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April 4, 2008 Part B Medicare Bulletin

Posted April 4, 2008

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2007 Update of HCPCS Codes and Payments for Ambulatory Surgical Centers (ASCs)

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

Note: This article was revised on January 24, 2008, to add a reference to SE0742. SE0742 announced that CMS was implementing significant revisions to the payment system for ASC services beginning with services rendered on or after January 1, 2008. SE0742 may be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/se0742.pdf on the CMS Web site. All other information remains the same.

Provider Types Affected
Ambulatory surgical centers (ASCs) submitting claims to Medicare carriers or fiscal intermediaries (Fish) for ASC services provided to Medicare beneficiaries.

Impact on Providers
This article is based on Change Request (CR) 5211, which updates the 2007 HCPCS codes and ASC payment rates, effective for services furnished on or after January 1, 2007.

Background
Section 5103 of the Deficit Reduction Act of 2005 (DRA) limits ASC payments to:

 

Also, §1833(i)(1) of the Social Security Act requires that the list of payable ASC procedures be updated as least every two years.

CR5211, from which this article is taken, implements the required biennial ASC update, which includes changes made by the American Medical Association for the CY 2007 Common Procedural Terminology (CPT). These changes include replacing the ASC 2-digit payment group code designation next to the ASC-approved Healthcare Common Procedure Coding System (HCPCS) codes with a “yy” designation for these codes, which will be defined as “the procedure is approved to be performed in an ambulatory surgical center.”

CR5211 also revises the manner in which ASC payment groups are defined. The number of ASC payment groups that carriers and fiscal intermediaries (FI) currently use to identify ASC payment amounts for individual HCPCS codes is being expanded in order to accommodate the new payment amounts that will be assigned to certain ASC services in Calendar Year (CY) 2007 under the DRA requirement. The ASC payment groups will now be called ASC PRICER groups

The additional ASC PRICER groups reflect the DRA-driven payment amounts, which will be included in the ASC PRICER files that carriers, and certain FIs, use to process ASC facility claims. And lastly, CR5211 includes payment file retrieval instructions that your carriers and FIs will use to access the final payment files on, or after, the specified retrieval date provided in CMS’s notification. You should be aware that final ASC payment rates are established after publication of the OPPS final rule and the code change update will be published as part of the OPPS final rule in the Federal Register. This publication usually occurs in late October. Shortly after publication, you can reach this rule through a link at http://www.cms.hhs.gov/center/asc.asp on the CMS Web site.

Also note that your carriers and FIs will continue to use the wage index values contained in Transmittal 51, dated February 4, 2004, to calculate payment amounts for all type of service F Healthcare Common Procedural Coding System (HCPCS) codes until further notice. This transmittal is available at http://www.cms.hhs.gov/Transmittals/downloads/R51OTN.pdf on the CMS site.

Additional Information
For complete details, please see CR 5211, the official instruction issued to your carrier/intermediary regarding this change, located at http://www.cms.hhs.gov/Transmittals/downloads/R1134CP.pdf on the CMS Web site. The “2007 ASC Approved HCPCS Codes and Payment Rates” Changes are available at http://www.cms.hhs.gov/ASCPayment/01_Overview.asp on the CMS site.

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

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

Emergency -- Legislative Change Affecting the 2008 Medicare Physician Fee Schedule (MPFS), and Extension of the 2008 Participation Open Enrollment Period

News Flash – Test Your Medicare Claims Now! After you have submitted claims containing both National Provider Identifiers (NPIs) and legacy identifiers and those claims have been paid, Medicare urges you to send a small batch of claims now with only the NPI in the primary provider fields. If the results are positive, begin increasing the number of claims in the batch. (Reminder: For institutional claims, the primary provider fields are the Billing and Pay-to Provider fields. For professional claims, the primary provider fields are the Billing, Pay-to, and Rendering Provider fields. If the Pay-to Provider is the same as the Billing Provider, the Pay-to Provider does not need to be identified.)

Provider Types Affected
Physicians and other providers who bill Medicare contractors (fiscal intermediaries (FI), regional home health intermediaries (RHHI), carriers, and Medicare Administrative Contractors (A/B MAC)) for professional services paid under the MPFS.

What You Need to Know
CR5944, from which this article is taken, provides Medicare contractors with information about (and instructions for implementing) legislative changes to the 2008 MPFS, and about the extension of the Participation Open Enrollment period for 2008.

Effective for claims with dates of service January 1, 2008, through June 30, 2008, the update to the conversion factor will be 0.5%; and for claims with dates of service July 1, 2008 and after, will revert back to the previous payment methodology (the -10.1% update) that was outlined in the Final Rule, published in the Federal Register on November 27, 2007.

Additionally, the Centers for Medicare & Medicaid Services (CMS) has extended the 2008 Participation Open Enrollment period from December 31, 2007, to February 15, 2008 – therefore, it now runs from November 15, 2007, through February 15, 2008.

Background
The “Medicare, Medicaid, and SCHIP Extension Act of 2007” changes the rates of the 2008 Medicare Physician Fee Schedule (MPFS). CR5944 informs Medicare contractors of this legislative change to the 2008 MPFS; the release of the new MPFS files for them to load; the need to be ready to process beginning January 7, all claims with dates of service on or after January 1, 2008, which contain MPFS services; and the extension of the Participation Open Enrollment period for 2008.

MPFS Rate Change
Effective for claims with dates of service January 1, 2008, through June 30, 2008, the update to the conversion factor will be 0.5%.

It is important that you understand, however, that this new legislation only impacts the MPFS rates during the first half of 2008 (claims with dates of service January 1, 2008, through June 30, 2008). Claims with dates of service July 1, 2008, and after will revert back to the previous payment methodology (the -10.1% update) that was outlined in the Final Rule, published in the Federal Register on November 27, 2007.

Note: The legislation also extends the 1.0 floor on the work geographic practice cost index for six months, i.e., through June 30, 2008.

This MPFS rate change also impacts several other fee schedule rates which are MFPS-derived, including the anesthesia conversion factors, purchased diagnostic file, and ambulatory surgical center (ASC) facility rates; but does not impact services that are not paid under the MPFS (e.g., DME, clinical lab, etc.).

Physicians do not need to take any additional action in order for their claims to be paid at the new 0.5 percent rate. Medicare contractors are able to process claims for services paid under the Medicare Physician Fee Schedule that contain dates of service January 1 and after with the new 2008 rates. No adjustments should be necessary. Your Medicare contractors have been instructed to be ready to process all claims with 2008 dates of service with the new MPFS fees beginning January 7, 2008.

2008 Participation Open Enrollment Period Extension
Because this new legislation changes the 2008 MPFS rates, the CMS has extended the 2008 Participation Open Enrollment period from December 31, 2007, to February 15, 2008; – therefore, it now runs from November 15, 2007, through February 15, 2008.

The effective date for any Participation status change during the extension, however, remains January 1, 2008; and will be in force for the entire year. You should make your Participation decision for 2008 based on the two new fee rates (i.e., the 0.5% update that is effective January through June, and the -10.1% update that is effective July through December).

Note: CR5944 revises CR 5732 (Transmittal 1356 – Calendar Year (CY) 2008 Participation Enrollment and Medicare Participating Physicians and Suppliers Directory (MEDPARD) Procedures, dated October 19, 2007) to reflect the extension.

CR5944 also contains additional Medicare contractor instructions:

Additional Information
You can find the official instruction, CR5944, issued to your carrier, FI, RHHI, or A/B MAC by visiting http://www.cms.hhs.gov/Transmittals/downloads/R312OTN.pdf on the CMS Web site.

If you have any questions, please contact your carrier, FI, 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.

News Flash – It’s Not Too Late to Give and Get the Flu Shot! In the U.S., the peak of flu season typically occurs anywhere from late December through March; however, flu season can last as late as May. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a one time pneumococcal vaccination. Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Don’t Get the Flu. Don’t Give the Flu. Get Vaccinated! Remember – Influenza and pneumococcal vaccinations and their administration are covered Part B benefits. Note that influenza and pneumococcal vaccines are NOT Part D covered drugs. You and your 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.

 

Additional Payable Healthcare Common Procedure Coding System (HCPCS) “C” Drug Codes in Ambulatory Surgical Centers (ASCs)

News Flash – The Ambulatory Surgical Center Fee Schedule Fact Sheet, which provides general information about the Ambulatory Surgical Center (ASC) Fee Schedule, ASC payments, and how ASC payment amounts are determined, is now available in downloadable format from the Centers for Medicare & Medicaid Services Medicare Learning Network at http://www.cms.hhs.gov/MLNProducts/downloads/AmbSurgCtrFeepymtfctsht508.pdf on the CMS Web site.

Provider Types Affected
Ambulatory Surgical Centers submitting claims to Medicare contractors (carriers and/or Part A/B Medicare Administrative Contractors (A/B MACs)) for services provided to Medicare beneficiaries.

Provider Action Needed

STOP – Impact to You
This article is based on Change Request (CR) 5885 which lists additional payable HCPCS “C” drug codes for Ambulatory Surgical Centers (ASCs).

CAUTION – What You Need to Know
CR 5885 instructs Medicare contractors to modify systems to accept four additional Healthcare Common Procedure Coding System (HCPCS) “C” codes (C9327, C9240, C9354, and C9355) and ensure that these HCPCS “C” codes are processed and paid using the same payment and claims processing policies issued by the Centers for Medicare & Medicaid Services (CMS) for the 2008 revision to the ASC payment system.

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

Background
A final list of Ambulatory Surgical Center (ASC) payable Healthcare Common Procedure Coding System (HCPCS) codes for January 1, 2008 was released in the recently issued ASC final rule (CMS-1392-FC) in the Federal Register (November 27, 2007).

However, there were four “C” codes recognized as payable in the ASC setting by the Centers for Medicare & Medicaid Services (CMS) that were approved too late in the process to be included in the Federal Register’s final rule issuance. In addition, these “C” codes were not annotated as ASC payable codes in the 2008 HCPCS file release.

CR 5885 instructs that the following HCPCS “C” codes will be included on the final version ASC DRUG file released by CMS, as discussed in CR 5831.

HCPCS "C" Code Descriptor Effective Date
C9237 Inj. Lanreotide acetate January 1, 2008
C9240 Injection, ixabepilone January 1, 2008
C9354 Vertias collagen matrix, cm2 January 1, 2008
C9355 Neruomatriz nerve cuff, cm January 1, 2008

CR 5885 also instructs Medicare contractors that when these HCPCS “C” codes are submitted by ASCs for payment, they will be processed and paid using the same payment and claims processing policies issued by CMS for the 2008 revision to the ASC payment system.

Medicare Contractors will make available to ASCs both:

Additional Information
The official instruction, CR 5885, issued to your Medicare carrier and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1415CP.pdf on the CMS Web site.

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

News Flash – It’s Not Too Late to Get the Flu Shot. We are in the midst of flu season and a flu vaccine is still the best way to prevent infection and the complications associated with the flu. But re-vaccination is necessary each year because flu viruses change each year. Please encourage your Medicare patients who haven’t already done so to get their annual flu shot. 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. Note that 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.

Ambulance Providers

A recent review of ambulance transport claims has demonstrated a significant concern regarding billing for emergency transport to destination of home, skilled nursing facilities and other sites to which it is not normally reasonable to run emergency traffic.

Please inform your billing staff that HCPCS Codes A0427 and A0429 should not be billed with destination modifiers (second letter) –D, -E, -J, -N, -R. No medical necessity exists for an emergency transfer of a patient to one of these destinations. Similarly the emergency transfers using destinations –P and –X should be rare and should be clearly justified in the run ticket documentation. An example of this is a rural county with no hospital, an unstable, critically ill or injured patient where the unit stops at a physician’s office for physician assistance in stabilizing the patient prior to proceeding on to the hospital emergency department.

 

Ambulatory Surgical Center (ASC) Claims Processing Manual Clarification

Note: This article was revised on January 24, 2008, to add a reference to SE0742. SE0742 announced that CMS was implementing significant revisions to the payment system for ASC services beginning with services rendered on or after January 1, 2008. SE0742 may be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/se0742.pdf on the CMS Web site. All other information remains the same.

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

Provider Types Affected
Providers and suppliers of ambulatory surgical center (ASC) services

Provider Action Needed
This article is for informational purposes. CR5026 revises the Medicare Claims Processing Manual, Chapter 14 (Ambulatory Surgical Centers), Sections 10.3 (Services Furnished in ASCs Which Are Not ASC Facility Services) and 10.4 (Coverage of Services in ASCs Which Are Not ASC Facility Services) to clarify policy regarding the provision, coverage, and payment of services furnished in an ASC.

Background
Medicare conventionally reimburses ASCs in the form of a single payment that includes all “facility services” that the ASC furnishes in connection with a covered procedure. However, an ASC (perhaps as part of a medical complex that may include other entities, such as an independent laboratory, supplier of durable medical equipment, or a physician’s office) may also furnish a number of covered items and services that are not considered facility services.

Be aware that such entities, which are separate from the ASC, are covered separately under Part B. Further, in general, the items or services that these entities provide are not considered ASC services, and are therefore not included in the ASC payment, but are rather covered and paid for under the applicable Part B provisions.

Examples of such services include:

Table 1 - Examples of Services Not Included in the ASC Facility Rate

Items or Services Who Receives Payment Submit Bills To

Physicians’ services
Physicians who perform covered services in ASCs receive separate payment under Part B. Such services include:

- Anesthesiologists administering or supervising the administration of anesthesia to ASC patients and the patients’ recovery from the anesthesia;

- Routine pre- or post- operative services, such as office visits, consultations, diagnostic tests, suture removal, dressing changes, and other services which are usually included in the physician fee for a given surgical procedure.

Physician Carrier
Non-implantable durable medical equipment (DME) to ASC patients for in-home use
ASCs who sell, lease, or rent items of DME to patients, are treated as DME suppliers. All of the ordinary DME-applicable rules and conditions apply to the ASC, including obtaining a supplier number and billing the DMERC as required.

Supplier
an ASC can be a supplier of DME if it has a DME supplier number fromt he National Supplier Clearinghouse

DMERC
Implantable DME and accessories ASC Carrier

Items or Services Who Receives Submit Bills Payment To

Items or Services Who Receives Payment Submit Bills To

ASCs who furnish implantable DME items to patients,bil the local acarrier for the surgical procedure and the implantable device.

   
Non-implantable prosthetic devices
ASCs who furnish non-implantable prosthetic devices to patients are treated as suppliers, and all the ordinary DME-applicable rules and conditions apply to the ASC, including obtaining a supplier number and billing the DMERC as required.

Suppier
An ASC can be a supplier of non-implantable prosthetics if it has a supplier number from the National Supplier Clearinghouse.

DMERC
Implantable prosthetic devices except intraocular lenses (IOLs and NTIOLs [new technology intraocular lenses]), and accessories
ASCs may bill and receive separate payment for prosthetic devices (other than intraocular lenses [IOLs]) that are implanted, inserted, or otherwise applied by surgical procedures on the ASC list of approved procedures. The ASC bills the local Carrier and receives payment according to the DMEPOS fee schedule.
An intraocular lens (IOL) inserted during or subsequent to cataract surgery in an ASC is included in the facility payment rate. ASCs may receive additional payment for approved NTIOLs that are furnished in an ASC during or subsequent to certain cataract procedures. 		ASC Carrier

Ambulance services
ASCs who furnish ambulance services, may obtain approval as ambulance suppliers to bill covered ambulance services.

 Certified ambulance supplier Carrier
Leg, Arm, back and neck braces
These items of equipment are not included in the ASC Facility payment amount, but are covered under Part B.
ASCs who furnish these items to pateints are treated as suppliers, and all the rules and conditions ordinarily a supplier number and billing the DMERC as required. 		Supplier DMERC
Artifical legs, arms, and eyes
These items of equipment are not included in the ASC facillity payment rate, but are covered under part B.
ASCs who furnish these items to patients are treated as suppliers, and all the rules and conditions ordinarily applicable to suppliers apply to the ASC, including obtaining as supplier number and billing the DMERC as required.		 Supplier DMERC
Services furnished by an independent laboratory
Only very limited numbers and types of diagnostic tests are considered ASC facility services and these are included in the ASC facility payment rate.
Since coverage of diagnostic lab tests in facilities other than physicians’ offices, rural health clinics or hospitals is limited to facilities that meet the statutory definition of an independent laboratory, in most cases diagnostic tests performed directly by an ASC are not considered ASC facility services (in fact are usually not covered under Medicare).
ASC laboratories must be CLIA Certified and will need to enroll with the carrier as a laboratory. Otherwise, the ASC makes arrangement with a covered laboratory or laboratories for laboratory services. If the ASC has a certified independent laboratory, the laboratory itself bills the carrier. 		Certified lab. ASCs can receive lab certification and a CLIA number Carrier

Procedures NOT On the ASC list
Physicians bill the carrier for the procedures and any implantable prosthetics/DMERC,using the ASC as the place of services

Physician Carrier

Additional Information
You can find more information about services not included in the ASC facility rate (and the coverage of such services) by reviewing CR5026, which is available at http://www.cms.hhs.gov/Transmittals/downloads/R975CP.pdf on the CMS Web site.

The revised Medicare Claims Processing Manual, Chapter 14 (Ambulatory Surgical Centers), Sections 10.3 (Services Furnished in ASCs Which Are Not ASC Facility Services) and 10.4 (Coverage of Services in ASCs Which Are Not ASC Facility Services) are attached to CR5026.

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

 

Change in the Amount in Controversy Requirement for Administrative Law Judge Hearings and Federal District Court Appeals

News Flash – Test Your Medicare Claims Now! After you have submitted claims containing both National Provider Identifiers (NPIs) and legacy identifiers and those claims have been paid, Medicare urges you to send a small batch of claims now with only the NPI in the primary provider fields. If the results are positive, begin increasing the number of claims in the batch. (Reminder: For institutional claims, the primary provider fields are the Billing and Pay-to Provider fields. For professional claims, the primary provider fields are the Billing, Pay-to, and Rendering Provider fields. If the Pay-to Provider is the same as the Billing Provider, the Pay-to Provider does not need to be identified.)

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

Impact on Providers
This article is based on Change Request (CR) 5897 which notifies Medicare contractors of an increase in the Amount in Controversy (AIC) required to sustain Administrative Law Judge (ALJ) and Federal District Court appeal rights beginning January 1, 2008. The amount remaining in controversy requirement for ALJ hearing requests made before January 1, 2008, is $110. The amount remaining in controversy requirement for requests made on or after January 1, 2008, is $120. For Federal District Court review, the amount remaining in controversy goes from $1,130 for requests prior to January 1, 2008, to $1,180 for requests on or after that date.

Background
The Medicare claims appeal process was amended by the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA). In addition, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 provides for annual reevaluation (beginning in 2005) of the dollar amount in controversy required for an Administrative Lay Judge (ALJ) hearing and Federal District Court review. Change Request (CR) 5897 revises the Medicare Claims Processing Manual (Publication 100-4, Chapter 29, Section 330.1 and Section 345.1) to update the Amount In Controversy (AIC) required for an ALJ hearing or Federal District Court review. As of January 1, 2008, the amount remaining in controversy must be at least $120 for an ALJ hearing or at least $1,180 for a Federal District Court review requested on or after January 1, 2008.

Additional Information
The official instruction, CR5897, issued to your carrier, FI, RHHI, A/B MAC, and DME MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1437CP.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site.

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

News Flash – It’s Not Too Late to Give and Get the Flu Shot! In the U.S., the peak of flu season typically occurs anywhere from late December through March; however, flu season can last as late as May. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a one time pneumococcal vaccination. Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Don’t Get the Flu. Don’t Give the Flu. Get Vaccinated! Remember – Influenza and pneumococcal vaccinations and their administration are covered Part B benefits. Note that influenza and pneumococcal vaccines are NOT Part D covered drugs. You and your 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.

 

Clarification of Bone Mass Measurement (BMM) Billing Requirements Issued in CR 5521

News Flash – Medicare Remit Easy Print (MREP) software allows professional providers and suppliers to view and print the Health Insurance Portability and Accountability Act (HIPAA) compliant 835. This software, which is available for free can be used to access and print RA information, including special reports, from the HIPAA 835. Please go to your Carrier or DME MAC’s Web site to download the MREP software. To find your carrier or DME MAC’s web address, see http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

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

Provider Action Needed
This article is based on Change Request (CR) 5847 which clarifies the claims processing instructions contained in CR 5521. Only those business requirements changing from CR 5521 are listed in CR 5847, and the BMM benefit policy is not changing. The basic clarification is that Medicare allows codes other than CPT code 77080 (i.e., 76977, 77078, 77079, 77081, 77083, and G0130) to be paid even though claims for such services report both a screening diagnosis code and an osteoporosis code.

Background
The Social Security Act (Sections 1861(s)(15) and (rr)(1)) (as added by the Balanced Budget Act of 1997 (BBA; §4106)) standardize Medicare coverage of medically necessary BMMs by providing for uniform coverage under Medicare Part B. Effective for dates of service on and after January 1, 2007, the Calendar Year (CY) 2007 Physician Fee Schedule (PFS) final rule expanded the number of beneficiaries qualifying for BMM by reducing the dosage requirement for glucocorticoid (steroid) therapy from 7.5 mg of prednisone per day to 5.0 mg. It also changed the definition of BMM by removing coverage for a single-photon absorptiometry as it is not considered reasonable and necessary under the Social Security Act (Section 1862 (a)(1)(A)) . Finally, it required in the case of monitoring and confirmatory baseline BMMs, that they be performed with a dual-energy x-ray absorptiometry (axial) test.

The Centers for Medicare & Medicaid Services (CMS) issued change request (CR) 5521 (Transmittal 70; May 11, 2007) to provide benefit policy and claims processing instructions for BMM tests. CMS has learned that the updated policy described in CR 5521 is not being implemented uniformly and some covered services are being denied in error.

You can review the MLN Matters article related to CR 5521 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/mm5521.pdf on the CMS Web site. CR 5847 clarifies the claims processing instructions contained in CR 5521 and lists only those business requirements changing from CR 5521. The key clarifications are as follows, effective for dates of services on and after January 1, 2007, the following apply to BMM:

Note: As mentioned, these are clarifications and the BMM benefit policy is not changing. Also, note that while Medicare contractors will not search their files to reprocess claims already processed, they will adjust claims that you bring to their attention.

Additional Information
The official instruction, CR5847, issued to your Medicare carrier, FI, and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1416CP.pdf on the CMS Web site.

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

News Flash – It’s Not Too Late to Get the Flu Shot. We are in the midst of flu season and a flu vaccine is still the best way to prevent infection and the complications associated with the flu. But re-vaccination is necessary each year because flu viruses change each year. Please encourage your Medicare patients who haven’t already done so to get their annual flu shot. 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. Note that 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.

 

Clarification Regarding the Coordination of Benefits Agreement (COBA) Medigap Claim-based Crossover Process

News Flash – The Hospice Payment System Fact Sheet, which offers providers information about the Medicare hospice benefit, is now available from the Centers for Medicare & Medicaid Services Medicare Learning Network in downloadable format at
http://www.cms.hhs.gov/MLNProducts/downloads/hospice_pay_sys_fs.pdf on the CMS Web site

Note: This article was revised on January 30, 2008, to show the correct implementation date (see above), which is February 1, 2008. All other information remains the same.

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

Provider Action Needed

STOP – Impact to You
This article is based on Change Request (CR) 5837 which clarifies instructions regarding the Coordination of Benefits Agreement (COBA) Medigap claim-based crossover process.

CAUTION – What You Need to Know
CR 5837 provides formal confirmation of recent Centers for Medicare & Medicaid Services (CMS) decision to not require Medicare Part B contractors (including Durable Medical Equipment Medicare Administrative Contractors (DME MACs) to update their internal insurer tables or files with each Medigap insurer’s newly assigned Coordination of Benefits Agreement (COBA) Medigap claim-based ID, as was previously prescribed in CR 5662. In addition, CR 5837 conveys clarifying provider billing requirements in relation to Medigap claim-based crossovers.

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

Background
Effective October 1, 2007, the CMS transferred responsibility for the mandatory Medigap crossover process (also known as the “Medicare claim-based crossover process”) to its Coordination of Benefits Contractor. With this change, Part B contractors, including A/B MACs and DME MACs:

In a directive issued on September 18, 2007, CMS communicated to Medicare Part B contractors (carriers, DME MACs, and A/B MACs) its decision that they are not required to update their internal insurer files or tables with the Coordination of Benefits Contractor (COBC)-assigned COBA Medigap claim-based identifiers (IDs). This is because, as discussed in Change Request (CR) 5601, the contractors’ front-end system now simply verifies that a Medigap claim-based crossover identifier on an incoming claim is syntactically correct (5 digits, beginning with a “5”). CMS’ Common Working File (CWF) system is now tasked with validation of the actual ID submitted on incoming claims.

The September 18, 2007, directive represented a departure from previous guidance communicated in CR5662 (see MLN Matters article, MM5662, at
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5662.pdf on the CMS Web site), in which CMS provided for transitional updating of the contractors’ internal insurer files/tables prior to October 1, 2007, once the COBC had:

CR 5837 instructs Part B contractors (including A/B MACs and DME MACs) that they are not required to update their internal insurer files/tables following a Medigap insurer’s readiness to move into production with the COBC. This requirement formerly applied to situations where CMS expected that contractors update their internal insurer files/tables prior to October 1, 2007, in accordance with CR 5662 (Transmittal 283). These Part B contractors may retain their older Other Carrier Name and Address (OCNA) or N-key identifiers within their internal insurer files/tables for purposes of avoiding system issues or for the printing of post-hoc beneficiary-requested Medicare Summary Notices (MSNs). However, in accordance with CR 5601, at http://www.cms.hhs.gov/transmittals/downloads/R1242CP.pdf on the CMS Web site, contractors will have disabled the logic that they formerly used to tag claims for crossover to Medigap insurers effective prior to claims they received for processing on October 1, 2007.

Effective with CR 5837, all Part B contractors (including A/B MACs and DME MACs) will discontinue publication of their routine Medigap newsletters. These contractors may, however, at their discretion, publish one last edition of this newsletter if desired to include the provider education language that follows:

In accordance with the language modification to MSN message 35.3
—“A copy of this notice will not be forwarded to your Medigap insurer because the information submitted on the claim was incomplete or invalid. Please submit a copy of this notice to your Medigap insurer.”—which contractors made as part of Transmittal 1242, CR 5601, all Part B contractors, including A/B MACs, and DME MACs shall make available a Spanish translation of the modified MSN message, which shall read as follows: “No se enviará copia de esta notificación a su asegurador de Medigap debido a que la información estaba incompleta o era inválida. Favor de someter una copia de esta notificación a su asegurador Medigap.”

All Part B contractors (including A/B MACs, and DME MACs) are to inform their associated billing providers that are exempted from billing their claims electronically under the Administrative Simplification Compliance Act (ASCA) that they should only be entering the newly assigned 5-byte COBA Medigap claim-based ID (range 55000 to 59999) with item 9-D of the CMS-1500 claim form for purposes of triggering a crossing over of the claim to a Medigap insurer.

All Part B contractors (including A/B MACs, and DME MACs) are also to provide a link on their provider Web sites (preferably under “Hot Topics”) to the recently published special edition MLN article (SE0743 at
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0743.pdf on the CMS Web site) that clarifies for providers the differences between:

Providers should note that the listing at http://www.cms.hhs.gov/COBAgreement/Downloads/Medigap%20Claim-based%20COBA%20IDs%20for%20Billing%20Purpose.pdf on the CMS COB Web site is:

Additional Information
The official instruction, CR 5837, was issued in two transmittals issued to your Medicare carrier, DME MAC, or A/B MAC. Those transmittals may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1420CP.pdf and http://www.cms.hhs.gov/Transmittals/downloads/R135FM.pdf on the CMS Web site. These transmittals make revisions to the Medicare Claims Processing and Medicare Financial Management Manuals, respectively

If you have any questions, please contact your Medicare carrier, DME MAC, 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 Not Too Late to Get the Flu Shot. We are in the midst of flu season and a flu vaccine is still the best way to prevent infection and the complications associated with the flu. But re-vaccination is necessary each year because flu viruses change each year. Please encourage your Medicare patients who haven’t already done so to get their annual flu shot. – 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. Note that 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.

 

Clarification to CR 5744 - Payment Allowance Update for the Influenza Virus Vaccine CPT 90660 and further instruction regarding the Pneumococcal Vaccine Current Procedural Terminology (CPT) 90669

Note: This article was revised on March 7, 2008, to delete a reference to “institutional providers” in the first bullet point on page two regarding the use of HCPCS code G0009. The sentence referencing that code has been changed to begin with “providers” rather than “institutional providers.” All other information remains the same.

News Flash – Test Your Medicare Claims Now! After you have submitted claims containing both National Provider Identifiers (NPIs) and legacy identifiers and those claims have been paid, Medicare urges you to send a small batch of claims now with only the NPI in the primary provider fields. If the results are positive, begin increasing the number of claims in the batch. (Reminder: For institutional claims, the primary provider fields are the Billing and Pay-to Provider fields. For professional claims, the primary provider fields are the Billing, Pay-to, and Rendering Provider fields. If the Pay-to Provider is the same as the Billing Provider, the Pay-to Provider does not need to be identified.)

Provider Types Affected
Physicians, hospitals, and other providers who bill Medicare contractors (fiscal intermediaries (FI), carriers, or A/B MACs) for providing influenza and pneumococcal vaccines to Medicare beneficiaries.

What You Need to Know
CR 5910, from which this article is taken, clarifies CR 5744 (Payment Allowances for the Influenza Virus Vaccine and the Pneumococcal Vaccine When Payment is Based on 95 Percent of the Average Wholesale Price (AWP)), released October 26, 2007. It provides Medicare contractors additional instructions regarding the pediatric pneumococcal vaccine CPT code 90669, and the updated payment allowance for the nasal influenza virus vaccine CPT code 90660.

The Medicare Part B payment allowance for CPT 90660 is $22.031, effective September 19, 2007. Make sure that your billing staffs are aware of these CPT code updates.

Background
Change Request 5744 (Payment Allowances for the Influenza Virus Vaccine and the Pneumococcal Vaccine When Payment is Based on 95 Percent of the Average Wholesale Price (AWP)), released October 26, 2007; provided the payment allowances for Pneumococcal Vaccine Current Procedural Terminology (CPT) codes 90732 and 90669, and Influenza Virus Vaccines CPT codes 90655, 90656, 90657, 90658, and 90660).

CR 5910, from which this article is taken, augments CR 5744 by providing additional instructions regarding pediatric pneumococcal vaccine CPT code 90669, and the updated payment allowance for the nasal influenza virus vaccine CPT code 90660. These changes are:

Note: All other instructions in CR 5744 remain in effect.

Please note that, except when the vaccine is furnished in the hospital outpatient department, the Medicare Part B payment allowance limits for influenza and pneumococcal vaccines are 95% of the average wholesale price (AWP), as reflected in the published compendia payment for the vaccine is based on reasonable cost. Also note that annual Part B deductible and coinsurance amounts do not apply; and that all physicians, non-physician practitioners, and suppliers who administer the influenza virus and pneumococcal vaccinations must take assignment on the claim for the vaccine.

Finally, your Medicare contractor will not search their files to either retract payment for claims already paid or to retroactively pay claims, but will adjust claims that you bring to their attention.

Additional Information
You can find more information about the additional information regarding CPT codes 90669 and 90660 by going to CR 5910, located at http://www.cms.hhs.gov/Transmittals/downloads/R1461CP.pdf on the CMS Web site. You might also want to review the MLN Matters article related to CR 5744. You can find that article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5744.pdf on the CMS Web site.

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

News Flash – It’s Not Too Late to Give and Get the Flu Shot! In the U.S., the peak of flu season typically occurs anywhere from late December through March; however, flu season can last as late as May. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a one time pneumococcal vaccination. Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Don’t Get the Flu. Don’t Give the Flu. Get Vaccinated! Remember – Influenza and pneumococcal vaccinations and their administration are covered Part B benefits. Note that influenza and pneumococcal vaccines are NOT Part D covered drugs. You and your 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.

 

Clinical Lab: New Automated Test for the Automated Multi-channel Chemistry Code (AMCC) Panel Payment Algorithm

News Flash – Test Your Medicare Claims Now! After you have submitted claims containing both National Provider Identifiers (NPIs) and legacy identifiers and those claims have been paid, Medicare urges you to send a small batch of claims now with only the NPI in the primary provider fields. If the results are positive, begin increasing the number of claims in the batch. (Reminder: For institutional claims, the primary provider fields are the Billing and Pay-to Provider fields. For professional claims, the primary provider fields are the Billing, Pay-to, and Rendering Provider fields. If the Pay-to Provider is the same as the Billing Provider, the Pay-to Provider does not need to be identified.)

Provider Types Affected
All physicians and providers, who submit claims for the AMCC to Medicare contractors (carriers, Medicare Administrative Contractors (A/B MACs), and Fiscal Intermediaries (FIs)) for services provided to Medicare beneficiaries.

Provider Action Needed

STOP – Impact to You
The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 5874 to alert providers that existing current procedural terminology (CPT) code 82330, Calcium; ionized is being paid as in individual test and was not included in the AMCC Panel Payment Algorithm. That changes effective July 1, 2008.

CAUTION – What You Need to Know
Effective July 1, 2008, CPT 82330 will become an automated chemistry test within the AMCC Panel Payment Algorithm for payment purposes.

GO – What You Need to Do
Make certain your office staffs are aware of this change.

Background
Effective January 1, 2008, the CPT Editorial Panel created a new code 80047 Basic metabolic panel (Calcium, ionized) which is an automated multi-channel chemistry (AMCC) code and is currently included in the automated multi-channel chemistry code (AMCC) Panel Payment Algorithm. The new code 80047 is comprised of eight component test codes (see table below). Also, new code 80047 is not a replacement for code 80048 Basic metabolic panel. Both codes 80048 and 80047 are included in the 2008 clinical laboratory fee schedule.

Key Points

For ESRD dialysis patients, CPT code 82330 Calcium; ionized will be included in the calculation for the 50/50 rule (Pub 100-04, Chapter 16, Section 40.6). When CPT code 82330 is billed as a substitute for CPT code 82310, Calcium; total, it should be billed with modifier CD or CE. When CPT code 82330 is billed in addition to CPT 82310, it should be billed with CF modifier.

Note that, in accordance with the Medicare Claims Processing Manual, section 40.6.1, the new panel code 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. The Medicare Claims Processing Manual is available at http://www.cms.hhs.gov/Manuals/IOM/list.asp on the CMS Web site.

Additional Information
To see the official instruction (CR5874) issued to your Medicare Carrier, FI, or A/B MAC, refer to http://www.cms.hhs.gov/Transmittals/downloads/R83BP.pdf on the CMS Web site.

If you have 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.

News Flash – It’s Not Too Late to Give and Get the Flu Shot! In the U.S., the peak of flu season typically occurs anywhere from late December through March; however, flu season can last as late as May. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a one time pneumococcal vaccination. Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Don’t Get the Flu. Don’t Give the Flu. Get Vaccinated! Remember – Influenza and pneumococcal vaccinations and their administration are covered Part B benefits. Note that influenza and pneumococcal vaccines are NOT Part D covered drugs. You and your 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.

 

Attention Part B Medicare Providers: Modifier Finder Tool Now Available on the CIGNA Government Services Web site!

Are you a Part B Medicare provider who routinely uses modifiers in billing your claims to Medicare? If so, CIGNA Government Services has a new online tool just for you!

The Modifier Finder tool has been designed to aid Medicare providers in using modifiers correctly. You may search this database by modifier or keyword. All records matching your search criteria will be returned for your review. Or, if you wish, you may also view the entire listing of modifiers, their definitions, and additional billing information by clicking on the “Show all Modifiers” option.

The new Modifier Finder Tool is available at the following link to the CIGNA Government Services Web site: http://www.cignagovernmentservices.com/medicare_dynamic/modifiers/search.asp.

 

Emergency Update to the 2008 Medicare Physician Fee Schedule Database (MPFSDB)

News Flash – An additional election period for the Competitive Acquisition Program (CAP) for Medicare Part B drugs will start on January 15 and run through February 15, 2008, to give physicians a chance to take advantage of new changes to the program that began on January 1, 2008. The CAP is a voluntary program that provides an alternative to ASP for physicians to obtain certain Part B drugs. More information about the CAP is available at http://www.cms.hhs.gov/CompetitiveAcquisforBios/01_overview.asp on the CMS Web site.

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

Provider Action Needed
The article is based on Change Request (CR) 5902 which amends payment files that were issued to Medicare contractors based upon the November 1, 2007, Medicare Physician Fee Schedule (MPFS) Final Rule.

Background
The Social Security Act (Section 1848(c)(4); see http://www.ssa.gov/OP_Home/ssact/title18/1848.htm on the Internet) authorizes the Centers for Medicare & Medicaid Services (CMS) to establish ancillary policies necessary to implement relative values for physicians’ services. Previously, payment files were issued to Medicare contractors based upon the November 1, 2007, Medicare Physician Fee Schedule Final Rule.

Change Request (CR) 5902 amends those payment files.

In summary, CR 5902 instructs your Medicare contractor to:

Note: See Attachment 1 of CR 5902 for a list of detailed changes for certain CPT/HCPCS codes included in the Emergency Update to the 2008 Medicare Physician Fee Schedule Database (MPFSDB). The Web address for accessing CR5902 is in the next section of this article.

Additional Information
The official instruction, CR 5902, issued to your Medicare carrier, FI, and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1435CP.pdf on the CMS Web site.

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

News Flash – It’s Not Too Late to Give and Get the Flu Shot! In the U.S., the peak of flu season typically occurs anywhere from late December through March; however, flu season can last as late as May. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a one time pneumococcal vaccination. Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Don’t Get the Flu. Don’t Give the Flu. Get Vaccinated! Remember – Influenza and pneumococcal vaccinations and their administration are covered Part B benefits. Note that influenza and pneumococcal vaccines are NOT Part D covered drugs. You and your 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.

 

Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions

News Flash – Test Your Medicare Claims Now! After you have submitted claims containing both National Provider Identifiers (NPIs) and legacy identifiers and those claims have been paid, Medicare urges you to send a small batch of claims now with only the NPI in the primary provider fields. If the results are positive, begin increasing the number of claims in the batch. (Reminder: For institutional claims, the primary provider fields are the Billing and Pay-to Provider fields. For professional claims, the primary provider fields are the Billing, Pay-to, and Rendering Provider fields. If the Pay-to Provider is the same as the Billing Provider, the Pay-to Provider does not need to be identified.)

Provider Types Affected
Providers and suppliers who bill Medicare contractors (carriers, fiscal intermediaries (FI), Regional Home Health Intermediaries (RHHI), Medicare Administrative Contractors (A/B MAC) and Durable Medical Equipment Medicare Administrative Contractors (DME MAC)) for administering or supplying Erythropoiesis Stimulating Agents (ESAs) for cancer and related neoplastic conditions to Medicare beneficiaries.

What You Need to Know
Following a National Coverage Analysis (NCA) to evaluate the uses ESAs in non-renal disease applications, the Centers for Medicare & Medicaid Services (CMS), on July 30, 2007, issued a Decision Memorandum (DM) that addressed ESA use in non-renal disease applications (specifically in cancer and other neoplastic conditions).

CR 5818 communicates the NCA findings and the coverage policy in the National Coverage Determination (NCD). Specifically, CMS determines that ESA treatment is reasonable and necessary for anemia secondary to myelosuppressive anticancer chemotherapy in solid tumors, multiple myeloma, lymphoma, and lymphocytic leukemia under specified conditions; and not reasonable and necessary for beneficiaries with certain other clinical conditions, as listed below.

The HCPCS codes specific to non-end-stage renal disease (ESRD) ESA use are J0881 and J0885. Claims processed with dates of service July 30, 2007, through December 31, 2007, do not have to include the ESA modifiers as the modifiers are not effective until January 1, 2008. However, providers are to begin using the modifiers as of January 1, 2008, even though full implementation of related system edits are not effective until April 7, 2008.

Make sure that your billing staffs are aware of this guidance regarding ESA use.

Background
Emerging safety concerns (thrombosis, cardiovascular events, tumor progression, and reduced survival) derived from clinical trials in several cancer and non-cancer populations prompted CMS to review its coverage of ESAs. In so doing, on March 14, 2007, CMS opened an NCA to evaluate the uses of ESAs in non-renal disease applications, and on July 30, 2007, issued a DM specifically narrowed to the use of ESAs in cancer and other neoplastic conditions.

Reasonable and Necessary ESA Use
CMS has determined that ESA treatment for the anemia secondary to a regimen of myelosuppressive anticancer chemotherapy in solid tumors, multiple myeloma, lymphoma, and lymphocytic leukemia is reasonable and necessary only under the following specified conditions:

Not Reasonable and Necessary ESA Use
Either because of a deleterious effect of ESAs on the underlying disease, or because the underlying disease increases the risk of adverse effects related to ESA use, CMS has also determined that ESA treatment is not reasonable and necessary for beneficiaries with the following clinical conditions:

Claims Processing
Effective for claims with dates of service on or after January 1, 2008, Medicare will deny non-ESRD ESA services for J0881 or J0885 when:

Note: Denial of claims for non-ESRD ESAs for cancer and related neoplastic indications as outlined in NCD 110.21 are based on reasonable and necessary determinations. A provider may have the beneficiary sign an Advance Beneficiary Notice (ABN), making the beneficiary liable for services not covered by Medicare. When denying ESA claims, contractors will use Medicare Summary Notice 15.20, The following policies [NCD 110.21] were used when we made this decision, and remittance reason code 50, These are non-covered services because this is not deemed a `medical necessity’ by the payer. However, standard systems shall assign liability for the denied charges to the provider unless documentation of the ABN is present on the claim. Denials are subject to appeal and standard systems shall allow for medical review override of denials. Contractors may reverse the denial if the review results in a determination of clinical necessity.

Medicare contractors have discretion to establish local coverage policies for those indications not included in NCD 110.21

Medicare Contractors shall not search files to retract payment for claims paid prior to April 7, 2008.

However, contractors shall adjust claims brought to their attention.

Additional Information
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.

This addition/revision of section 110.21 of Pub.100-03 is an NCD. NCDs are binding on all carriers, FIs, quality improvement organizations, qualified independent contractors, the Medicare Appeals Council, and administrative law judges (ALJs) (see 42 CFR section 405.1060(a)(4) (2005)). An NCD that expands coverage is also binding on a Medicare advantage organization. In addition, an ALJ may not review an NCD. (See section 1869(f)(1)(A)(i) of the Social Security Act.)

The official instruction, CR5818, was issued to your contractor in two transmittals. The first is the NCD transmittal and that is available at http://www.cms.hhs.gov/Transmittals/downloads/R80NCD.pdf on the CMS Web site. The second transmittal revises the Medicare Claims Processing Manual and it is at http://www.cms.hhs.gov/Transmittals/downloads/R1413CP.pdf on the same site.

News Flash – It’s Not Too Late to Get the Flu Shot. We are in the midst of flu season and a flu vaccine is still the best way to prevent infection and the complications associated with the flu. But re-vaccination is necessary each year because flu viruses change each year. Please encourage your Medicare patients who haven’t already done so to get their annual flu shot. 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. Note that 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.

 

Extension of the Dates of Service Eligible for the Physician Scarcity Area (PSA) Bonus Payment

News Flash – It’s Not Too Late to Give and Get the Flu Shot! In the U.S., the peak of flu season typically occurs anywhere from late December through March; however, flu season can last as late as May. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a one time pneumococcal vaccination. Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Don’t Get the Flu. Don’t Give the Flu. Get Vaccinated! Remember – Influenza and pneumococcal vaccinations and their administration are covered Part B benefits. Note that influenza and pneumococcal vaccines are NOT Part D covered drugs. You and your 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, and other providers, who bill Medicare contractors (fiscal intermediaries (FI), carriers, or Medicare Administrative Contractors (A/B MAC)) for providing services to Medicare beneficiaries in designated physician scarcity areas.

What You Need to Know
CR 5937, from which this article is taken announces the extension of the physician scarcity area (PSA) bonus payment for dates of service through June 30, 2008. You should make sure that your billing staffs are aware of this PSA bonus payment extension.

Background
Section 413(a) of the Medicare Modernization Act of 2003 (MMA) required the Centers for Medicare & Medicaid Services (CMS) to pay a 5% bonus to physicians in a designated PSA for dates of service from January 1, 2005 through December 31, 2007. The Medicare, Medicaid, and State Children’s Health Insurance Program (SCHIP) Extension Act of 2007 amended Section 1833(u)(1) of the Social Security Act, extending the payment of the PSA bonus for dates of service through June 30, 2008. CR 5937, from which this article is taken, announces this extension and provides Medicare contractors with implementing instructions.

Medicare contractors will continue to pay PSA bonuses for dates of service from January 1, 2005 through June 30, 2008, regardless of whether the bonus is requested through submission of a modifier or made through an automated payment based on ZIP code. The primary care and specialty care scarcity areas in effect on December 31, 2007 will be used for 2008 services. Fiscal Intermediaries (FI) and Medicare Administrative Contractors (A/B MACs) processing Part A claims will implement this CR on January 7, 2008, and carriers and A/B MACs Processing Part B claims will implement it 30 days from issuance;

Carriers and A/B MACs processing Part B claims will Identify claims that contain the AR modifier (physician providing services in a PSA) and are submitted with dates of service on or after January 1, 2008 and processed prior to this CR’s implementation so that they may be included in the calculation in the first quarterly 2008 bonus payment. Additionally, when brought to their attention, carriers and A/B MACs processing Part B claims will re-open and re-process claims with these dates of service that are processed prior to the CR’s implementation date in order to include the AR modifier and make the appropriate bonus payment.

Additional Information
You can find the official instruction, CR 5937, issued to your FI, carrier, or A/B MAC by visiting
http://www.cms.hhs.gov/Transmittals/downloads/R1434CP.pdf on the CMS Web site. The updated Medicare Claims Processing Manual, Chapter 4 (Part B Hospital (Including Inpatient Hospital Part B and OPPS)), Sections 250.2.1 (Billing and Payment in a Physician Scarcity Area (PSA)) and 250.2.2 (Zip Code Files); and Medicare Claims Processing Manual, Chapter 12 (Physicians/Nonphysician Practitioners, Sections 90.5 (Billing and Payment in a Physician Scarcity Area (PSA)) and 90.5.2 (Identifying Physician Scarcity Area Locations) are attachments to that CR.

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

 

Health Care Provider Taxonomy Code Set

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

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

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

TYPE OF CHANGE PROVIDER TAXONOMY VALUE CODE
Additions • 111NP0017X
• 173C00000X
• 173F00000X
• 1835P0018X
• 253J00000X
Revisions • 207ND0101X
• 207NS0135X
• 2084A0401X
• 2086X0206X
• 2086S0127X

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

 

Implementation of the Medicare Clinical Laboratory Services Competitive Bidding Demonstration

News Flash – It’s Not Too Late to Give and Get the Flu Shot! In the U.S., the peak of flu season typically occurs anywhere from late December through March; however, flu season can last as late as May. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a one time pneumococcal vaccination. Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Don’t Get the Flu. Don’t Give the Flu. Get Vaccinated! Remember – Influenza and pneumococcal vaccinations and their administration are covered Part B benefits. Note that influenza and pneumococcal vaccines are NOT Part D covered drugs. You and your 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 or suppliers who bill Medicare contractors (carriers, fiscal intermediaries (FI), or Medicare Administrative Contractors (A/B MAC)) and/or order laboratory services for Medicare fee-for-service (FFS) beneficiaries under the Medicare Clinical Laboratory Services Competitive Bidding Demonstration project.

What you need to know
CR 5772, from which this article is taken, implements the Centers for Medicare & Medicaid Services (CMS) Medicare Clinical Laboratory Services Competitive Bidding Demonstration in the first Competitive Bidding Area (San Diego-Carlsbad-San Marcos, California metropolitan statistical area, or CBA1); and changes some of the demonstration’s requirements that were stated in CR5205, issued August 1, 2006, (see the MLN Matters article at
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5205.pdf on the CMS Web site) and superceded by CR5359, issued November 1, 2006, (see the MLN Matters article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5359.pdf on the CMS Web site).

Specifically, CR5772 requires that:

Background
Section 302(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) requires CMS to conduct a project to demonstrate the application of competitive acquisition for the payment of most clinical laboratory services that would otherwise be payable under the Medicare Part B fee schedule.

In this project, each of two demonstration sites (competitive bidding areas – CBA1 and CBA2) will run for three years with a staggered start of one year. It will cover certain “demonstration tests” furnished under Medicare Part B to any beneficiary enrolled in FFS Medicare who lives in the CBAs. <