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December 4, 2007 Part B Medicare Bulletin

Posted December 4, 2007

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2008 Medicare Provider Satisfaction Survey

Beginning in December 2007, the Centers for Medicare & Medicaid Services (CMS) will once again begin conducting the Contractor Provider Satisfaction Survey (MCPSS) to measure provider satisfaction with the key services provided by Medicare contractors, including CIGNA Government Services. For those who participated in last year's survey, we thank you for your feedback and participation. Over the last few months, we have implemented a number of new initiatives building on the strengths that you identified and improving areas you identified as concerns. We anticipate our efforts will be reflected in this year's survey results.

About 400 randomly selected Part B providers per state will be selected to participate in this year's survey. The survey takes approximately 20 minutes to complete and focuses on six key areas of the provider-contractor interface, including provider communications, provider inquiries, claims processing, appeals, provider enrollment, and medical review.

If a provider is asked to participate, they will receive a packet of information that will include a letter from CIGNA Government Services, a letter from Westat, the company performing the survey, and instructions on how to access and complete the survey via a secure Internet Web site. It will also include contact information to request a paper copy of the survey instrument, which can be returned by mail or fax.

We value your feedback and we urge all providers chosen to participate in the survey to proactively respond to the survey request to help CIGNA Government Service improve the service we provide to the medical community.

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2008 Payment Limits for Splints and Casts

The following HCPCS codes and payment limits were provided in Attachment A, of Change Request 5740 issued by CMS on September 28, 2007.

2008 Payment Limits for Splints and Casts
HCPCs Code Payment Limit HCPCS Code Payment Limit
A4565 $7.38 Q4025 $32.45
Q4001 $42.01 Q4026 $101.30
Q4002 $158.81 Q4027 $16.23
Q4003 $30.18 Q4028 $50.66
Q4004 $104.49 Q4029 $24.81
Q4005 $11.12 Q4030 $65.31
Q4006 $25.08 Q4031 $12.41
Q4007 $5.58 Q4032 $32.65
Q4008 $12.54 Q4033 $23.14
Q4009 $7.43 Q4034 $57.56
Q4010 $16.72 Q4035 $11.57
Q4011 $3.71 Q4036 $28.79
Q4012 $8.36 Q4037 $14.12
Q4013 $13.52 Q4038 $35.37
Q4014 $22.81 Q4039 $7.08
Q4015 $6.76 Q4040 $17.68
Q4016 $11.40 Q4041 $17.16
Q4017 $7.82 Q4042 $29.30
Q4018 $12.47 Q4043 $8.59
Q4019 $3.91 Q4044 $14.66
Q4020 $6.24 Q4045 $9.96
Q4021 $5.78 Q4046 $16.03
Q4022 $10.44 Q4047 $4.97
Q4023 $2.91 Q4048 $8.02
Q4024 $5.22 Q4049 $1.82

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Application of Administrative Simplification Compliance Act (ASCA) Enforcement Review Decisions Made by Other Medicare Contractors to the Same Providers When Selected for ASCA Review by the Railroad Medicare Carrier, Elimination of References to Claim Status and COB Medicare HIPAA Contingency Plans and Changes to Reflect Transfer of Responsibility for Medigap Claims to the COBC Contractor

News Flash - The 2008 Physician Election Period for the Medicare Part B Drug Competitive Acquisition Program (CAP) will begin on October 1, 2007 and concludes on November 15, 2007. The CAP is a voluntary program that offers physicians the option to acquire many injectable and infused drugs they use in their practice from an approved CAP vendor, thus reducing the time they spend buying and billing for drugs. The 2008 CAP program will run from January 1 to December 31, 2008. Once a physician has elected to participate in CAP, they must obtain all drugs on the CAP drug list from the CAP drug vendor. Physicians can still continue to purchase and bill Medicare under the Average Sale Price (ASP) system for those drugs that are not provided by the physician's CAP vendor. Additional information about the CAP is available at http://www.cms.hhs.gov/CompetitiveAcquisforBios/02_infophys.asp on the CMS Web site. Please note that completed and signed physician election forms should be returned by mail to your local carrier. Forms must be postmarked on or before November 15, 2007. DO NOT return forms to CMS offices.

Provider Types Affected
Physicians, providers, and suppliers submitting claims to the Railroad Medicare carrier, and other Medicare carriers, Part A/B Medicare Administrative Contractors (A/B MACs), and/or DME Medicare Administrative Contractors (DME MACs) for services provided to both Railroad and non-Railroad Medicare beneficiaries.


Provider Action Needed

STOP – Impact to You
This article is based on Change Request (CR) 5606, which implements a process to enable the application of the Administrative Simplification Compliance Act (ASCA) enforcement review decisions made by non-Railroad (non-RR) Medicare Contractors to the same providers when they bill the Railroad (RR) Medicare Carrier (RMC).

CAUTION – What You Need to Know
Due to distribution of RR retirees, many providers submit fewer than 10 claims a month to the RR Medicare Carrier (RMC), and these providers have been allowed to continue to submit paper claims to the RMC. The same providers may also treat non-RR Medicare beneficiaries and submit more than 10 claims a month to other Medicare contractors. ASCA electronic claim filing exceptions apply to Medicare overall, and do not differentiate based on contractors or between RR and non-RR contractors. By adding ASCA enforcement review decision information to the file sent from non-RR Medicare contractors to the RMC to share provider data, the RMC can apply decisions that providers are ineligible to submit paper claims to those same providers when they bill the RMC.

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

Background
The Administrative Simplification Compliance Act (ASCA) requires that providers submit claims to Medicare electronically to be considered for payment, with a limited number of exceptions including an exception that allows providers that submit fewer than 120 claims per year (no more than 10 claims per month or 30 claims per quarter) to Medicare to continue to submit paper claims. See the Medicare Claims Processing Manual, Chapter 24, Sections 90-90.6 at http://www.cms.hhs.gov/manuals/downloads/clm104c24.pdf.

Due to the dispersion of railroad (RR) retirees in the United States, however, few physicians/practitioners/suppliers treat a large number of RR Medicare beneficiaries. As result, many of these providers submit fewer than 10 claims a month to the RR Medicare Carrier (RMC), and they have been allowed to continue to submit paper claims to the RMC. In addition, the same providers generally treat non-RR Medicare beneficiaries and submit more than 10 claims a month to other Medicare contractors.

However, ASCA electronic claim filing exceptions apply to Medicare overall, and do not differentiate based on contractors or between RR and non-RR contractors. Providers that submit paper claims to multiple Medicare contractors, including both RR and non-RR Medicare contractors, are subject to ASCA Enforcement Review by each of those contractors.


If a non-RR Medicare contractor 1) determines that a provider does not meet criteria which would permit that provider to continue to submit Medicare claims on paper and 2) notifies the provider that all paper claims submitted on or after a specific date will be denied, then that same decision is to be applied to that provider if submitting paper claims to the RMC even if that provider would not normally submit 10 or more paper claims to the RMC monthly.

If a provider reports that another Medicare contractor has reversed a decision that the provider is ineligible to submit paper claims, the RMC will ask that provider to submit a copy of the reversal letter from that contractor and to hold all new paper claims until such time as the RMC reviews the reversal letter and can advise the provider by letter that they can submit the paper claims.

Effective with the implementation date of CR5606, the Medicare Claims System (MCS) maintainer that prepares the provider files for transfer to the RMC will add ASCA Enforcement Review information when that information is in the non-RR provider files used to prepare the report for the RMC. Once added to the file, information concerning ASCA Enforcement decisions made by the non-RR Medicare contractors (such as providers are ineligible to submit paper claims) will be accessible to the RMC so the same decisions can be applied to the same providers when they bill the RMC.

CR5606 also updates the Medicare Claims Processing Manual to eliminate references to Claims Status and Coordination of Benefits ((COB) Medicare HIPAA Contingency Plans and changes to reflect transfer
of responsibility for Medigap claims to the COB contractor.

Additional Information
The official instruction, CR5606, issued to your Medicare carrier, A/B MAC, or DME MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1353CP.pdf on the CMS Web site.

If you have any 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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Bevacizumab (Avastin) in the Treatment of Neovascular (Wet) Macular Degeneration

The Article for Bevacizumab (Avastin) in the Treatment of Neovascular (Wet) Macular Degeneration (NC – A38592, TN – A38516, ID – A38595) has been retired for all three CIGNA Government Services states, effective July 1, 2007.

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CDC Toll Free Number

The CERT Documention Center (CDC) now has a toll–free number, 1.888.779.7477 for questions regarding documentation. This number is NOT for faxing documentation.

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CMN Ambulance

Data analysis by several agencies has found significant concerns regarding the proper use of Certificates of Medical Necessity (CMN)/Physician Certification Statement (PCS) to justify ambulance transport of Medicare beneficiaries. Of particular interest is the area of transport of ESRD patients.

As this area undergoes further review, both medical providers and the ambulance providers will be considered for audits/reviews. Physicians should be sure that the patient's medical record clearly supports the need for a CMN/PCS for ambulance transport to include the specific deficits that would require the ambulance transport. Physicians should routinely review the continuing need for a CMN/PCS as often the reason for the initial issuance resolves and a CMN/PCS is no longer valid. Be very careful in cases where a patient has no other obvious means of transport. In the absence of other reasons, lack of transportation is not a valid indication for a CMN/PCS for ambulance transfer.

Medicare will not pay for transports that are not clearly medically necessary and reasonable and it is a violation to bill for such transports.

EMS providers should also be cognizant that the patient's condition has not changed such that a CMN/PCS is no longer valid. A patient who is able to walk from the porch to the ambulance is likely not eligible for ambulance transfer in routine non-emergent settings. Such cases should be brought to the attention of the provider signing the CMN/PCS. Abuse of a CMN/PCS should be reported to the Medicare Carrier or the Medicare Program Safeguard Contractor for further review. Failure to report suspected fraud and abuse in the Medicare Program is a violation.

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Coding for Polypectomy Performed During Screening Colonoscopy or Flexible Sigmoidoscsopy

News Flash - Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers, and Billers serves as a resource on how to read and understand a Remittance Advice (RA). Inside the guide, you will find useful information on topics such as the types of RAs, the purpose of the RA, and the types of codes that appear on the RA. To order your copy today, go to the Medicare Learning Network Product Ordering page at http://www.cms.hhs.gov/MLNProducts on the CMS Web site.

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

Provider Action Needed
This special edition article is being provided by the Centers for Medicare & Medicaid Services to clarify billing instructions for the Medicare beneficiary who 1) presents for a screening colonoscopy (or flexible sigmoidoscopy), 2) has no gastrointestinal symptoms, and 3) during their screening colonoscopy (or flexible sigmoidoscopy), have an abnormality identified (such as a polyp, etc.) which is biopsied or removed.

Background
CMS has become aware of confusion regarding billing for colorectal screening arising because of wording in the Medicare Physician Fee Schedule (MPFS) Final Rule for 2007 (Federal Register, Vol. 71, No. 231, page 69665, December 1, 2006 (See the MPFS Final Rule at http://www.cms.hhs.gov/quarterlyproviderupdates/downloads/cms1321fc.pdf on the CMS Web site).

The relevant section of the 2007 MPFS states, regarding screening colonoscopies, that:
"if during the course of such screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the lesion or growth, payment under this part shall not be made for the screening colonoscopy but shall be made for the procedure classified as a colonoscopy with such biopsy or removal.'' Based on this statutory language, in such instances the test or procedure is no longer classified as a "screening test.'' Thus, the deductible would not be waived in such situations.

The above scenario can be restated as follows:

CMS advises that, whether or not an abnormality is found, if a service to a Medicare beneficiary starts out as a screening examination (colonoscopy or sigmoidoscopy), then the primary diagnosis should be indicated on the form CMS-1500 (or its electronic equivalent) using the ICD-9 code for the screening examination.

As an example, the above scenario should be billed as follows using claim form CMS-1500 (or its electronic equivalent):

A Medicare beneficiary undergoing a screening colonoscopy (no symptoms and no abnormal findings prior to the procedure) will be responsible for the deductible if a polyp is identified and either biopsied or removed.

When there is no need for a therapeutic procedure, the appropriate HCPCS G-code is reported with the ICD-9-CM code reflecting the indication. Effective January 1, 2007, CMS began waiving the annual Medicare Part B deductible for colorectal cancer screening tests billed with the HCPCS G-codes listed in the following table:

HCPCS Screening Code Description
G0104 Colorectal cancer screening: Flexibale sigmoidoscopy
G0105
G0121

Colorectal cancer screening: Colonoscopy on individual at high risk;

Colorectal cancer screening:
Colonoscopyon individual not meetig ciriteria for high risk

G0106 Colorectal cancer screenin: Barium emea as a aalternative to G0104, screening sigmoidoscopy
G0120 Colorectal cancer screening: Barium enema as an alternative to G0105, screening colonoscopy

Additional Information
For related MLN Matters articles on colorectal cancer screenings, see articles SE0710 and MM5387, which are available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0710.pdf and
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5387.pdf, respectively, 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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CY 2008 Participation Enrollment and MEDPARD Procedures

The fees for CY 2008 Medicare Physician Fee schedule (MPFSDB) will be posted to our Web site after the 2008 physician fee schedule regulation is put on display.

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How to Handle the National Provider Identifier (NPI) for Ordering/Referring and Attending/Operating/Other/Service Facility for Medicare Claims

Note: This article was revised on November 1, 2007, to delete the parenthetical phrase (MD and DO) from the 8th bullet point under "Key Points." All other information remains the same.

News Flash
Flu Season is upon us! Begin now to take advantage of each office visit as an opportunity to talk with your patients about the flu virus and their risks for complications associated with the flu. (Medicare provides coverage of the flu vaccine without any out of pocket costs to the Medicare patient. No deductible or copayment/coinsurance applies.) Remember Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For information about Medicare's coverage of flu vaccine and its administration, please go to http://www.cms.hhs.gov/MLNProducts/Downloads/flu_products.pdf on the CMS Web site.

Get Your Flu Shot – Not the Flu

Provider Types Affected
Physicians and providers who bill Medicare Carriers, fiscal intermediaries (FI), and Medicare Administrative Contractors (A/B MAC) for claims for services provided to Medicare beneficiaries.

What Providers Need to Know
Be cognizant of the fact that in accordance with the NPI final rule, when an identifier is reported on a claim for ordering/referring/attending provider, operating/other/service facility provider, or for any provider that is not a billing, pay-to or rendering provider, that identifier must be an NPI. For Medicare purposes this means that submission of an NPI for an ordering/referring provider is mandatory effective May 23, 2008. Legacy numbers cannot be reported on any claims sent to Medicare on or after May 23, 2008.

Medicare has always required that a provider identifier be reported for ordering/referring providers. Effective May 23, 2008, that number must be an NPI, regardless of whether that referring or ordering provider participates in the Medicare program or not or is a covered entity.

Key Points

Established NPI business requirements for beneficiary submitted (CR 5328), deceased physician (CR 5416), adjustments (CR 5416), beneficiary submitted (CR 4169), flu claims (CR 4169), foreign claims (CR 4169) and pandemic flu claims (CR 4169) remain as written.

Background
This article is based on Change Request (CR) 5674. Please note that the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandate the adoption of a standard unique health identifier for each health care provider. The (NPI) final rule, published on January 23, 2004, establishes the NPI as this standard. All health care providers covered under HIPAA must comply with the requirements of the NPI final rule (45 CFR Part 162, CMS-045-F). All entities covered under HIPAA must comply with the requirements of the NPI final rule.

Additional Information
If you have questions, please contact your Medicare A/B MAC, FI, 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.

You may see the official instruction (CR5674) issued to your Medicare A/B MAC, FI, or carrier by going to http://www.cms.hhs.gov/Transmittals/downloads/R225PI.pdf on the CMS Web site.

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Important NPI And Enrollment Information for Physicians And Non-Physician Practitioners

News Flash - Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers, and Billers serves as a resource on how to read and understand a Remittance Advice (RA). Inside the guide, you will find useful information on topics such as the types of RAs, the purpose of the RA, and the types of codes that appear on the RA. To order your copy today, go to the Medicare Learning Network Product Ordering page at http://www.cms.hhs.gov/MLNProducts on the CMS Web site.

Provider Types Affected
Physicians and other practitioners who submit Medicare fee-for-service (FFS) claims to Medicare Carriers or Part A/B Medicare Administrative Contractors (A/B MACs).

Provider Action Needed

STOP – Impact to You
By October 31, 2007, a Medicare system, known as the National Provider Identifier (NPI) Crosswalk, will validate your claims if they contain a legacy number, such as a Medicare Provider Identification Number (PIN), and a NPI. If the NPI/PIN combination in your claim does do not match an NPI/PIN combination in the NPI crosswalk, your claim will reject.

CAUTION – What You Need to Know
The Medicare NPI crosswalk contains legacy numbers, which you identified to the National Plan and Provider Enumeration System (NPPES) as part of the process in obtaining your NPI.

GO – What You Need to Do
Be sure you supplied the correct information to the NPPES and be sure your billing staff submit the correct NPI/PIN number combination when both a legacy number and NPI are submitted on a claim. Your NPI must be compatible with the PIN you received upon Medicare enrollment.

Background
By October 31, 2007, all Medicare carriers (and A/B MACs that service providers who formerly billed carriers) will be rejecting Part B claims if they are unable to "match" a NPI and a PIN combination submitted on a claim to an NPI/PIN combination in the Medicare NPI crosswalk. The NPI/PIN combination may be used to identify the Billing, Pay-to, or Rendering Provider (the Pay-to Provider is identified only if it is different from the Billing Provider). This applies to claims that are submitted by corporations that physicians and non-physician practitioners have formed, or by physicians and non-physician practitioners who bill Medicare directly. In this article, we refer to these physicians and non-physician practitioners as "physicians/practitioners."

Past Medicare Enrollment Practices May Have Contributed to the Use of Incompatible NPI/PIN Combinations
One reason a claim will reject is if the NPI and PIN used in combination on the claim does not identify the same entity. For example, the NPI in the "Billing Provider" field might be the corporation's NPI, but the PIN used in combination with it might be the physician/practitioner's PIN.

This pairing may be the result of variations in past Medicare enrollment and PIN assignment procedures. For example, Medicare carriers may have combined the enrollment of a physician/practitioner and his/her corporation into a single enrollment; or, a sole proprietorship may have been enrolled as a corporation because the sole proprietorship was issued an Employer Identification Number (EIN) by the IRS.

These and similar situations may require physician/practitioners who are experiencing claims rejections to ensure their Medicare enrollment information, and that of their corporations (if they are incorporated), is correct. This may require the completion of the appropriate CMS-855 Medicare Provider Enrollment Application.

Physicians/Practitioners Who Are Incorporated.
Corporations include professional corporations, most limited liability companies, professional associations, and partnerships. Generally, the corporations that physicians/practitioners form are referred to as groups or group practices. Corporations are not sole proprietorships. When you are billing Medicare through your corporation, both you and your corporation must enroll in Medicare.

If you are a physician/practitioner who has established a corporation, you must obtain an NPI for yourself and an NPI for your corporation. A corporation applies for an NPI as an Entity type 2 (Organization) and you apply for an NPI as an Entity type 1 (Individual). If you, or your corporation, is not enrolled in Medicare, and you use the NPI of the non-enrolled entity in combination with the PIN of the enrolled entity (or vice versa), you will encounter claims problems because the combination is incompatible and will not be found in the Medicare NPI crosswalk. If the corporation will be billing Medicare, it may use only its NPI (once it has one), only its PIN (once it has one), or its NPI/PIN in combination (once it has both) to identify itself as the Billing/Pay-to Provider. Your NPI (once you have one), your PIN (once you have one), or your NPI/PIN combination (once you have both) would be used to identify you – the physician/practitioner – as the Rendering Provider. Until the enrollment application of the non-enrolled entity can be processed, you may want to use only the PIN or only the NPI of the enrolled entity to avoid claims processing problems.

Physicians/Practitioners Who Have Sole Proprietorships.
A sole proprietorship is a business whereby all of the business's assets and liabilities are tied directly to the physician/practitioner's (the sole proprietor's) Social Security account. The sole proprietor and the sole proprietorship are considered a single legal entity: an individual. The sole proprietor's Social Security Number (SSN) serves as the Taxpayer Identification Number (TIN) of the sole proprietorship. Often, the Internal Revenue Service (IRS) issues an Employer Identification Number (EIN) to a sole proprietorship to protect the sole proprietor's SSN from being disclosed on W-2s and in transactions, such as claims sent to health plans. Therefore, at the option of the sole proprietor, the EIN (if issued) instead of the SSN could be used as the TIN in submitting a sole proprietorship's Medicare claims. The IRS links that EIN to the sole proprietor's SSN for tax reporting purposes. You/your sole proprietorship must be enrolled in Medicare.

If you are a physician/practitioner who has a sole proprietorship, you must obtain an NPI for yourself as an Entity type 1 (Individual). There is no separate NPI for the sole proprietorship. When you/your sole proprietorship are billing Medicare, you may use only your NPI (once you have one), only your PIN (once you have one), or your NPI and PIN in combination (once you have both) to identify yourself as the Billing/Pay-to Provider and as the Rendering Provider.

Physicians/Practitioners Who Have No Private Practice.
You must be enrolled in Medicare in order for the services you render to Medicare beneficiaries to be reimbursed by the Medicare program. If you do not have a sole proprietorship and have not formed a corporation, you do not bill Medicare directly; instead, you reassign your benefits to another entity, usually a group or group practice, and the group or group practice bills Medicare for the services that you perform. That group or group practice must also be enrolled in Medicare, but you are not responsible for the enrollment of the group or group practice. The group or group practice would submit claims in which you would be identified as a Rendering Provider.

You must obtain an NPI for yourself as an Entity type 1 (Individual). The group would be responsible for ensuring that you are appropriately identified in the group's claims; that is, the group would ensure that your NPI (once you have one) is used with the compatible PIN (your PIN, once you have one) if using the NPI/PIN combination; or, the group may use only your NPI (once you have one) or only your PIN (once you have one) to identify you as the Rendering Provider. The group must have its own NPI and would use only the NPI (the group's NPI, once it has one), only the PIN (the group's PIN, once it has one), or the NPI (the group's NPI, once it has one) with the compatible PIN (the group's PIN, once it has one) in combination to identify itself as the Billing Pay-to Provider.

New Product to Assist Physicians/Practitioners in Understanding Medicare Enrollment
All physician/practitioners, including sole proprietors and incorporated physician/practitioners, applying for enrollment in Medicare must have the appropriate NPI(s) and must report those NPIs on the CMS-855 Medicare Provider Enrollment Application. Physician/practitioners must also report the NPI(s) of the corporations, sole proprietorships, groups, or group practices to which they will be reassigning their benefits. Further information on enrollment scenarios is now available at http://www.cms.hhs.gov/Medicareprovidersupenroll/Downloads/EnrollmentNPI.pdf on the CMS Web site. General Medicare enrollment information can be found at http://www.cms.hhs.gov/MedicareProviderSupEnroll on the CMS Web site.

If Your Claims Are Rejected

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Ixabepilone

Ixabepilone (Ixempra T) was recently approved by the Food and Drug Administration for use in the treatment of metastatic or locally advanced breast cancer. Ixabepilone In combination with capecitabine may be used in patient with metastatic or locally advanced breast cancer who has failed an anthracycline and a taxane. Ixabepilone may be used as monotherapy in patients with metastatic or locally advanced breast cancer with a failure of an anthracycline, a taxane and capecitabine.

At this time any other utilization would be considered investigational and not medically reasonable or necessary.

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Key Medicare News for 2008 for Physicians and Other Health Care Professionals

Provider Types Affected
Physicians and health care professionals and their staff who bill Medicare carriers and/or Medicare Administrative Contractors (MACs)

Introduction
This Special Edition article is being provided to keep you, the Medicare physician and health care professional, informed about important Medicare initiatives and new Medicare benefits available in Calendar Year (CY) 2008.

As you once again make your decision to enroll in or terminate enrollment in the Medicare participation program, the Centers for Medicare & Medicaid Services (CMS) would like to take this opportunity to review some important news for 2008. CMS believes this information provides significant benefits to providers and their Medicare patients. It encourages providers to enroll or stay in the Medicare participation program in order to take full advantage of the upcoming changes.

Information You Need to Know

National Provider Identifier (NPI) - Get it! Share it! Use it!
Medicare carriers and A/B MACs began transitioning their systems to start rejecting claims when the NPI and legacy provider identifier pair that are reported on the claim cannot be found on the Medicare crosswalk. We urge you to pay attention to the reject reports you receive. The reject reports will help you and your staff identify problems that cause claims to reject.

You should also ensure that your Medicare enrollment information is up to date. If you need to submit a completed CMS-855 (Medicare provider enrollment form), remember to list all of the NPIs that will be used in place of legacy identifiers. If you need to apply for an NPI or update your information in the National Plan and Provider Enumeration System (NPPES), please include ALL of your Medicare legacy numbers. (NPPES can accept only 20 Other Provider Identifiers, but is being expanded to accept more in the future.) If the information is different between your Medicare enrollment information and your NPPES record, there is a very good chance your claims will reject. NPPES data may be verified at https://nppes.cms.hhs.gov on the CMS Web site. Contact the NPI Enumerator at 1.800.465.3203 if you need assistance in viewing your NPPES record.

A recent MLN Matters article lists the informational edits that preceded the reject report messages and their meanings. Visit http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0725.pdf on the CMS Web site to view the article.

Some incorporated physicians and non-physician practitioners have obtained NPIs as follows: an individual (Entity Type 1) NPI for the physician or non-physician practitioner and an organization (Entity Type 2) NPI for the corporation. If you enrolled in Medicare as an individual and obtained a Medicare Provider Identification Number (PIN) as an individual, and you want to use your NPI and your PIN pair in your Medicare claims, be sure you use your individual NPI with your individual PIN. Pairing your corporation's NPI with your individual PIN will result in your claims being rejected. If you wish to bill Medicare with your corporation's NPI, then you must be sure your corporation is enrolled in Medicare so that it can be assigned a PIN. Please contact your servicing Medicare carrier for more information about this enrollment. Until your corporation has been enrolled in Medicare, you may continue to bill by using your individual NPI with your individual PIN to ensure no disruption in your claims being processed and paid. Please note that similar problems may result if you bill Medicare by using your individual NPI with your corporation's PIN (if the corporation is enrolled and has been assigned a PIN). In other words, when billing with the NPI/PIN pair, you must use compatible NPIs and PINs.

Note that after May 23, 2008, legacy identifiers will not be permitted on any inbound or outbound transactions. This includes inbound claims, crossover claims, both paper and electronic remittance advices, the 276/277 claims status inquiries/replies, NCPDP claims, and the 270/271 eligibility inquiries/replies. Also, for up-to-date information on the NPI, CMS recommends periodic visits to http://www.cms.hhs.gov/NationalProvIdentStand/ on the CMS Web site.

Unique Physician Identification Numbers (UPINs)
CMS discontinued assigning unique physician identification numbers (UPINs) on June 29, 2007, but will maintain its UPIN public "look-up" functionality and Registry Web site (http://www.upinregistry.com/) through May 23, 2008.

Competitive Acquisition Program (CAP) for Part B Drugs
The Medicare Modernization Act requires CMS to implement a competitive acquisition program (CAP) for Medicare Part B drugs and biologicals that are not paid on a cost or prospective payment system (PPS) basis. This program is an alternative to the average sales price (ASP) methodology for acquiring certain Part B drugs which are administered incident to a physician's services. In it, physicians are given a choice between buying and billing these drugs under the ASP system, or selecting a Medicare-approved CAP vendor that will supply these drugs.

Participation in the CAP is voluntary, and each year Medicare physicians can elect to participate. Those who do participate will obtain drugs through CAP vendors; the vendors will bill Medicare for the administered drug and will bill the beneficiary for any applicable co-insurance or deductible.

All physicians who participated in the CAP in 2007, and wish to participate in 2008, will need to make the 2008 CAP election during the regular fall election period which will run from October 1, 2007, to November 15, 2007.

Participating physicians can sign up to receive CAP updates from the CMS-CAP-Physicians-L electronic mailing list at http://www.cms.hhs.gov/apps/mailinglists/default.asp?audience=3 on the CMS CAP Information for Physicians Web page (http://www.cms.hhs.gov/CompetitiveAcquisforBios/02_infophys.asp#TopOfPage).

Physician Quality Reporting Initiative (PQRI)
The Tax Relief and Health Care Act of 2006 (TRHCA) authorizes a physician quality reporting system. This program, which CMS has named the "Physician Quality Reporting Initiative" (PQRI), was implemented on July 1, 2007, and establishes a financial incentive for eligible professionals who participate in a voluntary quality-reporting program.

These eligible professionals, who successfully report a designated set of quality measures on claims for dates of service from July 1 to December 31, 2007, may earn a bonus payment (subject to a cap) of 1.5% of total allowed charges for covered Medicare physician fee schedule services during that same period.

The proposed 2008 PQRI quality measures were published in the Federal Register as a part of the 2008 Medicare Physician Fee Schedule (MPFS) Proposed Rule. The final 2008 PQRI measures will be published in the 2008 MPFS Final Rule and posted at http://www.cms.hhs.gov/PQRI on the CMS PQRI Web site.

For more information about the PQRI and to access important educational tools, go to http://www.cms.hhs.gov/PQRI on the CMS Web site.

New Durable Medical Equipment, Prosthetics, Orthotics & Supplies (DMEPOS) Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFS) for Claims Processing Certificates of medical necessity (CMN) provide a mechanism for suppliers of durable medical equipment and medical equipment and supplies to demonstrate that the item they provide meets the minimal criteria for Medicare coverage. Durable Medical Equipment Medicare Administrative Contractors (DME MAC) review the documentation that physicians, suppliers, and providers supply on the CMNs and DME Information Forms (DIFs), and determine if the medical necessity and applicable coverage criteria for selected DMEPOS were met.

On April 13, 2007, CMS announced the development of improved CMNs and DIFs that are consistent with current medical practices and that conform to Medicare guidelines. In this improvement process, CMS revised several CMNs, replaced three CMNs with two DIFs, and revised Medicare Program Integrity Manual, Chapter 5, Items and Services Having Special DME Review Considerations. Additionally, these new Office of Management and Budget (OMB) approved forms permit the use of a signature and date stamp that resulted in revision of the Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.1, Documentation Specifications for Areas Selected for Prepayment or Post Payment Medical Review.

You can learn more about these revised forms by reading MLN Matters article MM5571 (based on CR 5571, the official instruction issued to the DME MAC); available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5571.pdf. The new forms are available at http://www.cms.hhs.gov/CMSForms/CMSforms/list.asp#TopOfPage on the CMS Web site.

Preventive Services
Medicare, which began covering preventive services in 1981 with the pneumococcal vaccination, now covers a broad range of services to prevent disease, detect disease early when it is most treatable and curable, and manage disease so that complications can be avoided.

These services include:

To learn more details about these preventive benefits, see The Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Health Care Professionals located at http://www.cms.hhs.gov/MLNProducts/downloads/mps_guide_web-061305.pdf on the CMS Web site.

CMS has a variety of educational products and resources to help you become familiar with coverage, coding, billing, and reimbursement for all Medicare-covered preventive services, including:

For products to share with your Medicare patients, visit http://www.medicare.gov/ on the Internet.

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding
Section 302(b) of the Medicare Modernization Act, requires Medicare to replace the current durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) payment methodology, for select items in select areas, with a competitive acquisition process to improve the effectiveness of its payment-setting methodology. This new program will establish payment amounts for certain durable medical equipment, enteral nutrition, and off-the-shelf orthotics by replacing the current payment amounts (under Medicare's DMEPOS fee schedule) with payment rates derived from a bidding process.

Suppliers that want to furnish competitively bid items in a competitive bidding area (CBA) will be required to submit bids to furnish those items, and the winning bids will be used to establish a single Medicare payment amount for each item. Contracts will be awarded to a sufficient number of winning bidders in each CBA to ensure access and service to high quality DMEPOS items.

CMS is phasing in this new program. Bidding for the first phase began in 2007 in CBAs within 10 of the largest Metropolitan Statistical Areas (MSAs), excluding New York, Los Angeles, and Chicago. Prices from the first phase of bidding are scheduled to go into effect in 2008. The program will be expanded into 70 additional MSAs in 2009. After 2009, CMS will expand the program to additional areas.

While this program may have no direct impact on most physicians, it might have impact on where your patients receive their DMEPOS. Some suppliers currently serving your patients may not be selected to continue Medicare participation under the new program and your patients may have to go to new suppliers. While this may happen, please be assured that Medicare will continue to meet the same patient needs for DMEPOS as it has prior to the new program. Medicare is just attempting to meet those concerns in a more cost effective manner in order to protect Medicare funding.

You can find more information about the Medicare DMEPOS competitive bidding program at http://www.cms.hhs.gov/CompetitiveAcqforDMEPOS/ on the CMS Web site.

Provider Education Updates

The Medicare Learning Network
The Medicare Learning Network (MLN), the brand name for official CMS provider educational products, is designed to promote national consistency in Medicare provider information developed for CMS initiatives. The MLN products available on the MLN Web page provide easy access to Web-based training courses, comprehensive training guides, brochures, fact sheets, CD-ROMs, videos, educational Web guides, electronic listservs, and links to other important Medicare Program information. All educational products are available free of charge and can be ordered and/or downloaded from the MLN Web page located at http://www.cms.hhs.gov/MLNGenInfo on the CMS Web site. Some of the new information for 2007 on the MLN web page follows.

Physician Educational Tools

Companion Facilitator's Guide – To The Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals: Includes all the information and instructions necessary to prepare for and present a Medicare Resident, Practicing Physician, and Other Health Care Professional Training Program, including instructions for facilitators, a customization guide, two PowerPoint presentations with speaker notes, pre- and post-assessments, master assessment answer keys, and evaluation tools. (January 2007) Available in hard copy, CD Rom, and downloadable formats.

Other Educational Tools

Brochures
Changes in Medicare Coverage of Power Mobility Devices (PMDs): Power Wheelchairs and Power
Operated Vehicles (POVs): Addresses the CMS multi- faceted plan to ensure the appropriate prescription of wheelchairs to beneficiaries who need them. (May 2007)

Diabetes-Related Services – This tri-fold brochure provides health care professionals with an overview of Medicare's coverage of diabetes screening tests, diabetes self-management training, medical nutrition therapy, and supplies and other services for Medicare beneficiaries with diabetes. (August 2007)

Fact Sheets

Intermediary Standard System, which processes outpatient claims. (January 2007)

National Provider Identifier

Physician Quality Reporting Initiative (PQRI) Tool Kit
CMS has developed a "PQRI Tool Kit Six Steps for Success" that will assist eligible professionals with successful reporting, as well as education of staff. This Tool Kit is also useful for group presentations and training programs. Currently, the Tool Kit consists of six educational resources (listed below). Each resource in the Tool Kit is designed to stand alone or can be combined with other resource for a training session tailored to the particular audience.


The Tool Kit includes:

Physician Quality Reporting Initiative (PQRI) PowerPoint Presentations
CMS has developed PowerPoint presentation modules that will assist eligible professionals with successful reporting, as well as education of staff. These PowerPoint presentation modules are also useful for group presentations and training programs.

Beneficiary Related News

MyMedicare.com
As announced in last year's article, Medicare beneficiaries can access Medicare's free secure online service to view their Medicare information by registering for MyMedicare.com. At this site, they can access their personalized information about their Medicare benefits and services, and can:

Registration is simple. Medicare beneficiaries should go to http://www.medicare.gov and click on the box in the upper left of the screen to sign up for MyMedicare.gov.

Additional Information
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 on the CMS Web site.

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LCD For Erythropoietin Analogs For Non-ESRD Use (Epoetin Alfa And Darbepoetin Alfa)

The LCDs for ERYTHROPOIETIN ANALOGS FOR NON-ESRD USE (EPOETIN ALFA AND DARBEPOETIN ALFA) have been revised to be in compliance and congruency with the National Coverage Determination released July 31, 2007. Please refer to the CIGNA Government Services Web site at
http://www.cignagovernmentservices.com to view the policy.

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Medicare Clinical Trial Policy (CTP)

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. Medicare 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
All physicians, providers, and suppliers who submit claims related to clinical trials 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) 5719, which implements two changes to the 2000 clinical trial policy by: (1) modifying for clarity the language describing coverage of an investigational item/service in the context of a clinical trial, and, (2) adopting coverage with evidence development (CED). The remainder of the 2000 clinical trials policy continues without change.

CR 5719 states that for items and services furnished on and after July 9, 2007, the routine costs of a clinical trial include all items and services that are otherwise generally available to Medicare beneficiaries (i.e., there exists a benefit category, it is not statutorily excluded, and there is not a national non-coverage decision) that are provided in either the experimental or the control arms of a clinical trial. The investigational item or service itself is excluded, unless otherwise covered outside of the clinical trial.

CAUTION – What You Need to Know
In addition, the National Coverage Determination (NCD) is revised to add coverage with evidence development (CED). CED is for items and services in clinical research trials for which there is some evidence of significant medical benefit, but for which there is insufficient evidence to support a "reasonable and necessary" determination. CED is determined through the NCD process, and conditional upon meeting standards of patient safety and clinical evidence, items and services not otherwise covered would be considered "reasonable and necessary" in the context of a clinical trial. Coverage determined under CED is implemented via subsequent NCDs, CRs, and MLN Matters articles specific to the coverage issue.

GO – What You Need to Do
Make certain your billing staffs are aware of these changes. Medicare contractors will adjust claims processed prior to the implementation date of this change if you bring such claims to their attention.

Background
On June 7, 2000, the President of the United States issued an executive memorandum directing the Secretary of Health and Human Services to "explicitly authorize [Medicare] payment for routine patient care costs and costs due to medical complications associated with participation in clinical trials." In keeping with the President's directive, the Centers for Medicare & Medicaid Services (CMS) engaged in defining the routine costs of clinical trials and identifying the clinical trials for which payment for such routine costs should be made. On September 19, 2000, CMS implemented its initial Clinical Trial Policy through the NCD process. On July 10, 2006, CMS opened a reconsideration of its NCD on clinical trials in the NCD Manual, section 310.1. CR5719 communicates the findings resulting from that analysis.

Additional Information
To see the official instruction (CR5719) issued to your Medicare FI, carrier, DME/MAC, RHHI or A/B MAC, visit http://www.cms.hhs.gov/transmittals/downloads/R74NCD.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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Medicare Fee–for–Service (FFS) National Provider Identifier (NPI) Final Implementation

News Flash - The 2008 Physician Election Period for the Medicare Part B Drug Competitive Acquisition Program (CAP) will begin on October 1, 2007 and concludes on November 15, 2007. The CAP is a voluntary program that offers physicians the option to acquire many injectable and infused drugs they use in their practice from an approved CAP vendor, thus reducing the time they spend buying and billing for drugs. The 2008 CAP program will run from January 1 to December 31, 2008. Once a physician has elected to participate in CAP, they must obtain all drugs on the CAP drug list from the CAP drug vendor. Physicians can still continue to purchase and bill Medicare under the Average Sale Price (ASP) system for those drugs that are not provided by the physician's CAP vendor.

Additional information about the CAP is available at http://www.cms.hhs.gov/CompetitiveAcquisforBios/01_overview.asp on the CMS Web site. Please note that completed and signed physician election forms should be returned by mail to your local carrier. Forms must be postmarked on or before November 15, 2007. DO NOT return forms to CMS offices.

Provider Types Affected
Physicians, providers, and suppliers who submit any HIPAA standard transactions to Medicare contractors (carriers, Fiscal Intermediaries, (FIs), including Regional Home Health Intermediaries (RHHIs), Medicare Administrative Contractors (A/B MACs), and DME Medicare Administrative Contractors (DME MACs))

Provider Action Needed

STOP – Impact to You
This article is based on CR5728, which describes the policy change brought about as a result of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, that requires issuance of a unique national provider identifier (NPI) to each physician, supplier, and other provider of health care who conducts HIPAA standard electronic transactions.

CAUTION – What You Need to Know
Once CMS ends its' NPI contingency, the legacy number will NOT be permitted on any inbound electronic and outbound electronic transaction (there are exceptions to the 835 remittance advice (see CR5452)). Medicare contractors will begin rejecting claims, electronic, including direct data entry, that contain legacy provider numbers for any primary provider instead of or in addition to the NPI number. The following HIPAA transactions are also affected:

GO – What You Need to Do
No later than May 23, 2008, providers should ensure that all HIPAA transactions sent to Medicare contractors contain only valid NPI numbers (no legacy provider numbers).

Background
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 required issuance of a unique national provider identifier (NPI) to each physician, supplier, and other provider of health care who conducts HIPAA standard electronic transactions. The Centers for Medicare & Medicaid Services (CMS) began to issue NPIs on May 23, 2005. CMS has been allowing transactions adopted under HIPAA to be submitted with a variety of identifiers. They are:

On April 2, 2007, the Department of Health and Human Services (DHHS) provided guidance to covered entities regarding contingency planning for the implementation of the NPI. As long as a health plan is compliant, meaning they can accept and send NPIs on electronic transactions, they may establish contingency plans to facilitate the compliance of their trading partners. As a compliant health plan, Medicare fee–for–service (FFS) established a contingency plan on April 20, 2007, that followed this guidance. CR5728 directs Medicare contractors to begin rejecting HIPAA inbound claims when directed by CMS, if they contain legacy provider identifiers.

Since paper claims are not HIPAA transactions, these requirements do not apply to paper claims, however, providers should not submit legacy numbers on paper claims once CMS ends its NPI contingency plan.

Additional Information
The official instruction, CR5728, issued can be found at http://www.cms.hhs.gov/Transmittals/downloads/R1349CP.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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Medicare Summary Notice (MSN) Message: Revised 38.13

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

Provider Action Needed
This article is informational for providers and the article is based on Change Request (CR) 5722, which outlines a change to MSN message 38.13 that will advise beneficiaries that they may need to pay their provider before receiving their MSN due to the change to quarterly mailing schedule (see CR 5062.)

Background
In an effort to reduce overall operating costs, CR5062 changed the No-Pay MSN mailing schedule from a monthly schedule to a quarterly schedule. As a result, it is possible that a beneficiary may receive a bill from a provider before receiving the MSN and may not be able to wait for the MSN before provider payment is due.

The change to MSN Message 38.13 clarifies this potential timing conflict to beneficiaries. The revised MSN message is as follows:

"If you aren't due a payment check from Medicare, your Medicare Summary Notices (MSN) will now be mailed to you on a quarterly basis. You will no longer get a monthly statement in the mail for these types of MSNs. You will now get a statement every 90 days summarizing all of your Medicare claims. Your provider may send you a bill that you may need to pay before you get your MSN. When you get your MSN, look to see if you paid more than the MSN says is due. If you paid more, call your provider about a refund. If you have any questions about the bill from your provider, you should call your provider."

Additional Information
You can review the official instruction issued to you're A/B MAC, FI, carrier, DME MAC, or RHHI regarding this message modification by going to CR 5722, located at http://www.cms.hhs.gov/transmittals/downloads/R1347CP.pdf on the CMS Web site.

You can review CR5062 at http://www.cms.hhs.gov/transmittals/downloads/R955CP.pdf on the CMS Web site. The related MLN Matters article (MM5062: Quarterly Medicare Summary Notice (MSN) Printing Cycle) is at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5062.pdf on the CMS Web site.

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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Observation Care Codes (CPT Codes 99234 through 99236)

This article is a reprint from the Medicare Bulletin March/April 2001. Recent inquiry into time and date of service requirements for these services prompted republication of this article to remind providers that for Medicare purposes there are guidelines that are not outlined in the AMA – CPT Manual.

This explains the use of CPT codes 99234 through 99236:

The physician must satisfy the documentation requirements for both admission to and discharge from inpatient or observation care to bill CPT codes 99234, 99235, or 99236. The length of time for observation care or treatment status must also be documented.

References: Physician Fee Schedule Final Rule, Vol.65, No. 212, published November 1, 2000; pages 65408 – 65409

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Payable Diagnosis Codes for PET Scans

Medicare coverage for PET scans is determined by National Coverage Determinations (NCD). Only those diagnoses/conditions specifically designated as covered may be paid, except for some malignancies which are not specifically named. Some such cancers can be covered if the institution performing the study is participating in the National Oncology PET Registry (NOPR), but not otherwise.

When several of the PET NCDs and coverages first were implemented, the PET scan procedures covered were designated by temporary "G" codes that were condition-specific and corresponded to the NCD coverages. The covered conditions could easily be linked to the corresponding G code for payment. Subsequently, AMA/CPT and CMS published CPT codes for PET scans that were anatomically and functionally oriented, and deleted the G codes. This created somewhat of a disconnect between the condition-specific coverages as defined in the NCDs and the CPT codes describing the procedures. Numerous provides have asked which ICD-9 diagnoses are covered for which procedure (CPT code). This is published to provide our coverages based on the specific ICD-9 codes.

CPT Code Payable Diagnoses/ICD-9 Codes

CPT Code Payable Diagnoses/ ICD-9 Codes
78608-PET Brain imaging; metabolic evaualtion 290.0, 290.10-290.13, 290.20-290.21, 290.3, 294.10-294.11, 331.0, 331.11, 331.19, 331.2, 345.01, 345.11, 345.2, 345.3, 345.41, 345.51, 345.61, 345.71, 345.8, 345.91, 780.93
78609 - PET brainimaging; perfusion evaluation 290.0, 290.10-290.13, 290.20-290.21, 290.3, 294.10-294.11, 331.0, 331.11, 331.19, 331.2, 345.01, 345.11, 345.2, 345.3, 345.41, 345.51, 345.61, 345.71, 345.8, 345.91, 780.93
78459 - PET myocardial imaging; metabolic evaluation 410.0-414.9
78491 - PET heart image; single study 410.0-414.9
78492 - PET heart image; multiple studies 410.0-414.9
78811 - PET tumor imaging inlimited area (head, chest/neck) 140.0-149.9, 150.0-150.9, 153.0-154.8, 160-162.9, 170.0-170.1, 172.0-172.9, 174.0-175.9, 180.0-180.9, 183.0, 190.0-190.9, 193, 195.0, 196.0, 200.00-202.29, 202.70 - 202.78, 208.80-202.88, 518.89, 793.1
78812 - PET tumor imaging skullbase to mid-thigh 140.0-149.9, 150.0-150.9, 153.0-154.8, 160-162.9, 170.0-170.1, 172.0-172.9, 174.0-175.9, 180.0-180.9, 183.0, 190.0-190.9, 193, 195.0, 196.0, 200.00-202.29, 202.70 - 202.78, 208.80-202.88, 518.89, 793.1
78813 - PET tumor imaging; whole body 140.0-149.9, 150.0-150.9, 153.0-154.8, 160-162.9, 170.0-170.1, 172.0-172.9, 174.0-175.9, 180.0-180.9, 183.0, 190.0-190.9, 193, 195.0, 196.0, 200.00-202.29, 202.70 - 202.78, 208.80-202.88, 518.89, 793.1
78814 - PET tumor imaging w/concurrent CT for attenuation correction and anatomical localization; limited area (head/neck, chest) 140.0-149.9, 150.0-150.9, 153.0-154.8, 160-162.9, 170.0-170.1, 172.0-172.9, 174.0-175.9, 180.0-180.9, 183.0, 190.0-190.9, 193, 195.0, 196.0, 200.00-202.29, 202.70 - 202.78, 208.80-202.88, 518.89, 793.1
78815 - PET tumor imaging w/concurrent CT for attenuation correction and anatomical localization: skull base to mid-thigh 140.0-149.9, 150.0-150.9, 153.0-154.8, 160-162.9, 170.0-170.1, 172.0-172.9, 174.0-175.9, 180.0-180.9, 183.0, 190.0-190.9, 193, 195.0, 196.0, 200.00-202.29, 202.70 - 202.78, 208.80-202.88, 518.89, 793.1
78816 - PET tumor imaging w/concurrent CT for attenuation correction and anatomical localization: whole body 140.0-149.9, 150.0-150.9, 153.0-154.8, 160-162.9, 170.0-170.1, 172.0-172.9, 174.0-175.9, 180.0-180.9, 183.0, 190.0-190.9, 193, 195.0, 196.0, 200.00-202.29, 202.70 - 202.78, 208.80-202.88, 518.89, 793.1

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Payment Allowances for the Influenza Virus Vaccine and the Pneumococcal Vaccine When Payment is Base on 95 Percent of the Average Wholesale Price (AWP)


News Flash - The 2008 Physician Election Period for the Medicare Part B Drug Competitive Acquisition Program (CAP) will begin on October 1, 2007 and concludes on November 15, 2007. The CAP is a voluntary program that offers physicians the option to acquire many injectable and infused drugs they use in their practice from an approved CAP vendor, thus reducing the time they spend buying and billing for drugs. Additional information about the CAP is available at http://www.cms.hhs.gov/CompetitiveAcquisforBios/02_infophys.asp on the CMS Web site. Please note that completed and signed physician election forms should be returned by mail to your local carrier. Forms must be postmarked on or before November 15, 2007. DO NOT return forms to CMS offices.

Provider Types Affected
Providers who bill Medicare contractors (fiscal intermediaries (FI), carriers, and Medicare Administrative Contractors (A/B MACs)) for influenza virus and pneumococcal vaccines.

Provider Action Needed
Be sure your billing staff are aware of the billing rates that are effective for influenza and pneumococcal vaccines provided on or after September 1, 2007. These rates apply, except where the vaccine is furnished in the hospital outpatient department, in which payment for the vaccine is based on reasonable cost.

Background
Change Request (CR) 5744, from which this article is taken, provides the payment allowances for: Influenza Virus Vaccines (Current Procedural Terminology (CPT) codes 90655, 90656, 90657, 90658, and 90660), and Pneumococcal Vaccine (CPT 90732 and 90669); when payment is based on 95% of the AWP.

This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2006 American Medical Association.

Effective September 1, 2007, the Medicare Part B payment allowance in these situations is as follows:
Influenza vaccine payments are:

Pneumococcal vaccine payments are:

Please note:

Additional Information
The official instruction, CR5744, issued to your Medicare contractor is located at http://www.cms.hhs.gov/Transmittals/downloads/R1357CP.pdf on the Centers for Medicare & Medicaid (CMS) Web site.

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

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Recent CERT Errors for Home Health Certification/Re-certification

Currently, CMS (Centers for Medicare & Medicaid Services) calculates a national paid claims error rate, a contractor–specific error rate, and a provider compliance error rate (which measures how well providers prepared claims for submission). In order to calculate this error rate, The Comprehensive Error Rate Testing (CERT) contractor reviews 200 randomly chosen claims processed by CIGNA Government Services each month.

During recent CERT reviews over the past few months we have noticed the following errors recurring relating to use of the home health certification and re-certification codes:

  1. Inappropriate use of HCPCS Codes
    1. The home health agency certification code (HCPCS code G0180) can be billed only when the patient has not received Medicare-covered home health services for at least 60 days.
    2. Whereas, the home health agency recertification code (HCPCS Code G0179) is used after a patient has received services for at least 60 days (or one certification period), G0179 will be reported only once every 60 days.
  2. Record Retention
    When requesting medical records through the CERT program to support Home Health certification or recertification we often find the following:
    1. The provider saw the patient outside the office; the office bills the service, but has no supporting documentation. They do not know who the home health agency might be, or in some cases, where he saw this patient because the office has no chart.
    2. Providers did not keep a copy of the certification/re-certification.

In either scenario, offices do not appear to be retaining documentation when it comes to home health.

Remember that the person/office submitting the claim will be the person/office contacted by CERT for submitting the necessary documentation to support the services billed.

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Removal of Benign Lesions

The LCDs for REMOVAL OF BENIGN LESIONS for all three CGS states have been revised to remove the requirement of the use of the –KX modifier, effective December 1, 2007. In addition several ICD.9 codes have been added to the LCDs as covered indications. After the effective date, providers must bill with one of the covered ICD-9 codes for payment. Please refer to the CIGNA Government Services Web site at http://www.cignagovernmentservices.com to view the policy.

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Removal of EDI Voice Mail

The CIGNA Government Services EDI department will be modifying the phone system that supports our EDI Helpdesk on 12/01/2007. This change will provide the same functionality to the EDI department that exists in the Provider Contact Center; the most notable difference to our EDI customers will be the elimination of the voice mail system during normal operating hours. Our phone numbers will remain the same and our helpdesk remains committed to responding with prompt, courteous responses to your questions, concerns and issues. We are continually adding materials to the EDI section of the CIGNA Government Services Web site to better assist our customers in finding the answers they need as an alternative to calling. For example, we have recently added a feature to our Web site that will allow you to request an electronic report be reposted in your Stratus mailbox as this is one of the most common calls we receive. We will continue to look for items we can offer online in order to free up your time and provide the ability to request information when it is convenient for you. If there are items you don't see on our Web site that you feel would be beneficial, please let your EDI representative know.

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Skilled Nursing Facility Consolidated Billing and Preventive/Screening Services

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.

Note: This article was revised on October 9, 2007, to add additional information on vaccines as well as information on the Part D benefit.

Provider Types Affected
Skilled Nursing Facilities (SNFs), physicians, suppliers, and providers.

Provider Action Needed
This Special Edition is an informational article that describes SNF Consolidated Billing (CB) as it applies to preventive and screening services provided to SNF residents.

Clarification: The SNF CB requirement makes the SNF itself responsible for including on the Part A bill that it submits to its Medicare intermediary almost all of the services that a resident receives during the course of a Medicare-covered stay, except for a small number of services that are specifically excluded from this provision. These "excluded" services can be separately furnished to the resident and billed under Medicare Part B by a variety of outside sources. These sources can include other providers of service (such as hospitals), which would submit the bill for Part B services to their Medicare intermediary, as well as practitioners and suppliers who would generally submit their bills to a Medicare Part B carrier. (Bills for certain types of items or equipment would be submitted by the supplier to their Durable Medical Equipment Medicare Administrative Contractor (DME MAC)).

Background
When the Skilled Nursing Facility (SNF) prospective payment system (PPS) was introduced in the Balanced Budget Act of 1997 (BBA, P.L. 105-33, Section 4432), it changed the way SNFs are paid, and the way SNFs must work with suppliers, physicians, and other practitioners. CB assigns to the SNF itself the Medicare billing responsibility for virtually all of the services that the SNF's residents receive during the course of a covered Part A stay. See MLN Matters article SE0431 for a detailed overview of SNF CB, including a section on services excluded from SNF CB. This article can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0431.pdf on the CMS Web site.

Preventive and Screening Services
The BBA identified a list of services that are excluded from SNF CB. These services are primarily those provided by physicians and certain other types of medical practitioners, and they can be separately billed to Medicare Part B carriers directly by the outside entity that furnishes them to the SNF's resident (Social Security Act, Section 1888(e)(2)(A)(ii)). Since the BBA did not list preventive and screening services among the services identified for exclusion, these services are included within the scope of the CB provision.

However, reimbursement for covered preventive and screening services, such as vaccines and mammographies, is subject to special billing procedures. As discussed in the May 12, 1998 Federal Register (63 FR 26296), since preventive services (such as vaccinations) and screening services (such as screening mammographies) do not appear on the exclusion list, they are subject to CB.

Accordingly, if an SNF resident receives, for example, a flu vaccine during a covered Part A stay, the SNF itself is responsible for billing Medicare for the vaccine, even if it is furnished to the resident by an outside entity.

Billing for Preventive and Screening Services
Nevertheless, even though the CB requirement makes the SNF itself responsible for billing Medicare for a preventive or screening service furnished to its Part A resident, the SNF would not include the service on its Part A bill, but would instead submit a separate bill for the service. This is because the Part A SNF benefit is limited to coverage of "diagnostic or therapeutic" services (i.e., services that are reasonable and necessary to diagnose or treat a condition that has already manifested itself). (See Sections 1861(h) following (7), 1861(b)(3), and 1862(a)(1) of the Social Security Act.)

Accordingly, the Part A SNF benefit does not encompass screening services (which serve to check for the possible presence of a specific condition while it is still in an early, asymptomatic stage) or preventive services (which serve to ward off the occurrence of a condition altogether). As discussed below, such services are always covered under the applicable Part B benefit (or, in certain circumstances, under the Part D drug benefit), even when furnished to a beneficiary during the course of a covered Part A SNF stay.

Priority of Payments
Priority of payment between the various parts of the Medicare law (title XVIII of the Social Security Act) basically proceeds in alphabetical order: Part A is primary to Part B (see Section 1833(d) of the Social Security Act), and both Parts A and B are primary to Part D (see Section 1860D-2(e)(2)(B) of the Social Security Act). In the case of a vaccine, for example, this means that Part B can cover the vaccine only to the extent that it is not already coverable under Part A; similarly, the Part D drug benefit can cover such a vaccine only to the extent that it is not already coverable under either Part A or Part B.

Thus, when an SNF's Part A resident receives a preventive vaccine for which a specific Part B benefit category exists (i.e., pneumococcal pneumonia, hepatitis B, or influenza), the vaccine would be covered under Part B. It would not be covered under Part A (because, as explained above, the scope of the Part A SNF benefit does not encompass preventive services), and it also would not be covered under Part D (because Part B already includes a specific benefit category that covers each of these three types of vaccines and, as discussed above, Part B is primary to Part D). Similarly, a preventive vaccine (such as poliomyelitis) for which no Part B benefit category exists would be coverable under the Part D drug benefit when administered to the SNF's Part A resident, rather than being covered under the Part A SNF benefit.

Example of Special Circumstance
However, there are certain limited circumstances in which a vaccine would no longer be considered preventive in nature, and this can affect how the vaccine is covered. For example, while a booster shot of tetanus vaccine would be considered preventive if administered routinely in accordance with a recommended schedule, it would not be considered preventive when administered in response to an actual exposure to the disease (such as an animal bite, or a scratch on a rusty nail). In the latter situation, such a vaccine furnished to an SNF's Part A resident would be considered reasonable and necessary to treat an existing condition and, accordingly, would be included within the SNF's global Part A per diem payment for the resident's Medicare-covered stay.

In terms of billing for an SNF's Part A resident, a vaccine that is administered for therapeutic rather than preventive purposes (such as a tetanus booster shot given in response to an actual exposure to the disease) would be included on the SNF's global Part A bill for the resident's covered stay.

Alternatively, if a vaccine is preventive in nature and is one of the three types of vaccines for which a Part B benefit category exists (i.e., pneumococcal pneumonia, hepatitis B, or influenza), then the SNF would submit a separate Part B bill to its fiscal intermediary for the vaccine. (Under Section 1888(e)(9) of the Social Security Act, payment for an SNF's Part B services is made in accordance with the applicable fee schedule for the type of service being billed.) Finally, if the resident receives a type of preventive vaccine for which no Part B benefit category exists (e.g., poliomyelitis), then the vaccine would not be covered under either Parts A or B, and so would be coverable under the Part D drug benefit.

Additional Information
See MLN Matters Special Edition SE0431 for a detailed overview of SNF CB. This article lists services
excluded from SNF CB and can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0431.pdf on the CMS Web site.
The Centers for Medicare & Medicaid Services (CMS) MLN Consolidated Billing Web site is at http://www.cms.hhs.gov/SNFConsolidatedBilling/.

It includes the following relevant information:
General SNF consolidated billing information;
HCPCS codes that can be separately paid by the Medicare carrier (i.e., services not included in consolidated billing);

Therapy codes that must be consolidated in a non-covered stay; and

All code lists that are subject to quarterly and annual updates and should be reviewed periodically for the latest revisions.

The SNF PPS Consolidated Billing Web site can be found at http://www.cms.hhs.gov/SNFPPS/05_ConsolidatedBilling.asp on the CMS Web site. It includes the following relevant information:

Background;
Historical questions and answers;

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Skilled Nursing Facility Consolidated Billing as It Relates to Ambulance Services

News Flash - Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers, and Billers serves as a resource on how to read and understand a Remittance Advice (RA). Inside the guide, you will find useful information on topics such as the types of RAs, the purpose of the RA, and the types of codes that appear on the RA. To order your copy today, go to the Medicare Learning Network Product Ordering page at http://www.cms.hhs.gov/MLNProducts on the CMS Web site.

Note: This article was revised on October 9, 2007, to provide clarification on page 3, regarding "trips for excluded outpatient services." This clarification is intended to state explicitly that the CB exclusion for ambulance trips related to the receipt of excluded outpatient hospital services would apply to the entire ambulance roundtrip (the SNF-to-hospital trip plus the return trip back to the SNF), and not just to the outbound (SNF-to-hospital) portion alone. All other information remains the same.

Provider Types Affected
Skilled Nursing Facilities (SNFs), physicians, ambulance suppliers, and providers

Provider Action Needed
This Special Edition article describes SNF Consolidated Billing (CB) as it applies to ambulance services for SNF residents.

Clarification: The SNF CB requirement makes the SNF responsible for including on the Part A bill that it submits to its Medicare intermediary almost all of the services that a resident receives during the course of a Medicare-covered stay, except for a small number of services that are specifically excluded from this provision. These "excluded" services can be separately furnished to the resident and billed under Medicare Part B by a variety of outside sources. These sources can include other providers of service (such as hospitals), which would submit the bill for Part B services to their Medicare intermediary, as well as practitioners and suppliers who would generally submit their bills to a Medicare Part B carrier. (Bills for certain types of items or equipment would be submitted by the supplier to their Durable Medical Equipment Medicare Administrative Contractor (DME MAC).

Background
When the SNF Prospective Payment System (PPS) was introduced in 1998, it changed not only the way SNFs are paid but also the way SNFs must work with suppliers, physicians, and other practitioners. CB assigns the SNF the Medicare billing responsibility for virtually all of the services that the SNF residents receive during the course of a covered Part A stay. Payment for this full range of service is included in the SNF PPS global per diem rate.

The only exceptions are those services that are specifically excluded from this provision, which remain separately billable to Medicare Part B by the entity that actually furnished the service. See MLN Matters Edition SE0431 for a detailed overview of SNF CB, including a section on services excluded from SNF CB. This instruction can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0431.pdf on the CMS Web site.

Ambulance services have not been identified as a type of service that is categorically excluded from the CB provisions. However, certain types of ambulance transportation have been identified as being separately billable in specific situations (i.e. based on the reason the ambulance service is needed). This policy is comparable to the one governing ambulance services furnished in the inpatient hospital setting, which has been subject to a similar comprehensive Medicare billing or "bundling" requirement since 1983. Since the law describes CB in terms of services that are furnished to a "resident" of a SNF, the initial ambulance trip that brings a beneficiary to a SNF is not subject to CB, as the beneficiary has not yet been admitted to the SNF as a resident at that point.

Similarly, an ambulance trip that conveys a beneficiary from the SNF at the end of a stay is not subject to CB when it occurs in connection with one of the events specified in regulations at 42 CFR 411.15(p)(3)(i)-(iv) as ending the beneficiary's SNF "resident" status. The events are as follows:

Ambulance Trips to Receive Excluded Outpatient Hospital Services
The regulations specify the receipt of certain exceptionally intensive or emergency services furnished during an outpatient visit to a hospital as one circumstance that ends a beneficiary's status as an SNF resident for CB purposes. Such outpatient hospital services are, themselves, excluded from the CB requirement, on the basis that they are well beyond the typical scope of the SNF care plan.

Currently, only those categories of outpatient hospital services that are specifically identified in Program Memorandum (PM) No. A-98-37, November 1998 (reissued as PM No. A-00-01, January 2000) are excluded from CB on this basis. These services are the following:


Since a beneficiary's departure from the SNF to receive one of these excluded types of outpatient hospital services is considered to end the beneficiary's status as an SNF resident for CB purposes with respect to those services,, any associated ambulance trips are, themselves, excluded from CB as well. Therefore, an ambulance trip from the SNF to the hospital for the receipt of such services should be billed separately under Part B by the outside supplier. Moreover, once the beneficiary's SNF resident status has ended in this situation, it does not resume until the point at which the beneficiary actually arrives back at the SNF; accordingly, the return ambulance trip from the hospital to the SNF would also be excluded from CB.

Other Ambulance Trips
By contrast, when a beneficiary leaves the SNF to receive offsite services other than the excluded types of outpatient hospital services described above and then returns to the SNF, he or she retains the status of a SNF resident with respect to the services furnished during the absence from the SNF. Accordingly, ambulance services furnished in connection with such an outpatient visit would remain subject to CB, even if the purpose of the trip is to receive a particular type of service (such as a physician service) that is, itself, categorically excluded from the CB requirement.

However, effective April 1, 2000, the Balanced Budget Refinement Act of 1999 (BBRA 1999, Section 103) excluded from SNF CB those ambulance services that are necessary to transport an SNF resident offsite to receive Part B dialysis services (Social Security Act, Section 1888(e)(2)(A)(iii)(I)).

Transfers Between Two SNFs
A beneficiary's departure from an SNF is not considered to be a "final" departure for CB purposes if he or she is readmitted to that or another SNF by midnight of the same day (see 42 CFR 411.15(p)(3)(iv)). Thus, when a beneficiary travels directly from SNF 1 and is admitted to SNF 2 by midnight of the same day, that day is a covered Part A day for the beneficiary, to which CB applies. Accordingly, the ambulance trip that conveys the beneficiary would be bundled back to SNF 1 since, under §411.15(p)(3), the beneficiary would continue to be considered a resident of SNF 1 (for CB purposes) up until the actual point of admission to SNF 2.

However, when an individual leaves an SNF via ambulance and does not return to that or another SNF by midnight, the day is not a covered Part A day and, accordingly, CB would not apply.

Roundtrip to a Physician's Office
If an SNF's Part A resident requires transportation to a physician's office and meets the general medical necessity requirement for transport by ambulance (i.e., using any other means of transport would be medically contraindicated) (see 42 CFR 409.27(c)), then the ambulance roundtrip is the responsibility of the SNF and is included in the PPS rate. The preamble to the July 30, 1999 final rule (64 Federal Register 41674-75) clarifies that the scope of the required service bundle furnished to Part A SNF residents under the PPS specifically encompasses coverage of transportation via ambulance under the conditions described above, rather than more general coverage of other forms of transportation.

Additional Information
See MLN Matters Special Edition SE0431 for a detailed overview of SNF CB. This article lists services excluded from SNF CB and can be found at
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0431.pdf on the CMS Web site.

The Centers for Medicare & Medicaid Services (CMS) MLN Consolidated Billing Web site is at http://www.cms.hhs.gov/SNFConsolidatedBilling/ on the CMS Web site.

It includes the following relevant information:

The SNF PPS Consolidated Billing Web site can be found at http://www.cms.hhs.gov/SNFPPS/05_ConsolidatedBilling.asp on the CMS Web site.

It includes the following relevant information:

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Ultrasound Diagnostic Procedures

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.

Note: This article was changed on October 15, 2007, to correct the code for Ultrasound diagnostic procedures professional services to 76999, 76999-TC, and 76999-26 (page 2). The article had incorrectly stated 76999, 76999-T, and 76999-26. All other information remains the same.

Provider Types Affected
Physicians and other providers who bill Medicare carriers, fiscal intermediaries (FIs), and Medicare Administrative Contractors (MACs) for ultrasound diagnostic procedures

What Providers Need to Know
CR 5608, from which this article is taken, announces that effective on and after May 22, 2007, the Centers for Medicare & Medicaid Services (CMS) will allow payment for the monitoring of cardiac output (Esophageal Doppler) for ventilated patients in the intensive care unit (ICU) and for operative patients with a need for intra-operative fluid optimization.

Make sure that your billing staffs are aware of this change in the National Coverage Determinations (NCD) Manual, Chapter 1 (Coverage Determinations),

Section 220.5 (Ultrasound Diagnostic Procedures) to allow coverage for this procedure.

Background
CR 5608, from which this article is taken, announces:

Specifically, in CR 5608, CMS amends the Medicare NCD Manual, Chapter 1 (Coverage Determinations), Section 220.5 (Ultrasound Diagnostic Procedures), by adding: "Monitoring of cardiac output (Esophageal Doppler) for ventilated patients in the ICU and operative patients with a need for intra-operative fluid optimization" to Category I (covered procedures), and deleting "Monitoring of cardiac output (Doppler)" from Category II (non-covered procedures).

Notes:
There is no specific CPT code for this service. CPT code 76999 is for unlisted ultrasound procedures.

When performed in a hospital setting for ventilated patients in the ICU or for operative patients with a need for ultrasound diagnostic procedures, the professional services only are separately payable when billed using CPT code 76999 with the modifier -26 to show professional component.

Such services, when globally billed in a hospital setting with code 76999, will be returned as unprocessable to the provider with a reason code such as 58 denoting "Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service."

When such services are billed in a hospital setting as technical services with the code 76999-TC, Medicare will deny the services with the 58 reason code and an M77 remark code to show "Missing/Incomplete/Invalid place of service."

When performed in an ambulatory surgery center (ASC), ultrasound diagnostic procedures are covered when performed by an entity other than the ASC if globally billed using code 76999, or the technical and professional components may be separately billed using codes 76999-TC and 76999-26, respectively.

Ultrasound diagnostic procedures professional services billed using codes 76999, 76999-TC, and 76999-26 are carrier-priced.

Medicare contractors will not search their files to identify and adjust claims processed prior to the implementation of this change, which are for services rendered on or after May 22, 2007. However, they will adjust such claims when you bring the claims to their attention.

Additional Information
You can find more information about the coverage of esophageal Doppler monitoring of cardiac output by going to CR 5608, located at http://www.cms.hhs.gov/Transmittals/downloads/R76NCD.pdf on the CMS Web site. You will find the amended Medicare NCD Manual, Chapter 1 (Coverage Determinations), Section 220.05 (Ultrasound Diagnostic Procedures), as an attachment to that CR.

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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Unlabeled Use for Anti-Cancer Drugs: Medical Literature used to Determine Medically Accepted Indications for Drugs and Biologicals used in Anti-Cancer Treatment

News Flash - A new preventive services brochure entitled Diabetes-Related Services, ICN# 006840, is now available from the Centers for Medicare & Medicaid Services' (CMS), Medicare Learning Network (MLN). This tri-fold brochure provides health care professionals with an overview of Medicare's coverage of diabetes screening tests, diabetes self-management training, medical nutrition therapy, and supplies and other services for Medicare beneficiaries with diabetes. The new brochure is available as a downloadable pdf file on the Medicare Learning Network's (MLN) Publications Web page at http://www.cms.hhs.gov/MLNProducts/downloads/DiabetesSvcs.pdf on the CMS Web site.

Note: This article was revised on October 16, 2007, to reflect that the Centers for Medicare & Medicaid Services decision memorandum on this issue has now been posted at http://www.cms.hhs.gov/mcd/ncpc_view_document.asp?id=9 on their Web site. All other information remains the same.

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

Provider Action Needed
This article is informational only and it is based on Change Request (CR) 5729, which revises the Medicare Benefit Policy Manual, (Chapter 15, Section 50.4.5 (Unlabeled Use for Anti-Cancer Drugs)).CR 5729 adds 11 peer-reviewed medical journals to the existing list of 15 peer-reviewed medical journals used to determine medically accepted indications for drugs and biologicals used in Anti-Cancer Treatment. Medicare contractors processing Medicare claims use this list of medical journals to determine whether there is supportive clinical evidence for a particular use of a drug in the treatment of Medicare beneficiaries. None of the 15 existing peer-reviewed medical journals are being deleted at this time.

Background
The Social Security Act (Section 1861(t)(2)(B)(ii)(II); http://www.ssa.gov/OP_Home/ssact/title18/1861.htm) states that "the carrier involved determines, based upon guidance provided by the Secretary to carriers for determining accepted uses of drugs, that such use is medically accepted based on supportive clinical evidence in peer reviewed medical literature appearing in publications which have been identified for purposes of this subclause by the Secretary."
Accordingly, Section 50.4.5 of the Medicare Benefit Policy Manual (Chapter 15, Section 50.4.5;
(http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf) lists 15 peer-reviewed journals that a Medicare contractor must use to determine "whether there is supportive clinical evidence for a particular use of a drug."

These 15 peer-reviewed medical journals include:

In letters dated May 21, 2003 (2003 letter) and May 4, 2006 (2006 letter), the American Society of Clinical Oncology (ASCO) noted that this list of 15 journals was created in 1993, and it has not been revised since that time. ASCO formally submitted requests for the Centers for Medicare & Medicaid Services (CMS) to revise the list of 15 journals by adding 14 more journals.

CMS staff conducted a review of the journals listed in the ASCO requests. In addition, CMS informally consulted oncology experts from the National Cancer Institute (NCI) at the National Institutes of Health (NIH) and from the Center for Drug Evaluation and Research at the Food and Drug Administration (FDA) to request their opinions about the ASCO-recommended journals. CMS also provided public notice and solicited public comment through a CMS Web site posting from October 27, 2006, through December 26, 2006 (http://www.cms.hhs.gov/mcd/ncpc_view_document.asp?id=9). The CMS decision memorandum on this issue has also been posted at this Web site. CMS staff integrated the data from its review and from the above sources into its final decision to add the following 11 journals to the current list of 15 journals at section 50.4.5 of the Medicare Benefit Policy Manual:

Medicare carriers are not required to maintain copies of these publications. If a claim raises a question about the use of a drug for a purpose not included in the FDA-approved labeling or the compendia, the carrier will ask the physician to submit copies of relevant supporting literature.

Additional Information
The official instruction, CR5729, issued to your carrier and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R78BP.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 on the CMS Web site.

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Usually Self-Administered Drug List For Idaho, North Carolina, & Tennessee as of 10/01/2007

HCPCS Descriptor Effective date of exclusion End date of exclusion Comments
J0135 Adalimumab (Humira) Effective 01/01/05 bill under J0135, previously billed under J3490 - no change to coverage) 09/21/2003 N/A
Apparent on its face/USA/SC every other week
J0270 Alprostadil (Caverject, Prostaglandins, Muse) 01/01/1997 N/A Apparent on its face/USA/ Intracavernosal or Intraurethral/ Use as Needed
J0364 Apomorphine Hydrochloride (Apokyn) New code for 2007 01/01/2007 N/A Frequency/Apparent on it face/USA/ SC Daily
J3490 Becaplerim, a self-administered, non-autologous growth factor for chronic, nonhealing, subcutaneous wounds, is nationally non-covered. 04/27/2006 N/A Based on CMS National Coverage Decisions Manual 100-03 section 270.3.
J0630 Calcitonin Salmon 01/01/1982 N/A Frequency/Apparent on its face/USA/ SC as needed
J1324 Enfuvirtide (Fuzeon) New code for 2007 01/01/2007 N/A Frequency/Apparent on its face/USA/SC twice daily
J1438 Etanercept (Enbrel) 01/01/2003 N/A Apparent on its face/USA/SC twice a week
J1595 Glatiramer Acetate (Copaxone) (previously billed under code Q2010, this code has been deleted - no change to coverage) 01/01/2003 N/A Frequency/Apparent on its face/USA/SC Daily
J1675 Histrelin Acetate (effective 01/01/06 use J1675 - previously billed under HCPCS Q2020 - no change to coverage) 01/01/2000 N/A Frequency/Apparent on its face/USA/ SC Daily
J1815
J1817		 Insulin 01/01//2003 N/A Frequency/apparent on its face/USA/SC/Daily
J3490 Kitapressin (previously billed under code J1910, this code has been deleted 01/01/2003 N/A Frequency/USA/SC or IM Daily
J3490 Kutapressin (previously billed under code J1910, this code has been deleted) 01/01/2003 N/A Frequency/USA/ SC or IM Daily
J9218 Leuprolide Acetate Injection - 1 mg. daily subcutaneous 01/01/1990 N/A Frequency/Apparent on its face/USA/ SC Daily
J2170 Mecasermin (Increlex or Iplex) New code for 2007 01/01/2007 N/A Frequency/Apparent on its face/USA/SC Daily
J3490 Pegvisomant for injection (Somavert) 07/20/2003 N/A Frequency/Apparent on it face/USA/SC Daily
J2940 Somatrem 01/01/2003 N/A Frequency/Apparent on its face/USA/ SC or IM Daily
J2941 Somatropin, Inj. (Genotropin, Humatrope, Norditropin, Nutropin AQ, Saizen, Serostim are all SC {Daily or 3 times weekly} and Nutropin Depot once monthly or twice monthly on same days {i.e., 1st & 15th}) 01/01/2003 N/A Apparent on its face/Frequency/USA/SC Daily/SC or IM 3 times weekly
J3030 Sumatriptan Succinate 01/01/1995 N/A Apparent on its face/USA/SC as needed
J3110 Teriparatide (Forteo) (effective 01/01/05 use J3110 - previously billed under HCPCS J3490 - no change to coverage) 07/20/2003 N/A Frequency/apparent on its face/USA/SC Daily

Contractors must provide notice 45 days prior to the date a drug will be excluded/not covered. During the 45 day time period, contractors wil maintain existing medical review and payment procedures.


Comment Period: N/A There has been no change since 01/01/07

Update Effective: 01/01/2007


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