 2007. It is replaced with this article to assist providers who may use this technology. A National Coverage Determination (NCD) is in effect for this testing as well, and takes precedence (CMS IOM Pub 100-3, Ch 1, Sect 20.30). The NCD is excerpted below:

Microvolt T-wave Alternans (MTWA) testing is a non-invasive diagnostic test that detects minute electrical activity in a portion of the electrocardiogram (EKG) known as the T-wave. MTWA testing has a role in the risk stratification of patients who may be at risk for sudden cardiac death (SCD) from ventricular arrhythmias.

Within patient groups that may be considered candidates for implantable cardioverter defibrillator (ICD) therapy, a negative MTWA test may be useful in identifying low-risk patients who are unlikely to benefit from, and who may experience worse outcomes from ICD placement.

The test is performed by placing highly sensitive electrodes on a patient’s chest prior to a period of controlled exercise. These electrodes detect tiny beat-to-beat changes, on the order of one-millionth of volt, in the EKG T-wave. Spectral analysis is used to calculate these minute voltage changes. Spectral analysis is a sensitive mathematical method of measuring and comparing time and the EKG signals. Software then analyzes these microvolt changes and produces a report to be interpreted by a physician.

Indications and Limitations of Coverage
Nationally Covered Indications

Microvolt T-wave Alternans diagnostic testing is covered for the evaluation of patients at risk for SCD, only when the spectral analysis method is used.

Nationally Non-Covered Indications
Microvolt T-wave Alternans diagnostic test is non-covered for the evaluation of patients at risk for SCD if measurement is not performed employing the spectral analysis.

For the CGS jurisdictions (Idaho, North Carolina & Tennessee), MTWA assessment using spectral analysis is indicated in special circumstances where the predictability of a cardiac event adds significantly to marginal clinical decisions. The following clinical situations are considered appropriate for use of T-Wave Alternans testing:

LIMITATIONS OF COVERAGE:

MTWA is billed with AMA-CPT code 93025, microvolt T-wave alternans for assessment of ventricular arrhythmias.
The ICD-0 diagnostic codes that will be covered for this test when performed byt he spectal analysis method are:
410.10 - 410.92 ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCATION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE
411.89 OTHER ACUTE AND SUBACUTE FORMS OF ISCHEMIC HEART DISEASE OTHER
425.0 - 425.9 ENDOMYOCARDIAL FIBROSIS - SECONDARY CARDIOMYOPATHY UNSPECIFIED
427.1 PAROXYSMAL VENTRICULAR TACHYCARDIA
427.41 VENTRICULAR FIBRILLATION
427.42 VENTRICULAR FLUTTER
780.2 SYNCOPE AND COLLAPSE
794.31 NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG)
V15.1 PERSONAL HISTORY OF SURGERY TO HEART AND GREAT VESSELS PRESENTING HAZARDS TO HEALTH

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New Remark Code for Denying Separately Billed Services

Note: This article was revised on September 10, 2007, to reflect that CR5659 was revised. The CR transmittal number (see above) and the Web address for accessing CR5659 were revised. All other information remains the same.

Provider Types Affected
Medicare providers who submit claims to Medicare Part A/B Medicare Administrative Contractors (A/B MACs) or carriers for ambulance services rendered to Medicare beneficiaries.

Provider Action Needed
Be aware that contractors will use a new Remittance Advice Remark Code (RARC) message when denying ambulance claims submitted with a code(s) that is not separately billable and already included in the base rate. For claims submitted by ambulance suppliers that Medicare processes on or after October 1, 2007, and which Medicare denies because the code for the service does not appear on the Ambulance Fee Schedule, Medicare will return the RARC of N390 to show “This service cannot be billed separately.” See the remainder of this article for further details.

Key Points of CR5659

Background
CR5659 is the official document that announces these changes in Medicare processes and states that effective January 1, 2006, items and services which include but are not limited to oxygen, drugs, extra attendants, supplies, EKG, and night differential are no longer paid separately for ambulance services. This occurred when the Centers for Medicare & Medicaid Services (CMS) fully implemented the Ambulance Fee Schedule. Therefore, payment is based solely on the Ambulance Fee Schedule amount as cited in 42 CFR § 414.615 (e) and such payment represents payment in full for all services, supplies, and other costs for an ambulance service furnished to a Medicare beneficiary. CMS was made aware that some providers are submitting claims with ancillary services that are included in the base rate.

CMS decided that a clearer denial message was needed to explain the reason for the denial and that this service is not separately billable and as a result, these claims/services should not be resubmitted. This is true whether the primary transportation service is allowed or denied. Remember that when these services are denied, the services are not separately billable to the beneficiaries.

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR5659) issued to your Medicare carrier or A/B MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1333CP.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.

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Notice to Idaho and Tennessee Providers

Recently, seven-digit PTANs were deleted for Idaho and Tennessee providers. As a result, we will in some circumstances need to assign eight-digit PTANs. Idaho and Tennessee providers can submit claims using only their ten-digit National Provider Identifier (NPI) if they experience difficulty billing with the eight-digit PTANs.

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Nurse Practitioner (NP) Services and Clinical Nurse Specialist (CNS) Services

Provider Types Affected
Nurse practitioners (NP) and clinical nurse specialist (CNS) who bill Medicare Carriers and Medicare Administrative Contractors (A/B MACs) for services provided to Medicare Beneficiaries.

What You Need to Know
In CR 5639, from which this article is taken, the Centers for Medicare & Medicaid Services (CMS) announces that their manuals are being updated by adding the National Board on Certification of Hospice and Palliative Nurses (NBCHPN) to the list of recognized national certifying bodies for NPs. This list will also provide the new name for the National Certification Board of Pediatric Nurse Practitioners and Nurses and provide the correct reference for the Critical Care Certification Corporation. This same list of recognized national certifying bodies for advanced practice nurses will be included under the manual instruction on CNS services.

Carriers and A/B MACs will enroll nurses, under the NP and CNS benefits, who meet all of the other NP or CNS qualifications; and are certified as advanced practice nurses by any of the recognized national certifying bodies listed below, effective November 19, 2007.

Background
Federal regulations that govern nurse practitioner (NP) services at 42 CFR 410.75 and those governing the clinical nurse specialists (CNS) services at 42 CFR 410.76 require that these advanced practice nurses be certified by a national certifying body that has established standards for NPs and CNSs.

CR 5639, from which this article is taken, announces that CMS is adding the National Board on Certification of Hospice and Palliative Nurses (NBCHPN) to the list of recognized national certifying bodies for NPs at the advanced practice level, located in the Medicare Benefit Policy Manual, Chapter 15 (Covered Medical and Other Health Services), Section 200 (Nurse Practitioner (NP) Services). CR5639 also announces the addition of this same list of recognized national certifying bodies for advanced practice CNSs in Section 210 (Clinical Nurse Specialist (CNS) Services) and in Chapter 10, Sections 12.4.5 and 12.4.8 of the Medicare Program Integrity Manual.

Effective November 19, 2007, the list of recognized national certifying bodies for NPs and CNSs at the advanced practice level is as follows:

Additional Information
You can find more information about NP and CNS services by going to CR 5639, which is in two transmittals located on the CMS Web site. As an attachment to transmittal R75BP (http://www.cms.hhs.gov/Transmittals/downloads/R75BP.pdf), you will find updated Medicare Benefit Policy manual, Chapter 15 (Covered Medical and Other Health Services), Sections 200 (Nurse Practitioner (NP) Services) and 210 (Clinical Nurse Specialist (CNS) Services). As an attachment to transmittal R219PI (http://www.cms.hhs.gov/Transmittals/downloads/R219PI.pdf), you will find updated Chapter 10, Sections 12.4.5 and 12.4.8 of the Medicare Program Integrity Manual.

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

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October Update to the 2007 Medicare Physician Fee Schedule Database

News Flash — Since May 29, 2007, Medicare Fiscal Intermediaries, as well as Part B CIGNA Idaho and Tennessee, have been validating NPIs and Legacy Provider Identifier pairs submitted on claims against the Medicare NPI Crosswalk. Between the period of September 3, 2007 and October 29, 2007, all other Part B carriers and DME MACS will begin to turn on edits to validate the NPI/Legacy pairs submitted on claims. If the pair is not found on the Medicare NPI crosswalk, the claim will reject. Contractors have been instructed to inform providers at a minimum of seven days prior to turning on the edits to validate the NPI/Legacy pairs against the Crosswalk.

Provider Types Affected
Physicians and other providers who bill Medicare contractors (carriers, fiscal intermediaries, or Medicare Administrative Contractors (MACs)) for professional services paid under the MPFS.

What You Need to Know
CR5714, from which this article was taken, amends the payment files previously issued to your Medicare contractor (based upon the December 1, 2006, Medicare Physician Fee Schedule (MPFS) Final Rule); and includes new codes for the Physician Quality Reporting Initiative.

Background
Section 1848(c)(4) of the Social Security Act authorizes the Secretary to establish ancillary policies necessary to implement relative values for physicians’ services. Medicare contractors, in accordance with the Medicare Claims Processing Manual, Chapter 23, Section 30.1, give providers 30 days notice before implementing the revised payment amounts and the changes identified in CR5714, which (unless otherwise stated in the CR5714) will be retroactive to January 1, 2007.

You should be aware that carriers will adjust claims that you bring to their attention, but are not required to search their files to either retract payment for claims already paid or to retroactively pay claims. The changes made as a result of CR5714 are as follows:

Changes included in the October Update to the 2007 Medicare Physician Fee Schedule Database are as follows:

The following changes are retroactive to January 1, 2007:

CPT/HCPCS ACTION
16035 Global period = 000
Pre Op = 0.00
Intra Op = 0300
post Op - 0.00
20690 Bilateral Indicator = 0
38740 Bilateral Indicator = 0
38745 Bilateral Indicator = 1
54150

Transitional Non-Facility
PE RVU = 3.38
Transitional Facility PE
RVU = 0.73
64412 Bilateral Indicator = 1
64418 Bilateral Indicator = 1
64613 Bilateral Indicator = 1

As stated in Transmittal 1301, dated July 20, 2007, (Change Request 5665 — Revised Information on PET Scan Coding), effective January 28, 2005, CPT code 78609 became a non-covered service for Medicare purposes.

CPT Code Procedure Status Indicator*
78609
N
78609 - TC (Technical Component)
N
78609 - 26 (Professional Component)
N

*Effective for dates of service on or after January 28, 2005
New Category II codes for the Physician Quality Reporting Initiative (PQRI)
Effective for dates of service on or after October 1, 2007, the following Category II codes will be added to the MPFS with a status indicator of “M”.

Code Long Descriptor Short Descriptor
1116F Auricular or periauricular pain assessed Auric/peri pain assessed
2035F Tympanic membrane mobility assessed with pneumatic otoscopy or tympanometry tymp memb motion exam'd
3215F Patient has documented immunity to Hepatitis A Pt immunity to hep a doc’d
3216F Patient has documented immunity to Hepatitis B Pt immunity to hep b doc’d
3219F Hepatitis C genotype testing docymented as performed prior to initiation of anitviral treatment for Hepatitis C Hep c geno tstngdoc’d - done
3220F Hepatitis C quantitative RNA testing documented as performed at 12 weeks from initiation of antiviral treatment Hep c quant rna tstng doc’d
3230F Documentation that hearing test was performed within 6 months prior to tympanostomy tube insertion Note hring tst w/in 6 mon
3260F pT category (primary tumor), pN category (regional lymph nodes), and histologic grade documented in pathology report Pt cat/pn cat/hist grd doc’d
4130F Topical preparations (including OTC) prescribed for acute otitis externa Topical prep rx, aoe
4131F Systemic antimicrobial therapy prescribed Syst antimicrobial thx rx
4132F Systemic antimicrobial therapy not prescribed No syst antimicrobial thx rx
4133F Antihistamines or decongestants prescribed or recommended Antihist/decong rx/recom
4134F Antihistamines or decongestants neither prescribed nor recommended No antihist/decong rx/recom
4135F Systemic Systemic corticosteroids prescribed Systemic corticosteroids rx
4136F Systemic corticosteroids not prescribed Syst corticosteroids not rx
4150F Patient receiving antiviral treatment for Hepatitis C Pt recvng antivir txmnt hepc
4151F Patient not receiving antiviral treatment for Hepatitis C Pt not recvng antiv hep c
4152F Documentation that combination peginterferon and ribavirin therapy considered Doc’d pegintf/rib thxy consd
4153F Combination peginterferon and ribavirin therapy prescribed Combo pegintf/rib rx
4154F Hepatitis A vaccine series recommended Hep a vac series recommended
4155F Hepatitis A vaccine series previously received Hep a vac series prev recvd
4156F Hepatitis B vaccine series recommended Hep b vac series recommended
4157F Hepatitis B vaccine series previously received Hep b vac series prev recvd
4158F Patient education regarding risk of alcohol consumption performed Pt edu re: alcoh drnkng done
4159F Counseling regarding contraception received prior to initiation of antiviral treatment Contrcp talk b/4 antiv txmnt

The payment indicators are identical for all of the above PQRI CPT codes and those indicators are as follows:

Procedure Status: M
WRVU: 0.00
Non-Facility PE RVU: 0.00
Facility PE RVU: 0.00
Malpractice RVU: 0.00
PC/TC: 9
Site of Service: 9
Global Surgery: XXX
Multiple Procedure Indicator: 9
Bilateral Surgery Indicator: 9
Assistant at Surgery Indicator: 9
Co-Surgery Indicator: 9
Team Surgery Indicator: 9
Physician Supervision Diagnostic Indicator: 9
Type of Service: 1
Diagnostic Family Imaging Indicator: 99

*Effective for services performed on or after October 1, 2007

The short descriptor for G8370 was listed incorrectly in Transmittal 1258, dated May 29, 2007 (Change Request 5614 – July Update to the 2007 Medicare Physician Fee Schedule Database). The short descriptor has been corrected to read:

HCPCS Revised Short Descriptor
G8370 Asthma pt w survey not docum

Additional Information
You can find the official instruction about the October update to the 2007 Medicare Physician Fee Schedule Database by going to CR5714, located at http://www.cms.hhs.gov/Transmittals/downloads/R1326CP.pdf on the CMS Web site.

If you have any questions, please contact your carrier, FI, 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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Quarterly Update to Correct Coding Initiative (CCI) Edits, Version 13.3, Effective October 1, 2007

News Flash — Since May 29, 2007, Medicare Fiscal Intermediaries, as well as Part B CIGNA Idaho and Tennessee, have been validating National Provider Identifiers (NPIs) and Legacy Provider Identifier pairs submitted on claims against the Medicare NPI Crosswalk. Between the period of September 3, 2007 and October 29, 2007, all other Part B carriers and DME MACS will begin to turn on edits to validate the NPI/Legacy pairs submitted on claims. If the pair is not found on the Medicare NPI crosswalk, the claim will reject. Contractors have been instructed to inform providers at a minimum of seven days prior to turning on the edits to validate the NPI/Legacy pairs against the Crosswalk.

Provider Types Affected
Physicians who submit claims to Medicare carriers and Part A/B Medicare Administrative Contractors (A/B MACs)

Background
This article is based on Change Request (CR) 5703 which provides a reminder for physicians to take note of the quarterly updates to Correct Coding Initiative (CCI) edits. The latest package of CCI edits, Version 13.3, effective October 1, 2007, and the current Mutually Exclusive Code (MEC) edits will be available at http://www.cms.hhs.gov/NationalCorrectCodInitEd/ on the Centers for Medicare & Medicaid Services (CMS) Web site.

The National Correct Coding Initiative developed by CMS helps promote national correct coding methodologies and controls improper coding. The coding policies developed are based on coding conventions defined in:

The latest package of CCI edits, Version 13.3, includes all previous versions and updates from January 1, 1996, to the present and will be organized in two tables:

Additional Information
The CCI and MEC file formats will be maintained in the Medicare Claims Processing Manual (Chapter 23, Section 20.9) which can be found at http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage on the CMS Web site.

The official instruction, CR 5703, issued to your carrier and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1330CP.pdf on the CMS Web site.

If you have any questions, please contact your Medicare carrier 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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Response to Competitive Acquisition Program (CAP) for Part B Drugs and Biologicals Claims When the Medicare System Common Working File (CWF) 69XD Error Code is Received

Provider Types Affected
Participating CAP physicians and other providers billing Medicare carriers or Medicare Administrative Contractors (A/B MAC) for Part B drugs and biologicals under the Competitive Acquisition Program (CAP).

Provider Action Needed

STOP – Impact to You
If you submit the same prescription order number more than once on a single CAP claim, your carrier or A/B MAC will return the entire claim as unprocessable.

CAUTION – What You Need to Know
CR 5658, from which this article is taken, instructs carriers and A/B MACs to return as unprocessable CAP claims received with duplicate prescription order numbers.

GO – What You Need to Do
Make sure that your billing staffs are aware that they should not submit the same prescription order number more than once on a CAP claim, nor should they use the JW modifier on CAP claims, per CR5658.

Background
Carriers and A/B MACs receive an error code when the same prescription order number is submitted more than once on a CAP claim. This inclusion of duplicate prescription order numbers on a single claim can happen, for example, when:

In order to resolve the issue of units that exceed 999, the Centers for Medicare & Medicaid Services (CMS) will be working with the approved CAP vendor to issue additional prescription order numbers when the units of the drug exceed 999.

Finally, CR 5658 rescinds (from CR 4309, issued on February 17, 2006) the instructions that addressed applying the unused drug modifier (JW) to indicate billing for the unused portion of a single-use drug product under the CAP. Claims for drugs provided under CAP submitted with the JW modifier will be treated as unprocessable. This CR does not affect the use of the JW modifier for non CAP claims.

Additional Information
You can find the official instruction, CR5658, issued to your carrier or A/B MAC by visiting http://www.cms.hhs.gov/Transmittals/downloads/R1313CP.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.

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Revision to Certification for Hospital Services Covered by the Supplementary Medical Insurance Program As It Pertains to Ambulance Services

Provider Types Affected
Physicians and hospitals who bill Medicare Fiscal Intermediaries (FIs), Carriers, and A/B Medicare Administrative Contractors (MAC) for ambulance services for Medicare patients.

Background
CR5684 furnishes the revised Certification for Hospital Services by the Supplementary Medical Insurance Program as those requirements pertain to physician certification of ambulance services in Chapter 4, Section 20 of the Medicare General Information, Eligibility, and Entitlement Manual.

Key Points of CR5684

Additional Information
To view the official instruction (CR5684) issued to your Medicare FI, Carrier or A/B MAC, visit http://www.cms.hhs.gov/Transmittals/downloads/R47GI.pdf on the CMS Web site. The revised manual section is attached to CR5684. If you have questions, please contact your Medicare FI, Carrier, or A/B MAC at their toll-free number which may be found at: http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

 

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Revision to Certification for Hospital Services Covered by the Supplementary Medical Insurance Program as it pertains to Ambulance Services

Provider Types Affected
Physicians and hospitals who bill Medicare Fiscal Intermediaries (FIs), Carriers, and A/B Medicare Administrative Contractors (MAC) for ambulance services for Medicare patients.

Background
CR5684 furnishes the revised Certification for Hospital Services by the Supplementary Medical Insurance Program as those requirements pertain to physician certification of ambulance services in Chapter 4, Section 20 of the Medicare General Information, Eligibility, and Entitlement Manual.

Key Points of CR5684

Additional Information
To view the official instruction (CR5684) issued to your Medicare FI, Carrier or A/B MAC, visit http://www.cms.hhs.gov/Transmittals/downloads/R47GI.pdf on the CMS Web site. The revised manual section is attached to CR5684.

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


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Temsirolimus (Torisel)- Revised Information

Temsirolimus (Torisel) new FDA approved drug for the treatment of advanced renal cell carcinoma (189.0 malignant neoplasm of kidney, except pelvis). Temsirolimus is supplied as a 25 mg vial with diluents for IV infusion.

Claim filing instructions:
File using the not otherwise classified code J9999 EMC filing: Enter the name of the drug and dosage administered in the NTE segment (narrative field).

Paper claims: Enter the name of the drug, the dosage administered in field 19 of the CMS—1500 form.

Allowed Amount per kit (25mg vial of temsirolimus plus the diluent): PAR = $1221.851 and Non-Par= $1160.759

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The 2007 Medicare Contractor Provider Satisfaction Survey (MCPSS) Shows Positive Results for Medicare’s Fee-for-Service Contractors

Provider Types Affected
All Medicare physicians, providers, and suppliers billing the Medicare program.

Provider Action Needed
No action is needed. This article is informational only and provides a summary of the findings from the second annual survey by Medicare to assess provider satisfaction with service from Medicare contractors (carriers, fiscal intermediaries (FIs), Medicare Administrative Contractors (MACs), and Durable Medical Equipment Medicare Administrative Contractors (DME MACs)).

Background
The Centers for Medicare & Medicaid Services (CMS) reports that most Medicare health care providers continue to find satisfaction with the services provided by Medicare contractors.

The Medicare Contractor Provider Satisfaction Survey (MCPSS), recently conducted by CMS for the second year, is designed to garner objective, quantifiable data on provider satisfaction with the fee-for-service contractors that process and pay Medicare claims. The survey revealed that 85 percent of respondents rated their contractors between 4 and 6 on a 6-point scale, with “1” representing “not at all satisfied” and “6” representing “completely satisfied.” The national average score for 2007 is 4.56.

Contractors received an overall composite score for the seven business functions of the provider-contractor relationship: provider communications, provider inquiries, claims processing, appeals, provider enrollment, medical review, and provider audit and reimbursement. For all contractor types, a contractor’s handling of provider inquiries surpassed claims processing as the key predictor of a provider’s satisfaction. CMS has provided contractors information for process improvement based on individual MCPSS results.

The MCPSS was sent early this year to more than 36,000 randomly selected providers, including physicians, suppliers, health care practitioners, and institutional facilities that serve Medicare beneficiaries across the country. The survey was expanded this year to include hospice locations and federally qualified health centers.

The full results of the 2007 survey are now available at http://www.cms.hhs.gov/MCPSS on the CMS Web site.

In January 2008, the next MCPSS will be distributed to a new sample of Medicare providers. The views of each provider in the survey are important because they represent many other organizations similar in size, practice type and geographical location. If you are one of the providers randomly chosen to participate in the 2008 MCPSS implementation, you have an opportunity to help CMS improve service to all providers.

Additional Information
Remember, your Medicare contractor is available to assist you in providing services to Medicare beneficiaries and in being reimbursed timely for those services. Whenever you have questions, contact your contractor at their toll free number, which is available at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

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Top NPI Billing Issues

Claims should include group PTAN and individual PTAN and/or Individual NPI and Group NPI. Providers are strongly encouraged to begin billing claims including their NPI.

More information and education on the NPI may be found at the CMS NPI page, http://www.cms.hhs.gov
NationalProvIdentStand on the CMS Web site. Also, providers can apply for an NPI online at
https://nppes.cms.hhs.gov.

Ways to Avoid Billing Errors:
Submitters are encouraged to send a small batch of claims with an NPI only to validate the legacy selected to match with the NPI is correct. This would be a helpful tool to detect problems early without affecting cash flow.

If you are receiving billing issues, please refer to the CMS MLN Matters article on common billing errors. The address is http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0725.pdf.

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Transitioning the Mandatory Medigap (“Claim-Based”) Crossover Process to the Coordination of Benefits Contractor (COBC)

Note: This article was revised on September 3, 2007, to reflect changes CMS made to CR5601, which was re-issued on August 31, 2007. The CR transmittal number, release date, and the Web address for accessing CR5601 were revised in this article. All other information remains the same.

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.

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

Provider Action Needed

STOP – Impact to You
This article is based on Change Request (CR) 5601, which outlines the Centers for Medicare & Medicaid Services (CMS) systematic requirements for the transitioning of its mandatory Medigap (“claim-based”) crossover process from its Part B contractors to the COBC. During the period from June through September 2007, CMS’ Coordination of Benefits Contractor (COBC) will sign national crossover agreements with Medigap claim-based crossover insurers and will assign new 5-digit Coordination of Benefits (COBA) Medigap claim-based crossover identifiers to these entities for inclusion on incoming Medicare claims. CMS is also preparing a separate change request (CR 5662) that includes the Web site where provider billing staffs may go to obtain the listing of new COBA Medigap claim-based identifiers for purposes of initiating Medigap claim-based crossovers. Within the next few weeks, following the issuance of CR 5662, providers will also receive more detailed information regarding this change via their Medicare contractors’ provider newsletters/bulletins and Web sites.

CAUTION – What You Need to Know
October 1, 2007 is the effective date for completing the transition of the Medigap crossover process to the COBC. At that time, CMS will then only support the Health Insurance Portability and Accountability Act (HIPAA) American National Standards Institute (ANSI) X-12N 837 professional COB (version 4010-A1) claim format and National Council for Prescription Drug Programs (NCPDP) version 5.1 batch standard 1.1 claim format for such crossovers. As CMS’ COBC assigns the new COBA Medigap claim-based ID to the Medigap insurers, it will populate this information on its COB Web site so that provider billing staffs may access it for purposes of including the new identifiers on incoming Medicare Part B claims, claims for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), and NCPDP Part B drug claims. By October 1, 2007, providers will exclusively be including the new identifiers on incoming claims to initiate Medigap claim-based crossovers.

GO – What You Need to Do
During June through September, 2007, CMS will gradually be moving Medigap insurers to the new process. Be certain that your billing staffs are aware of these changes and that claims are sent to Medicare contractors in a timely and correct manner.

Background
Currently, in accordance with §1842(h)(3)(B) of the Social Security Act and §4081(a)(B) of Public Law 100-203 (the Omnibus Budget Reconciliation Act of 1987), Part B contractors, including carriers and Medicare Administrative Contractors (MACs), and Durable Medical Equipment Medicare Administrative Contractors (DME MACs) transfer participating provider claims to Medigap insurers if the beneficiary has assigned rights to payment to the provider and if other claims filing requirements are met. This form of claims transfer is commonly termed “Medigap claims-based crossover.” One of the “other” claims filing requirements for Medigap claim-based crossover is that the participating provider must include an Other Carrier Name and Address (OCNA) or N-key identification number on the incoming electronic claim to trigger the crossing over of the claim.

Key Points of CR5601

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR5601) issued to your Medicare carrier, A/B MAC, or DME MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1332CP.pdf on the CMS Web site.

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

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Web Site Domain Name Change: IMPORTANT

Background:
Effective Monday, September 3, 2007, http://www.cignamedicare.com will no longer be a valid, alternate domain name for http://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 http://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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When to Request a Reopening vs. a Redetermination and the Proper Forms to Use

To ensure that Reopenings and Redetermination requests are submitted properly to Medicare, a basic overview and examples of these requests as well as the proper forms to use is provided below. By filing these requests on the proper forms, this will ensure they are handled in a timely fashion.

Reopenings Request (formerly known as Written Adjustments)
The Reopenings process has been established for the correction of denials with minor errors and omissions that do not necessitate the use of the formal appeals process. A Reopening Request must be made within one year from the date of notice of the initial determination. For situations that fall into the category of a minor error/omission, the provider should request a Reopening. A Reopening must state the reason the inquiry is being sent to the Medicare office and can be submitted (but is not required) on the Written Adjustment form (see link below). Below are some examples of requests that may be resubmitted as Reopenings:

Written Adjustment Request Form :
http://www.cignagovernmentservices.com/partb/forms/pdf/GEN_written_adjust.pdf
Helpful Hints: Please do not use the Written Adjustment Request form for claims that denied as unprocessable with MOA code MA130 and/or Reason Code CO-16 on the Medicare remittance advice. A new claim will need to be submitted with all necessary information. Also ensure that all the information provided on the form is legible.

Please mail your Reopenings request to the following PO Boxes: