October 2007 Medicare Bulletin - North Carolina Insert
Posted October 4, 2007
Download a PDF copy
of this issue 
Table of Contents
- Lifting the National Provider Identifier (NPI) Crosswalk Bypass Logic
- New Requirements for Low Vision Rehabilitation Demonstration Billing
- North Carolina Health Professional Shortage Areas (HPSAs)
- North Carolina Mental Health Professional Shortage Areas (HPSAs)
- POE Event Refund Policy
TopLifting the National Provider Identifier (NPI) Crosswalk Bypass Logic
Since October 2, 2006, providers have been encouraged to submit both the NPI and Medicare legacy identifier (PIN) on their claims. During this timeframe providers were not penalized for invalid NPI/legacy ID combinations.
(Effective October 15, 2007, CIGNA NC Part B,) will begin editing the NPI/legacy ID combinations for validity against the NPI crosswalk file. Where a match cannot be located on the crosswalk, claims will be rejected or returned to the provider.
When the claim is returned, a provider should first verify that the correct NPI was submitted. If correct, you will need to verify that your legacy identifier (PIN or NSC) number corresponds with the information on file with the National Plan and Provider Enumeration System (NPPES). NPPES data may be checked on line at https://nppes.cms.hhs.gov.
If your NPPES information is correct and you have included and matched ALL Medicare legacy identifiers with a corresponding NPI in NPPES, but you are experiencing provider identifier problems with your claims that contain an NPI, you may need to submit a Medicare enrollment application (i.e., the CMS-855). Please contact your contractor if you need more information.
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.
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 effecting cash flow.
If you are receiving billing issues, please refer to the CMS Medlearn article on common billing errors. The address is http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0725.pdf.
Please note, Part B CIGNA Idaho and Tennessee lifted the NPI bypass logic May 21, 2007.
New Requirements for Low Vision Rehabilitation Demonstration Billing
Note: Please note that MLN Matters article MM5023 contains updated information regarding remittance advice and remark codes and regarding the use of provider identifiers, especially UPINs and the National Provider Identifier. MM5023 is based on CR5023, released on April 28, 2006. To see MM5023, go to http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5023.pdf on the CMS Web site.
Provider Types Affected
Physicians, providers, and suppliers
Provider Action Needed
Physicians, providers, and suppliers should note that the Centers for Medicare & Medicaid Services (CMS) is:
- Implementing an outpatient vision rehabilitation demonstration project in selected areas across the country to examine the impact of standardized Medicare coverage for vision rehabilitation services; and
- Extending coverage under Part B for the same services to provide vision rehabilitation that would otherwise be payable when provided by an occupational or physical therapist if they are now provided by a vision rehabilitation professional under the general supervision of a qualified physician.
This demonstration project will last for five years through March 31, 2011, and is limited to services provided in specific demonstration locales. These areas are New Hampshire, New York City (all five boroughs), North Carolina, Atlanta, Kansas, and Washington State.
Background
The Secretary of the Department of Health and Human Services is directed to carry out an outpatient vision rehabilitation demonstration project as part of the FY 2004 appropriations conference report to accompany Public Law HR 2673. This demonstration project will examine the impact of standardized Medicare coverage for vision rehabilitation services provided in the home, office, or clinic, under the general supervision of a physician. The services may be supplied by the following:
- Physicians;
- Occupational therapists;
- Certified low vision therapists;
- Certified orientation and mobility specialists; and
- Certified vision rehabilitation therapists.
Under this Low Vision Rehabilitation Demonstration, Medicare is extending coverage under Part B for the same rehabilitation services to treat vision impairment that would otherwise be payable when provided by an occupational or physical therapist if they are now provided by a certified vision rehabilitation professional under the general supervision of a qualified physician.
This demonstration will last for five years through March 31, 2011, and is limited to services provided specifically in New Hampshire, New York City (all 5 boroughs), North Carolina, Atlanta, Kansas, and Washington State.
Payment for vision rehabilitation services under this demonstration may be made to:
- Either the qualified physician who is supervising the occupational therapist or certified vision rehabilitation professional; or an occupational therapist in private practice; or
- A qualified facility, such as a rehabilitation agency or clinic that has a contractual relationship with the certified vision rehabilitation professional; and
- Where the services are furnished under the individualized written plan of care.
Payment for these services will be made under the physician fee schedule even when such services are billed by a facility. They are not subject to bundling under the Outpatient Prospective Payment System (OPPS).
Under this Low Vision Rehabilitation Demonstration, Medicare will cover low vision rehabilitation services to people with a medical diagnosis of moderate or severe vision impairment that is not correctable by conventional methods or surgery (i.e., cataracts).
Services will be provided under an individualized, written plan of care developed by a qualified physician or qualified Occupational Therapist in Private Practice (OTPP) that is reviewed at least every 30 days by a qualified physician.
The plan of care must attest that vision rehabilitation services are medically necessary and the beneficiary receiving vision rehabilitation is capable of receiving rehabilitation and deriving benefit from such services, and should include:
- An initial assessment that documents the level of visual impairment;
- Specific measurable goals to be fulfilled during rehabilitation and the criteria by which the goals will be measured;
- The location where the rehabilitation services will be conducted;
- Description of specific rehabilitative services to be directed toward each goal provided during the course of rehabilitation; and
- A reasonable estimate of the amount of treatment necessary to reach the goals.
Rehabilitative services will be conducted within a three-month period of time, in intervals appropriate to the patient’s rehabilitative needs, and will not exceed 36 units of 15 minutes each, or 9 hours total.
Rehabilitation will be judged completed when the treatment goals have been attained and any subsequent services would be for maintenance of a level of functional ability, or when the patient has demonstrated no progress on two consecutive visits.
All services covered under this demonstration are one-on-one, face-to-face services. Group services will not be covered.
Vision rehabilitation services will be furnished in an appropriate setting, including the home of the individual receiving the services, as specified in the plan of care and can be provided by the following:
- A qualified physician as defined in the Social Security Act (Section 1861r (1) and (4)) and who is an ophthalmologist or a doctor of optometry;
- A qualified occupational therapist in private practice;
- A qualified occupational therapist who is an employee of the physician; or
- A certified vision rehabilitation professional including low vision therapists, orientation and mobility specialists, and vision rehabilitation therapists who have received certification from the Academy for Certification of Vision Rehabilitation and Education Professionals (ACVREP).
Occupational therapists employed by the physician and certified vision rehabilitation professionals may furnish services while under the general supervision of a qualified physician.
General supervision means that the physician does not need to be “on premises” nor in the immediate vicinity of the rehabilitation services as would be the case with “incident to” requirements stated in Section 2050 of the Medicare Carriers Manual.
Payment for vision rehabilitation services will be made to the qualified physician under the Medicare Physician Fee Schedule (MPFS) or to a facility, including the following:
- Hospitals;
- Comprehensive Outpatient Rehabilitation Facilities (CORF);
- Other rehabilitation agencies or clinics; or
- Facilities that bill Medicare for providing occupational therapy, through which services are furnished under an individualized, written plan of care.
Occupational therapists in private practice may also submit claims under their own provider number for providing low vision rehabilitation services. However, for occupational therapists in private practice who are participating in the low vision rehabilitation demonstration, claims submitted must contain the same information as on a physician’s claim form and must use the demonstration “G” code for occupational therapists (G9041) for the claim to be considered.
Occupational therapists in private practice may not supervise therapy assistants or certified low vision rehabilitation professions, nor may they submit claims for the services of these individuals under the demonstration.
Certified vision rehabilitation professionals provide services pursuant to a plan of care and under the general supervision of the qualified physician who develops the plan of care. However, if the certified vision rehabilitation professional has a contractual arrangement with the facility where services are furnished, the facility may submit the bill for services.
Payment to practitioners and facilities will be made using the Medicare Physician Fee Schedule (MPFS) with jurisdictional pricing; vision services covered under the demonstration provided in a hospital outpatient setting will not be paid under the OPPS system.
Payment for services under this demonstration is limited to low vision rehabilitation. E&M services are not billable under the demonstration. Vision impairment refers to significant vision loss from disease, injury or degenerative condition that cannot be corrected by conventional means, such as medication or surgery. The impairment must be manifest by one or more of the conditions listed in the
following table:
| Levels of Vision Impairment | Description |
| Moderate Visual impariment | Best corrected visual acutity is less than 20/60 in th ebetter eye (including a range of 20/70 to 20/160 |
| Severe visual impariment (legal blindness) | Best corrected visual acuity is less than 20/160 including 20/200 to 20/400; or visual field diameter is 20 degrees or less (largest field diameer for Goldman isopter III4e, 1/100 white test object or equivalent) in the better eye. |
| Profound visual impairment (moderate blindness) | Best corrected visual acuity is less than 20/400, or visual field is 10 degrees or less. |
| Near-total visual impairment (severe blindness) | Best corrected visual acuity is less than 20/1000, or visual field is 5 degrees or less. |
| Total visual impairment (total blindness | No light perception |
The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes included in the following table will be used to support medical necessity for coverage under the demonstration.
ICD-9 CM CODE |
Description |
| 368.41 | Scotoma involving central area |
| 368.45 | Generalized contraction or constriction |
| 368.46 | Homonymous Bilateral Field Defect |
| 368.47 | Heteronymous Bilateral Field Defect |
| 369.01 | Better Eye: Total Vision Impairment Lesser Eye: Total Vision Impairment |
| 369.03 Better Eye: | Near-Total Vision
Impairment Lesser Eye: Total Vision Impairment |
| 369.04 | Better Eye: Near-Total Vision
Impairment Lesser Eye: |
| 369.06 | Better Eye: Profound Vision
Impairment Lesser Eye: Total Vision Impairment |
| 369.07 | Better Eye: Profound Vision
Impairment Lesser Eye: Near-Total Vision Impairment |
| 369.08 | Better Eye: Profound Vision
Impairment Lesser Eye: Profound Vision Impairment |
| 369.12 | Better Eye: Severe Vision
Impairment Lesser Eye: Total Vision Impairment |
| 369.13 | Better Eye: Severe Vision Impairment
|
| 369.14 | Better Eye: Severe Vision
Impairment Lesser Eye: Profound Vision Impairment |
| 369.16 | Better Eye: Moderate Vision
Impairment Lesser Eye: Total Vision Impairment |
| 369.17 | Better Eye: Moderate Vision
Impairment Lesser Eye: Near-Total Vision Impaiment |
| 369.18 | Better Eye: Moderate Vision
Impairment Lesser Eye: Profound Vision Impairment |
| 369.22 | Better Eye: Severe Vision
Impairment Lesser Eye: Severe Vision Impairment |
| 369.24 | Better Eye: Moderate Vision
Impairment Lesser Eye: Severe Vision Impairment |
| 369.25 | Better Eye: Moderate Vision
Impairment Lesser Eye: Moderate Vision Impairment |
Most rehabilitation is short-term and intensive, and sessions are generally conducted over a consecutive 90-day period of time with intervals appropriate to the patient’s rehabilitative needs.
Patients usually receive therapy one or two times per week, and not less frequently than once every two weeks. The sessions are generally 30-60 minutes in duration.
Periodic follow-up and evaluation should be documented by the physician at least every 30 days during the course of the rehabilitation.
For the purposes of this demonstration, vision rehabilitation services will not be subject to physical or occupational therapy caps.
CMS established four different series of temporary demonstration, or “G”, codes to accommodate rehabilitation services for low vision. Each code series will correspond to the low vision rehabilitation professional that provided the service and will be included in the official instruction issued to your carrier/intermediary.
That instruction, CR3816, may be viewed by going to http://www.cms.hhs.gov/Transmittals/2005Trans/List.asp#TopOfPage on the CMS web site.
From that web page, look for CR3816 and CR 4294, and click on the files for those CRs. Example “G” codes include the following:
- Code G9041 for services provided by a qualified occupational therapist;
- Code G9042 for services provided by a certified orientation and mobility specialist;
- Code G9043 for services provided by a certified low vision rehabilitation therapist, and
- Code G9044 for services provided by a certified vision rehabilitation therapists.
Payable Places Of Service (POS) for Part B claims include the following:
- Office (11);
- Home (12);
- Assisted living facility (13);
- Group home (14);
- Custodial care facility (33); and
- Independent clinic (49).
In addition, facilities that are qualified to submit claims include the following:
- Outpatient hospital clinics (TOB 13x);
- Outpatient CAH clinics (TOB 85x);
- Comprehensive Outpatient Rehabilitation Facilities (CORFs) (TOB 75x); and
- Freestanding rehabilitation clinics (TOB 74x).
Fiscal intermediaries (FIs) will use the claim related condition code 79 to indicate when services are provided outside the facility. When no condition code appears it will indicate that rehabilitation services were provided in the facility. Providers will be required to indicate either no code or code 79 on claims.
Facility claims will also use the revenue code 0949 (other rehabilitation services) in addition to the demonstration G-code, which indicates the type of professional who provided the rehabilitation service.
This will apply to all institutional settings and CAH outpatient departments. CAHs that elect to use method II billing will use revenue code 0969 or revenue code 0962, whichever is most appropriate.
Carriers will accept and process claims from qualified physicians when those claims include:
- An appropriate ICD-9-CM code that supports medical necessity;
- An appropriate rehabilitation (“G”) code for the demonstration; and
- Evidence of a written plan of care that specifies the type and duration of the rehabilitative services being furnished.
The plan of care and date can be indicated in block 19 (Reserved for Local Use) of the HCFA 1500. Facilities will use occurrence code 17 for the date the plan of care was established or reviewed.
Qualified physicians, occupational therapists, and low vision professionals practicing in designated demonstration areas may provide low vision rehabilitation services to eligible residents of the demonstration areas.
Approved demonstration locales are limited to the following; New Hampshire, New York City (all 5 Boroughs), North Carolina, Atlanta, Kansas, and Washington State.
Providers should note that the residence of the beneficiary receiving services and the physician or facility providing the services must be in the same approved demonstration locale (state or metropolitan area) as determined by matching primary residence and primary practice zip codes.
Implementation
The implementation date for the instruction is April 3, 2006.
Additional Information
As mentioned above, CMS will establish four different series of temporarydemonstration, or “G”, codes to accommodate rehabilitation services for low vision. Each code series will correspond to the low vision rehabilitation professional that provided the service and will be included in the official instruction issued to your carrier/intermediary.
You can view the official instruction issued to your carrier/intermediary for complete details regarding this change. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/2005Trans/List.asp#TopOfPage on the CMS web site. Search for 3816 and 4294 and click on the file for those CRs.
If you have any questions, please contact your carrier/intermediary at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.pdf
on the CMS web site
POE Event Refund Policy
For all CIGNA Government Services scheduled educational events where a charge is applied, the fee is used to offset the cost of the meeting room and equipment rental. In the event you must cancel your registration, you may do so up to 10 business days prior to the educational event and receive a full refund. If you need to cancel less than 10 business days prior to the event, you will be responsible for the full charge and will not be eligible to receive a refund. We encourage you to send a substitute from your organization without penalty. This policy is effective for all events on and after September 1, 2007.
Please note: Medicare reserves the right to cancel an event if registration is insufficient. If we must cancel due to lack of participation, we will notify all registrants at least 48 hours before the date of the event and return the fee for that cancelled event.
North Carolina Mental Health Professional Shortage Areas (HPSAs)
Designated Geographic Areas
|
1 Classified as a Mental Health HPSA, Effective February 2, 2005
2 Classified as a Mental Health HPSA, Effective June 30, 2005
3Classified as a Mental Health HPSA, Effective December 15, 2006
North Carolina Health Professional Shortage Areas (HPSAs)
Designated Geographic Areas
|
1 No longer classified as a HPSA, effective August 1, 2002.
2 Classifed as a HPSA, effective June 1, 2004.
3 No longer classified as a HPSA, effective December 1, 2004.
4 No longer classified as a HPSA, effective September 8, 2006
5 Classified as a HPSA, effective May 11, 2007
6 No longer classified as a HPSA, effective May 11, 2007
