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September 2009 Part B Medicare Bulletin

Posted September 4, 2009

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2009 Durable Medical Equipment Prosthetics, Orthotics, and Supply (DMEPOS) Healthcare Common Procedure Coding System (HCPCS) Codes Jurisdiction List - MM6522

News Flash – Suppliers submitting a bid for a product category in a competitive bidding area (CBA) must meet all state licensure requirements for DMEPOS and other applicable state licensure requirements, if any, for that product category for every state in that CBA. Prior to submitting a bid for a CBA and product category, the supplier must have a copy of the applicable state licenses on file with the NSC. Suppliers must be accredited for a product category to submit a bid for that product category. Suppliers subject to the surety bond requirement must be bonded in order to bid. For more information on the Medicare DMEPOS Competitive Bidding Program please visit http://www.cms.hhs.gov/CompetitiveAcqforDMEPOS/ on the CMS website.

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

Impact on Providers
This article is informational and is based on Change Request (CR) 6522 that notifies providers that the spreadsheet containing an updated list of the HCPCS codes for DME MAC, Part B carrier, or A/B MAC jurisdictions is updated annually to reflect codes that have been added or discontinued (deleted) each year. The spreadsheet is helpful to billing staff by showing the appropriate Medicare contractor to be billed for HCPCS appearing on the spreadsheet. The spreadsheet for the 2009 Jurisdiction List is an Excel® spreadsheet and is available at http://www.cms.hhs.gov/center/dme.asp on the Centers for Medicare & Medicaid Services (CMS) website.

Additional Information
To see the official instruction (CR6522) issued to your Medicare DME MAC, carrier, or A/B MAC, visit http://www.cms.hhs.gov/Transmittals/downloads/R1765CP.pdf on the CMS website. The 2009 Jurisdiction List is attached to CR 6522.

If you have questions, please contact your Medicare DME MAC, 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 website.

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2009 Reminder for Roster Billing and Centralized Billing for Influenza and Pneumococcal Vaccinations

News Flash – The Centers for Medicare & Medicaid Services (CMS) announces that two new section pages have been created on the 2009 Electronic Prescribing (E-Prescribing) Incentive Program web page on the CMS website. E-Prescribing Measure Section page – This page contains several resources including: Measure Specifications; new Claims-Based Reporting Principles and a Sample E-Prescribing Claim. To access this page, visit http://www.cms.hhs.gov/ERxIncentive/06_E-Prescribing_Measure.asp on the CMS website. Educational Resources Section Page – This page contains MLN Matters articles; E-Prescribing Incentive Program fact sheets; a link to Medicare's Practical Guide to the E-Prescribing Incentive Program, and information on how to receive continuing education credit related to the E-Prescribing Incentive Program. To access this page, visit http://www.cms.hhs.gov/ERxIncentive/09_Educational_Resources.asp on the CMS website.

Provider Types Affected
This article has information for 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 influenza and pneumococcal vaccinations provided to Medicare beneficiaries.

Provider Action Needed
The Centers for Medicare & Medicaid Services (CMS) issued change request (CR) 6539 to remind the Medicare physician community of the requirements to correctly enroll in order to conduct Mass Immunization Roster Billing and Centralized Billing for influenza and pneumococcal immunizations. Remember that centralized billers participation is limited to one year and such billers must reapply each year they wish to be a centralized biller. The yearly reapplication process is not required for Mass Immunizer Roster Billers.

Providers Take Note : A vaccine is being developed for the H1N1 virus and the development of the H1N1 vaccine could result in beneficiaries being eligible to receive more than one influenza vaccine during the upcoming influenza season. CMS will release more information regarding the development of the H1N1 vaccine and any coding updates in future CRs as necessary.

Background
CMS is issuing CR 6539 as a reminder for Mass Immunization Roster Billing and Centralized Billing for Influenza and Pneumococcal vaccinations. Mass immunizers are providers and suppliers who enroll in the Medicare program to offer the influenza and/or pneumococcal vaccinations to a large number of individuals, and they must be properly licensed in the States in which they plan to operate influenza (flu) clinics. Enrollment for mass immunizers is ongoing and must be completed through the local A/B MAC or carrier. Mass immunizers submit their claims to the local Medicare contractor.

Centralized billers are mass immunizers who have applied to become centralized billers when they operate in at least three payment localities for which there are three different Medicare contractors or A/B MACs processing claims. Individuals and entities must be properly licensed in the States in which they plan to operate influenza (flu) and/or pneumococcal clinics.

All providers, except Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers, already enrolled in the Medicare program may render and bill for providing influenza and/or pneumococcal vaccinations. DMEPOS suppliers must enroll as a mass immunization roster biller (specialty provider type 73) with a carrier or A/B MAC to render influenza vaccination services to Medicare beneficiaries.

Providers/suppliers who will only render influenza and/or pneumococcal vaccination services must enroll as one of two types of providers including a mass immunization roster biller (specialty provider type 73), or a Centralized Biller.

They must:

Participation as a centralized biller is limited to one year and must be renewed annually by contacting the CMS central office by June 1 to request participation for the upcoming year. Claims for centralized billers are processed by one Medicare specialty contractor regardless of the locality where the service was rendered. Centralized billers submit their claims to the designated specialty contractor.

Providers and suppliers must enroll using the appropriate CMS 855 provider enrollment form. Information on provider enrollment forms can be found at http://www.cms.hhs.gov/MedicareProviderSupEnroll/02_EnrollmentApplications.asp on the CMS website. Refer to the Medicare Claims Processing Manual Chapter 18, Sections 10-10.5 for more information on billing requirements. This manual is available at http://www.cms.hhs.gov/Manuals/IOM/list.asp on the CMS website.

CMS offers a number of free educational products on its Medicare Learning Network (MLN). These products are available on the MLN Preventive Services Educational Products web page located at http://www.cms.hhs.gov/MLNProducts/35_PreventiveServices.asp#TopOfPage on the CMS website.

Note: Medicare Part B pays 100 percent for pneumococcal vaccines, influenza virus vaccines, and their administration. The Part B deductible and coinsurance do not apply for influenza virus and pneumococcal vaccine.

Remember the following regarding the influenza vaccine:

Remember the following with regard to the pneumococcal vaccine, effective for services furnished on or after July 1, 2000:

Typically, the pneumococcal vaccine is administered once in a lifetime. Claims for pneumococcal vaccines are paid for beneficiaries who:

Additional Information
CMS offers a number of free educational products on its Medicare Learning Network (MLN). These products are available on the MLN Preventive Services Educational Products web page located at http://www.cms.hhs.gov/MLNProducts/35_PreventiveServices.asp#TopOfPage on the CMS website.

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

The official instruction, CR6539, issued to your Medicare FI, carrier or A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R515OTN.pdf on the CMS website.

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Additional Clarification of Physician Signature

During reviews performed by the Comprehensive Error Rate Testing (CERT) contractor, concerns have emerged involving physician signatures. A few simple steps to remember:

Remember, providers have the same appeal rights for CERT initiated denials as they do for denials initiated through CIGNA Government Services. All of the same Medicare guidelines apply, including those regarding the 120-day time frame allowed for an appeal (redetermination).

The Redetermination (Appeal) Request Form can be found at: http://www.cignagovernmentservices.com/partb/forms/gateways/redetermination.html

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Changes to the Laboratory National Coverage Determination (NCD) Edit Software
for October 2009 - MM6548

News Flash – Did you know that the Medicare Learning Network (MLN) contains many products and tools to assist fee-for-service providers? If you find the MLN Matters® articles to be of help to you, then you will want to look at the other MLN products as well. Visit http://www.cms.hhs.gov/MLNGenInfo/ for a complete overview of the MLN as well as links to a "Spotlight" section and contact information for asking questions about MLN products. Also, look through the MLN Products Catalog at http://www.cms.hhs.gov/MLNProducts/downloads/MLNCatalog.pdf for a list and brief description of all the MLN products available to assist you and your support staff in serving Medicare patients.

Provider Types Affected
Physicians, providers, and suppliers submitting claims to Medicare carriers, fiscal intermediaries (FIs), or Part A/B Medicare Administrative Contractors (A/B MACs) for clinical diagnostic laboratory services provided for Medicare beneficiaries.

Provider Action Needed
This article is based on Change Request (CR) 6548 which announces the changes that will be included in the October 2009 release of Medicare's edit module for clinical diagnostic laboratory National Coverage Determinations (NCDs). The last quarterly release of the edit module was issued in July 2009. Be sure billing staff are aware of the changes.

Background
The NCDs for clinical diagnostic laboratory services were developed by the laboratory negotiated rulemaking committee and published in a final rule on November 23, 2001.

Nationally uniform software was developed and incorporated in Medicare's systems so that laboratory claims subject to one of the 23 NCDs were processed uniformly throughout the nation effective January 1, 2003.

In accordance with the Medicare Claims Processing Manual, Chapter 16, Section 120.2 (see http://www.cms.hhs.gov/manuals/downloads/clm104c16.pdf on the Centers for Medicare & Medicaid Services (CMS) website), the laboratory edit module is updated quarterly (as necessary) to reflect ministerial coding updates and substantive changes to the NCDs developed through the NCD process.

CR 6548 announces changes to the laboratory edit module for changes in laboratory NCD code lists for October 2009. These changes become effective for services furnished on or after October 1, 2009. The changes that are effective for dates of service on and after October 1, 2009 are as follows:

For the Urine Culture, Bacterial:

For Blood Counts:

For Partial Thromboplastin Time (PTT):

For Prothrombin Time (PT):

For Serum Iron Studies:

For Thyroid Testing:

For Lipids Testing:

For Digoxin Therapeutic Drug Assay :

For Alphafetoprotein:

For Carcinoembryonic Antigen:

For Gamma Glutamyl Transferase:

For the Hepatitis Panel/Acute Hepatitis Panel:

For Fecal Occult Blood Test:

For all 23 Lab NCDs:

Additional Information
If you have questions, please contact your Medicare 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 website.

The official instruction (CR6548) issued to your Medicare MAC, carrier, and/or FI may be found at http://www.cms.hhs.gov/Transmittals/downloads/R1766CP.pdf on the CMS website.

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Claim Status Category Code and Claim Status Code Update - MM6525

News Flash – As of January 1, 2009, eligible professionals can participate in the E-Prescribing Incentive Program by reporting on their adoption and use of an e-prescribing system by submitting information on one e-prescribing measure on their Medicare Part B claims. For the 2009 e-prescribing reporting year, to be a successful e-prescriber and to qualify to receive an incentive payment, an eligible professional must report one e-prescribing measure in at least 50% of the cases in which the measure is reportable by the eligible professional during 2009. There is no sign-up or pre-registration to participate in the E-Prescribing Incentive Program. For more information, visit http://www.cms.hhs.gov/ERxIncentive/ on the CMS website.

Provider Types Affected
All physicians, providers, and suppliers submitting claims to Medicare contractors (fiscal intermediaries (FI), Regional Home Health Intermediaries (RHHI), carriers, A/B Medicare Administrative Contractors (MAC) and Durable Medical Equipment MACs, or DME MACs) for Medicare beneficiaries are affected.

Provider Action Needed
This article, based on CR6525, explains that the Claim Status Codes and Claim Status Category Codes for use by Medicare contractors with the Health Claim Status Request and Response ASC X12N 276/277 were updated during the January 2009 meeting of the national Code Maintenance Committee and code changes approved at that meeting were posted at http://www.wpc-edi.com/content/view/180/223/ on the Internet on March 1, 2009. All providers should ensure that their billing staffs are aware of the updated codes.

Background
The Health Insurance Portability and Accountability Act (HIPAA) requires all health care benefit payers to use only Claim Status Category Codes and Claim Status Codes approved by the national Code Maintenance Committee in the X12 276/277 Health Care Claim Status Request and Response format adopted as the standard for national use (004010X093A1). These codes explain the status of submitted claim(s). Proprietary codes may not be used in the X12 276/277 to report claim status. All code changes approved during the January 2009 committee meeting were posted at
http://www.wpc-edi.com/content/view/180/223/ on March 1, 2009. Medicare will implement those changes on July 6, 2009 as a result of CR6525.

Additional Information
If you have questions, please contact your Medicare contractor at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the Centers for Medicare & Medicaid Services (CMS) website.

The official instruction issued to your Medicare contractor regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1756CP.pdf on the CMS website.

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Coding and Reporting Principles for the Physician Quality Reporting Initiative (PQRI) and the Electronic Prescribing (E-Prescribing) Incentive Programs

News Flash – The revised Medicare Preventive Services Quick Reference Information: Medicare Part B Immunization Billing Chart (revised March 2009), which provides billing and coding information related to adult immunizations, is now available in downloadable format from the Centers for Medicare & Medicaid Services Medicare Learning Network at http://www.cms.hhs.gov/MLNProducts/downloads/qr_immun_bill.pdf on the CMS website. Printed copies will be available at a later date.

Provider Types Affected
Physicians and practitioners (referred to as eligible professionals (EPs)) who wish to participate in the Medicare Physician Quality Reporting Initiative (PQRI) and/or the E-Prescribing Incentive programs in 2009.

What You Need to Know
CR 6514, from which this article is taken, provides a high-level overview of the coding and reporting principles for the claims-based reporting of quality measures data for the 2009 PQRI, and for the claims-based reporting of the e-prescribing measure for the 2009 E-Prescribing Incentive Program. Because the information in CR6514 is quite detailed and important for these two programs, this article will mirror virtually all of that detail.

Background
The 2006 Tax Relief and Health Care Act (TRHCA) required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals (EPs) who satisfactorily report data on quality measures for covered services furnished to Medicare beneficiaries during the second half of 2007. The Centers for Medicare & Medicaid Services (CMS) named this program the Physician Quality Reporting Initiative (PQRI).

For the 2009 PQRI, the Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) Extension Act of 2007 (MMSEA) required the Secretary of Health and Human Services (HHS) to select measures for 2009 through rulemaking, and to establish alternative reporting criteria and alternative reporting periods for reporting on a group of measures, or measures groups, and for registry-based reporting. In addition, the Medicare Improvements for Patients and Providers Act (MIPPA), which was enacted on July 15, 2008, includes many provisions that impact the 2009 PQRI. Thus, for 2009, PQRI submission of quality data may be performed via claims or via a qualified registry; and multiple reporting options are available for each method of submission, including the option of reporting on individual quality measures or on measures groups.

Section 132 of the MIPPA also authorizes a new and separate incentive program for EPs who are successful electronic prescribers (e-prescribers) as defined by MIPPA. This new incentive is separate from, and in addition to, the PQRI. To be considered a successful e-prescriber for 2009, an EP must report an e-prescribing measure in at least 50% of reportable cases. For 2009, the e-prescribing measure may be reported via claims only. To be considered a successful e-prescriber for 2009, an EP must report an e-prescribing measure on at least 50% of reportable cases and at least 10% of an EP's total allowed Medicare Part B charges must come from the services delineated in the measure's denominator. For 2009, the e-prescribing measure may be reported via claims only.

CR 6514, from which this article is taken, provides a high-level overview of the coding and reporting principles for the claims-based reporting of quality measures data for the 2009 PQRI, and for the claims-based reporting of the e-prescribing measure for the 2009 E-Prescribing Incentive Program.

Coding and Reporting Principles for the Claims-based Reporting of PQRI Measures
To implement 2009 PQRI claims-based reporting of measures or measures groups, eligible professionals (EPs), using your individual national provider identifier (NPI) and submitting billable services on Part B claims for allowable Medicare Physician Fee Schedule (MPFS) charges, may report the quality action for selected PQRI quality measure(s) or measures groups, which are comprised of four or more PQRI quality measures. In general, the PQRI quality measures consist of a unique denominator (eligible case) and numerator (quality action) that permit the calculation of the percentage of a defined patient population: 1) who receive a particular process of care or achieve a particular outcome, or 2) for whom care was delivered using a particular structural element. It is important that you review and understand each measure specification, which provides definitions and specific instructions for reporting a measure.

Note: 1) You should review the following documents if you choose to report individual PQRI quality measures:

2) You should review the following documents if you choose to report PQRI measures groups:

You can find the first four documents on the Measures/Codes section of the CMS PQRI website at http://www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp#TopOfPage on the CMS website, and the fifth on the Educational Resources section of the CMS PQRI website at http://www.cms.hhs.gov/PQRI/30_EducationalResources.asp#TopOfPage on the CMS website.

As mentioned above PQRI measures consist of two major components: 1) A denominator that describes the eligible cases for a measure (the eligible patient population associated with a measure's numerator); and 2) A numerator that describes the quality action required by the measure for reporting and performance. Each component is defined by specific codes described in each measure specification along with reporting instructions and use of modifiers.

Current Procedural Terminology (CPT) Category I Modifiers
The PQRI measure specifications include specific instructions regarding inclusion of CPT Category I modifiers. Unless otherwise specified, CPT Category I codes may be reported with or without CPT modifiers. You should refer to each individual measure specification for detailed instructions to identify CPT Category I modifiers that qualify or do not qualify a claim for denominator inclusion.

Please note that PQRI-eligible CPT Category I procedure codes, billed by surgeons performing surgery on the same patient, submitted with modifier 62 (indicating two surgeons, i.e., dual procedures) will be included in the denominator population for applicable PQRI measure(s). Both surgeons participating in PQRI will be fully accountable for the quality action(s) described in the PQRI measure(s).

However, surgical procedures billed by an assistant surgeon(s) will be excluded from the denominator population so their performance rates will not be negatively impacted for PQRI. PQRI analyses will exclude otherwise PQRI-eligible CPT Category I codes, when submitted with assistant surgeon modifiers 80, 81, or 82. The primary surgeon, not the assistant surgeon, is responsible for performing and reporting the quality action(s) in applicable PQRI measures.

Quality-Data Codes (QDCs)
QDCs are non-payable Healthcare Common Procedure Coding System (HCPCS) codes comprised of specified CPT Category II codes and/or G-codes that describe the quality action required by a measure's numerator. Quality actions can apply to more than one condition, and therefore can also apply to more than one measure. Where necessary, to avoid shared CPT Category II codes, G-codes are used to distinguish quality actions across measures. Some measures require more than one quality action and therefore have more than one CPT Category II code, G-code, or a combination associated with them. You should review numerator reporting instructions carefully.

CPT Category II Codes
CPT Category II or CPT II codes, developed through the CPT Editorial Panel for use in performance measurement, serve to encode the quality action(s) described in a measure's numerator. CPT II codes consist of five alphanumeric characters in a string ending with the letter "F." CPT II codes are not modified or updated during the reporting period and remain valid for the entire program year as published in the measure specifications manuals and related documents for PQRI.

Use of CPT II Modifiers
CPT II modifiers are unique to CPT II codes and may be used to report PQRI measures by appending the appropriate modifier to a CPT II code as specified for a given measure. The modifiers for a code are mutually exclusive and their use is guided by the measure's coding instructions, which are included in the numerator coding section of the measure specifications. Use of the modifiers is unique to CPT II codes and may not be used with other types of CPT codes. Only CPT II modifiers may be appended to CPT II codes. Descriptions of each modifier are provided below to help identify circumstances when the use of an exclusion modifier may be appropriate. Note that in a pay-for-reporting model, accurate reporting on all selected applicable measures counts the same, whether reporting that the quality action was performed or not.

CPT II code modifiers fall into two categories, exclusion modifiers and the 8P reporting modifier.

1) Exclusion modifiers may be appended to a CPT II code to indicate that an action specified in the

measure was not provided due to medical, patient, or system reason(s) documented in the medical record. These modifiers serve as denominator exclusions for the purpose of measuring performance. Some measures do not allow performance exclusions. Reasons for appending a performance measure exclusion modifier fall into one of three categories:

2) The 8P reporting modifier is available for use only with CPT II codes to facilitate reporting a denominator eligible case when an action described in a measure is not performed and the reason is not specified. Instructions for appending this reporting modifier to CPT Category II codes are included in applicable measures. Use of the 8P reporting modifier indicates that the patient is eligible for the measure; however, there is no indication in the record that the action described in the measure was performed, nor was there any documented reason attributable to the exclusion modifiers.

The 8P reporting modifier facilitates reporting an eligible case on a given measure when the quality action does not apply to a specific encounter. EPs can use the 8P modifier to receive credit for satisfactory reporting but will not receive credit for performance.

For example, a clinician who has selected and submitted QDCs during the reporting period for 2009 PQRI Measure #6, Oral Antiplatelet Therapy, sees a patient during an encounter and the claim for services for that encounter contains ICD-9-CM and CPT codes that will draw the patient into the measures' denominator during analysis. The 8P modifier serves to include the patient in the numerator when reporting rates are calculated for PQRI.

Claims-Based Reporting Principles for PQRI

The following principles apply to the reporting of QDCs for PQRI measures:

You may submit QDCs to your carriers/MACs either through electronic or paper based submission.

When using electronic submission, which is accomplished using the ASC X 12N Health Care Claim Transaction (Version 4010A1), you should submit CPT Category II and/or temporary G-codes in the SV101-2 "Product/Service ID" Data Element on the SV1 "Professional Service" Segment of the 2400 "Service Line" Loop.

You must also identify in this segment that a HCPCS code is being supplied by submitting the HC in data element SV101-1 within the SV1 "Professional Service" Segment. Further, you should submit diagnosis codes at the claim level, Loop 2300, in data element HI01, and if there are multiple diagnosis codes, in HI02 through HI08 as needed with a single reference number in the diagnosis pointer. In general for group billing, you should report the NPI for the rendering provider in Loop 2310B (Rendering Provider Name, claim level) or 2420A (Rendering Provider Name, line level), using data element NM109 (with NM108=XX).

For paper-based submissions, use the CMS-1500 claim form (version 08-05). Enter the relevant ICD-9-CM diagnosis codes in Field 21 and enter Service codes (including CPT, HCPCS, CPT Category II and/or G-codes) with any associated modifiers in Field 24D with a single reference number in the diagnosis pointer Field 24E that corresponds with the diagnosis number in Field 21.

For group billing, you should enter the National Provider Identifier (NPI) of the rendering in Field 24J, and the Tax Identification Number (TIN) of the employer is entered in Field 25.

Group and Solo NPI Submission
When a group bills, the group's NPI is submitted at the claim level, therefore, the individual rendering physician's NPI must be placed on each line item, including all allowed charges and quality-data line items.

Solo practitioners must include your individual NPI on the claim line as is the normal billing process for submitting Medicare claims. For PQRI, the QDC must be included on the same claim that is submitted for payment at the time the claim is initially submitted in order to be included in PQRI analysis.

Timeliness of Quality Data Submission
You should be aware that claims processed by the Carrier/MAC must reach the national Medicare claims system data warehouse (National Claims History file) by February 28, 2010 to be included in the analysis. Claims for services furnished toward the end of the reporting period should be filed promptly. Claims that are resubmitted only to add QDCs will not be included in the analysis.

Analysis of PQRI Data: Reporting Frequency and Performance Timeframes
Instructions for some measures limit the frequency of reporting necessary in certain circumstances, such as for patients with chronic illness for whom a particular process of care is provided only periodically. Some measures, due to their complexity, are reportable as registry only or measures group only.

Each measure specification includes a reporting frequency for each denominator-eligible patient seen during the reporting period. The reporting frequency described in the instructions applies to each individual EP participating in PQRI. PQRI uses the reporting frequency to analyze each measure for determination of satisfactory reporting:

A measure's performance timeframe is defined in the measure's description and is distinct from the reporting frequency requirement. The performance timeframe, unique to each measure, delineates the timeframe in which the quality action described in the numerator may be accomplished.

Coding and Reporting Principles for Claims-based Reporting of the E-Prescribing Measure Similar to the PQRI, the e-prescribing measure consists of a unique denominator (eligible case) and numerator (quality action) that permit the calculation of the percentage of a defined patient population for whom care was delivered using a particular structural element. Also, similar to PQRI, claims-based reporting of the e-prescribing measure requires EPs, using their individual national provider identifier (NPI) and submitting billable services on Part B claims for allowable PFS charges, to report the quality action for the e-prescribing measure. You should review and understand the e-prescribing measure specification, which provides definitions and specific instructions for reporting the measure.

Note: you should review the following documents if you choose to participate in the E-Prescribing Incentive Program:

These documents are all available on the E-Prescribing Measure section page of the E-Prescribing Incentive website at http://www.cms.hhs.gov/ERXIncentive on the CMS website. In addition, Educational resources to assist you in successfully participating in the E-Prescribing Incentive Program are also available on the Educational Resources section page of the E-Prescribing Incentive Website at http://www.cms.hhs.gov/ERxIncentive/09_Educational_Resources.asp#TopOfPage on the CMS website.

The following principles apply for claims-based reporting of the e-prescribing measure:

  1. You should report one of the three e-prescribing codes listed below as the claim numerator:
  1. You must report the e-prescribing code (which supplies the numerator):
  1. You must submit the e-prescribing code with a line-item charge of zero dollars ($0.00) at the time the associated covered service is performed.

Submission through Carriers/MACs
You may submit E-prescribing codes to carriers/MACs either through electronic submission using the ASC X 12N Health Care Claim Transaction (Version 4010A1), or paper-based submission using the CMS-1500 claim form.

When using electronic submission you should submit the E-prescribing codes in the SV101-2 "Product/Service ID" Data Element on the SV1 "Professional Service" Segment of the 2400 "Service Line" Loop. You will need to identify in this segment that a HCPCS code is being supplied by submitting the HC in data element SV101-1 within the SV1 "Professional Service" Segment.

You should submit diagnosis codes at the claim level, Loop 2300, in data element HI01, and if there are multiple diagnosis codes, in HI02 through HI08 as needed with a single reference number in the diagnosis pointer.

In general for group billing, report the NPI for the rendering provider in Loop 2310B (Rendering Provider Name, claim level) or 2420A (Rendering Provider Name, line level), using data elements NM108 and NM109.

For Paper-based submissions, use the CMS-1500 claim form (version 08-05) and enter relevant ICD-9-CM diagnosis codes in Field 21. Enter service codes (including CPT, HCPCS, CPT Category II and/or G-codes) with any associated modifiers in Field 24D with a single reference number in the diagnosis pointer Field 24E that corresponds with the diagnosis number in Field 21.

For group billing, the NPI of the rendering/performing provider is entered in Field 24J and the TIN of the employer is entered in Field 25.

Timeliness of Quality Data Submission
As mentioned above, claims processed by the Carrier/MAC must reach the Medicare NCH file by February 28, 2010 to be included in the analysis. Claims for services furnished toward the end of the reporting period should be filed promptly. Claims that are resubmitted only to add QDCs will not be included in the analysis

Additional Information
The official instruction, CR6514, issued to your carrier/MAC is available at http://www.cms.hhs.gov/Transmittals/downloads/R513OTN.pdf on the CMS website. You can find additional information about PQRI at http://www.cms.hhs.gov/PQRI on the CMS website. Additional information on the E-Prescribing Incentive Program is available at http://www.cms.hhs.gov/ERXIncentive on the CMS website. If you have any questions, please contact your carrier or MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website.

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Feraheme ™ (Ferumoxytol) Injection

Feraheme is an iron replacement product indicated for the treatment of iron deficiency anemia in adult patients with chronic kidney disease (CKD).

Feraheme should be billed under miscellaneous HCPCS code J3490. Include the name of the drug and the exact dosage administered in Block 19 for paper claims or the electronic equivalent for electronically filed claims.

Ferumoxytol Injection (Feraheme ™) will be covered for Iron Deficiency Anemia (280.9) in adult patients with Chronic Kidney Disease (585.1 through 585.5). The claim must contain the Iron Deficiency Anemia ICD-9 plus one of the Chronic Kidney Disease  ICD-9 codes. Allowable will be based on 510 mg/17ml @ $420.587 for participating providers and @ $399.557 for non-participating providers.

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Medicare Contractor Annual Update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) - MM6520

News Flash – The Second in Series: General Equivalence Mappings – ICD-9-CM to and from ICD-10-CM and ICD-10-PCS Fact Sheet (May 2009), which provides basic information about the General Equivalence Mappings (GEM) including possible users of the GEMs, why the GEMs are needed, and how the GEMs files are formatted as well as Reimbursement Mappings information, is now available in downloadable format from the Centers for Medicare & Medicaid Services Medicare Learning Network at http://www.cms.hhs.gov/MLNProducts/downloads/ICD-10Mappingfctsht.pdf on the CMS website.

Provider Types Affected
Physicians, suppliers, and providers billing Medicare contractors (carriers, Part A/B Medicare Administrative Contractors (MACs), Durable Medical Equipment Medicare Administrative Contractors, and fiscal intermediaries (FIs) including regional home health intermediaries).

Provider Action Needed
This article is based on Change Request (CR) 6520 and reminds the Medicare contractors and providers that the annual ICD-9-CM update will be effective for dates of service on and after October 1, 2009 (for institutional providers, effective for discharges on or after October 1, 2009). You can see the new, revised, and discontinued ICD-9-CM diagnosis codes on the Centers for Medicare & Medicaid Services (CMS) website at http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/07_summarytables.asp#TopOfPage, or at the National Center for Health Statistics (NCHS) website at http://www.cdc.gov/nchs/icd9.htmin June of each year.

Background
The ICD-9-CM codes are updated annually as stated in the Medicare Claims Processing Manual, Chapter 23 (Fee Schedule Administration and Coding Requirements), Section 10.2 (Relationship of ICD-9-CM Codes and Date of Service).

CMS issued CR 6520 as a reminder that the annual ICD-9-CM coding update will be effective for dates of service on or after October 1, 2009 (for institutional providers, effective for discharges on or after October 1, 2009).

Remember that an ICD-9-CM code is required for all professional claims (including those from physicians, non-physician practitioners, independent clinical diagnostic laboratories, occupational and physical therapists, independent diagnostic testing facilities, audiologists, ambulatory surgical centers), and for all institutional claims; but is not required for ambulance supplier claims.

Additional Information
If you have questions, please contact your Medicare MAC and/or FI/carrier at their toll-free number which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the Centers for Medicare & Medicaid Services (CMS) website.

The official instruction (CR6520) issued to your Medicare MAC and/or FI/carrier is available at http://www.cms.hhs.gov/Transmittals/downloads/R1770CP.pdf on the CMS website.

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New Interest Rates

Prompt Payment Interest Rate

The web page of the U.S. Treasury Department has been updated to reflect that effective July 1, 2009 , the new prompt payment interest rate is 4.875%. The new rate is effective for scheduled Medicare payment dates of July 1 through December 31, 2009 . The rate is applicable to clean electronic and paper claims that have not been paid by the 30th day after the date of receipt. Providers may access the Treasury Department web page http://fms.treas.gov/prompt/rates.html for past and current rates.

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Rescinded - Review of Durable Medical Equipment, Prosthetics, Orthotics, and
Supplies (DMEPOS)

News Flash – The Centers for Medicare & Medicaid Services (CMS) has announced the next steps for the Round 1 Rebid of the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program. Suppliers interested in bidding should prepare now! Suppliers must ensure the information listed on their enrollment files at the National Supplier Clearinghouse (NSC) is accurate to enable participation in this program. Suppliers submitting a bid for a product category in a competitive bidding area (CBA) must meet all state licensure requirements for DMEPOS and other applicable state licensure requirements, if any, for that product category for every state in that CBA. Prior to submitting a bid for a CBA and product category, the supplier must have a copy of the applicable state licenses on file with the NSC. Suppliers must be accredited for a product category to submit a bid for that product category. Suppliers subject to the surety bond requirement must be bonded in order to bid. For more information on the Medicare DMEPOS Competitive Bidding Program please visit http://www.cms.hhs.gov/CompetitiveAcqforDMEPOS/ on the CMS website.

This article was rescinded on July 2, 2009 , because related CR 6468 was rescinded on that date.

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Revised: ESRD: Placement of a List of Diagnostic Tests that are Considered End Stage Renal Disease (ESRD) Related in Publication 100-04, Chapter 16 - MM6515

News Flash – A HIPAA 5010 Special Edition MLN Matters provider education article is now available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0904.pdf on the CMS website. This Special Edition article alerts providers regarding the implementation of HIPAA 5010, which presents substantial changes in the content of the data that providers submit with their claims as well as the data available to them in response to their electronic inquiries and outlines how providers need to plan for implementation of these changes.

Note: This article was revised on July 13, 2009 , to reflect the revised CR 6515 issued by the Centers for Medicare & Medicaid Services on July 10, 2009 . The effective and implementation dates of CR 6515 were revised to July 31, 2009. Also, the CR release date, transmittal number, and Web address for viewing CR 6515 were revised. All other information is the same.

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

Provider Action Needed
This article is informational in nature and conveys that the purpose of Change Request (CR) 6515 is to place a listing of diagnostic tests that are considered ESRD-related as Exhibit 1 (new) at the end of Chapter 16 of the Medicare Claims Processing Manual.

Background
Change Request (CR) 6515 places the listing of diagnostic tests that are considered End Stage Renal Disease (ESRD)-Related as Exhibit 1 (formerly Attachment 1 in CR 2906) at the end of Chapter 16 of the Medicare Claims Processing Manual. This listing was inadvertently omitted from the manual during the implementation of CR 2906 (Transmittal 69, January 25, 2004 ; see http://www.cms.hhs.gov/transmittals/downloads/R69CP.pdf on the Centers for Medicare & Medicaid Services (CMS) website).

The purpose of CR 2906 was to address specific areas of concerns regarding Medicare system edits for Skilled Nursing Facilities (SNF) consolidated billing (CB) to permit payment for certain diagnostic services furnished to beneficiaries receiving treatment for ESRD at an Independent Provider-based dialysis facility. One of the areas of concern was that providers and suppliers needed a listing of diagnostic tests that are considered ESRD-Related that would require the "CB" modifier. Consequently, a list defining specific diagnostic tests as ESRD-Related was included in CR 2906. This list applies only to SNF CB. According to CR 2906, any diagnostic services related to the beneficiary's ESRD treatment/care must be submitted using the "CB" modifier, however, if these services are not on the list labeled as Attachment 1 in CR 2906 or the list being added to the Medicare Claims Processing Manual by CR6515, your Medicare contractor may require supporting medical documentation.

To view the list being added to the end of Chapter 16 of the Medicare Claims Processing Manual, see CR6515, which is available at http://www.cms.hhs.gov/Transmittals/downloads/R1763CP.pdf on the CMS website.

Additional Information
The official instruction, CR 6515, issued to your carrier, FI, and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1769CP.pdf on the CMS website.

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 website.

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Revised: MM6417 - Expansion of the Current Scope of Editing for Ordering/Referring Providers for claims processed by Medicare Carriers and Part B Medicare Administrative Contractors (MACs)

News Flash – The reporting period for the 2009 Physician Quality Reporting Initiative (PQRI) has begun. Eligible professionals choosing to participate in the 2009 PQRI through claims-based submission of individual quality measures should have started submitting appropriate 2009 Quality Data Codes on qualifying Part B claims with a date of service of January 1, 2009 or later. Information on the 153 2009 PQRI measures, release notes, detailed specifications, and a guide to assist implementing PQRI measure reporting are available at http://www.cms.hhs.gov/PQRI//15_MeasuresCodes.asp on the CMS website. Information on alternative reporting periods and reporting criteria for satisfactory reporting of measures groups can be found at http://www.cms.hhs.gov/PQRI/25_AnalysisAndPayment.asp and registry-based information can be found at http://www.cms.hhs.gov/PQRI/20_Reporting.asp on the CMS website.

Note: This article was revised on June 29, 2009 , to reflect revisions that the Centers for Medicare & Medicaid Services (CMS) made to CR 6417 on June 26. In the revised CR 6417, CMS clarified the way claims will be processed in phases 1 and 2 and the article was revised accordingly. The article also reflects the remittance advice message that will be supplied on certain claims during phase 1. The CR release date, transmittal number, and the CR Web address were also changed. All other information is the same.

Provider Types Affected
Physicians and non-physician practitioners who order and/or refer services that are billed to Medicare carriers or Part B Medicare Administrative Contractors (MAC) for Medicare beneficiaries.

What You Need to Know
CR 6417, on which this article is based, announces that in order to comply with Social Security Act requirements, the Centers for Medicare & Medicaid Services (CMS) is expanding claim editing to verify that the ordering/referring provider on a claim is enrolled in Medicare and is eligible to order or refer Medicare services. PLEASE NOTE: The changes being implemented with CR 6417 does not alter any existing regulatory restrictions that may exist with respect to the types of items or services for which some of the provider types listed above can order or refer or any claims edits that may be in place with respect to those restrictions. Please refer to the Background Section, below, for more details.

Background
Only physicians and non-physician practitioners (who meet the definitions at section 1861(r) and 1842(b)(18)(C)of the Social Security Act (the Act)) are eligible to order or refer services for Medicare beneficiaries. In addition, Section 1833(q) of the Act requires that all physicians and non-physician practitioners who meet these definitions must be uniquely identified on all claims for services that they order or refer. More specifically, effective January 1, 1992 , a physician or supplier who bills Medicare for a service or item that was the result of an order or referral must show the name and unique identifier of the ordering/referring provider on the claim. As of May 23, 2008 , this unique identifier must be the National Provider Identifier (NPI).

CR 6417, from which this article is taken, announces that, effective October 5, 2009 , CMS is expanding claim editing to meet these Social Security Act requirements to verify that the ordering/referring provider on a claim is enrolled in Medicare and is eligible to order or refer.

CR 6417 provides that only the following provider specialties can order or refer beneficiary services:

During Phase 1 implementation (beginning October 5, 2009), if the claim does not pass the edits described above, Medicare will continue to process the claim and will include a remark message (M68 – missing/incomplete/invalid attending, ordering, rendering, supervising, or referring physician identification) on the remittance advice.

In Phase 2, if the billed service requires an ordering/referring provider and none is present, the claim will not be paid.

If the ordering/referring provider is on the claim, Medicare will verify the ordering/referring provider's NPI and name reported on the claim against Medicare's provider enrollment records to ensure the ordering/referring provider is enrolled in Medicare and is a specialty eligible to order or refer.

Notes: If multiple provider identification numbers (PINs) are associated to the NPI in MCS, Medicare contractors will use the first active PIN with an eligible specialty to order and refer.

Therefore, upon Phase 2 implementation and thereafter, the claim that does not pass the edits described above the claim will not be paid.

All physician and non-physician practitioners who order and refer items or services for Medicare beneficiaries should verify their Medicare enrollment. They may do so by going to http://www.cms.hhs.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp#TopOfPage on the CMS website.

Additional Information
You can find the official instruction, CR6417, issued to your carrier or B MAC by visiting http://www.cms.hhs.gov/Transmittals/downloads/R510OTN.pdf on the CMS website.

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

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Revised: MM6431 - Billing Routine Costs of Clinical Trials

News Flash - As of January 1, 2009 , eligible professionals can participate in the E-Prescribing Incentive Program by reporting on their adoption and use of an e-prescribing system by submitting information on one e-prescribing measure on their Medicare Part B claims. For the 2009 e-prescribing reporting year, to be a successful e-prescriber and to qualify to receive an incentive payment, an eligible professional must report one e-prescribing measure in at least 50% of the cases in which the measure is reportable by the eligible professional during 2009. There is no sign-up or pre-registration to participate in the E-Prescribing Incentive Program. For more information, visit http://www.cms.hhs.gov/ERxIncentive/ on the CMS website.

Note: This article was revised on June 29, 2009 , to reflect a revised CR 6431, issued by the Centers for Medicare & Medicaid Services (CMS) on June 26, 2009 . The transmittal number, CR release date (see above), and the Web address for accessing CR 6431 have changed. In addition, the implementation date was changed to September 28, 2009 . All other information is the same.

Provider Types Affected
Physicians and non-physician practitioners submitting claims to Medicare Administrative Contractors (MACs) and carriers for clinical trials

Provider Action Needed
This article is based on Change Request (CR) 6431 that alerts providers that they should continue to report the International Classification of Diseases diagnosis code V70.7 (Examination of participant in clinical trial) on clinical trial claims. It is no longer necessary to make a distinction between a diagnostic and therapeutic clinical trial service on the claim.

Background
CR 6431 revises the Medicare Claims Processing Manual, Chapter 32, Section 69.6 (Requirements for Billing Routine Costs of Clinical Trails). The revised manual section is attached to CR 6431. The Centers for Medicare & Medicaid Services (CMS) is clarifying that there no longer remains a need to make a distinction between a diagnostic versus therapeutic clinical trial service on the claim.

If the QV or Q1 modifier is billed and diagnosis code V70.7 is submitted by practitioners as a secondary rather than the primary diagnosis, your Medicare contractor will not consider the service as having been furnished to a diagnostic trial volunteer. Instead, they will process the service as a therapeutic clinical trial service.

Note: Healthcare Common Procedure Coding System (HCPCS) codes are not reported on inpatient claims. Therefore, the HCPCS modifier requirements (i.e., QV or Q1) as outlined in the outpatient clinical trial section immediately below, are not applicable to inpatient clinical trial claims.

On all outpatient clinical trial claims, providers need to do the following:

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

The official instruction (CR6431) issued to your Medicare MAC, or carrier is available at http://www.cms.hhs.gov/Transmittals/downloads/R1761CP.pdf on the CMS website.

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Revised: Wrong Surgical or Other Invasive Procedure Performed on a Patient; Surgery or Other Invasive Procedure Performed on the Wrong Body Part; and Surgical or Other Invasive Procedure Performed on the Wrong Patient - MM6405

News Flash – The revised Medicare Preventive Services Quick Reference Information: Medicare Part B Immunization Billing Chart (revised March 2009), which provides billing and coding information related to adult immunizations, is now available in downloadable format from the Centers for Medicare & Medicaid Services Medicare Learning Network at http://www.cms.hhs.gov/MLNProducts/downloads/qr_immun_bill.pdf on the CMS website. Printed copies will be available at a later date.

Note: This article was revised on July 27, 2009 , to reflect a revised CR6405, which the Centers for Medicare & Medicaid Services issued on July 2, 2009 . The third bullet point at the top of page 5 of this article has been added to reflect a similar addition to CR 6405. The CR release date and transmittal numbers (see above) were revised. The Web addresses for accessing the CR6405 transmittals are also changed in this article. All other information remains the same.

Provider Types Affected
Physicians, other practitioners, and providers billing Medicare contractors (carriers, fiscal intermediaries (FIs) or Medicare Administrative Contractors (MACs)) for services provided to Medicare beneficiaries.

Provider Action Needed

STOP – Impact to You
Effective January 15, 2009, the Centers for Medicare & Medicaid Services (CMS) does not cover a particular surgical or other invasive procedure to treat a particular medical condition when the practitioner erroneously performs: 1) a different procedure altogether; 2) the correct procedure but on the wrong body part; or 3) the correct procedure but on the wrong patient.

Medicare will also not cover hospitalizations and other services related to these non-covered procedures as defined in the Medicare Benefit Policy Manual (BPM) Chapter 1, sections 10 and 180 and Chapter 16, section 120. This is pursuant to the National Coverage Determinations (NCDs) made as part of CR 6405.

CAUTION – What You Need to Know
For inpatient claims, hospitals are required to bill two claims when the erroneous surgery related to the NCD is reported, one claim with covered services or procedures unrelated to the erroneous surgery, the other claim with the non-covered services/procedures as a no-pay claim. For outpatient and practitioner claims, providers are required to append the applicable HCPCS modifiers to all lines related to the erroneous surgery/procedure.

GO – What You Need to Do
Make sure that your billing staff are aware of these new billing and claim requirements.

Background
In 2002, the National Quality Forum (NQF) published Serious Reportable Events in Healthcare: A Consensus Report, which listed 27 adverse events that were "serious, largely preventable and of concern to both the public and health care providers." (That report is available at http://www.qualityforum.org/Publications/2002/Serious_Reportable_Events_in_Healthcare.aspx on the Internet.) These events and subsequent revisions to the list became known as "never events." This concept and need for the proposed reporting led to NQF's "Consensus Standards Maintenance Committee on Serious Reportable Events," which maintains and updates the list that currently contains 28 items.

In order to address and reduce the occurrence of these surgeries, CR 6405 establishes three new NCDs that nationally non-cover the three surgical errors and sets billing policy to implement appropriate claims processing.

Effective January 15, 2009 , CMS will not cover a particular surgical or other invasive procedure to treat a particular medical condition when the practitioner erroneously performs: 1) a different procedure altogether; 2) the correct procedure but on the wrong body part; or 3) the correct procedure but on the wrong patient. Medicare will also not cover hospitalizations and other services related to these non-covered procedures as defined in the Medicare Benefit Policy Manual (BPM) Chapter 1, sections 10 and 180, and Chapter 16, section 120. All services provided in the operating room when an error occurs are considered related and therefore not covered. All providers in the operating room when the error occurs, who could bill individually for their services, are not eligible for payment. All related services provided during the same hospitalization in which the error occurred are not covered.

NOTE: Related services do not include performance of the correct procedure.

Definitions

NOTE: Emergent situations that occur in the course of surgery and/or whose exigency precludes obtaining informed consent are not considered erroneous under this decision. Also, the event is not intended to capture changes in the plan upon surgical entry into the patient due to the discovery of pathology in close proximity to the intended site when the risk of a second surgery outweighs the benefit of patient consultation; or the discovery of an unusual physical configuration (e.g., adhesions, spine level/extra vertebrae).

Beneficiary Liability
Generally, a beneficiary liability notice such as an Advance Beneficiary Notice of Non-coverage (ABN) or a Hospital Issued Notice of Non-coverage (HINN) is appropriate when a provider is furnishing an item/service that the provider reasonably believes Medicare will not cover on the basis of Section 1862(a)(1) of the Social Security Act.

Thus, a provider cannot shift financial liability for the non-covered services to the beneficiary, unless the ABN or the HINN satisfies all of the applicable requirements in Chapter 30, Sections 50.6.3 and 200, respectively, of the Medicare Claims Processing Manual.

Given these requirements, CMS cannot envis ion a scenario in which HINNs or ABNs could be validly delivered in these NCD cases. However, an ABN or a HINN could be validly delivered prior to furnishing follow-up care for the non-covered surgical error that would not be considered a related service to the non-covered surgical error (see Chapter 1, Sections 10 and 180, and Chapter 16, Section 120, of the Benefit Policy Manual).

Implementation

Inpatient Claims
Effective for inpatient discharges on or after January 15, 2009 , hospitals are required to bill two claims when the erroneous surgery(s) related to the NCD is reported:

The non-covered TOB 110 will be required to be submitted via the UB-04 (hard copy) claim form, clearly indicating in Form Locator (FL) 80 (Remarks), or the 837i (electronic) claim form, Loop 2300, one of the applicable 2-digit surgical error codes as follows:

The claim for the non-covered services will be denied using:

Outpatient, Ambulatory Surgical Centers (ASCs), Other Appropriate Bill Types and Practitioner Claims
Hospital outpatient departments, ASCs, practitioners, and those submitting other appropriate TOBs are required to append one of the following applicable NCD modifiers to all lines related to the erroneous surgery(s) with dates of service on or after January 15, 2009 :

Contractors shall suspend claims with dates of service on and after January 15, 2009 , with surgical errors identified by one of the above HCPCS modifiers.

Contractors shall create/maintain a list that includes the beneficiary health information code and the surgical error date of service. Each new surgical error occurrence shall be added to the list, and an MPP event or a system control facility (SCF) rule shall be implemented so that all claims for that beneficiary for that date of service will be suspended. Contractors shall then continue to process the claim.

Claim lines submitted with one of the above HCPCS modifiers will be line-item denied using the following:

Related Claims
Within 5 days of receiving a claim for a surgical error, contractors shall begin to review beneficiary history for related claims as appropriate (both claims already received and processed and those received subsequent to the notification of the surgical error). Also, contractors shall review any claims applied to SCF rules and MPP events to identify incoming claims that have the potential to be related. When Medicare identifies such claims, it will take appropriate action to deny such claims and to recover any overpayments on claims already processed.

Every 30 days for an 18-month period from the date of the surgical error, contractors shall continue to review beneficiary history for related claims and take appropriate action as necessary.

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR 6405) issued to your Medicare FI, RHHI, DMERC, DME/MAC, or A/B MAC. That instruction was issued in two transmittals. The first transmittal presents the National Coverage Determination related to this issue and that transmittal is at http://www.cms.hhs.gov/Transmittals/downloads/R102NCD.pdf on the CMS website. The other transmittal presents the Medicare Claims Processing Manual revision and instructions. That transmittal is at http://www.cms.hhs.gov/Transmittals/downloads/R1778CP.pdf on the CMS website.

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 website.

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Revisions to Certain Items in CMS Change Request 6310 - MM6491

News Flash – Suppliers submitting a bid for a product category in a competitive bidding area (CBA) must meet all state licensure requirements for DMEPOS and other applicable state licensure requirements, if any, for that product category for every state in that CBA. Prior to submitting a bid for a CBA and product category, the supplier must have a copy of the applicable state licenses on file with the National Supplier Clearinghouse (NSC). Suppliers must be accredited for a product category to submit a bid for that product category. Suppliers subject to the surety bond requirement must be bonded in order to bid. For more information on the Medicare DMEPOS Competitive Bidding Program please visit http://www.cms.hhs.gov/CompetitiveAcqforDMEPOS/ on the CMS website.

Provider Types Affected
Physicians, suppliers and other providers who bill Medicare carriers or Medicare Administrative Contractors (MACs)

Provider Action Needed
This article, based on CR 6491, clarifies manual instructions found in the Centers for Medicare & Medicaid Services' (CMS) CR 6310.

Background
The Medicare Program Integrity Manual, chapter 10, section 13, available at http://www.cms.hhs.gov/manuals/downloads/pim83c10.pdf on the CMS website, contains information about deactivations, reactivations and revocations of Medicare billing privileges and their respective effective dates. Portions of this manual chapter are being revised by CR6491 and those changes are summarized below:

Additional Information
If you have questions, please contact your Medicare carrier and/or MAC at their toll-free number which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website. The official instruction, CR 6491, issued to your Medicare carrier and/or MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R295PI.pdf on the CMS website. Attached to the CR are the revised portions of the Program Integrity Manual.

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SE0915 - Take Action Now to Prepare for the Medicare Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program

News Flash – Suppliers submitting a bid for a product category in a competitive bidding area (CBA) must meet all state licensure requirements for DMEPOS and other applicable state licensure requirements, if any, for that product category for every state in that CBA. Prior to submitting a bid for a CBA and product category, the supplier must have a copy of the applicable state licenses on file with the NSC. Suppliers must be accredited for a product category to submit a bid for that product category. Suppliers subject to the surety bond requirement must be bonded in order to bid. For more information on the Medicare DMEPOS Competitive Bidding Program please visit http://www.cms.hhs.gov/CompetitiveAcqforDMEPOS/ on the CMS website.

Provider Types Affected
Suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) that wish to participate in the upcoming Round 1 Rebid of the Medicare DMEPOS Competitive Bidding Program.

Provider Action Needed
In order to participate in the 2009 Round 1 Rebid of the DMEPOS Competitive Bidding Program, suppliers will be required to register in the Centers for Medicare & Medicaid Services (CMS) security system known as the Individuals Authorized Access to the CMS Computer Services (IACS). This includes suppliers that bid in the first round of competition in 2007 and are interested in competing in the Round 1 Rebid. CMS urges suppliers' planning to bid in the 2009 bidding cycle to be sure that they have provided the National Supplier Clearinghouse (NSC) an updated CMS-855S (Medicare Enrollment Application), with any changes made concerning their Authorized Official(s) information and correspondence mailing address which have occurred since their last CMS-855S submission. The accuracy of this data is critical for successful bidder registration.

Background
In this year's bid cycle, suppliers who wish to bid will need to first register in IACS once the registration window opens. There will be three user roles available, which are described as follows:

Save Time and Potential Delay by Verifying CMS-855S Information Prior to Registering to Bid
Only those AOs listed on the CMS-855S as an AO can register in IACS to approve and certify as described above for the AO and BAO user roles. As part of the CMS-855S, a supplier designates one or more AO(s). The AO means an appointed official (for example, chief executive officer, chief financial officer, general partner, chairman of the board, or direct owner) to whom the organization has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the organization's status in the Medicare program, and to commit the organization to fully abide by the statutes, regulations and program instructions of the Medicare program.

Take Action Now
Be sure the most recent CMS-855S submission is current and accurate. In particular, this concerns:

If any of these data elements have changed since your last submission of the CMS-855S to the NSC or if the AO's personal identifying information on the CMS-855S does not exactly reflect that which is on file with the SSA, then you should PROMPTLY complete a change of information on the CMS-855S. Remember, any change of name reported to SSA should also be reported to the NSC on the CMS-855S.

CMS urges suppliers to do it now. The NSC processing time to complete a change of information on the CMS-855S is approximately 45 days, and all submissions are processed in the order in which they are received.

Overview of IACS Registration Process
For an AO, the verification of his/her legal name, date of birth, and SSN must be validated against SSA's records and AO data maintained by the NSC. The NSC received this AO data when the supplier completed its most recent CMS-855S. The AO's legal name, date of birth, and SSN are listed in sections 6 and 15 of the CMS-855S. If the AO legal name, date of birth and SSN data input into IACS during registration does not match SSA's records and NSC AO data, the registration will be rejected.

Following successful registration, as an added measure of security, the AO's User ID and password are then mailed in two separate correspondences to the mailing address listed in section 2A2 of the CMS-855S.

The BAO goes through the same verification process described above for the AO and the AO for the organization must approve a BAO's request for access before a User ID and password will be e-mailed to the BAO. The BAO must be listed on the CMS-855S as an AO, sections 6 and 15. It is critical that the BAO's legal name, date of birth and SSN data input into IACS during registration matches SSA's records and NSC AO data, otherwise the BAO registration will be rejected.

End Users do not need to be listed on the CMS-855S as an AO. However, their legal name, date of birth and SSN will be verified against SSA's records, and the AO or BAO for the organization will need to approve an End User's request for access to the bidding system.

Do I need a BAO role?
The establishment of a BAO is encouraged, if the organization has someone that can occupy the BAO role, to avoid any disruption in the bidding process. The AO's role is instrumental to bidding, as the AO's role must be active to avoid all other users of the organization from losing access to the bidding system. If the AO leaves the organization, the BAO role can be changed to an AO role by the Competitive Bidding Implementation Contractor (CBIC) Help Desk.

Additional Information
This article provides you with an overview of the registration process. More detailed instructions will be published in future MLN Matters® articles, listserv messages, and other announcements.

For more information on the DMEPOS competitive bidding program, visit http://www.cms.hhs.gov/CompetitiveAcqforDMEPOS/ on the CMS website.

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Sleep Testing for Obstructive Sleep Apnea (OSA) - MM6534

News Flash – The Centers for Medicare & Medicaid Services (CMS) has launched its website for agency-wide information and education on Versions 5010, D.0 and 3.0. As you may already know, Version 5010 is the new version of the X12 standards for HIPAA transactions; version D.0 is the new version of the National Council for Prescription Drug Program (NCPDP) standards for pharmacy and supplier transactions; and version 3.0 is a new NCPDP standard for Medicaid pharmacy subrogation. Visit the new website at http://www.cms.hhs.gov/Versions5010andD0 to view background information on the new standards, regulatory information, the latest outreach messages from CMS, educational resources, resources specific to D.0 and 3.0, as well as implementation information for the Medicare Fee-For-Service systems. CMS plans to add additional information as it becomes available so bookmark the site today!

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

Provider Action Needed
This article is based on Change Request (CR) 6534 which announces that Medicare will allow for coverage of specified sleep tests for adult beneficiaries based upon clinical evaluation and a suspicion of OSA as contained in section 240.4.1 of the National Coverage Determination (NCD) Manual. Make sure your billing staffs are aware of these changes.

Background
The Centers for Medicare & Medicaid Services (CMS) has addressed the coverage of continuous positive airway pressure (CPAP) in three separate decisions in October 2001, April 2005, and March 2008. In each of those decisions, CMS limited coverage of CPAP in patients with OSA to those patients whose diagnosis was based on specific testing modalities. Initially, it limited coverage to OSA diagnosed with polysomnography (PSG). In the latest decision, it expanded coverage to OSA diagnosed with several types of home sleep tests. However, CMS has not, at a national level, specifically addressed coverage of the tests themselves. In other words, CPAP is nationally covered for beneficiaries with OSA if diagnosed with these specific tests; yet, coverage of the specific tests has previously been left to local contractor discretion.

After careful consideration, Medicare will allow for coverage of specified sleep tests for adult beneficiaries based upon clinical evaluation and a suspicion of OSA as contained in section 240.4.1 of the NCD Manual.

Effective for claims with dates of service on and after March 3, 2009 , Medicare will allow for coverage of the following:

  1. Type I PSG when used to aid the diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA if performed attended in a sleep lab facility.
  2. Type II or Type III sleep testing device when used to aid the diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility.
  3. Type IV sleep testing device measuring three or more channels, one of which is airflow, when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility.
  4. Sleep testing device measuring three or more channels that include actigraphy, oximetry, and peripheral arterial tone when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility.

Nationally Non-Covered Indications:
Effective for claims with dates of services on and after March 3, 2009 , other diagnostic sleep tests for the diagnosis of OSA, other than those noted above for prescribing CPAP, are not sufficient for the coverage of CPAP and are not covered.

NOTE: All current claims processing and associated coding remain unchanged. Consult CR 6048, dated October 15, 2008, for detailed claims processing information. The MLN Matters® Article related to CR6048 is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6048.pdf on the CMS website.

Additional Information
Note that Medicare contractors will not search their files to adjust claims processed prior to the implementation date of CR 6534. However, they will adjust such claims that you bring to their attention.

If you have questions, please contact your Medicare 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 website.

The official instruction (CR6534) issued to your Medicare MAC, carrier, and/or FI may be found at http://www.cms.hhs.gov/Transmittals/downloads/R103NCD.pdf on the CMS website.

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Stratus Users

To ensure compliance with Security Standards, Stratus password requirements will change effective September 27th, 2009 . Stratus passwords must be changed every 60 days. When you receive a message indicating you need to change your password, enter your new password using the mask/format provided.

The following list describes the password change mask/format. The letter in the string describes the type of character that must be entered for the new password.

MASK = SNAALLLLXXXXXXXX

New password must be 8 - 16 characters in length and conform to the above password mask/format.

      V -> aeiou

      C -> bcdfghjklmnpqrstvwxyz

      X -> any character

      N -> 1234567890

      A -> abcdefghijklmnopqrstuvwxyz

      B -> space character

      S -> !\"#$%&'()*+,-./:;<=>?@[\\]^`{|}~_

      L -> A-Z a-z 0-9

Enter a new password:  (example: @5mnABCDqpqp)

If you are not required to enter a login and a password once you have dialed into our system, this means that your access codes have been preprogrammed or scripted. In this case you must make the necessary changes in the script to handle password expirations and changes. Without these changes, you will not be able to change your password resulting in an inability to access the network, submit claims and/or download receipts and remittances.

If you need help with this process you can contact the Electronic Data Interchange (EDI) Help Desk at 866.352.1608 from 8:00 am to 4:30 pm Eastern Standard Time (EST). If you need your password reset because you have been locked out, please call the Electronic Commerce Help Desk at 800.810.3388 from 8:00 am to 6:00 pm EST.

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Telehealth Services in Indian Health Service (IHS) or Tribal Providers - MM6493

News Flash – The revised Rural Referral Center Fact Sheet (April 2009), which provides information about Rural Referral Center program requirements, is now available in downloadable format from the Centers for Medicare & Medicaid Services (CMS) Medicare Learning Network at http://www.cms.hhs.gov/MLNProducts/downloads/RuralRefCtrfctsht2008.pdf on the CMS website.

Provider Types Affected
Indian Health Service (HIS) and tribal providers who bill Medicare carriers, fiscal intermediaries (FI), or Medicare Administrative Contractors (A/B MAC) for providing telehealth services to Medicare Beneficiaries.

What You Need to Know
CR 6493, from which this article is taken, expands the instructions for telehealth services (effective January 1, 2009) to include Indian Health Service (IHS) and tribal providers as eligible to receive the telehealth originating site facility fee. The CR also clarifies the payment basis to the distant site physician or practitioner. You should make sure that your billing staffs are aware of this new information.

Background
CR 6493, from which this article is taken, announces that the Centers for Medicare & Medicaid Services (CMS) is expanding the instructions for telehealth services to include Indian Health Service (IHS) and tribal providers.

Effective January 1, 2009 , IHS and tribal providers are included in the telehealth service polices (presented below) and eligible to receive:

Telehealth Policies
Section 223 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) - Revision of Medicare Reimbursement for Telehealth Services amended Section 1834 of the Social Security Act (the Act) to provide for an expansion of Medicare payment for telehealth services. With this amendment, effective October 1, 2001 , coverage and payment for Medicare telehealth includes consultation, office visits, individual psychotherapy, and pharmacologic management delivered via a telecommunications system.

An interactive telecommunications system is required as a condition of payment; however, BIPA does allow the use of asynchronous "store and forward" technology in delivering these services when the originating site is a Federal telemedicine demonstration program in Alaska or Hawaii . In addition, BIPA does not require that a practitioner present the patient for interactive telehealth services.

Originating Site Facility and Distant Site Practitioner Services
The originating site facility fee is equal to $23.72 for the period January 1, 2009 through December 31, 2009 . For telehealth services provided on or after January 1 of each subsequent calendar year, the telehealth originating site facility fee is increased as of the first day of the year by the percentage increase in the Medicare Economic Index (MEI). For CY 2009, the payment amount is 80 percent of the lesser of the actual charge or $23.72. (No clinic visit is to be billed if this is the only service received.)

The following facility types are authorized by law to be eligible for payment of the telehealth originating site facility fee when a beneficiary is presented to a distant site practitioner:

NOTE: Except for the Federal telemedicine demonstration in Alaska and Hawaii , eligibility of originating sites is limited to rural health professional shortage areas (HPSAs) and counties not classified as a metropolitan statistical area (MSA).

IHS/Tribal facilities should submit claims for the originating site facility fee on Types of Bills (TOB) 12x, 13x, 71x, 73x, or 85x, using HCPCS code Q3014 and revenue code 0780.

Distant site practitioners include only physicians and selected medical practitioners, specifically physician assistants (PA), nurse practitioners (NP), clinical nurse specialists (CNS), certified nurse-midwives, clinical social workers (CSW), clinical psychologists (CP), or registered dietician or nutrition professionals.

Distant site practitioners services are payable as if they were provided face-to-face, using the Medicare Physician Fee Schedule (MPFS); and are based on 80% of the Medicare Physician Fee Schedule (MPFS) payment amount for a physician, and the appropriate step down percentages for other practitioners. The usual Part B coinsurance and deductible apply, but are waived for IHS/Tribal facilities.

Billing providers should use the following Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes on claims for distant site practitioner services:

You must include either the GT modifier (for interactive telecommunications) on your claims, or the GQ modifier (for the store and forward communication) if used in the Federal Telemedicine Demonstration in Alaska or Hawaii.

Additional Information
Your Medicare contractor will not search their files to find and adjust claims with dates of service on or after January 1, 2009 that were processed prior to the January 4, 2010 implementation date of CR 6493. However, they will adjust such claims that you bring to their attention.

You can find more information about the provision of telehealth services by IHS or tribal providers by going to CR 6493, located at http://www.cms.hhs.gov/Transmittals/downloads/R1776CP.pdf on the Centers for Medicare & Medicaid Services (CMS) website. You will find the updated Medicare Claims Processing Manual, Chapter 19 (Indian Health Services), Sections 100.16 (Payment for Telehealth Services to Indian Health Service/Tribal Facilities and Practitioners), 100.16.1 (FI--Payment for Telehealth Services to Indian Health Service/Tribal Facilities and Practitioners), 100.16.2 (FI – Telehealth Originating Site Facility Fee – Medicare Part B – Payment Policy) and (FI – Telehealth Originating Site Facility Fee – Medicare Part B – Claims Processing) as an attachment to that CR.

You might also want to review Medicare Claims Processing Manual Chapter 12 (Physicians/Nonphysician Practitioners), Section 190 (Medicare Payment for Telehealth Services); and Medicare Benefit Policy Manual Chapter 15 (Covered Medical and Other Health Services), Section 270 (Telehealth Services) for more information on telehealth services. This manual is available at http://www.cms.hhs.gov/manuals/IOM/list.asp on the CMS website.

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 website.

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