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February 5, 2008 Part B Medicare Bulletin

Posted February 5, 2008

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2008 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

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. The RA Guide is available as a downloadable document from the Medicare Learning Network Publications Web page. To download and view, please go to http://www.cms.hhs.gov/MLNProducts/downloads/RA_Guide_Full_03–22–06.pdf on the CMS Web site.

Provider Types Affected
Clinical laboratories billing Medicare Carriers, Fiscal Intermediaries (FIs), or Part A/B Medicare Administrative Contractors (A/B MACs).

What Providers Need to Know
This article and related CR5813 contain important information regarding:

Key Points

Updates to Fees
In accordance with Section 1833(h)(2)(A)(i) of the Social Security Act (the Act), as amended by Section 628 of the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003, the annual update to the local clinical laboratory fees for 2008 is 0 percent. Payment for a clinical laboratory test is the lesser of the actual charge billed for the test, the local fee, or the national limitation amount (NLA). For a cervical or vaginal smear test (pap smear), Section 1833(h)(7) of the Act requires payment to be the lesser of the local fee or the NLA, but not less than a national minimum payment amount.

Remember that the Part B deductible and coinsurance do not apply for services paid under the clinical laboratory fee schedule.

National Minimum Payment Amounts
The 2008 national minimum payment amount is $14.76 ($14.76 plus 0 percent update for 2008). The affected codes for the national minimum payment amount include the following:

88142 88143 88147 88148
88150 88152 88153 88154
88164 88165 88166 88167
88174 88175 G0123 G0144
G0145 G0147 G0148 P3000

National Limitation Amounts (Maximum)
For tests for which NLAs were established before January 1, 2001, the NLA is 74 percent of the median of the local fees. For tests for which NLAs are first established on or after January 1, 2001, the NLA is 100 percent of the median of the local fees in accordance with §1833(h)(4)(B)(viii) of the Act.

Access to 2008 Clinical Laboratory Fee Schedule
Internet access to the 2008 clinical laboratory fee schedule data file should be available after November 16, 2007, at http://www.cms.hhs.gov/ClinicalLabFeeSched on the Centers for Medicare & Medicaid Services (CMS) Web site.

Medicaid State agencies, the Indian Health Service, the United Mine Workers, Railroad Retirement Board, and other interested parties should use the Internet to retrieve the 2008 clinical laboratory fee schedule. It will be available in multiple formats: Excel, text, and comma delimited.

Public Comments
On July 16, 2007, CMS hosted a public meeting to solicit input on the payment relationship between 2007 codes and new 2008 Current Procedural Terminology codes. Notice of the meeting was published in the Federal Register on May 25, 2007 and on the CMS Web site on June 18, 2007.

Recommendations were received from many attendees, including individuals representing laboratories, manufacturers, and medical societies. CMS posted a summary of the meeting and the tentative payment determinations at http://www.cms.hhs.gov/ClinicalLabFeeSched on the CMS Web site. Additional written comments from the public were accepted until October 5, 2007.

Comments after the release of the 2008 laboratory fee schedule can be submitted to the following address so that CMS may consider them for the development of the 2009 laboratory fee schedule. A comment should be in written format and include clinical, coding, and costing information. To make it possible for CMS and its contractors to meet a January 3, 2009 implementation date, comments must be submitted before August 1, 2008.

Centers for Medicare & Medicaid Services (CMS)
Center for Medicare Management
Division of Ambulatory Services
Mailstop: C4–02–14
7500 Security Boulevard
Baltimore, Maryland 21244–1850

Additional Pricing Information
The 2008 laboratory fee schedule includes separately payable fees for certain specimen collection methods (codes 36415, P9612, and P9615).

For dates of service January 1, 2008 through December 31, 2008, the fee for clinical laboratory travel code P9603 is $0.935 per mile and for code P9604 is $9.35 per flat rate trip basis. The clinical laboratory travel codes are billable only for traveling to perform a specimen collection for either a nursing home or homebound patient. If there is a revision to the standard mileage rate for calendar year 2008, CMS will issue a separate instruction on the clinical laboratory travel fees.

The 2008 laboratory fee schedule also includes codes that have a ‘QW’ modifier to both identify codes and determine payment for tests performed by a laboratory registered with only a certificate of waiver under the Clinical Laboratory Improvement Amendments (CLIA).

Organ or disease Oriented Panel Codes
Similar to prior years, the 2008 pricing amounts for certain organ or disease panel codes and evocative/suppression test codes were derived by summing the lower of the fee schedule amount or the NLA for each individual test code included in the panel code. The CPT Editorial Panel has created code 80047 (Basic Metabolic Panel (Calcium, ionized)), which is an automated multi–channel chemistry (AMCC) code.

New code 80047 is not a replacement for code 80048 (Basic metabolic panel). Code 80047 is comprised of eight component test codes, i.e.:

Note that 80047 cannot be billed for services ordered through an ESRD facility. All tests billed for services ordered through an ESRD facility must be billed individually, not in an organ disease panel.

Mapping Information
CMS advises the following:

Laboratory Costs Subject to Reasonable Charge Payment in 2008
For outpatients, the following codes are paid under a reasonable charge basis. In accordance with 42 CFR 405.502 – 405.508, the reasonable charge may not exceed the lowest of the actual charge or the customary or prevailing charge for the previous 12–month period ending June 30, updated by the inflation–indexed update. The inflation–indexed update is calculated using the change in the applicable Consumer Price Index for the 12–month period ending June 30 of each year as prescribed by §1842(b)(3) of the Act and 42 CFR 405.509(b)(1). The inflation–indexed update for year 2008 is 2.7 percent.

Manual instructions for determining the reasonable charge payment can be found in the Medicare Claims Processing Manual, Chapter 23, Section 80–80.8. If there is insufficient charge data for a code, the instructions permit considering charges for other similar services and price lists. The Medicare Claims Processing Manual is located at http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage on the CMS Web site.

When these services are performed for independent dialysis facility patients, the Medicare Claims Processing Manual, Chapter 8, Section 60.3 instructs that the reasonable charge basis applies. However, when these services are performed for hospital based renal dialysis facility patients, payment is made on a reasonable cost basis. Also, when these services are performed for hospital outpatients, payment is made under the hospital outpatient prospective payment system (OPPS).

Blood Products

P9010 P9011 P9012 P9016 P9017
P9019 P9020 P9021 P9023 P9031
P9032 P9033 P9034 P9035 P9036
P9037 P9038 P9039 P9040 P9043
P9044 P9048 P9050 P9051 P9052
P9053 P9054 P9055 P9056 P9057
P9058 P9059 P9060    

Also, the following codes should be applied to the blood deductible as instructed in the Medicare General Information, Eligibility and Entitlement Manual, Chapter 3, Section 20.5–20.54 (located at http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage on the CMS Web site):

P9010 P9016 P9021 P9022 P9038
P9039 P9040 P9051 P9054 P9057
P9058        

NOTE: Biologic products not paid on a cost or prospective payment basis are paid based on §1842(o) of the Act. The payment limits based on section 1842(o), including the payment limits for codes P9041, P9043, P9045, P9046, P9047, and P9048 should be obtained from the Medicare Part B Drug Pricing Files.

Transfusion Medicine

86850 86860 86870 86880 86885
86886 86886 86890 86891 86900
86901 86903 86904 86905 86906
86920 86921 86922 86923 86927
86930 86931 86932 86945 86950
86960 86965 86970 86971 86972
86975 86976 86977 86978 86985
G0267        

Reproductive Medicine Procedures

89250 89251 89253 89254 89255
89257 89258 89259 89260 89261
89264 89268 89272 89280 89281
89290 89291 89335 89342 89343
89344 89346 89352 89353 89354
89356        

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

To see the official instruction, CR5813, issued to your Medicare FI, Carrier or A/B MAC, go to http://www.cms.hhs.gov/Transmittals/downloads/R1400CP.pdf on the CMS Web site.

Instruction for calculating reasonable charges are located in the Medicare Claims Processing Manual, Chapter 23, Section 80–80.8 at http://www.cms.hhs.gov/manuals/downloads/clm104c23.pdf on the CMS Web site.

News Flash – It’s seasonal flu time again! If you have Medicare patients who haven’t yet received their flu shot, you can help them reduce their risk of contracting the seasonal flu and potential complications by recommending an annual influenza and a one–time pneumococcal vaccination. Medicare provides coverage for flu and pneumococcal vaccines and their administration. Anddon’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot – Not the Flu! Remember – Influenza vaccination is a covered Part B benefit but the influenza vaccine is NOT a Part D covered drug. Health care professionals and their staff can learn more about Medicare’s coverage of adult immunizations and related provider education resources, by reviewing Special Edition MLN Matters article SE0748 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0748.pdf on the CMS Web site.

2008 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payment

Note: This article was revised on December 31, 2007, to reflect that CR5698 was revised. The CR release date, transmittal number and Web address for accessing CR5698 were changed. All other information remains the same.

Provider Types Affected
Physicians and providers submitting claims to Medicare Administrative Contractors (A/B MACs), carriers, and fiscal intermediaries (FIs) for services provided in HPSAs.

Impact on Providers
This article is based on Change Request (CR) 5698, which alerts affected physicians, carriers, A/B MACs and FIs that the new HPSA bonus payment information for 2008 will be available soon. This article is informational only for physicians that the 2008 automated bonus payments applies to claims with dates of service on or after January 1, 2008 through December 31, 2008.

Background
The Medicare Prescription Drug Improvement and Modernization Act of 2003 (Section 413(b)) mandated an annual update to the automated HPSA bonus payment files, and the Centers for Medicare & Medicaid Services (CMS) creates these new automated HPSA bonus payment files annually. The 2008 HPSA bonus payment file will be used for the automated bonus payment for claims with dates of service on or after January 1, 2008, through December 31, 2008. Physicians and providers should review the CMS Web site to determine whether a HPSA bonus will automatically be paid for services provided in their ZIP code area or whether a modifier must be submitted.


In addition, physicians will find annual HPSA bonus payment files, as they become available, and other important HPSA information at http://www.cms.hhs.gov/hpsapsaphysicianbonuses/ on the CMS Web site.

Additional Information
The official instruction (CR5698) issued to your Medicare A/B MAC, carrier, or FI is available at
http://www.cms.hhs.gov/Transmittals/downloads/R1404CP.pdf on the CMS Web site.

For the CMS information about HPSA/PSA (Physician Bonuses), you may visit: http://www.cms.hhs.gov/HPSAPSAPhysicianBonuses/ on the CMS Web site.

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

2008 Healthcare Common Procedure Coding System (HCPCS) Update

2008 Healthcare Common Procedure Coding System (HCPCS) Update

 

Addition to Medicare Telehealth 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. The RA Guide is available as a downloadable document from the Medicare Learning Network Publications Web page. To download and view, please go to http://www.cms.hhs.gov/MLNProducts/downloads/RA_Guide_Full_03–22–06.pdf on the CMS Web site.

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

Provider Action Needed

STOP – Impact to You
This article is based on Change Request (CR) 5628 which adds the neurobehavioral status exam (as represented by HCPCS code 96116) to the list of Medicare telehealth services.

CAUTION – What You Need to Know
Effective January 1, 2008, the telehealth modifiers “GT” (via interactive audio and video telecommunications system) and modifier “GQ” (via asynchronous telecommunications system) are valid when billed with HCPCS code 96116.

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

Background
The Centers for Medicare & Medicaid Services (CMS) announced in CR 5628 that the neurobehavioral status exam (Healthcare Common Procedure Coding System (HCPCS) code 96116) has been added to the list of Medicare telehealth services (see the final rule for the calendar year (CY) 2008 physician fee schedule (CMS–1385–FC)). Previously, CMS determined that, if the eligibility criteria, and conditions of payment are satisfied, the use of a telecommunications system may substitute for a face–to–face, “hands on” encounter for consultation, office visits, individual psychotherapy, pharmacologic management, psychiatric diagnostic interview examination, end stage renal disease related services, and individual medical nutrition therapy. CR5628 added neurobehavioral status exam to the list of telehealth services (bolded). Medicare telehealth services are listed below.

Modifier Descriptor

GT Via interactive audio and video telecommunications system
GQ Via asynchronoous telecommunications system

In addition, effective January 1, 2008, the following modifiers are valid when billed with HCPCS code 96116:

The expansion to the list of Medicare telehealth services does not change the eligibility criteria, conditions of payment, or payment or billing methodology applicable to Medicare telehealth services as set forth in the Medicare Benefit Policy Manual (Publication 100–02, Chapter 15, Section 270) and the Medicare Claims Processing Manual (Publication 100–04, Chapter 12, Section 190).

For example, originating sites must be located in either a non–Metropolitan Statistical Area (non–MSA) county or rural Health Professional Shortage Area (HPSA) and must be one of the following:

Also, an interactive audio and video telecommunications system must be used permitting real–time communication between the distant site physician or practitioner and the Medicare beneficiary, and as a condition of payment, the patient must be present and participating in the telehealth visit. The only exception to the interactive telecommunications requirement is in the case of Federal telemedicine demonstration programs conducted in Alaska or Hawaii. In this circumstance, Medicare payment is permitted for telehealth services when asynchronous store and forward technology is used.

Effective January 1, 2008, CR 5628 instructs that:

Additional Information
To view the official instructions issued to your carrier, FI, or A/B MAC, see the two transmittals for CR5628 at http://www.cms.hhs.gov/Transmittals/downloads/R1277CP.pdf and http://www.cms.hhs.gov/transmittals/downloads/R74BP.pdf on the CMS Web site.

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

News Flash — It’s seasonal flu time again! If you have Medicare patients who haven’t yet received their flu shot, you can help them reduce their risk of contracting the seasonal flu and potential complications by recommending an annual influenza and a one–time pneumococcal vaccination. Medicare provides coverage for flu and pneumococcal vaccines and their administration. And don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot – Not the Flu! Remember – Influenza vaccination is a covered Part B benefit but the influenza vaccine is NOT a Part D covered drug. Health care professionals and their staff can learn more about Medicare’s coverage of adult immunizations and related provider education resources, by reviewing Special Edition MLN Matters article SE0748 http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0748.pdf on the CMS Web site.

Addressing Misinformation Regarding Chiropractic Services and Medicare

News Flash – Effective March 1, 2008, Medicare fee–for–service 837P and CMS–1500 claims must include an NPI in the primary fields on the claim (i.e., the billing, pay–to, and rendering fields). You may continue to submit NPI/legacy pairs in these fields or submit only your NPI on the claim. You may not submit claims containing only a legacy identifier in the primary fields. Failure to submit an NPI in the primary fields will result in your claim being rejected or returned as unprocessable beginning March 1, 2008. Until further notice, you may continue to include legacy identifiers only for the secondary fields.

Provider Types Affected
Providers submitting claims to Medicare contractors (carriers, and/or Part A/Part B Medicare Administrative Contractors (A/B MACs)) for Chiropractic services provided to Medicare beneficiaries

Provider Action Needed
This special edition article is being provided by the Centers for Medicare & Medicaid Services (CMS) to correct misinformation in the chiropractic community relating to Medicare and its regulations as they relate to chiropractic services. This article is informational only and represents no changes to existing Medicare policy.

Background
In order to correct misinformation about Medicare and its regulations which exist in the chiropractic community, the American Chiropractic Association (ACA) works to check the validity of all claims and provide accurate information based on the Medicare manual system maintained by CMS, as well as information in regulatory and statutory language. CMS is providing this special edition article which it hopes will clarify certain issues, around which there may be some confusion. The specific issues being addressed are:

MISINFORMATION #1: There is a 12 visit cap or limit for chiropractic services.

Correction: There are no caps/limits in Medicare for covered chiropractic care rendered by chiropractors who meet Medicare’s licensure and other requirements as specified in the Medicare Benefit Policy Manual, Chapter 15, Section 30.5. (This manual is available at http://www.cms.hhs.gov/manuals/IOM/list.asp on the CMS Web site.)

There may be review screens (numbers of visits at which the Medicare carrier or A/B MAC may require a review of documentation), but caps/limits are not allowed.

The Social Security Act (Section 1862 (a)(1); see http://www.ssa.gov/OP_Home/ssact/title18/1862.htm on the Internet) provides that Medicare will only pay for items or services it determines to be “reasonable and necessary,” and if those items or services can be shown to be “reasonable and necessary,” then those items or services are covered and will be paid by Medicare.

MISINFORMATION #2: If you are a non–participating (non–par) provider, you do not have to worry about billing Medicare.

Correction: Being non–par does not mean you don’t have to bill Medicare. All Medicare covered services must be billed to Medicare, or the provider could face penalties. A non–par provider is actually a provider involved in the Medicare program who has enrolled to be a Medicare provider but chooses to receive payment in a different method and amount than Medicare providers classified as participating. The non–par provider may receive reimbursement for rendered services directly from their Medicare patients. They submit a bill to Medicare so the beneficiary may be reimbursed for the portion of the charges for which Medicare is responsible.

It is important to note that non–par providers may choose to accept assignment, therefore, the amount paid by the beneficiary must be reported in Item 29 of the CMS–1500 claim form. This ensures that the beneficiary is reimbursed (if applicable) prior to Medicare sending payment to the provider.

Whether or not a non–par provider chooses to accept assignment on all claims or on a claim–by–claim basis, their Medicare reimbursement is five percent less than a participating provider, as reflected in the annual Medicare Physician Fee Schedule.

You can find a copy of the Medicare Participating Provider Agreement at http://www.cms.hhs.gov/cmsforms/downloads/cms460.pdf on the CMS Web site. The form contains important information regarding the participation process and the annual opportunity you have to make or change your participation decision.

Additional information is available in the Medicare Benefit Policy Manual (Chapter 15; Covered Medical and Other Health Services) at http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf on the CMS Web site and the Medicare Claims Processing Manual (Chapter 12; Physician/Nonphysician Practitioners) at http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf on the CMS Web site.

MISINFORMATION #3: If you are a non–participating (non–par) provider, you will never be audited nor have claims reviewed, etc.

Correction: Any Medicare claim submitted can be audited/reviewed; the non–participating (non–par) or participating (par) status of the physician does not affect the possibility of this occurring. CMS audits/reviews are intended to protect Medicare trust funds and also to identify billing errors so providers and their billing staff can be alerted of errors and educated on how to avoid future errors. Correct coverage, reimbursement, and billing requirements are readily available to assist you in understanding Medicare requirements. This information is in Medicare manuals that are at
http://www.cms.hhs.gov/Manuals/ on the CMS Web site. In addition, an excellent way to stay informed about changes to Medicare billing and coverage requirements is to monitor MLN Matters articles, such as this one, which are available at http://www.cms.hhs.gov/MLNMattersArticles/ on the same site.

MISINFORMATION #4: You can opt out of Medicare.

Correction: Opting out of Medicare is not an option for Doctors of Chiropractic. Note that opting out and being non–participating are not the same things. Chiropractors may decide to be participating or non–participating with regard to Medicare, but they may not opt out.

For further discussions of the Medicare “opt out” provision, see the Medicare Benefits Policy Manual (Chapter 15, Section 40; Definition of Physician/Practitioner) at http://www.cms.hhs.gov/manuals/downloads/bp102c15.pdf on the CMS Web site.

MISINFORMATION #5: You should get an Advance Beneficiary Notification (ABN) signed once for each patient, and it will apply to all services, all visits.

Correction: The decision to deliver an ABN must be based on a genuine reason to expect that Medicare will not pay for a particular service on a specific occasion for that beneficiary due to lack of medical necessity for that service. The ABN then allows the beneficiary to make an informed decision about receiving and paying for the service. Should the beneficiary decide to receive the service, you must then submit a claim to Medicare even though you expect the beneficiary to pay and you expect that Medicare will deny the claim.

For further information, see the Medicare Claims Processing Manual (Chapter 30) at http://www.cms.hhs.gov/manuals/downloads/clm104c30.pdf and the Medicare Benefits Policy Manual (Chapter 15) at
http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf on the CMS Web site. Also see “What Doctors Need to Know about the Advance Beneficiary Notice (ABN)” at http://www.cms.hhs.gov/MLNProducts/downloads/ABN_READERS.pdf on the CMS Web site.

MISINFORMATION #6: Maintenance care is not a covered service under Medicare.

Correction: Spinal manipulation is a covered service under Medicare, no matter which phase of care you may be in; however, maintenance care is not medically reasonable and necessary and therefore not reimburseable by Medicare. Acute, chronic, and maintenance adjustments are all “covered” services, but only acute and chronic services are considered active care and may, therefore, be reimbursable. Maintenance therapy is defined (per Chapter 15, Section 30.5.B. of the Medicare Benefits Policy Manual)) as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.

See MM3449 (Revised Requirements for Chiropractic Billing of Active/Corrective Treatment and Maintenance Therapy) at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3449.pdf on the CMS Web site. This article contains important information on completing claims and how to identify acute and chronic adjustments as opposed to maintenance adjustments. The article also recommends you consider issuing an ABN to the Medicare beneficiary when you provide maintenance services. Additional details are available in the Medicare Benefits Policy Manual, Chapter 15, Section 30.5 (Chiropractor’s Services) at http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf on the CMS Web site.

MISINFORMATION #7: Non–par providers do not have the same documentation requirements as par providers.

Correction: Chiropractic care has documentation requirements to show medical necessity. The participating status of the provider is irrelevant to the documentation requirements.

Specific details regarding documentation are in the Medicare Benefit Policy Manual (Chapter 15, Sections 30.5 and 240) at http://www.cms.hhs.gov/manuals/downloads/bp102c15.pdf on the CMS Web site. Also, see the Medicare Claims Processing Manual (Chapter 12, Section 220) at http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf on the CMS Web site.

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

News Flash – It’s seasonal flu time again! If you have Medicare patients who haven’t yet received their flu shot, you can help them reduce their risk of contracting the seasonal flu and potential complications by recommending an annual influenza and a one–time pneumococcal vaccination. Medicare provides coverage for flu and pneumococcal vaccines and their administration. And don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot – Not the Flu! Remember – Influenza vaccination is a covered Part B benefit but the influenza vaccine is NOT a Part D covered drug. Health care professionals and their staff can learn more about Medicare’s coverage of adult immunizations and related provider education resources, by reviewing Special Edition MLN Matters article SE0748 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0748.pdf on the CMS Web site.

An Overview of Medicare Covered Diabetes Supplies and Services

Note: This article was revised on December 12, 2007, to remove a bullet point on page 3 which indicated an initial prescription needed to specify how many lancets and test strips were needed for a month and to remove a second bullet from the same page that stated a new prescription is needed every 12 months for lancets and test strips. Both of these requirements were eliminated from local policy.

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. The RA Guide is available as a downloadable document from the Medicare Learning Network Publications Web page. To download and view, please go to http://www.cms.hhs.gov/MLNProducts/downloads/RA_Guide_Full_03–22–06.pdf on the CMS Web site.

Provider Types Affected
Physicians, providers, suppliers, and other health care professionals who furnish or provide referrals for and/or file claims to Medicare contractors (carriers, DME Medicare Administrative Contractors (DME MACs), Fiscal Intermediaries (FIs), and/or Part A/B Medicare Administrative Contractors (A/B MACs)) for Medicare–covered diabetes benefits.

Provider Action Needed
This article is informational only and represents no Medicare policy changes.

Background
Diabetes is the sixth leading cause of death in the United States, and approximately 20 million Americans have diabetes with an estimated 20.9 percent of the senior population age 60 and older being affected. Millions of people have diabetes and do not know it. Left undiagnosed, diabetes can lead to severe complications such as heart disease, stroke, blindness, kidney failure, leg and foot amputations, and death related to pneumonia and flu. Scientific evidence now shows that early detection and treatment of diabetes with diet, physical activity, and new medicines can prevent or delay much of the illness and complications associated with diabetes.

This special edition article presents an overview of the diabetes services and supplies covered by Medicare (Part B and Part D) to assist physicians, providers, suppliers, and other health care professionals who provide diabetic supplies and services to Medicare beneficiaries.

Medicare Part B Covered Diabetic Supplies
Medicare covers certain supplies if a beneficiary has Medicare Part B and has diabetes. These supplies include:

Blood Glucose Self–testing Equipment and Supplies
Blood glucose self–testing equipment and supplies are covered for all people with Medicare Part B who have diabetes. This includes those who use insulin and those who do not use insulin. These supplies include:

Medicare Part B covers the same type of blood glucose testing supplies for people with diabetes whether or not they use insulin. However, the amount of supplies that are covered varies.

If the beneficiary

If a beneficiary’s doctor documents why it is medically necessary, Medicare will cover additional test strips and lancets for the beneficiary.

Medicare will only cover a beneficiary’s blood glucose self–testing equipment and supplies if they get a prescription from their doctor.

Their prescription should include the following information:

Note: Medicare will not pay for any supplies not asked for, or for any supplies that were sent to a beneficiary automatically from suppliers. This includes blood glucose monitors, test strips, and lancets. Also, if a beneficiary goes to a pharmacy or supplier that is not enrolled in Medicare, Medicare will not pay. The beneficiary will have to pay the entire bill for any supplies from non–enrolled pharmacies or non–enrolled suppliers.

All Medicare–enrolled pharmacies and suppliers must submit claims for blood glucose monitor test strips. A beneficiary cannot submit a claim for blood glucose monitor test strips themselves. The beneficiary should make sure that the pharmacy or supplier accepts assignment for Medicare–covered supplies. If the pharmacy or supplier accepts assignment, Medicare will pay the pharmacy or supplier directly. Beneficiaries should only pay their coinsurance amount when they get their supply from their pharmacy or supplier for assigned claims. If a beneficiary’s pharmacy or supplier does not accept assignment, charges may be higher, and the beneficiary may pay more. They may also have to pay the entire charge at the time of service and wait for Medicare to send them its share of the cost.

Before a beneficiary gets a supply, it is important for them to ask the supplier or pharmacy the following questions:

If the answer to either of these two (2) questions is “no,” they should call another supplier or pharmacy in their area who answers “yes” to be sure their purchase is covered by Medicare, and to save them money.

If a beneficiary can not find a supplier or pharmacy in their area that is enrolled in Medicare and accepts assignment, they may want to order their supplies through the mail, which may also save them money.

Therapeutic Shoes and Inserts
If a beneficiary has Medicare Part B, has diabetes, and meets certain conditions (see below), Medicare will cover therapeutic shoes if they need them. The types of shoes that are covered each year include one of the following:

Note: In certain cases, Medicare may also cover shoe modifications instead of inserts.

In order for Medicare to pay for the beneficiary’s therapeutic shoes, the doctor treating their diabetes must certify that they meet all of the following three conditions:

Medicare also requires the following:

Medicare helps pay for one pair of therapeutic shoes and inserts per calendar year, and the fitting of the shoes or inserts is covered in the Medicare payment for the shoes.

Insulin Pumps and the Insulin Used in the Pumps
Insulin pumps worn outside the body (external), including the insulin used with the pump, may be covered for some people with Medicare Part B who have diabetes and who meet certain conditions. If a beneficiary needs to use an insulin pump, their doctor will need to prescribe it. In the Original Medicare Plan, the beneficiary pays 20% of the Medicare–approved amount after the yearly Part B deductible. Medicare will pay 80% of the cost of the insulin pump. Medicare will also pay for the insulin that is used with the insulin pump.

Medicare Part B covers the cost of insulin pumps and the insulin used in the pumps. However, if the beneficiary injects their insulin with a needle (syringe), Medicare Part B does not cover the cost of the insulin, but the Medicare prescription drug benefit (Part D) covers the insulin and the supplies necessary to inject it. This includes syringes, needles, alcohol swabs and gauze. The Medicare Part D plan will cover the insulin and any other medications to treat diabetes at home as long as the beneficiary is on the Medicare Part D plan’s formulary.

Coverage for diabetes–related durable medical equipment (DME) is provided as a Medicare Part B benefit. The Medicare Part B deductible and coinsurance or copayment applies after the yearly Medicare part B deductible has been met. In the Original Medicare Plan, Medicare covers 80% of the Medicare–approved amount (after the beneficiary meets their annual Medicare Part B deductible of $131 in 2007), and the beneficiary pays 20% of the total payment amount (after the annual Part B deductible of $131 in 2007). This amount can be higher if the beneficiary’s doctor does not accept assignment, and the beneficiary may have to pay the entire amount at the time of service. Medicare will then send the beneficiary its share of the charge.

Medicare Part D Covered Diabetic Supplies and Medications
This section provides information about Medicare prescription drug coverage (Part D) for beneficiaries with Medicare who have or are at risk for diabetes. If a beneficiary wants Medicare prescription drug coverage, they must join a Medicare drug plan. The following diabetic medications and supplies are covered under Medicare drug plans:

Diabetes Supplies
Diabetes supplies associated with the administration of insulin may be covered for all people with Medicare Part D who have diabetes. These medical supplies include the following:

Insulin
Injectable insulin not associated with the use of an insulin infusion pump is covered under Medicare Part D drug plans.

Anti–diabetic Drugs
Medicare drug plans can cover anti–diabetic drugs such as:

Medicare Part B Covered Diabetic Services
All of the diabetes services listed in this section are covered by Medicare Part B unless otherwise noted. For people with diabetes, Medicare covers certain services. A doctor must write an order or referral for the beneficiary to get these services. These services include the following:

Diabetes Screenings
Medicare pays for a beneficiary to get diabetes screening tests if they are at risk for diabetes. These tests are used to detect diabetes early, and some, but not all, of the conditions that may qualify a beneficiary as being at risk for diabetes include:

Diabetes screening tests are also covered if a beneficiary answers “yes” to two or more of the following questions:

Based on the results of these tests, a beneficiary may be eligible for up to 2 diabetes screenings every year at no cost (no coinsurance, or copayment or Part B deductible). Medicare will pay for a beneficiary to get 2 diabetes screening tests in a 12–month period, but not less than 6 months apart. After the initial diabetes screening test, the beneficiary’s doctor will determine when to do the second test. Diabetes screening tests that are covered include the following:

Diabetes Self–management Training (DSMT)
Diabetes self–management training helps a beneficiary learn how to successfully manage their diabetes. Their doctor or qualified non–physician practitioner must prescribe this training for them for Medicare to cover it. A beneficiary can get diabetes self–management training if they met one (1) of the following conditions during the last twelve (12) months:

A beneficiary must get this training from an accredited diabetes self–management education program as part of a plan of care prepared by their doctor or qualified non–physician practitioner. These programs are accredited by the American Diabetes Association or the Indian Health Service. Classes are taught by health care providers who have special training in diabetes education.

A beneficiary is covered by Medicare to get a total of 10 hours of initial training within a continuous 12–month period. One of the hours can be given on a one–on–one basis. The other 9 hours must be training in a group class. The initial training must be completed no more than 12 months from the time the beneficiary starts the training.

A doctor or qualified non–physician practitioner may prescribe 10 hours of individual training if the beneficiary is blind or deaf, has language limitations, or no group classes have been available within 2 months of the doctor’s order. To be eligible for 2 more hours of follow–up training each year after the year the beneficiary received initial training, they must get another written order from their doctor. The 2 hours of follow–up training can be with a group or they may have one–on–one sessions. A doctor or qualified non–physician practitioner must prescribe the follow–up training each year for Medicare to cover it.

Beneficiaries learn how to successfully manage their diabetes in DSMT classes, and the training includes information on self–care and making lifestyle changes. The first session consists of an individual assessment to help the instructors better understand the beneficiary’s needs. Classroom training includes topics such as the following:

Note: If a patient lives in a rural area, they may be able to get DSMT in a Federally Qualified Health Center (FQHC). For more information about FQHCs, visit http://www.cms.hhs.gov/center/fqhc.asp on the CMS Web site. FQHCs are special health centers, usually located in urban or rural areas, and they can give routine health care at a lower cost. Some FQHCs are Community Health Centers, Tribal FQHC Clinics, Certified Rural Health Clinics, Migrant Health Centers, and Health Care for the Homeless Programs.

Medical Nutrition Therapy (MNT) Services
In addition to DSMT, medical nutrition therapy services are also covered for beneficiaries with diabetes or renal disease. To be eligible for this service, a beneficiary’s fasting blood glucose has to meet certain criteria. Also, their doctor must prescribe these services for them. These services can be given by a registered dietitian or certain nutrition professionals. MNT services covered by Medicare include the following:

Medicare covers 3 hours of one–on–one medical nutrition therapy services the first year the service is provided, and 2 hours each year after that. Additional MNT hours of service may be obtained if the beneficiary’s doctor determines there is a change in their diagnosis, medical condition, or treatment regimen related to diabetes or renal disease and orders additional MNT hours during that episode of care.

Foot Exams and Treatment
If a beneficiary has diabetes–related nerve damage in either of their feet, Medicare will cover 1 foot exam every 6 months by a podiatrist or other foot care specialist, unless they have seen a foot care specialist for some other foot problem during the past 6 months. Medicare may cover more frequent visits to a foot care specialist if a beneficiary has had a non–traumatic (not because of an injury) amputation of all or part of their foot or their feet have changed in appearance which may indicate they have serious foot disease.

Hemoglobin A1c Tests
A hemoglobin A1c test is a lab test ordered by the beneficiary’s doctor. It measures how well a beneficiary’s blood glucose has been controlled over the past 3 months. Anyone with diabetes is covered for this test if it is ordered by their doctor. Medicare may cover this test when a beneficiary’s doctor orders it.

Glaucoma Tests
Medicare will pay for a beneficiary to have their eyes checked for glaucoma once every 12 months. This test must be done or supervised by an eye doctor who is legally allowed to give this service in their state.

Special Eye Exam
People with Medicare who have diabetes can get special eye exams to check for eye disease (called a dilated eye exam). These exams must be done by an eye doctor who is legally allowed to provide this service in their state. The dilated eye exam is recommended once a year and must be performed by an eye doctor who is legally allowed to provide this service in the beneficiary’s state.

Supplies and Services Not Covered by Medicare
The Original Medicare Plan and Medicare drug plans (Part D) don’t cover everything. Diabetes supplies and services not covered by Medicare include:

Additional Information

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

News Flash – It’s seasonal flu time again! If you have Medicare patients who haven’t yet received their flu shot, you can help them reduce their risk of contracting the seasonal flu and potential complications by recommending an annual influenza and a one–time pneumococcal vaccination. Medicare provides coverage for flu and pneumococcal vaccines and their administration. And don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot – Not the Flu! Remember – Influenza vaccination is a covered Part B benefit but the influenza vaccine is NOT a Part D covered drug. Health care professionals and their staff can learn more about Medicare’s coverage of adult immunizations and related provider education resources, by reviewing Special Edition MLN Matters article SE0748 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0748.pdf on the CMS Web site.

Anesthesia Conversion Factors/Revised 12/21/2007

The 2008 anesthesia conversion factor for the state of Idaho is $18.93.
The 2008 anesthesia conversion factor for the state of North Carolina is $19.23.
The 2008 anesthesia conversion factor for the state of Tennessee is $19.12.

Annual Update of Healthcare Common Procedure Codes System (HCPCS) Codes Used for Home Health Consolidated Billing Enforcement

News Flash – It’s seasonal flu time again! If you have Medicare patients who haven’t yet received their flu shot, you can help them reduce their risk of contracting the seasonal flu and potential complications by recommending an annual influenza and a one–time pneumococcal vaccination. Medicare provides coverage for flu and pneumococcal vaccines and their administration. And don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot – Not the Flu! Remember – Influenza vaccination is a covered Part B benefit but the influenza vaccine is NOT a Part D covered drug. Health care professionals and their staff can learn more about Medicare’s coverage of adult immunizations and related provider education resources, by reviewing Special Edition MLN Matters article SE0748 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0748.pdf on the CMS Web site.

Provider Types Affected
Physicians, suppliers, and providers who bill Medicare contractors (Fiscal Intermediaries (FIs), carriers, regional home health intermediaries (RHHIs), and DME Medicare Administrative Contractors (DME MACs) and Part A/B Medicare Administrative Contractors (A/B MACs)) for medical supply or therapy services.

What Providers Need to Know
The Centers for Medicare & Medicaid Services (CMS) periodically updates the lists of Healthcare Common Procedure Codes System (HCPCS) codes subject to the consolidated billing provision of the Home Health Prospective Payment System (HH PPS). This article provides the annual HH consolidated billing update effective January 1, 2008. Affected providers may note the changes in the table listed within this article or consult the instruction issued to the Medicare contractors as listed in the Additional information section of this article.

Background
Section 1842(b)(6) of the Social Security Act (SSA) requires that payment for home health services provided under a home health plan of care be made to the home health agency (HHA.) As a result, billing for all such items and services is to be done by a single HHA overseeing that plan. This HHA is known as the primary agency for HH PPS for billing purposes. Services appearing on this list that are submitted on claims to Medicare contractors will not be paid separately on dates when a beneficiary for whom such a service is being billed is in a home health episode (i.e., under a home health plan of care administered by an HHA). Exceptions include the following:

Medicare has issued a Recurring Update Notification, which provides the annual HH consolidated billing updates for non–routine supplies and therapies effective January 1, 2008. These lists are updated annually, effective each January 1, to reflect the annual changes to the HCPCS code set. The lists may also be updated as frequently as quarterly if required by the creation of temporary HCPCS codes during the year.

CR5829 provides the annual HH consolidated billing update effective January 1, 2008. The following tables describe the HCPCS codes and the specific changes to each that this notification is implementing for claims with dates of service on or after January 1, 2008.

Table 1: Non Routine Supplies

Code Description Action
A5083 CONTINENT DEVICE, STOMA ABSORPTIVE COVER FOR CONTINENT STOMA Add
A5105 URINARY SUSPENSORY WITH LEG BAG WITH OR WITHOUT TUBE, EACH Redefine
A6200 COMPOSITE DRESSING, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING Delete
A6201 COMPOSITE DRESSING, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESVIE BORDER, EACH DRESSING Delete
A6202 COMPOSITE DRESSING, PAD SIZE MORE THAN 48 SQ.IN., WITHOUT ADHESIVE BORDER, EACH DRESSING Delete
A6413 ADHESIVE BANDAGE, FIRST–AID TYPE, ANY SIZE, EACH Add

Table 2: Therapies

Code Description Action Replacement Code or Code Being Replaced.
96125 STANDARIZED CONGNITIVE PERFORMANCE TESTING PER HOUR Add 96125

Additional Information
For details regarding this CR, please see the official instruction issued to your Medicare FI, carrier, A/B MAC, RHHI, or DME MAC. This may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1391CP.pdf on the CMS Web site.

If you have questions, please contact your Medicare FI, carrier, A/B MAC, RHHI, 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.

A complete historical listing of codes subject to HH consolidated billing can be found at http://www.cms.hhs.gov/HomeHealthPPS/03_coding&billing.asp on the CMS Web site.

To review the Medicare manual instructions discussed in this article see the Medicare Claims Processing Manual, Chapter 10, Section 20.1 at http://www.cms.hhs.gov/manuals/downloads/clm104c10.pdf on the CMS Web site.

 

Centers for Medicare & Medicaid Services (CMS) Seeks Provider Input on Satisfaction with Medicare Fee–for–Service Contractor Services

News Flash – A New MLN Feature – the Quarterly Journal Ad each calendar quarter, the Medicare Learning Network will create a journal advertisement based on an initiative or new product of particular importance during that time frame. National, state and local associations are encouraged to use this journal ad in their publications and/or newsletters and Web sites, as appropriate. This quarter’s journal ad features a basic message about the Medicare Learning Network and where to go on the CMS Web site to get more information. The ad is designed to fit the requirements for most journals’ print specifications. The files for this quarter’s ad, as well as future ads, can be found at http://www.cms.hhs.gov/MLNGenInfo/downloads/MLNQuarterly_Journal.zip on the CMS Web site.

Provider Types Affected
Sample of 35,000 Medicare providers served by Medicare Fee–for–Service (FFS) Contractors, including Medicare Administrative Contractors (A/B MACs), carriers, fiscal intermediaries (FIs), durable medical equipment Medicare Administrative Contractors (DME/MACs) and regional home health intermediaries (RHHIs))

Provider Action Needed

STOP – Impact to You
CMS offers providers the opportunity to voice your opinions about the services you receive from your FFS contractors. CMS announced it has begun its third annual provider satisfaction survey of Medicare FFS contractors who process and pay more than $280 billion in Medicare claims each year. The Medicare Contractor Provider Satisfaction Survey (MCPSS) is designed to gather quantifiable data on provider satisfaction with the performance of FFS contractors as well as aid future process improvement efforts at the contractor level. The survey is used by CMS as an additional measure to evaluate contractor performance. In fact, all MACs will be required to achieve performance targets on the MCPSS as part of their contract requirements by 2009.

CAUTION – What You Need to Know
CMS is sending the 2008 survey to about 35,000 randomly selected providers, including physicians and other health care practitioners, suppliers and institutional facilities that serve Medicare beneficiaries across the country. Those providers selected to participate in the survey will be notified by December 2007. The survey is designed so that it can be completed in about 15 minutes. Providers can submit their responses via a secure Web site, mail, fax, or over the telephone. CMS is urging all Medicare providers selected to participate in the survey by completing and returning their surveys upon receipt.

GO – What You Need to Do
Be alert for a notification via e–mail, phone or mail by the survey contractor, Westat. If you are selected to participate in the survey, please take the time to complete and submit your survey responses upon receipt.

Background
The 2008 MCPSS is designed to gather quantifiable data on provider satisfaction levels with the key services that comprise the provider–contractor relationship. The survey focuses on seven major parts of the relationship:

Respondents are asked to rate their experience working with contractors using a scale of 1 to 6 with “1” representing “not at all satisfied” and “6” representing “completely satisfied.” The results of the second MCPSS –– which are available to health care providers and contractors on at http://www.cms.hhs.gov/MCPSS on the CMS Web site. Last year’s findings showed that 85 percent of respondents rated their contractors between 4 and 6.

Further, the 2007 MCPSS results indicate that the provider inquiry function has the greatest influence on whether providers are satisfied with their contractors. This indicated a shift from 2006, when the claims processing function was the strongest predictor of a provider’s overall satisfaction.

Additional Information
CMS plans to make the survey results publicly available in July 2008. For questions or additional information about the MCPSS please visit: http://www.cms.hhs.gov/MCPSS on the CMS Web site.

News Flash – It’s seasonal flu time again! If you have Medicare patients who haven’t yet received their flu shot, you can help them reduce their risk of contracting the seasonal flu and potential complications by recommending an annual influenza and a one–time pneumococcal vaccination. Medicare provides coverage for flu and pneumococcal vaccines and their administration. And don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot – Not the Flu! Remember – Influenza vaccination is a covered Part B benefit but the influenza vaccine is NOT a Part D covered drug. Health care professionals and their staff can learn more about Medicare’s coverage of adult immunizations and related provider education resources, by reviewing Special Edition MLN Matters article SE0748 http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0748.pdf on the CMS Web site.

 

 

Clarification on the National Provider Identifier (NPI) Enumerator’s Responsibilities

News Flash – It’s seasonal flu time again! If you have Medicare patients who haven’t yet received their flu shot, you can help them reduce their risk of contracting the seasonal flu and potential complications by recommending an annual influenza and a one–time pneumococcal vaccination. Medicare provides coverage for flu and pneumococcal vaccines and their administration. And don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot – Not the Flu! Remember – Influenza vaccination is a covered Part B benefit but the influenza vaccine is NOT a Part D covered drug. Health care professionals and their staff can learn more about Medicare’s coverage of adult immunizations and related provider education resources, by reviewing Special Edition MLN Matters article SE0748 http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0748.pdf on the CMS Web site.

Provider Types Affected
All physicians, providers, and suppliers who submit claims to Medicare Contractors (Fiscal Intermediaries (FIs), Carriers, and Medicare Administrative Contractors (A/B MACs))

Provider Action Needed

STOP – Impact to You
The Centers for Medicare & Medicaid Services (CMS) is issuing this Special Edition (SE) 0751 article to clarify the type of assistance that the NPI Enumerator can and cannot provide to health care providers.

CAUTION – What You Need to Know
CMS is providing this information so you and your staff will know what issues should be referred to the NPI Enumerator and to identify issues on which the NPI Enumerator will not be able to help you. This will save you valuable time in resolving your Medicare questions.

GO – What You Need to Do
Please share this information with your office staff.

Background
The NPI Enumerator is responsible for assisting health care providers in applying for their NPIs and updating their information in the National Plan and Provider Enumeration System (NPPES). The NPI Enumerator’s responsibilities include:

Health care providers needing the above types of assistance may contact the NPI Enumerator at 1.800.465.3203, TTY 1.800.692.2326 or email the request to the NPI Enumerator at CustomerService@NPIEnumerator.com on the Internet. Please note that application processing times may vary based on current inventories. Please allow 15 working days to process your application/updates before contacting the NPI Enumerator.

Health care providers should NOT contact the NPI Enumerator for the following issues:

The NPI Enumerator cannot provide assistance with NPI–to–legacy number linkages (i.e., how to properly link multiple legacy numbers to one NPI or how to properly link one legacy number to multiple NPIs).

 

Additional Information
CMS advises providers to read the information available at http://www.cms.hhs.gov/NationalProvIdentStand/ on the CMS NPI Web site. Included on this site are NPI Frequently Asked Questions and Answers that can assist you with issues for which the NPI Enumerator is not responsible.

In addition, the NPI Application/Update form itself is also a good source of information. Providers should refer to the instructions (they are part of the form) for clarification on information to be submitted in order to obtain NPIs or update their records. You can also refer to the “Application Help” tab located at: https://nppes.cms.hhs.gov on the NPPES Web site for additional assistance when you are online.

If you have questions related to Medicare issues, 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.

CMS Has Revised the Average Sales Price (ASP) and Not Otherwise Classified (NOC) Drug Lists

CMS has revised the Average Sales Price (ASP) and Not Otherwise Classified (NOC) drug lists for the following calendar quarters:

 

CMS has also revised the Average Sales Price (ASP) lists only for the following calendar quarters:

 

The revised lists may be found by following the link below:
http://www.cignagovernmentservices.com/partb/coverage/fees/index.html

Fee Schedule Update for 2008 for Durable Medical Equipment, Prosthetics, Orthotics and Supplies

News Flash – It’s seasonal flu time again! If you have Medicare patients who haven’t yet received their flu shot, you can help them reduce their risk of contracting the seasonal flu and potential complications by recommending an annual influenza and a one–time pneumococcal vaccination. Medicare provides coverage for flu and pneumococcal vaccines and their administration. And don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot – Not the Flu! Remember – Influenza vaccination is a covered Part B benefit but the influenza vaccine is NOT a Part D covered drug. Health care professionals and their staff can learn more about Medicare’s coverage of adult immunizations and related provider education resources, by reviewing Special Edition MLN Matters article SE0748 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0748.pdf on the CMS Web site.

Provider Types Affected
Providers and suppliers submitting claims to Medicare contractors (carriers, DME Medicare Administrative Contractors (DME MACs), Fiscal Intermediaries (FIs), Part A/B Medicare Administrative Contractors (A/B MACs), and/or Regional Home Health Intermediaries (RHHIs)) for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) provided to Medicare beneficiaries.

Provider Action Needed
This article is based on Change Request (CR) 5803, which provides the annual update to the 2008 DMEPOS fee schedules in order to implement fee schedule amounts for new codes and to revise any fee schedule amounts for existing codes that were calculated in error. Be sure your billing staff are aware of these changes.

Background
This recurring update notification, CR5803, provides specific instructions regarding the 2008 annual update for the DMEPOS fee schedule. Payment on a fee schedule basis is required for durable medical equipment (DME), prosthetic devices, orthotics, prosthetics, and surgical dressings by §1834(a), (h), and (i) of the Social Security Act. Payment on a fee schedule basis is required for parenteral and enteral nutrition (PEN) by regulations contained at 42 CFR 414.102.

The update process for the DMEPOS fee schedule is located in the Medicare Claims Processing Manual (Publication 100–04), Chapter 23, Section 60;
http://www.cms.hhs.gov/manuals/downloads/clm104c23.pdf) on the Centers for Medicare & Medicaid Services (CMS) Web site. Other information on the fee schedule, including access to the DMEPOS fee schedules is at http://www.cms.hhs.gov/DMEPOSFeeSched/01_overview.asp on the CMS Web site.

Key Points