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June 6, 2008 Part B Medicare Bulletin

Posted June 6, 2008

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2nd Quarter Update Part B Not Otherwise Classified Drug Fee Schedule

2nd Quarter Update Part B Not Otherwise Classified Drug Fee Schedule

April 2008 Update to the Ambulatory Surgical Center (ASC) Payment System; Summary of Payment Policy Changes

News Flash — The Ambulatory Surgical Center Fee Schedule Fact Sheet, which provides general information about the Ambulatory Surgical Center (ASC) Fee Schedule, ASC payments, and how ASC payment amounts are determined, is now available in downloadable format from the Centers for Medicare & Medicaid Services Medicare Learning Network at http://www.cms.hhs.gov/MLNProducts/downloads/AmbSurgCtrFeepymtfctsht508.pdf on the CMS Web site and is also available in print format. To place your order for the printed version, visit http://www.cms.hhs.gov/mlngeninfo/, scroll down to “Related Links Inside CMS” and select “MLN Product Ordering Page.”

Provider Types Affected
Providers (ASCs) who submit claims to Medicare Administrative Contractors (A/B MACs) and carriers, for services provided to Medicare beneficiaries which are paid under the ASC payment system.

Provider Action Needed
This article is based on Change Request (CR) 5994 which describes changes to, and billing instructions for, payment policies implemented in the April 2008 ASC update. This update provides updated payment rates for selected separately payable drugs and biologicals and provides rates and descriptors for newly created Level II Healthcare Common Procedure Coding System (HCPCS) codes for drugs and biologicals.

Key Points
Billing for Drugs and Biologicals

Drugs and Biologicals with Payment Based on Average Sales Price (ASP) Effective April 1, 2008

New HCPCS Drug Codes Separately Payable under the ASC Payment System as of April 1, 2008
Four new HCPCS codes have been created effective April 1, 2008. These new HCPCS codes and their descriptors are listed in Table 1 below.

Table 1
New Drugs Separately Payable under the ASC Payment System as of April 1, 2008
HCPCS Code Long Descriptor
C9241 Injection, doripenem, 10 mg
Q4096 Injection, Von Willebrand Factor Complex, human, Ristocetin Cofactor (Not otherwise specified), per I.U. VWF:RCO,
Q4097 Injection, immune globulin (Privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg
Q4098 Injection, iron dextran, 50 mg

The payment rates for the drugs in Table 1 can be found in the April 2008 update of the ASC Addendum BB which will be posted on the CMS Web site at the end of March.

HCPCS Drug Codes No Longer Payable under the ASC Payment System Effective April 1, 2008

The following drug codes have been deleted and are no longer payable by Medicare, effective April 1, 2008.

Table 2
Drugs HCPCS codes no longer eligible for payment under Medicare as of April 1, 2008
HCPCS Code Long Descriptor ASC Payment Status
J1751 Injection, iron dextran 165, 50 mg Not payable by Medicare
J1752 Injection, iron dextran 267, 50 mg Not payable by Medicare

Correct Reporting of Units for Drugs
ASCs are reminded to ensure that units of drugs administered to patients are accurately reported in terms of the dosage specified in the full HCPCS code descriptor. That is, units should be reported in multiples of the units included in the HCPCS descriptor.

Additional Information
To see the official instruction (CR5994) issued to your Medicare Carrier or A/B MAC refer to http://www.cms.hhs.gov/Transmittals/downloads/R1488CP.pdf on the CMS Web site.

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

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 September 21, 2007, to reflect a change made to the implementation dates in CR5452. For DME suppliers billing DME MACs, the implementation date remains the same.

For other providers who bill Medicare carriers, fiscal intermediaries, including Regional Home Health Intermediaries, and/or Part A/B Medicare Administrative Contractors (A/B MACs), the implementation date is now April 7, 2008. The CR transmittal date, number, and Web address for accessing CR5452 were also changed. 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.

Clinical Laboratory and Imaging Orders

Clinical laboratory and imaging tests are a routine part of most practices. Proper documentation is necessary to make sure that the test is correctly order, performed, reported, and reimbursed.

The physician’s clinic notes or hospital progress notes should clearly show what tests the physician wants ordered for the beneficiary. The clinic note or the hospital order must then be signed by the physician either physically or electronically.

Once ordered, the person actually completing the lab or imaging center’s request should assure that the ordering physician’s name is so noted on the requisition form and include the working diagnosis either verbatim or with an ICD-9 code. Ideally the physician should sign this sheet but understandably this is not always practical.

The clinic notes should be made available for CERT auditors reviewing lab and imaging claims upon request. The notes may also serve to remind the physician to review the chart for results and as a note for other providers as to what tests have been performed therein avoiding duplicative tests when not medically necessary.

The medical records containing the order should be maintained and be available to Medicare upon request.

Clinical Laboratory Fee Schedule – Implementation of Section 113 Medicare, Medicaid and State Children’s Health Insurance Program (MMSCHIP) Legislation

News Flash – The Clinical Laboratory Fee Schedule Fact Sheet, which provides general information about the Clinical Laboratory Fee Schedule, coverage of clinical laboratory services, and how payment rates are set, is now available in downloadable format from the Centers for Medicare & Medicaid Services Medicare Learning Network at http://www.cms.hhs.gov/MLNProducts/downloads/clinical_lab_fee_schedule_fact_sheet.pdf on the CMS Web site

Provider Types Affected
Clinical laboratories billing Medicare contractors (carriers, fiscal intermediaries, or Part A/B Medicare Administrative Contractors (A/B MACs)) for services to Medicare beneficiaries

Provider Action Needed
This article is based on Change Request (CR) 5987 which alerts clinical laboratories that, effective for tests furnished on or after April 1, 2008, the MMSCHIP Extension Act of 2007 sets payment for code 83037 and 83037QW (Hemoglobin; glycosylated (A1c) by device) by crosswalking it to be the same as 83036 (glycosylated (A1c)). Make certain your billing staffs are aware of this change.

Background
The MMSCHIP Extension Act of 2007 passed in December 2007 and included Section 113. Section 113 of the legislation set the price for any diagnostic test for HbA1C that is labeled by the Food and Drug Administration (FDA) for home use equal to the payment rate for a glycated hemoglobin test (identified as of October 1, 2007, by Healthcare Common Procedure Coding System (HCPCS) code 83036 (and any succeeding codes)). The legislation is effective for tests furnished on or after April 1, 2008.

Your Medicare contractor will adjust claims for services on or after April 1, 2008, processed prior to implementation of this change if you bring such claims to the contractor’s attention.

Additional Information
To see the official instruction (CR5987) issued to your Medicare contractor visit http://www.cms.hhs.gov/Transmittals/downloads/R331OTN.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.

Comprehensive Error Rate Testing (CERT) Faxing Documentation to the CERT Documentation Contractor (CDC)

The Comprehensive Error Rate Testing program (CERT) is a federally mandated program to monitor and improve the accuracy of Medicare payments to physicians and other providers.

The process begins when the CERT Review Contractor requests records for review for each sampled claim. A few helpful tips for faxing documentation to the CERT Documentation Contractor are listed below:

  1. Be sure you are using the correct fax number – (240)568.6222
  2. Documents containing small fonts, the recommended mode of resolution for faxing should be “fine” (The resolution modes on most fax machines can easily be changed at the time of faxing by a button usually labeled “resolution” that is easily accessible near the other buttons at the top of the machine. Note that on most fax machines, the button will not function or change resolutions unless the document to be faxed has first been inserted. Should you not see this at the top of your machine, check your fax machine’s instruction manual for the location of the “resolution” button)
  3. Documents containing either light colored or light grey text or text embedded within background in shades of gray or color should be faxed using a resolution mode of “photo,” alternatively referred to as “gray scale.” This mode is available via the same “resolution” button mentioned above. This mode may not be available on all fax machines. Check your fax machine’s instruction manual for availability of this mode
  4. The CERT Contractor tracks their requests for records using the Claim Identifier (CID) which is located at the top of the barcoded cover sheet sent with the request for records. When faxing information back to the CERT office include the barcoded cover sheet first, followed by the records you are faxing. If the barcoded cover sheet is missing you should write the Claim Identifier (CID) number on each page of the fax. This will help the CERT office make sure your records reach the appropriate person.
  5. The CERT Documentation Contractor’s fax modems are set to respond after two rings; be sure your fax machine does not hang up after two rings or the fax will not be received.
  6. Confirmation letters are sent from the CERT office acknowledging receipt of faxes whenever possible. This confirmation however, does not attest to the quality or legibility of the record nor does it guarantee completeness of the documentation. A fax confirmation will be sent only after the CERT Documentation Contractor Quality Assurance staff reviews the documentation received. If the documentation is incomplete or illegible, the CERT Documentation Contractor will contact you in an effort to obtain complete and/or legible documentation. The CERT Documentation Contractor is not able to fax a confirmation in the following situations:
    1. If you have a block on your fax number
    2. The fax number is not a direct line and has an extension. In that case, the confirmation may go back to the main number.
    3. Line noise or bad connections
    4. Fax machines must be set to receive

Should you have any problems providing the documentation requested, you may call the CERT Documentation Contractor at (888)779.7477. Please have the CID of the claim in question available when you call.

Comprehensive Error Rate Testing (CERT) Decreasing the CERT Error Rate

Providers help decrease the CERT error rate by sending all documentation requested to support the services billed on the sampled claim chosen by the CERT contractor. Prior to faxing/mailing documents providers should verify the following:

Providers will be asked to submit their medical record documentation in accordance with the following time standards.

Day 0: Initial Call/Letter
Day 30: Second Call/Letter
Day 45: Third Call/Letter
Day 60: OIG Letter
Day 76: Claim scored in error

Should you have any problems providing the documentation requested you may call the CERT Documentation Contractor at (888)779.7477, please have the CID of the claim in question available when you call.

REMEMBER:
No response = no records = overpayment = taking money back

Corrections to Covered Indications for Docetaxel and Gemcitabine

(Note: There were covered indications incorrectly listed in the articles on Covered Indications for Chemotherapy Drugs and their Adjuncts)

Docetaxel (Taxotere) J9170
140.0 to 151.9, 158.9, 160.0 to 162.9, 174.0 to 175.9, 183.0-183.9, 185, 188.0-188.9, 195.0

Gemcitabine J9201
156.0-156.9, 157.0 to 158.9, 162.2-162.9, 164.2, 164.3, 164.8, 164.9, 174.0 to 175.9, 181, 183.0-183.9, 186.0-186.9, 188.0-188.9, 194.4, 200.00 to 202.98

CR 5550 Clarification - Signature Requirements

News Flash — The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that a new educational resource, the 2008 PQRI Fact Sheet, has been posted to the Physician’s Quality Reporting Initiative (PQRI) Webpage on the CMS Web site. This Fact Sheet provides an overview of the 2008 Physician Quality Reporting Initiative. To access this new and all available PQRI educational resources, visit http://www.cms.hhs.gov/PQRI on the CMS Web site and click on the Educational Resources tab. Once on the Educational Resources page, scroll down to the “Downloads” section and click on the “2008 PQRI Fact Sheet” link.

Provider Types Affected
Physicians and other providers who bill Medicare Contractors (Carriers, Fiscal Intermediaries, Regional Home Health Intermediaries, Part A/B Medicare Administrative Contractors, including Durable Medical Equipment Medicare Administrative Contractors) for care provided to Medicare beneficiaries in hospice.

What You Need to Know
CR 5971, from which this article is taken, clarifies the instructions on signature requirements for the certification of terminal illness for hospice. It provides that Medicare contractors will accept a facsimile of an original written or electronic signature in documenting the certification of terminal illness for hospice.

Make sure that your billing staffs are aware that, to document the certification of terminal illness for hospice, a facsimile of an original written or electronic signature is acceptable.

Background
CR 5971, from which this article is taken, clarifies the instructions in Medicare Program Integrity Manual Chapter 3 (Verifying Potential Errors and Taking Corrective Actions), Subsection 3.4.1.1B (Signature Requirements) that address the signature requirements for the certification of terminal illness for hospice, that were provided in CR 5550 (Various Medical Review Clarifications).

Subsection 3.4.1.1B of the manual notes that Medicare contractors require a legible identifier for services provided/ordered. It further requires that when this documentation is for medical review purposes, the only acceptable method of documenting the provider signature is by written or an electronic signature. Stamp signatures are not acceptable to sign an order or other medical record documentation for medical review purposes.

CR 5971 provides that there is an exception to this requirement. It announces that a facsimile of an original written or electronic signature is acceptable for the certification of terminal illness for hospice. Please be sure to note however, that while a signature facsimile is acceptable in this instance; it and hard copies of a physician’s electronic signature must be present in the patient’s medical record.

Additional Information
You can find more information about the signature requirements for the certification of terminal illness for hospice by going to CR 5971, located at http://www.cms.hhs.gov/Transmittals/downloads/R248PI.pdf on the CMS Web site. You will find updated Medicare Program Integrity Manual Chapter 3 (Verifying Potential Errors and Taking Corrective Actions), Subsection 3.4.1.1B (Signature Requirements) as an attachment to this CR.

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.

Cytogenetic Studies

The LCDs for Cytogenetic Studies for all three CGS states effective April 1, 2008.

The coverage was expanded to include the 174.3-174.6, 174.8-174.9, and 599.7 as covered diagnoses for Cytogenetic Studies. Please refer to the CIGNA Government Services Web site at http://www.cignagovernmentservices.com to view the policy.

Delay of Enrollment Requirements for Audiologists

On February 29, 2008, the Centers for Medicare and Medicaid Services (CMS) issued Change Request 5717 titled “Update to Audiology Policies.” Transmittal 1470 of that change request provided clarifications to the Medicare Claims Processing Manual (Pub. 100-02). In Pub 100-02, Chapter 12, Section 30.3, the manual instructions state, “. . . the audiologist’s NPI is required on all claims for services furnished by audiologists.” Use of the NPI in the primary identifier field on a claim requires Medicare enrollment.
Note that CMS is instructing contractors to, prior to October 1, 2008, continue to process claims without the NPI of the audiologist. All other instructions in Change Request 5717 remain unchanged.

CMS will require the use of the NPI on claims for diagnostic test services furnished by audiologists on or after October 1, 2008. Audiologists are encouraged to obtain an NPI and enroll as soon as possible.

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program: Grandfathering, Repair and Replacement, Mail Order Diabetic Supplies and Advanced Beneficiary Notices (ABNs) – The second in a series of articles on the new DMEPOS competitive bidding program.

News Flash — CMS has announced the single payment amounts for Round 1 of the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program. Visit the CMS Web site at http://www.cms.hhs.gov/CompetitiveAcqforDMEPOS/ to view additional information. To view the Press Release, please click http://www.cms.hhs.gov/apps/media/press_releases.asp on the CMS Web site.

Provider Types Affected
Any Medicare Fee-for-Service (FFS) provider supplying DMEPOS to a Medicare beneficiary. This article also contains information of interest to those who order DMEPOS and to referral agents as defined in MLN Matters article SE0805.

Provider Action Needed
The first article (SE0805) in this series on the DMEPOS Competitive Bidding Program being instituted by the Centers for Medicare & Medicaid Services (CMS) presented an overview of how the program may affect your patients. There are also some key provisions of the program about which your patients may raise questions. While the competitive bidding program only affects ten areas of the country as of July 1, 2008, it will expand to 70 additional geographic areas in 2009. Thus, it is important for you to be familiar with this program.

Background
MLN Matters article SE0805, entitled “Overview of New Medicare Competitive Bidding Program for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS),” which is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0805.pdf on the CMS Web site, summarizes information on competitive bidding that may impact your patients. Article SE0805 contains the list of competitive bidding areas for the first phase of competitive bidding as well as a list of the DMEPOS product categories that are included in the program’s initial implementation.

In using this series of DMEPOS articles, it is important to remember that in most instances, beneficiaries maintaining a permanent residence in one of the Competitive Bidding Areas (CBAs) must obtain competitive bidding items from a contract supplier. There are also program requirements that apply to beneficiaries who reside in CBAs but travel outside of those CBAs and to beneficiaries who do not live in CBAs but travel to them.

Grandfathered Suppliers
The Medicare DMEPOS Competitive Bidding Program requires Medicare beneficiaries to obtain competitive bidding items from a contract supplier, unless an exception applies. Therefore, in some instances, your patient may be required to change from a non-contract supplier to a contract supplier. However, the program does allow for certain suppliers to be “grandfathered.” Grandfathered suppliers are allowed to continue to provide certain rented DME items and services even though they are not contract suppliers.

Grandfathering only applies when the patient is renting DME or oxygen equipment at the time the competitive bidding program becomes effective and the rental period for the item began before the start of the competitive bidding program.

Beneficiaries who are receiving oxygen, oxygen equipment or rented DME at the time the competitive bidding program becomes effective may elect to continue to receive these items from a non-contract supplier, if the supplier is willing to continue furnishing these items. If a non-contract supplier chooses not to be “grandfathered” or if a beneficiary wants to change to a contract supplier, the non-contract supplier must pick up the rental equipment and oxygen equipment. Unless a beneficiary relocates outside of the CBA and the supplier service area, the supplier cannot discontinue services by picking up a medically necessary item prior to the end of a rental month for which the supplier was eligible to receive a rental payment, even if the last day of a rental month is after the start date of the program. If the date of the beginning of a monthly rental period is prior to the start of the competitive bidding program, the supplier must submit a claim for that month. Note that the grandfathering provision also applies to Medicare beneficiaries who transition from a Medicare Advantage Plan to the Fee-for-Service program.

If the beneficiary stays with a “grandfathered” supplier, he or she may elect to change to a contract supplier at any time, and the contract supplier would be required to accept the beneficiary as a customer. For more details on the grandfathering provision, visit http://www.dmecompetitivebid.com on the CMS Web site.

Repair and Replacement of Beneficiary-Owned Items

Repair ONLY
A beneficiary who owns a competitively bid item that needs to be repaired may have the repairs performed by either a contract supplier or by a non-contract supplier. In these cases, Medicare pays for reasonable and necessary labor not otherwise covered under a manufacturer’s or supplier’s warranty.

Repair and Replacement
If a part needs to be replaced in order to make the beneficiary-owned equipment serviceable, and the replacement part is also a competitively bid item for the CBA in which the beneficiary maintains a permanent residence, the part may be obtained from either a contract supplier or a non-contract supplier. In either case, Medicare pays the single payment amount provided under the Competitive Bidding Program for the replacement part.

Replacement ONLY
Beneficiaries maintaining permanent residences in a CBA are required to obtain replacement of all items subject to competitive bidding from a contract supplier. This includes replacement of base equipment and replacement of parts or accessories for base equipment that are being replaced for reasons other than servicing of the base equipment.

Beneficiaries who are not permanent residents of a CBA but require a replacement of a competitively bid item while visiting a CBA, must obtain the replacement item from a contract supplier. The supplier will be paid the fee schedule amount for the state where the beneficiary is a permanent resident.

Mail Order Diabetic Supplies under the Program
Medicare beneficiaries who permanently reside in a CBA may purchase their diabetic testing supplies from:

The mail order contract period covers diabetic testing supplies furnished from July 1, 2008 through March 31, 2010. The term “mail order” refers to items ordered remotely (i.e., by phone, email, internet, or mail) and delivered to the beneficiary’s residence by common carriers (e.g., U.S. Postal Service, Federal Express, United Parcel Service) and does not include items obtained by beneficiaries from local supplier storefronts.

Mail order contract suppliers will be reimbursed at the single payment amount for the CBA where the beneficiary maintains a permanent residence.

For diabetic supplies that are not furnished through mail order, suppliers will be paid the fee schedule amount.

Medicare payment will not be made to non-contract suppliers that furnish mail order diabetic testing supplies to Medicare beneficiaries residing in a CBA. A special modifier, KL, will be used on each claim to indicate that the item was furnished on a mail order basis.

Note: Suppliers that furnish diabetic testing supplies on a mail order basis and do not attach the mail order modifier could be subject to significant penalties under the False Claims Act.

Both the Medicare program and beneficiaries will save money each time a mail order contract supplier is used; however, it is solely up to the beneficiaries to decide whether or not they wish to obtain their diabetic testing supplies on a mail order basis.

All mail order contract suppliers are required to report the manufacturer or make and model number of products they furnish and must update this list on a quarterly basis. This information will be made available to the public once the contract suppliers have been announced and will be updated on a routine basis. Contract suppliers will be required to make available the same range of products to Medicare beneficiaries that they make available to non-Medicare customers.

Advance Beneficiary Notice (ABN) Information

In general, if a non-contract supplier in a CBA furnishes a competitively bid item to any Medicare beneficiary regardless of whether that beneficiary maintains a permanent residence in the CBA or another area, and no applicable exceptions apply, Medicare will not make payment. In addition, the beneficiary is not liable for payment unless the non-contract supplier in a CBA obtains an ABN signed by the beneficiary.

A signed ABN indicates that the beneficiary was informed in writing prior to receiving the item that there would be no Medicare coverage due to the supplier’s contract status, and that the beneficiary understands that he/she will be liable for all costs that the non-contract supplier may charge the beneficiary for the item.

If a non-contract supplier furnishes a competitively bid item to a beneficiary and the beneficiary signs an ABN, the supplier must use the “GA” modifier on their claim. If the “GA” modifier is not present on the claim, the supplier may not hold the beneficiary liable for the cost of the item.

Additional Information
CMS contracted with the Competitive Bidding Implementation Contractor (CBIC) to administer the DMEPOS Competitive Bidding Program. Downloadable Patient Education Fact Sheets can be found at: http://www.dmecompetitivebid.com/palmetto/CBIC.nsf/docsCat/CBIC~Referral%20Providers~Patient%20Education%20Fact%20Sheets?open&cat=CBIC~Referral%20Providers~Patient%20Education%20Fact%20Sheets

If you have concerns, questions, or complaints about the quality of an item or the service that a patient received from a contract supplier, please call the Competitive Bidding Program helpline at 1.877.577.5331.

For more information about the Competitive Bidding Program, call 1.877.577.5331. TTY users call 1.877.486.2048. Stay tuned for additional articles in this series. You can also visit http://www.cms.hhs.gov/CompetitiveAcqforDMEPOS/ on the CMS Web site or http://www.dmecompetitivebid.com/ on the Internet for more details.

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 April 25, 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:

Not Reasonable and Necessary ESA Use

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.

Exception to 60-Day Limit on Substitute Physician Billing Arrangements for Physicians Called to Active Duty in the Armed Forces Reserves

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
Physician members of a reserve component of the Armed Forces who bill Medicare Carriers or Medicare Administrative Contractors (A/B MAC) for services provided to Medicare beneficiaries.

Physicians called to active duty in the Armed Forces who wish to bill for substitute physician services during the physician’s absence.

What You Need to Know
CR 5985, from which this article is taken, announces a 6-month extension of the exception to the 60-day limit on substitute physician billing for physicians called to active duty in the Armed Forces. This means that a physician who is called to active duty may continue to bill for substitute physician services furnished from January 1, 2008 through June 30 2008, which may be beyond the 60-day limit.

Make sure that your billing staffs are aware of this change.

Background
Section 1842(b)(6)(D)(iii) of the Social Security Act (the Act) and Medicare Claims Processing Manual Chapter 1 (General Billing Requirements), Sections 30.2.10 (Payment Under Reciprocal Billing Arrangements - Claims Submitted to Carriers) and 30.2.11 (Physician Payment Under Locum Tenens Arrangements - Claims Submitted to Carriers) state that when a physician is unavailable to provide services, a substitute physician’s services (either on a reciprocal or locum tenens basis) are not to be provided for a period longer than 60 continuous days.

On August 3, 2007, Public Law 110-54 amended the Act to provide an exception to this 60-day limit for physicians who are ordered to active duty in the Armed Forces.

By striking “January 1, 2008” and inserting “July 1, 2008,” Section 116 of the “Medicare, Medicaid, and State Children’s Health Insurance Program (SCHIP) Extension Act of 2007” (signed on December 29, 2007) extended this exception for another 6 months.

CR 5985, from which this article is taken updates these sections in Medicare Claims Processing Manual to reflect this change in the law.

Effective January 1, 2008, physicians called to active duty will be able to bill for substitute physician services furnished from January 1, 2008, through June 30 2008.

Additional Information
You can find more information about the exception to the 60-Day limit on substitute physician billing arrangements for physicians called to active duty in the Armed Forces reserves by going to CR 5985, located at http://www.cms.hhs.gov/transmittals/downloads/R1486CP.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site. You will find the updated Medicare Claims Processing Manual Chapter 1 (General Billing Requirements), Sections 30.2.10 and 30.2.11 as an attachment to that CR.

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

Important Exceptions and Special Circumstances that Occur under the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program: – The third in a series of articles on the new DMEPOS competitive bidding program.

News Flash — CMS has announced the single payment amounts for Round 1 of the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program. Visit the CMS Web site at http://www.cms.hhs.gov/CompetitiveAcqforDMEPOS/ to view additional information. To view the Press Release, please go to http://www.cms.hhs.gov/apps/media/press_releases.asp on the CMS Web site.

Provider Types Affected
The following providers may be affected by this program:

Many Medicare Fee-for-Service (FFS) providers may be in a position of ordering, referring, or supplying DMEPOS to a Medicare beneficiary. This includes physicians (including podiatric physicians), other treating practitioners (nurse practitioners, physician assistants, and clinical nurse specialists), physical and occupational therapists, and institutional providers (especially skilled nursing facilities and their social workers or care coordinators, hospitals and their discharge planners, home health agencies and pharmacists).

Provider Action Needed
Understand these special program rules that may affect you. This article is especially important if you are a Medicare enrolled DMEPOS supplier of items governed by the new program, even if you are not located in a competitive bidding area (CBA). It is important to understand that the program affects any beneficiaries who permanently reside in or travel to CBAs. Some program requirements apply to beneficiaries who reside in CBAs even if these beneficiaries travel outside their CBAs. Thus, it is important for you to be familiar with this program.

While the first phase of the competitive bidding program only affects ten CBAs in the country as of July 1, 2008, the second phase will expand to 70 additional geographic areas in 2009. See MLN article SE0805 for information about CBAs and items governed by this new program and for information about how the program applies to traveling beneficiaries.

Background
MLN Matters article SE0805 that is entitled, “Overview of New Medicare Competitive Bidding Program for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS),” which is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0805.pdf on the CMS Web site, summarizes information on competitive bidding that may impact your patients. Article SE0805 contains the list of competitive bidding areas for the first phase of competitive bidding as well as a list of the DMEPOS product categories that are included in the program’s initial implementation.

MLN Matters article SE0806 that is entitled, “Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program: Grandfathering, Repair and Replacement, Mail Order Diabetic Supplies and Advanced Beneficiary Notices (ABNs),” which is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0806.pdf on the CMS Web site, provides an overview of the rules regarding grandfathered suppliers, repair and replacement of beneficiary-owned equipment, mail order diabetic supplies under the program, and ABNs.

In this, the third in a series of articles on the new DMEPOS competitive bidding program, we provide information on some special circumstances and exceptions of particular interest to physicians and other treating practitioners, SNFs and NFs , and physical and occupational therapists in independent practice.

Note: It is important to note that the Competitive Bidding Program does not affect your patients’ choice of physician or treating practitioner.

In using this series of DMEPOS articles, remember that in most instances, beneficiaries maintaining a permanent residence in one of the Competitive Bidding Areas (CBAs) must obtain competitive bidding items from a contract supplier. There are also program requirements that apply to beneficiaries who reside in CBAs but travel outside of those CBAs and to beneficiaries who do not live in CBAs but travel to them.

Physicians and Other Treating Practitioners Who are Enrolled Medicare DMEPOS Suppliers
Medicare physicians and treating practitioners who have also enrolled as Medicare DMEPOS suppliers via the 855S enrollment form have the option to furnish certain types of competitively bid items to their own patients without submitting a bid or being awarded a competitive bid contract, provided the following requirements are met:

Where the furnished item is a bid item and the beneficiary resides in a CBA, the physician or treating practitioner will be paid the single payment amount established by this program for the item. This exception does not affect the applicability of the physician self-referral (Stark law) provisions in section 1877 of the Act. All provisions of the physician self-referral law remain fully in effect.

Physicians and Other Treating Practitioners Who Prescribe Specific Brand or Mode of Delivery to Avoid an Adverse Medical Outcome
A physician (including a podiatric physician) or treating practitioner may prescribe, in writing, a particular brand of DMEPOS bid item or mode of delivery for an item if he or she determines that the particular brand or mode of delivery would avoid an adverse medical outcome for the beneficiary. The physician or treating practitioner must document in the beneficiary’s medical record the reason why the specific brand or mode of delivery is necessary to avoid an adverse medical outcome.
In these cases, the contract supplier under the Competitive Bidding Program must:

Any change in the prescription requires a revised written prescription. A contract supplier is prohibited from submitting a claim to Medicare if it furnishes an item different from that specified in the written prescription received from the beneficiary’s physician or treating practitioner.

Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs) Specialty Suppliers
The DMEPOS Competitive Bidding Program applies to SNFs and NFs to the extent that their residents receive competitively bid items under Medicare Part B. Unlike most suppliers, SNFs and NFs have the option to bid for, and be awarded, contracts to be “specialty suppliers” that only furnish competitively bid items to their own residents. SNFs and NFs that become specialty suppliers may not furnish competitively bid items and services to Medicare beneficiaries outside their facilities for purposes of Medicare payment. SNFs and NFs can also become regular contract suppliers that furnish competitively bid items to beneficiaries throughout a CBA.

If a SNF or NF is not a contract supplier (either a specialty contract supplier or a regular contract supplier), it must use a contract supplier for its CBA to furnish competitively bid items to its residents.

Physical Therapists and Occupational Therapists in Private Practice Who are Enrolled Medicare DMEPOS Suppliers
Physical therapists and occupational therapists in private practice who are enrolled DMEPOS suppliers may eventually have the option to furnish certain types of competitively bid items to their own patients and be paid the single payment amount for such items without being contract suppliers, provided the following requirements are met:

Note: OTS orthotics are not included in the first phase of competitive bidding, this exception is not relevant in the first phase of the DMEPOS Competitive Bidding program beginning July1, 2008.

Additional Information
If you have concerns, questions, or complaints about the quality of an item or the service that a patient received from a contract supplier please call the Competitive Bidding Program helpline at 1.877.577.5331.

For more information about the Competitive Bidding Program, call 1.877.577.5331. TTY users call 1.877.486.2048. Stay tuned for additional articles in this series. You can also visit http://dmecompetitivebid.com/palmetto/cbic.nsf/DocsCat/Home on the Internet and at http://www.cms.hhs.gov/CompetitiveAcqforDMEPOS/ on the CMS Web site for more details.

Inappropriate Use of Modifiers 76 and 77

We have seen an increase recently in use of the 77 and 76 modifiers with E&M services to bypass edits related to concurrent care by two physicians of the same specialty on the same day. Communication with CMS Central Office has confirmed that this is an inappropriate use of these modifiers. Although the CMS Manual system doesn’t clearly state this, per se, the intent is and always has been for these modifiers to apply only to procedures, not to E&M services. Revised language making this clear will be coming out in a Manual revision later this year, and a forthcoming NCCI update will also make this clear. In the meantime, providers are encouraged to not append the 76 and 77 modifiers to claims for E&M services. Future audits of such inappropriate use of the modifiers on claims will likely result in recoupment of monies incorrectly paid.

Local Carrier Payment Allowance Limits for Medicare Part B Drugs

Local Carrier Payment Allowance Limits for Medicare Part B Drugs

Medicare Shared Systems Modifications Necessary to Accept and Crossover to Medicaid National Drug Codes (NDC) and Corresponding Quantities Submitted on CMS-1500 Paper Claims

News Flash — The NPI will be Required for all HIPAA Standard Transactions on May 23rd.
As of May 23, 2008, the NPI will be required for all HIPAA standard transactions. This means:

Provider Types Affected
All physicians, providers, and suppliers who submit paper claims using Form CMS-1500 to Medicare contractors (carriers, Medicare Administrative Contractors (A/B MACs), and durable medical equipment Medicare Administrative Contractors (DME/MACs)) for certain physician administered drugs provided to Medicare beneficiaries

Provider Action Needed

STOP – Impact to You - The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 5835 that notifies physicians and suppliers who use Claim Form CMS-1500 (those providers who qualify for a waiver from the Administrative Simplification Compliance Act (ASCA)) that changes are being made to Medicare systems to conform with instructions for submitting NDC drug code and quantity information on Form CMS-1500.

CAUTION – What You Need to Know - This article only applies to those providers eligible to submit paper claims and who do so for patients who are dually eligible for Medicaid and Medicare. Such claims need to include NDCs and corresponding quantity amounts for physician-administered drugs. The Key Points section of this CR outlines the changes required in the Form CMS-1500.

GO – What You Need to Do - Make certain your office staffs are aware of these changes in the content requirements of your paper claims.

Background
The Deficit Reduction Act (DRA) of 2005 required State Medicaid agencies to provide for the collection of National Drug Codes (NDC) on all claims for certain physician-administered drugs for the purpose of billing manufacturers for Medicaid drug rebates. Prior to the DRA, physicians’ offices, outpatient hospital departments and clinics generally used Healthcare Common Procedure Coding System (HCPCS) codes to bill Medicaid for drugs dispensed to Medicaid patients. However, because State Medicaid agencies are required to invoice manufacturers for rebates using NDCs for drugs for which the States have made payments, often States were not able to fulfill the rebate requirements for physician-administered drugs. The requirements for the collection of NDCs became effective beginning January 1, 2007. In addition, beginning January 1, 2008, in order for Federal financial participation (FFP) to be available for these drugs, State Medicaid agencies must be in compliance with the requirements. These requirements were implemented in a final rule published on July 17, 2007.

Also, the quantity field of the CMS-1500 paper claim should be captured on all crossover claims for Medicaid billing, as provided for by the National Uniform Claims Committee (NUCC). Information regarding the quantities of physician-administered drugs billed to Medicaid is also necessary for States to bill manufacturers for Medicaid drug rebates.

Key Points
When required to submit NDC drug number and quantity information for Medicaid rebates on the CMS-1500 paper claim be aware of the following:

Additional Information
To see the official instruction (CR5835) issued to your Medicare Carrier, DME/MAC, or A/B MAC refer to http://www.cms.hhs.gov/Transmittals/downloads/R1401CP.pdf on the CMS Web site.

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

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

New HCPCS Codes for the April 2008 Update

News Flash — CMS has announced the single payment amounts for Round 1 of the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program. Visit the CMS Web site at http://www.cms.hhs.gov/CompetitiveAcqforDMEPOS/ to view additional information. To view the Press Release, please click http://www.cms.hhs.gov/apps/media/press_releases.asp on the CMS Web site.

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

Provider Action Needed
This article is based on Change Request (CR) 5981, which instructs Medicare Contractors to implement Healthcare Common Procedure Coding System (HCPCS) code changes effective April 1, 2008. Make sure that your billing staffs are aware of these changes.

Background
The Centers for Medicare & Medicaid Services (CMS) updates the Healthcare Common Procedure Coding System (HCPCS) code set on a quarterly basis.

Effective for claims with dates of service on or after April 1, 2008,the following HCPCS codes will no longer be payable for Medicare:
HCPCS Code Short Description Long Description
J7602 Albuterol inh non-comp con ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 1 MG (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL)
J7603 Albuterol inh non-comp u d ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, PER 1 MG (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL)
J1751 Iron dextran 165 injection INJECTION, IRON DEXTRAN 165, 50 MG
J1752 Iron dextran 267 injection INJECTION, IRON DEXTRAN 267, 50 MG

Effective for claims with dates of service on or after April 1, 2008, the following HCPCS codes will be payable for Medicare:
HCPCS Code Short Description Long Description
J7611 Albuterol non-comp con ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, 1MG
J7612 Levalbuterol non-comp con LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, 0.5 MG
J7613 Albuterol non-comp unit ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTEREDTHROUGH DME, UNIT DOSE, 1MG
J7614 Levalbuterol non-comp unit LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG
Q4096 VWF complex, NOS INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, RISTOCETIN COFACTOR (NOT OTHERWISE SPECIFIED), PER I.U. VWF:RCO
Q4097 Inj IVIG Privigen 500 mg INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG
Q4098 Inj iron dextran INJECTION, IRON DEXTRAN, 50MG
Q4099 Formorterol fumarate, inh FORMORETOL FUMARATE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 20 MICROGRAMS

Currently, Alphanate® is the only product that should be billed using code Q4096. J7190 should continue to be billed when Alphanate® is furnished for purposes of administering Factor VIII. The blood clotting furnishing fee is payable when payment is allowed for Q4096. When a payment allowance limit for Q4096 is included on the quarterly Part B drug pricing files, the payment allowance limit will include payment for the blood clotting furnishing fee.

Effective for dates of service on or after April 1, 2008, the requirements under CR 5713 (See the MLN Matters article for CR5713, which is at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5713.pdf on the CMS Web site) are being updated by CR 5981 to apply to claims that bill Intravenous Immunoglobulins (IVIG) using Q4097 as follows:

Additional Information
The official instruction, CR 5981, issued to your carrier, FI, RHHI, A/B MAC, and DME MAC regarding these changes may be viewed at http://www.cms.hhs.gov/transmittals/downloads/R1492CP.pdf on the CMS Web site.

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

Nursing Facility Services (Codes 99304 - 99318)

News Flash – May 23rd is Only Two Months Away, Be Prepared! TEST NPI-only NOW - Now that the NPI is required on all Medicare claims in the primary provider fields, if your claims are being successfully processed with NPI/legacy pairs (and most are) now is the time to begin testing claims using the NPI alone. If the Medicare NPI Crosswalk cannot match your NPI to your Medicare legacy number, the claim with an NPI-only will reject. You can and should do this test now! If the claim is processed and you are paid, continue to increase the volume of claims sent with only your NPI. If the claims reject, go into your NPPES record and validate that the information you are sending on the claim is consistent with the information in NPPES. If it is different, make the updates in NPPES and resend a small batch of claims 3-4 days later. If your claims are still rejecting, you may need to update your Medicare enrollment information to correct this problem. Call the Customer Service Representative at your Medicare carrier, FI, or A/B MAC enrollment staff or your DME MAC to discuss your situation and, if necessary, have it investigated. Have a copy of your NPPES record or your NPI Registry record available. The contractor telephone numbers are likely to be quite busy, so don’t wait. Doing this testing now will allow time for any needed corrections prior to May 23, 2008, the date when only the NPI will be accepted in all provider fields.

Provider Types Affected
Physicians and qualified non-physician practitioners who bill Medicare contractors (Carriers or Medicare Administrative Contractors A/B MAC) for services provided to Medicare beneficiaries in skilled nursing facilities (SNF) or nursing facilities (NF)

What You Need to Know
CR 5986, from which this article is taken, updates the Medicare Claims Processing Manual, Chapter 12, (Physicians/Non-physician Practitioners), Section 30.6.13 (Nursing Facility Services (Codes 99304 – 99318) Subsection F (Use of the Prolonged Services Codes and Other Time-Related Services) by noting that the typical/average time units for Evaluation and Management (E/M) visit codes in the Nursing Facility Services code family are reestablished and applicable, as of January 1, 2008.

Effective for services on or after July 1, 2008, you may bill Medicare for medically necessary prolonged services for E/M visits (codes 99356 and 99357) in a SNF or NF with Nursing Facility Services codes (99304 – 99306, 99307 – 99310 and 99318). Additionally, you may use these prolonged services codes (99356 and 99357) with Nursing Facility Services in the code range (99304 – 99306, 99307 – 99310, and 99318) to bill for counseling and/or coordination of care services that are based on time.
Make sure that your billing staffs are aware of these new billing changes.

Background
Effective January 1, 2006, the American Medical Association (AMA) Current Procedural Terminology (CPT) Panel removed the typical/average time units for evaluation and management (E/M) services in the Nursing Facility code family. Until these typical/average times were reestablished, this action precluded the billing of: 1) prolonged services for E/M visits in a skilled nursing facility or nursing facility; and 2) time-based counseling and/or coordination of care for Nursing Facility Services.

CR 5986, from which this article is taken, updates the Medicare Claims Processing Manual, Chapter 12, (Physicians/Non-physician Practitioners), Section 30.6.13 (Nursing Facility Services (Codes 99304 – 99318)), Subsection F (Use of the Prolonged Services Codes and Other Time-Related Services) by announcing that the AMA CPT Panel has reestablished these typical/average time units beginning January 1, 2008.

Further, CR 5968 announces that, effective July 1, 2008, you may bill for medically necessary prolonged services for SNF or NF E/M visits (CPT codes 99356 and 99357) with Nursing Facility Services (code range 99304 – 99306, 99307 – 99310 and 99318); and you may also use the medically necessary prolonged services CPT codes (99356 and 99357) to bill for medically necessary E/M visits for time-based counseling and/or coordination of care for Nursing Facility Services in the code range 99304 – 99306, 99307 – 99310, and 99318.

Additional Information
You can find more information about using the prolonged services codes CPT codes (99356 and 99357) billing for medically necessary prolonged services for E/M visits in a SNF or NF, and for time-based counseling and/or coordination of care for Nursing Facility Services by going to CR 5968, located at