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May 7, 2008 Part B Medicare Bulletin

Posted May 7, 2008

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Additional Clarification to Chapter 17, Section 40, Regarding Processing of Drug Claims with the JW Modifier

News Flash — The Medicare Appeals Process: Five Levels to Protect Providers, Physicians and Other Suppliers brochure has been updated and is now available to order print copies or as a downloadable PDF file. To view the PDF file, go to http://www.cms.hhs.gov/MLNProducts/downloads/MedicareAppealsProcess.pdf
or to order hard copies, please visit the MLN Product Ordering Page at http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=5
on the CMS Web site.

Provider Types Affected
Physicians, providers, and suppliers billing Medicare Contractors (Medicare Administrative Contractors (A/B MACs), fiscal intermediaries (FIs), carriers and/or Durable Medical Equipment Medicare Administrative Contractors (DME MACs)) for drugs or biologicals provided to Medicare beneficiaries.

Impact on Providers
When processing all drugs except those provided under the Competitive Acquisition Program (CAP) for Part B drugs and biologicals, Medicare contractors may require the use of the modifier JW to identify unused drug or biologicals from single use vials or single use packages that are appropriately discarded. This modifier will provide payment for the discarded drug or biological.

Background
The Centers for Medicare & Medicaid Services (CMS) issued this CR 5923 to notify providers of the Medicare Claims Processing Manual update that clarifies the use of the JW modifier when processing all drugs except CAP drugs.

Additional Information
To see the official instruction (CR5923) issued to your Medicare Carrier, DME/MAC, FI and/or A/B MAC, visit http://www.cms.hhs.gov/Transmittals/downloads/R1478CP.pdf on the CMS Web site.

If you have questions, please contact your Medicare Carrier, DME/MAC, FI and/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 Information on Reporting a National Provider Identifier (NPI) for Ordering/Referring and Attending/ Operating/Other/Service facility for Medicare Claims

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.

Note: This article was revised on March 5, 2008, to remove the parenthetical phrase of “MD and DO” from the note box on page 3. All other information remains the same.

Provider Types Affected
Physicians, providers, and suppliers who bill Medicare contractors (carriers, fiscal intermediaries (FI), Medicare Administrative Contractors (A/B MAC), or Durable Medical Equipment Medicare Administrative Contractors (DME MAC)) for services or items furnished to Medicare beneficiaries.

Provider Action Needed

STOP – Impact to You
Effective with claims received on or after May 23, 2008, Medicare will not pay for referred or ordered services or items; unless the fields for the name and NPI of the ordering, referring and attending, operating, other, or service facility providers are completed on the claims.

CAUTION – What You Need to Know
CR 5890, from which this article is taken, provides that it is the claim/bill submitter‘s responsibility to obtain the ordering, referring and attending, operating, other, service facility providers, or purchased service providers NPIs for claims. Further, it requires that the provider or supplier who is furnishing the services or items, after unsuccessfully attempting to obtain the NPI from these providers; report their own name and NPI in the ordering/referring/attending/operating/other/service facility provider/purchased service provider fields of the claims.

GO – What You Need to Do
Make sure that your billing staffs are aware of this requirement to place the “furnishing” provider or supplier’s name and NPI in the appropriate fields and to use your name and NPI if those of the ordering/referring and attending/operating/other/service facility provider/purchased service providers are not obtainable.

Background
The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandate the adoption of a standard unique health identifier for each health care provider. The National Provider Identifier (NPI) final rule (45 CFR Part 162, CMS-045-F), published on January 23, 2004, established the NPI as this standard; and mandates that all entities covered under HIPAA (including health care providers) comply with the requirements of this NPI final rule.

Medicare previously required a unique physician identification number (UPIN) be reported on claims for any ordering, referring/attending, operating, other, and service facility providers (i.e., or for any provider that is not a billing, pay-to, or rendering provider). Further, in accordance with the NPI final rule; effective May 23, 2008, when reported on a claim, the identifier for such a provider must be an NPI, regardless of whether the provider is a covered entity, or participates in the Medicare program. Therefore, Medicare will not pay for referred or ordered services, or items, unless the name and NPI number of the ordering, referring and attending, operating, other, or service facility provider are on the claim.

Note: Physicians and the following non physician practitioners: 1) nurse practitioners (NP); 2) clinical nurse specialist (CNS); 3) physician assistants (PA); 4) and certified nurse midwives (CNM) are the only types of providers eligible to refer/order services or items for beneficiaries.

You should be aware that it is the claim/bill submitter‘s responsibility to obtain the ordering, referring and attending, operating, other, service facility providers, or purchased service providers’ NPIs on the claim. If these providers do not directly furnish their NPIs to the billing provider at the time of the order, the billing provider must contact them to obtain their NPIs prior to delivery of the services or items.

If, after several unsuccessful attempts to obtain the NPI from the ordering, referring, attending, operating, other, service facility provider, or purchased service provider; CR 5890, from which this article is taken, requires that (effective May 23, 2008) the provider or supplier who is furnishing the services or items report their own name and NPI in the claim’s ordering/referring/attending/operating/other/service facility provider/purchased service provider fields.

Additional Information
You can find more information about reporting an NPI for ordering, referring and attending, operating, other, service facility providers for Medicare Claims by going to CR 5890, located at http://www.cms.hhs.gov/Transmittals/downloads/R235PI.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site.

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

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.

 

 

Announcing the Release of the Revised CMS-855 Medicare Enrollment Applications

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
All Medicare physicians, providers, and suppliers

Background
The Centers for Medicare & Medicaid Services (CMS) issued revised CMS-855 Medicare enrollment applications in March 2008. With the exception of providers enrolling as a specialty hospital on the CMS-855A, Medicare contractors will continue to accept the 2006 version of the Medicare enrollment application through June 2008. Providers and suppliers should begin to use the new Medicare enrollment applications immediately. Initially, these applications will be available only from the CMS provider enrollment Web site. The link for that CMS Web site is listed in the Additional Information section of this article.

Over the last year, CMS has received numerous comments and suggestions regarding the proposed revisions to the Medicare enrollment applications. CMS reviewed the comments and adopted many of the suggested revisions. Also, CMS incorporated a number of enhancements and changes (see Key Points below) to clarify the enrollment process and to reduce the burden imposed on the provider and supplier communities.

Key Points
This Special Edition outlines the significant revisions to the Medicare enrollment applications and they are as follows:

Application-Specific Changes for Physicians and Non-Physician Practitioners (CMS-855I)

Application-Specific Changes for Clinics/Group Practices and Certain Other Suppliers (CMS-855B)

Application-Specific Changes for Institutional Providers (CMS-855A)

Application-Specific Changes for DMEPOS Suppliers (CMS-855S)

Additional Information
For additional information regarding the Medicare enrollment process, including the mailing address and telephone number for the carrier or FI serving your area, visit http://www.cms.hhs.gov/MedicareProviderSupEnroll on the CMS Web site.

Special Edition article SE0612 contains helpful information about the Medicare enrollment process. You may review that article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0612.pdf on the CMS Web site.

 

April 2008 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

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, providers and suppliers who submit claims to Medicare contractors (Medicare Administrative Contractors (A/B MACs), Fiscal Intermediaries (FIs), carriers, Durable Medical Equipment Medicare Administrative Contractors (DME MACs) or Regional Home Health Intermediaries (RHHIs)) for services provided to Medicare beneficiaries.

What You Need to Know
CR 5982, from which this article is taken, instructs Medicare contractors to download and implement the April 2008 Average Sales Price (ASP) drug pricing file for Medicare Part B drugs; and if released by CMS, also the revised January 2008, January 2007, April 2007, July 2007, October 2007, and October 2006 files.

Background
Section 303(c) of the Medicare Modernization Act of 2003 revised the payment methodology for Part B covered drugs and biologicals that are not paid on a cost or prospective payment basis. Beginning January 1, 2005, the vast majority of drugs and biologicals not paid on a cost or prospective payment basis are paid based on the average sales price (ASP) methodology, and pricing for compounded drugs has been performed by the local contractor.

Additionally, beginning in 2006, all end-stage renal disease (ESRD) drugs (that both independent and hospital-based ESRD facilities furnish), as well as specified covered outpatient drugs, and drugs and biologicals with pass-through status under the Outpatient Prospective Payment System (OPPS), are paid based on the ASP methodology.

The ASP methodology is based on quarterly data that drug manufacturers submit to the Centers for Medicare & Medicaid Services (CMS), which CMS then provides (quarterly) to Medicare contractors (carriers, DME MACs, FIs, A/B MACs, and/or RHHIs) through the ASP drug pricing files for Medicare Part B drugs.

As announced in late 2006, CMS has been working further to ensure that accurate and separate payment is made for single source drugs and biologicals as required by Section 1847A of the Social Security Act. As part of the effort to ensure compliance with this requirement, CMS has also reviewed how the terms “single source drug,” “multiple source drug,” and “biological product” have been operationalized in the context of payment under section 1847A.

For the purpose of identifying “single source drugs” and “biological products” subject to payment under section 1847A, CMS (and its contractors) will generally utilize a multi-step process that will consider:

The payment limit for the following will be based on the pricing information for products marketed or sold under the applicable FDA approval:

As appropriate, a unique HCPCS code will be assigned to facilitate separate payment. Separate payment may be operationalized through use of “not otherwise classified, (NOC)” HCPCS codes.

ASP Methodology
Beginning January 1, 2005, the payment allowance limits for Medicare Part B drugs and biologicals that are not paid on a cost or prospective payment basis are 106 percent of the ASP. Further, beginning January 1, 2006, payment allowance limits are paid based on 106 percent of the ASP for the following:

Beginning January 1, 2008, under the OPPS, payment allowance limits for specified covered outpatient drugs are paid based on 105 percent of the ASP. Drugs and biologicals with pass-through status under the OPPS continue to have a payment allowance limit of 106 percent of the ASP. CMS will update the payment allowance limits quarterly.

Exceptions are summarized as follows:

On or after March 18, 2008, the April 2008 ASP file will be available for download along with revisions to prior ASP payment files, if CMS determines that revisions to these prior files are necessary. On or after March 18, 2008, the April 2008 ASP NOC files will be available for retrieval from the CMS ASP Webpage along with revisions to prior ASP NOC files, if CMS determines that revisions to these prior files are necessary. The payment limits included in revised ASP and NOC payment files supersede the payment limits for these codes in any publication published prior to this document.

The payment files will be applied to claims processed or reprocessed on or after the implementation date of CR5982 for the dates of service noted in the following table:

Payment Allowance Limit Revision Date Applicable Dates of Service
April 2008 ASP and ASP NOC files April 1, 2008, through June 30, 2008
January 2008 ASP and ASP NOC files January 1, 2008, through March 31, 2008
October 2007 ASP and ASP NOC files October 1, 2007, through December 31, 2007
July 2007 ASP and ASP NOC files July 1, 2007, through September 30, 2007
April 2007 ASP and ASP NOC files April 1, 2007, through June 30, 2007
January 2007 ASP and ASP NOC files January 1, 2007, through March 31, 2007
October 2006 ASP and ASP NOC files October 1, 2006, through December 31, 2006

NOTE: The absence or presence of a HCPCS code and its associated payment limit does not indicate Medicare coverage of the drug or biological. Similarly, the inclusion of a payment limit within a specific column does not indicate Medicare coverage of the drug in that specific category. The local Medicare contractor processing the claim makes these determinations.

Drugs Furnished During Filling or Refilling an Implantable Pump or Reservoir
Physicians may be paid for filling or refilling an implantable pump or reservoir when it is medically necessary for the physician (or other practitioner) to perform the service. Medicare contractors must find the use of the implantable pump or reservoir medically reasonable and necessary in order to allow payment for the professional service to fill or refill the implantable pump or reservoir and to allow payment for drugs furnished incident to the professional service.

If a physician (or other practitioner) is prescribing medication for a patient with an implantable pump, a nurse may refill the pump if the medication administered is accepted as a safe and effective treatment of the patient’s illness or injury; there is a medical reason that the medication cannot be taken orally; and the skills of the nurse are needed to infuse the medication safely and effectively. Payment for drugs furnished incident to the filling or refilling of an implantable pump or reservoir is determined under the ASP methodology as described above. Note that pricing for compounded drugs is done by your local Medicare contractor.

Additional Information
To see the official instruction (CR5982) issued to your Medicare contractor visit http://www.cms.hhs.gov/Transmittals/downloads/R1484CP.pdf on the CMS Web site.

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

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.

 

 

Botulinum Toxin

Effective April 1, 2008, the LCDs for Botulinum Toxin for all three CGS states have been revised to add the following ICD.9 codes as covered indication for CPT codes 64613 and 64614:

344.00 QUADRIPLEGIA UNSPECIFIED
344.01 QUADRIPLEGIA C1-C4 COMPLETE
344.02 QUADRIPLEGIA C1-C4 INCOMPLETE
344.03 QUADRIPLEGIA C5-C7 COMPLETE
344.04 QUADRIPLEGIA C5-C7 INCOMPLETE
344.09 OTHER QUADRIPLEGIA

Please refer to the CIGNA Government Services Web site at www.cignagovernmentservices.com to view the policy.

 

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

Provider Types Affected
Physicians and providers submitting claims to Medicare contractors (carriers, Fiscal Intermediaries (FIs), and/or Part A/B Medicare Administrative Contractors (A/B MACs)) for professional services provided to Medicare beneficiaries that are paid under the Medicare Physician Fee Schedule (MPFS).

Provider Action Needed
This article is based on Change Request (CR) 5980 which amends payment files previously issued to Medicare contractors based upon the 2008 Medicare Physician Fee Schedule Final Rule. CR 5980 also includes new/revised codes for the Physician Quality Reporting Initiative (PQRI).

Background
Attachment 1 of CR 5980 contains changes included in the April Update to the 2008 MPFSDB, and CR5980 can be reviewed at http://www.cms.hhs.gov/Transmittals/downloads/R1482CP.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site. Specific changes are detailed in Attachment 1 of CR 5980 and are summarized as follows:

CPT/HCPCS code revisions
A number of CPT/HCPCS codes have been modified to reflect revised bilateral indicators, Relative Value Unit (RVU) revisions, or procedure status changes retroactive to January 1, 2008.

Reinstated “J” Codes
A number of “J” Codes (J7611 through J7614) are reinstated with a status indicator of “E” and the reinstated codes are effective for dates of service on or after April 1, 2008. Descriptors and payment indicators for the reinstated codes are in attachment 1 of CR5980.

New “Q” Codes
There are several new “Q” codes (Q4096 through Q4098) with a status indicator of “E” and which are effective for dates of service on or after April 1, 2008. The codes with their descriptors are in the following table:

Code

Long Descriptor

Short Descriptor

Q4096 Injection, Von Willebrand Factor Complex, Human, Ristocetin Cofactor (Not Otherwise Specified), Per I.U. VWF:RCO VWF complex, not Humate-P
Q4097 Injection, Immune Globulin (Privigen), Intravenous, Non-Lyophilized (E.G., Liquid), 500 mg Inj IVIG Privigen 500 mg
Q4098 Injection, Iron Dextran, 50 mg Inj iron dextran
Q4099 Formoterol fumarate, inhalation solution, FDA approved final product, non-compounded, administered through DME, unit dose form, 20 micrograms Formoterol fumarate, inh

New Category II Codes for PQRI
There are new Category II codes for the PQRI for dates of service on or after April 1, 2008. These new codes and their descriptors are in the following table: 

Code

Long Descriptor

Short Descriptor

0525F Initial visit for episode Initial visit for episode
0526F Subsequent visit for episode Subs visit for episode
1130F Back pain and function assessed, including all of the following: Pain assessment AND functional status AND patient history, including notation of presence or absence of “red flags” (warning signs) AND assessment of prior treatment and response, AND employment status Bk pain + fxn assessed
1134F Episode of back pain lasting six weeks or less Epsd bk pain for =< 6 wks
1135F Episode of back pain lasting longer than six weeks Epsd bk pain for > 6 wks
1136F Episode of back pain lasting 12 weeks or less Epsd bk pain for <= 12 wks
1137F Episode of back pain lasting longer than 12 weeks Epsd bk pain for > 12 wks
2040F Physical examination on the date of the initial visit for low back pain performed, in accordance with specifications Bk pn xm on init visit date
2044F Documentation of mental health assessment prior to intervention (back surgery or epidural steroid injection) or for back pain episode lasting longer than six weeks Doc mntl tst b/4 bk trxmnt
3330F Imaging study ordered Imaging study ordered (bkp)
3331F Imaging study not ordered Bk imaging tst not ordered
3340F Mammogram assessment category of “incomplete: need additional imaging evaluation,” documented Mammo assess inc xray docd
3341F Mammogram assessment category of “negative,” documented Mammo assess negative docd
3342F Mammogram assessment category of “benign,” documented Mammo assess bengn docd
3343F Mammogram assessment category of “probably benign,” documented Mammo probably bengn docd
3344F Mammogram assessment category of “suspicious,” documented Mammo assess susp docd
3345F Mammogram assessment category of “highly suggestive of malignancy,” documented Mammo assess hghlymalig doc
3350F Mammogram assessment category of “known biopsy proven malignancy,” documented Mammo bx proven malig docd
4240F Instruction in therapeutic exercise with follow-up by the physician provided to patients during episode of back pain lasting longer than 12 weeks Instr xrcz 4bk pn >12 weeks
4242F Counseling for supervised exercise program provided to patients during episode of back pain lasting longer than 12 weeks Sprvsd xrcz bk pn >12 weeks
4245F Patient counseled during the initial visit to maintain or resume normal activities Pt instr nrml lifest
4248F Patient counseled during the initial visit for an episode of back pain against bed rest lasting 4 days or longer Pt instr–no bd rest>= 4 days
4250F Active warming used intraoperatively for the purpose of maintaining normothermia, OR at least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit) recorded within the 30 minutes immediately before or the 30 minutes immediately after anesthesia end time Wrmng 4 surg - normothermia
5060F Findings from diagnostic mammogram communicated to practice managing patient’s on-going care within 3 business days of exam interpretation Fndngs mammo 2pt w/in 3 days
5062F Findings from diagnostic mammogram communicated to the patient within 5 days of exam interpretation Doc f2fmammo fndng in 3 days
6040F Use of appropriate radiation dose reduction devices OR manual techniques for appropriate moderation of exposure, documented Appo rad ds dvcs techs docd
6045F Radiation exposure or exposure time in final report for procedure using fluoroscopy, documented Radxps in end rprt4fluro pxd
7020F Mammogram assessment category [eg, Mammography Quality Standards Act (MQSA), Breast Imaging Reporting and Data System (BE-RADS®), or FDA approved equivalent categories] entered into an internal database to allow for analysis of abnormal interpretation (recall) rate Mammo assess cat in dbase
7025F Patient information entered into a reminder system with a target due date for the next mammogram Pt infosys alarm 4 nxt mammo

Revised Descriptors for PQRI Codes
Attachment 1 of CR5980 also contains a list of editorial changes to the short and/or long descriptors for a number of PQRI codes.

Additional Information
The official instruction, CR 5980, issued to your carrier, FI, and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1482CP.pdf on the CMS Web site.

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

 

Carotid Angioplasty With Stent Placement, Appropriate Documentation For Payment

According to CMS National Coverage Determination (NCD) 20.7, Percutaneous Transluminal Angioplasty (CMS IOM, Pub 100-3, NCD, sect 20.7), carotid angioplasty with stenting is covered only under certain circumstances. The facility where the procedure is performed must be an approved site; the device used must be an FDA-approved device; and, the patient must meet certain criteria as outlined in the NCD. Participation in an approved Category B IDE clinical trial, or participation in approved post-marketing studies also qualify for coverage.

If a patient is not in a clinical trial, the patient must be at high risk for carotid endarterectomy (CEA) and a poor risk for that surgery because of co-morbidities. If carotid PTA with stenting is undertaken, distal embolic protection must also be utilized. Additionally, the patient must meet one of the following;

Further, patients at high risk for CEA are defined as having significant comorbidities and/or anatomic risk factors (i.e., recurrent stenosis and/or previous radical neck dissection), and would be poor candidates for CEA. Significant comorbid conditions include but are not limited to:

Other conditions that were used to determine patients at high risk for CEA in the prior carotid artery stenting trials and studies, such as ARCHER, CABERNET, SAPPHIRE, BEACH, and MAVERIC II.

The determination that a patient is at high risk for CEA and the patient’s symptoms of carotid artery stenosis shall be available in the patient medical records prior to performing any procedure.

Symptoms of carotid artery stenosis include carotid transient ischemic attack (distinct focal neurological dysfunction persisting less than 24 hours), focal cerebral ischemia producing a nondisabling stroke (modified Rankin scale >3) shall be excluded from coverage.

Most claims for this procedure will be reviewed to determine that all criteria are met. Providers performing these procedures would be well advised to put a brief summary of the patient’s condition and symptoms, reason for being high risk for CEA, and co-morbid conditions, along with degree of stenosis as determined by angiography, in the introduction to their operative note. This would reduce the amount of paper that must be sent in upon request for records, make review much easier and speed payment. In lieu of such documentation, the history and physical should be sent along with the operative note so sufficient documentation will be available to make a correct adjudication and payment.

Effective immediately

3-26-08

 

Carrier-priced ASP Replacement Lists

***UPDATE***
In our efforts to make available to health care professionals the most current and up-to-date information possible, CIGNA Government Services (CGS) will now provide a Web link directly to the Average Sales Price (ASP) Payment Allowance Limits list(s) on the Centers for Medicare & Medicaid Services (CMS) Web site: http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01_overview.asp#TopOfPage

CGS will begin maintaining a quarterly “carrier-priced” ASP list for those codes that cease to appear on CMS’s list(s), which can be accessed by following the link below:
http://www.cignagovernmentservices.com/partb/coverage/fees/index.html

Claim Status Category Code and Claim Status Code Update

News Flash — The revised Medicare Physician Fee Schedule Fact Sheet (January 2008), which provides general information about the Medicare Physician Fee Schedule, can be accessed at http://www.cms.hhs.gov/MLNProducts/downloads/MedcrePhysFeeSchedfctsht.pdf
on the Centers for Medicare & Medicaid Services Web site.

Provider Types Affected
Physicians, providers, and suppliers who submit Health Care Claim Status Transactions to Medicare contractors (carriers, Medicare Administrative Contractors (A/B MACs), Durable Medical Equipment Medicare Administrative Contractors (DME MACs), fiscal intermediaries (FIs), and Regional Home Health Intermediaries (RHHIs)).

Provider Action Needed

STOP – Impact to You
This article is based on Change Request (CR) 5947 which indicates there have been updates to the Claim Status Category Codes and Claim Status Codes.

CAUTION – What You Need to Know
All code changes approved during the October 2007 meeting of the national Code Maintenance Committee have been posted at http://www.wpc-edi.com/content/view/180/223/ and will become effective April 1, 2008.

GO – What You Need to Do
See the Background section of this article for further details.

Background
The Health Insurance Portability and Accountability Act (HIPPA) requires all health care benefit payers, including Medicare, to use only Claim Status Category Codes and Claim Status Codes approved by the national Code Maintenance Committee. These codes are used in the X12 276/277 Health Care Claim Status Request and Response format to explain the status of submitted claim(s).

The decisions about additions, modifications, and retirement of existing Claim Status Category and Claim Status codes made at the October 2007 meeting of the national Code Maintenance Committee were posted at http://www.wpc-edi.com/content/view/180/223/ on November 5, 2007. These updates are effective April 1, 2008 and are to be used in editing of all X12 276 transactions processed by Medicare contractors on or after April 7, 2008.

Additional Information
To see the official instruction (CR5947) issued to your Medicare FI, carrier, DME MAC, or A/B MAC, refer to http://www.cms.hhs.gov/Transmittals/downloads/R1468CP.pdf on the CMS Web site.

If you have questions, please contact your Medicare Carrier, A/B MAC, DME MAC, FI or RHHI 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 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

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.)

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.

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.

 

Collapsing Medicare Provider Transaction Access Numbers (PTANs) to Ensure a One-to-One National Provider Identifier (NPI) Match

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 and suppliers billing Medicare contractors (Medicare Administrative Contractors (A/B MACs), and carriers) for services provided to Medicare beneficiaries.

Provider Action Needed
The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 5906 because it believes that providers and suppliers may want to collapse their assigned Medicare PTANs to insure a one-to-one NPI match. Providers may collapse PTANs that are assigned to additional locations only if the additional locations are all assigned the same tax identification number (TIN) and are within the same pricing locality.

Background
Changes in the Medicare provider and supplier enrollment process over the years have resulted in differences in the assignment of Medicare PTAN. Those differences, combined with Medicare’s requirement to capture the NPI as part of the enrollment process, affect the type of information that is collected and maintained in Provider Enrollment, Chain Ownership System (PECOS), and then transferred to Medicare Claims System (MCS) and Medicare’s NPI crosswalk.

Presently, some Medicare carriers issue separate PTANs to physicians, non-physician practitioners, and other suppliers with multiple practice locations. To ensure that carriers are assigning PTANs in a more consistent manner and to aid in the implementation of the NPI, carriers and A/B MACs will assign the minimum number of PTANs necessary to ensure that proper payments are made.

Key Points

Additional Information
To see the official instruction (CR5906) issued to your Medicare Carrier or A/B MAC, refer to http://wwww.cms.hhs.gov/Transmittals/downloads/R244PI.pdf on the CMS Web site. If you have 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.

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.)

Note: This article was revised March 18, 2008, to correct the bullet on page 3 regarding the “Maintenance of ESA therapy” (See bullet in bold). It should have stated that the “starting dose if the hemoglobin level remains below 10 g/dL (or hematocrit is < 30%) 4 weeks after initiation of therapy and the rise in hemoglobin is > 1g/dL (hematocrit > 3%).” All other information remains the same.

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:
The hemoglobin level immediately prior to the first administration is < 10 g/dL (or the hematocrit is < 30%) and the hemoglobin level prior to any maintenance administration is < 10g/dL (or the hematocrit is < 30%.);

The starting dose for ESA treatment is up to either of the recommended Food and Drug Administration (FDA) approved label starting doses for cancer patients receiving chemotherapy, which includes the,150 U/kg/3 times weekly or the 40,000 U weekly doses for epoetin alfa and the 2.25 mcg/kg/weekly or the 500 mcg once every three week dose for darbepoetin alpha;

Maintenance of ESA therapy is the starting dose if the hemoglobin level remains below 10 g/dL (or hematocrit is < 30%) 4 weeks after initiation of therapy and the rise in hemoglobin is > 1g/dL (hematocrit > 3%);

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 will 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.

 

Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits

News Flash — Test Your Medicare Claims Now! After you have submitted claims containing both 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
Clinical diagnostic laboratories billing Medicare Carriers or Part A/B Medicare Administrative Contractors (A/B MACs) for laboratory tests

Provider Action Needed

STOP – Impact to You
If you do not have a valid, current, CLIA certificate and submit a claim to your Medicare Carrier or A/B MAC for a HCPCS code that is considered to be a laboratory test requiring a CLIA certificate, your Medicare payment may be impacted.

CAUTION – What You Need to Know
The Clinical Laboratory Improvement Amendments of 1998 (CLIA) requires that for each test it performs, a laboratory facility must be appropriately certified. The HCPCS codes that CMS considers to be laboratory tests under CLIA (and thus requiring certification) change each year. CR 5926, from which this article is taken, informs carriers and A/B MACS about the new HCPCS codes for 2008 that are subject to CLIA edits and also about those that are now excluded from CLIA edits.

GO – What You Need to Do
Make sure that your billing staffs are aware of these CLIA-related HCPCS changes for 2008 and that you remain current with certification requirements.

Background
The Clinical Laboratory Improvement Amendments of 1998 (CLIA) require a laboratory facility to be appropriately certified for each test it performs.

To ensure that Medicare and Medicaid only pay for laboratory tests that are performed by certified facilities, carriers and A/B MACs will edit each Medicare claim submitted for a HCPCS code considered to be a CLIA laboratory test. These HCPCS codes change each year, and CR 5926, from which this article is taken, informs carriers and A/B MACs about the new HCPCS codes for 2008 that are both subject to, and excluded from, CLIA edits.

The HCPCS codes listed in the chart that follows are new for 2008 and are subject to CLIA edits. The list does not include new HCPCS codes for waived tests or provider-performed procedures. The HCPCS codes listed below require a facility to have either a CLIA certificate of registration (certificate type code 9), a CLIA certificate of compliance (certificate type code 1), or a CLIA certificate of accreditation (certificate type code 3). A facility without a valid, current, CLIA certificate, with a current CLIA certificate of waiver (certificate type code 2) or with a current CLIA certificate for provider-performed microscopy procedures (certificate type code 4) will not be paid for these tests and the claims will be denied. Failure to submit your CLIA number on claims containing one of these HCPCS codes will result in the Medicare carrier or A/B MAC returning your claim as unprocessable.

HCPCS Code Description
80047 Basic metabolic panel (Calcium, ionized)
82610 Cystatin C
83993 Calprotectin, fecal
84704 Gonadotropin, chorionic (hCG); free beta chain
86356 Mononuclear cell antigen, quantitative (eg, flow cytometry), not otherwise specified, each antigen
87500 Infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique
87809 Infectious agent antigen detection by immunoassay with direct optical observation; adenovirus
88381 Microdissection (ie, sample preparation of microscopically identified target); manual
89322 Semen analysis; volume, count, motility, and differential using strict morphologic criteria (eg, Kruger)
89331 Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and morphology, as indicated)

Other Key Points

Additional Information
To see the official instruction (CR5926) issued to your Medicare Carrier or A/B MAC visit http://www.cms.hhs.gov/Transmittals/downloads/R1471CP.pdf on the CMS Web site.

If you have 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.

Importance of Supplying Correct Provider Identification Information Required in Items 17, 17a, 24K, and 33 of the Form CMS-1500 (12-90), and the Electronic Equivalent

This article was revised on March 11, 2008, to clarify that all references to the form should state CMS-1500 (12-90). Providers may also want to refer to MLN Matters article MM5060 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/mm5060.pdf, which states the requirements for the newer form, CMS-1500 (08-05).The previous revision to the article added a reference to MLN Matters MM5890 (http://www.cms.hhs.gov/MLNMattersArticles/downloads/mm5890.pdf). MM5890 stated that effective with claims received on or after May 23, 2008, Medicare will not pay for referred or ordered services or items, unless the fields for the name and NPI of the ordering, referring and attending, operating, other, or service facility providers are completed on the claims.

Provider Types Affected
Physicians, providers, and suppliers who bill Medicare Carriers, including Durable Medical Equipment Medicare Administrative Contractors (DME MACs)

Provider Action Needed
The Centers for Medicare & Medicaid Services (CMS) would like to remind providers and their billing staffs of the importance of reporting the correct provider identification information in items 17, 17a, 24K, and 33 of the Form CMS-1500 (12-90), or the electronic equivalent. This information is critical for accurate and timely processing and payment of your claims.

Additional Information
Please be aware of the following instructions:

Items 17 and 17a
On the Form CMS-1500 (12-90), or electronic equivalent, the provider must submit the appropriate referring or ordering physician name in item 17, and the Unique Physician Identification Number (UPIN) of that referring/ordering physician in item 17a. These are required fields when a service was ordered or referred by a physician. When a claim involves multiple referring and/or ordering physicians, you must prepare a separate claim submission for each ordering/referring physician.

Item 17
Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician.

Item 17a
Enter the UPIN of the referring/ordering physician listed in item 17.

The ordering/referring requirement became effective January 1, 1992, and is required by §1833(q) of the Act. All claims for Medicare covered services and items that are the result of a physician’s order or referral shall include the ordering/referring physician’s name and UPIN. This includes parenteral and enteral nutrition, immunosuppressive drug claims, and the following:

Claims for other ordered/referred services not included in the preceding list shall also show the ordering/referring physician’s name and UPIN. For example, a surgeon shall complete items 17 and 17a when a physician refers the patient. When the ordering physician is also the performing physician (as often is the case with in-office clinical laboratory tests), the performing physician’s name and assigned UPIN appear in items 17 and 17a.

When a service is incident to the service of a physician or non-physician practitioner, the name and assigned UPIN of the physician or non-physician practitioner who performs the initial service and orders the non-physician service must appear in items 17 and 17a.

All physicians who order or refer Medicare beneficiaries or services must obtain a UPIN even though they may never bill Medicare directly. A physician who has not been assigned a UPIN must contact the local Medicare carrier to obtain the UPIN. A list of toll free numbers of the Medicare carriers is available at: http://www.cms.hhs.gov/apps/contacts/ on the CMS Web site.

When a physician extender or other limited licensed practitioner refers a patient for consultative service, the name and UPIN of the physician supervising the limited licensed practitioner must appear in items 17 and 17a.

When a patient is referred to a physician who also orders and performs a diagnostic service, a separate claim form is required for the diagnostic service. Enter the original ordering/referring physician’s name and UPIN in items 17 and 17a of the first claim form. Enter the ordering (performing) physician’s name and UPIN in items 17 and 17a of the second claim form (the claim for reimbursement for the diagnostic service).

Item 24K (See note above to reference MM5060, which changes the requirement for Item 24K.)

Enter the provider identification number (PIN) of the performing provider of service/supplier in item 24K if the provider is a member of a group practice. When several different providers of service or suppliers within a group are billing on the same Form CMS-1500 (12-90), or electronic equivalent, show the individual PIN of each performing provider in the corresponding line item. In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the PIN of the supervisor in item 24K.

UPINs are not appropriate identifiers for item 24K.
Item 33
Enter the provider of service/supplier’s billing name, address, ZIP code, and telephone number. This is a required field.

For a provider who is not a member of a group practice (e.g., private practice), enter the PIN at the bottom of item 33 for paper claims. The PIN should be entered on the left side, next to the PIN# field.

If a group practice is billing, then the group PIN is to be placed in item 33 for paper claims. Enter the group PIN at the bottom of item 33 on the right side, next to the GRP# field. Enter the PIN for the performing provider of service/supplier who is a member of that group practice in item 24K.

Suppliers billing a DME MAC will use the National Supplier Clearinghouse (NSC) number in this item.

NOTE: When implemented, the National Provider Identification (NPI) number will replace the PIN and UPIN. At that time, you will use the NPI number in items 17a, 24K, and 33.

The above instructions are included Chapter 26 of the Medicare Claims Processing Manual. That manual is available at http://www.cms.hhs.gov/Manuals/IOM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS018912 on the CMS Web site.

The Medicare Benefit Policy Manual may be found at http://www.cms.hhs.gov/Manuals/IOM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS012673 on the CMS Web site.

If you have questions, please contact your carrier/DME MAC at their toll free number, available at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Medical Review Frequently Asked Questions

The following represent a variety of questions the Medical Review department has received. CIGNA Government Services will address at least quarterly “Frequently Asked Questions” related to coverage and local medical review policy issues. Providers may submit questions to the website at
http://www.cignagovernmentservices.com/medicare_dynamic/customer_service/index.html

  1. Percutaneous Tibial Nerve Stimulation (PTNS) for treatment of Overactive Bladder
    Question: How should this be billed?
    Answer: Our research shows PTNS is an alternative to sacral nerve stimulation, but PTNS is still investigational. Therefore, Medicare would not cover this service.  Providers have reported they have been advised to code this with CPT code 64555, percutaneous implantation of neurostimulator electrodes, peripheral nerve. Since CPT code 64555 does not involve ‘’implantation’’ but simply the insertion of an electrode for temporary stimulation, providers should instead bill CPT code 64999. Claims for this will be denied as lack of medical necessity with provider liability unless the patient is informed prior to the service and signs an appropriate ABN assuming responsibility for payment of the service.
  2. “Incident To” and Smoking and Tobacco Cessation
    Question: For the new CPT Codes 99406 and 99407 can a RN or LPN provide the counseling for this code or does a Nurse Practitioner or Physician have to provide the counseling?
    Answer: The billing physician or nurse practitioner/physician assistant performing “incident to” visits should provide and document the counseling–not a RN or LPN.  Additionally, they must document the time spent doing this in order to justify the code they billed and distinguish it as a service separate from an E&M visit if one billed the same day. 

    The following CMS MLN Matters article announces that the 2008 Medicare Physician Fee Database (MPFSDB) included two new CPT codes for smoking and tobacco use cessation counseling services; replacing the temporary HCPCS G codes (G0375 and G0376) previously used for billing these services:
    http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5878.pdf
  3. Hospice Election Evaluation
    Question: Does Part B pay for a consult for Hospice consideration?
    Answer: A Hospice-Pre-Election Evaluation and Counseling Service should not be billed as a consult to Part B Medicare, but it should be billed to the fiscal intermediary/Part A using code HCPCS code G0337 if performed consistent with the guidelines from CMS Publication 100-4, the Medicare Claims Processing Manual , chapter 11, section 80 (accessible via the following link:
    http://www.cms.hhs.gov/manuals/downloads/clm104c11.pdf).
  4. Palliative Care
    Question: Does Medicare cover?
    Answer: Medicare may cover this service if it is medically necessary and does not duplicate what an attending/treating physician or other provider has already done nor duplicates care that is part of what a facility (e.g. a nursing facility) or Hospice should already be providing for its residents/patients.
  5. Observation Care
    Question: If a doctor gives orders over the phone to admit a patient to observation but does not see the patient till the next day and then decides to discharge the patient, what code would be billed?
    Answer: In this example, the doctor neither admitted the patient on the actual date of admission nor did a true “admission and discharge” service the same date of service as represented by CPT codes 99234-99236. These codes include an admission, keeping a record of observations/assessments performed by the physician, and discharge. In this example, the doctor made only one evaluative visit and decided to discharge the patient. The provider may bill a code from the series 99218-99220 if his/her documentation meets the code’s descriptor. A discharge visit (99217) should not be billed.

See MLN Matters articles # 5793 and 5791 for appropriate coding of other observation status scenarios via the following links:http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5793.pdf
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5791.pdf

  1. Implantable Cardiac Defibrillators
    Question: Which coverage policy do we use to allow payment for Implantable Cardiac Defibrillators (ICD) CPT code 33249?
    Answer: NCD 20.4 is guidance for the Automatic Implantable Cardiac Defibrillator (ICD). There is also an MLN Matters article MM4273 that specifically states what diagnosis codes are payable for this service when not performed as part of a clinical trial. LCDs L11585-NC, L12193-ID, and L6853-TN are for Resynchronization Therapy for Congestive Heart Failure (Biventricular Pacing) and also include CPT code 33249. The information in the MLN Matters article does not apply to these. This CPT code can be used for either service. However, because an NCD always supersedes an LCD follow the guidance of the NCD and the associated MLN Matters Article in billing for this service.

Mobile Cardiac Outpatient Telemetry Billing (Revised)

Guidelines including pricing for the above service were posted on the CIGNA Government Services Web site 121004. It incorrectly stated reimbursement would be based on CPT code 93732 (ELECTRONIC ANALYSIS OF DUAL-CHAMBER INTERNAL PACEMAKER SYSTEM (MAY INCLUDE RATE, PULSE AMPLITUDE AND DURATION, CONFIGURATION OF WAVE FORM, AND/OR TESTING OF SENSORY FUNCTION OF PACEMAKER); WITH REPROGRAMMING). Instead, reimbursement will be based on CPT code 93272 (Patient demand single or multiple event recording with presymptom memory loop, 24-hour attended monitoring, per 30 day period of time; physician review and interpretation only). The article is being republished in its entirety as follows to include this correction, and to clarify the date of service to be used to bill for the professional component.

Mobile Cardiac Outpatient Telemetry (MCOT) is real-time, outpatient cardiac monitoring system that is automatically activated and requires no patient intervention to either capture or transmit an arrhythmia when it occurs. Upon arrhythmia detection, the ECG waveform is transmitted by standard telephone line or wireless communications to the Pennsylvania receiving center monitoring the patient and reporting significant findings according to the physician’s patient-specific, pre-determined criteria.

At this point in time, there is no assigned CPT code for this service, nor is there a Local or National Coverage Decision (LCD or NCD) that specifically addresses this procedure. Providers rendering this service should know and follow these guidelines: