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July 7, 2008 Part B Medicare Bulletin

Posted July 7, 2008

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Ambulance Fee Schedule — Conversion Factor File for CY 2009 Ambulance Inflation Factor

News Flash — Don't be Surprised on May 23 . . . TRY 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 sending a small batch of claims with 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 try sending NPI-only 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 or at 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.

Note: This article was revised on May 6, 2008, to correct the implementation date of the instruction. That date is October 6, 2008. All other information remains the same.

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

What Providers Need to Know
This article is based on Change Request (CR) 6000, which revises the ambulance fee schedule file layout for Calendar Year (CY) 2009. Specifically, only the conversion factor field is being modified to:

For claims with dates of service on or after January 1, 2009, Medicare contractor(s) will recognize the new Ambulance Fee Schedule file layout. For claims with dates of service prior to January 1, 2009, Medicare contractors will recognize the current layout.

Additional Information
The official instruction, CR 6000, issued to your carrier, FI, or A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1499CP.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site.

The ambulance fee schedule public use files are available at http://www.cms.hhs.gov/AmbulanceFeeSchedule/02_afspuf.asp 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.

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Assignment of Providers to Medicare Administrative Contractors

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
All physicians, providers, and suppliers who submit claims to Medicare Administrative Contractors A/B MACs), fiscal intermediaries (FIs), carriers or Regional Home Health Intermediaries (RHHIs) for services provided to Medicare beneficiaries.

Impact on Providers
This "One Time Notice" CR describes the Centers for Medicare & Medicaid Services (CMS) approach for assigning providers to MACs and discusses the process of moving providers to MACs.

Background
This article is based on CR 5979 and Section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), Public Law 108–173, amended Title XVIII of the Social Security Act (the Act) to add section 1874A, Contracts with Medicare Administrative Contractors (MACs).

I. What are "MACs?"
Under section 911 of the MMA, Congress requires that CMS replace the current fiscal intermediary (FI) and carrier contracts with competitively procured contracts that conform to the Federal Acquisition Regulation (FAR). Under the new Medicare Administrative Contractor (MAC) contracting authority, CMS has 6 years - between 2005 and 2011 - to complete the transition of Medicare Fee-for-Service (FFS) claims processing activities from the FIs and carriers to the MACs.

For information on CMS' progress in awarding and implementing the MACs, please visit http://www.cms.hhs.gov/MedicareContractingReform/ on the CMS Web site.

II. What is "Provider Nomination?"
"Provider Nomination" is a phrase that describes the former right of an individual provider or a chain of providers to select assignment to the FI of its choice. In section 911(b) of the MMA, Congress repealed the provider nomination provisions of the Social Security Act. Provider nomination has been replaced with the geographic assignment rule. Generally, a provider will be assigned to the MAC that covers the state where the provider is located. The CMS regulation at 42 CFR 421.404 reflects this policy shift. Other CMS regulations and policy manuals are in the process of being updated.

A moratorium was placed on the "change of intermediary" process for individual providers in October of 2005. Transmittal 291 (CR # 5720), dated September 19, 2007, (see http://www.cms.hhs.gov/Transmittals/downloads/R291OTN.pdf on the CMS Web site) informed all FIs and A/B MACs that CMS would no longer accept a request to move from one FI/MAC to another FI/MAC from a provider moving in or out of a Medicare chain. There remains one exception for qualified chain providers (QCPs) as discussed in Section V below.

III. Where will providers eventually be assigned in the MAC environment?
A. Home Health & Hospice
All home health and hospice (HH&H) providers will be assigned to the MAC contracted by CMS to administer HH&H claims for the geographic locale in which the provider is physically located. See the following link for a description of the MAC-environment HH&H regions and the four MACs that will administer HH&H claims for those four regions.

http://www.cms.hhs.gov/MedicareContractingReform/06_SpecialtyMACJurisdictions.asp#TopOfPage

B. Durable Medical Equipment
Each supplier of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) will submit claims to the Durable Medical Equipment Medicare Administrative Contractors (DME MAC) contracted by CMS to administer DMEPOS claims for the geographic locale in which the beneficiary permanently resides. The link above under "A" also provides a description of the MAC-environment DMEPOS regions and the four MACs that will administer DMEPOS claims for those four regions.

C. Qualified Railroad Retirement Beneficiaries Entitled to Medicare
Physicians and other suppliers (except for DMEPOS suppliers) will continue to enroll with and bill the contractor designated by the Railroad Retirement Board (under Section 1842(g) of The Act) for Part B services furnished to these beneficiaries. Suppliers of DMEPOS will bill the DME MACs.

D. Specialty Providers and Demonstrations
Specialty providers, and providers involved with certain demonstrations, will submit claims to a specific MAC designated by CMS. A list of those specialty services and their designated MACs is reflected in the following table:

MACs Designated to Process Specialty or Demonstration Claims
Specialty Service or
Demonstration 		MAC Jurisdiction
Centralized Billing for Mass Immunizers 4
Indian Health Services 4
Low Vision Demonstration 5,10, 11, 13, and 14
Rural Community Hospital Demonstration 1, 2, 4 and 5
Veterans Affairs Medicare Equivalent Remittance Advice Project 4
Chiropractic Services Demonstration 4 and 5
Home Health Third Party Liability Demonstration Project 14
Medicare Adult Day Care Demonstration 11, 14 and 15
Independent Organ Procurement Organizations 10
Religious Non-medical Health Care Institution (RNHCI) 10
Histocompatibility Lab 10

The following material describes the demonstrations and specialty providers listed above. Generally, a provider will already know whether or not it is participating in one of these categories.

Centralized Billing for Mass Immunizers - In order to encourage providers to supply flu and pneumococcal (PPV) vaccinations to Medicare beneficiaries, CMS currently authorizes a limited number of providers to centrally bill for flu and PPV immunization claims. Centralized billing is an optional program available to providers who qualify to enroll with Medicare as the provider type "Mass Immunizer," as well as to other individuals and entities that qualify to enroll as regular Medicare providers. Centralized billers must roster bill, must accept assignment, and must bill electronically.

To qualify for centralized billing, a mass immunizer must be operating in at least three payment localities for which there are three different carriers processing claims. Centralized billers must send all claims for flu and PPV immunizations to a single carrier for payment, regardless of the carrier jurisdiction in which the vaccination was administered and the carrier must make payment based on the payment locality where the service was provided. IOM Pub. 100-04, Chapter 18, Sections 10.3 and 10.3.1 provide more specific information related to this activity.

Indian Health Services - The Indian Health Service (IHS) is the primary health care provider to Medicare beneficiaries who are members of federally recognized tribes living on or near reservations. The Indian health care system, consisting of tribal, urban, and federally operated IHS health programs, delivers a spectrum of clinical and preventive health services to its beneficiaries via a network of hospitals (including CAHs), freestanding clinics, FQHCs, RHCs and other entities.

While §§1814(c) and 1835(d) of the Social Security Act (the Act), as amended, generally prohibit payment to any Federal agency, passage of the Indian Health Care Improvement Act (IHCIA) in 1976 provided for an exception, amending §1880 of the Act, for facilities of the IHS whether operated by such Service or by an Indian tribe or tribal organization (as defined in section 4 of the IHCIA). The exception under § 1880 limited payment to Medicare services provided in hospitals and skilled nursing facilities.

Effective July 1, 2001, the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), §432 extended payment on a fee-for-service (FFS) basis to services of physician and non-physician practitioners furnished in IHS hospitals and freestanding clinics. This means that clinics associated with hospitals and freestanding clinics that are owned and/or operated by IHS are authorized to bill only the Jurisdiction 4 MAC. Additionally, Tribal health facilities operated under Indian Self Determination Education and Assistance Act (ISDEAA) authorities are an extension of the IHS and considered facilities of the IHS. By virtue of this, they are authorized to bill the Jurisdiction 4 MAC. ISDEAA authorities rovide flexibilities to tribes in the administration of their programs that are not provided to general public providers.

Low Vision Demonstration - The Secretary of the Department of Health and Human Services is directed to carry out an outpatient vision rehabilitation demonstration project as part of the FY 2004 appropriations conference report to accompany Public Law HR 2673. This demonstration project will examine the impact of standardized Medicare coverage for vision rehabilitation services provided in the home, office, or clinic, under the general supervision of a physician. The services may be supplied by the following:

This demonstration will last for five (5) years through March 31, 2011, and is limited to services provided specifically in New Hampshire, New York City (all 5 boroughs), North Carolina, Atlanta, Kansas, and Washington State.

Rural Community Hospital Association - The RCH Demonstration Program was mandated by section 410A of the MMA. The Secretary is required to conduct the RCH Demonstration, lasting five (5) years, to test the advisability and feasibility of establishing RCHs to provide Medicare covered inpatient hospital services in rural areas. This Demonstration will allow selected rural hospitals to benefit from cost-based reimbursement for inpatient services.

The Secretary is required to select not more than fifteen (15) hospitals to participate in the demonstration in States with low population densities. Currently, thirteen (13) hospitals participate in the program, serviced by seven different Fiscal Intermediaries (FIs).

Veteran Affairs Medicare Equivalent Remittance Advice Project - Current law permits the Department of VA to collect appropriate Medicare coinsurance and deductible amounts from supplemental insurers for claims for supplies and services ordinarily covered by Medicare but furnished:

To facilitate this process, the Centers for Medicare & Medicaid Services (CMS) entered into an interagency agreement with the VA whereby the CMS will help the VA work with a CMS contractor to adjudicate these claims to produce a remittance advice equivalent that ordinarily produced for Medicare claims. The remittance advice, sent to the supplemental insurers, will help the insurers determine payment amounts they owe to the VA. The CMS will not pay these claims. Trailblazer was the contractor selected to perform the work.

Chiropractic Services Demonstration - Section 651 of the MMA requires the Centers for Medicare & Medicaid Services (CMS) to conduct the Expansion of Coverage for Chiropractic Services Demonstration. The purpose of the demonstration is to evaluate the feasibility and advisability of expanding coverage of chiropractic services under Medicare. The demonstration is for two years and must be conducted in four geographic areas—two rural and two urban.

Home Health Third Party Liability Demonstration - The CMS and the States of Connecticut, Massachusetts, and New York have developed a demonstration program that will use a sampling approach to determine the Medicare share of the cost of home health services claims for dual eligible beneficiaries that were submitted to and paid by the Medicaid agencies. Sampling will be used in lieu of individually gathering Medicare claims from home health agencies (HHAs) for every dual eligible Medicaid claim each State may have paid in error. This process will eliminate the need for the HHAs to assemble, copy, and submit large numbers of medical records. The project currently covers the home health claims incurred in fiscal years (FY) 2000 through 2007 for Massachusetts and New York and FY 2001 through 2005 for Connecticut.

Medicare Adult Day Care Demonstration - Section 703 of the MMA directs CMS to conduct a demonstration project that will test an alternative approach to the delivery of Medicare home health services. Under this demonstration, Medicare beneficiaries receiving home health may be eligible to receive medical adult day care services as a substitute for a portion of home health services that would otherwise be provided in the beneficiary's home. The statute requires the demonstration to run for a period of three (3) years at no more than five (5) HHA sites in states that license certified medical adult day care facilities.

Implementation of the demonstration began at five (5) sites on August 1, 2006. Participation of Medicare beneficiaries is voluntary; up to 15,000 beneficiaries at any time will be eligible to enroll in the three (3)-year demonstration.

Medicare Home Health Agency Provider Enrollment Demonstration - This demonstration is designed to combat fraudulent home health activity in the Houston and Los Angeles areas. The principal provider enrollment task will be the revalidation of all HHAs in said areas.

Independent Organ Procurement Organizations – An Organ Procurement Organization performs or coordinates the retrieval, preservation, and transportation of organs and maintains a system of locating prospective recipients for available organs.

Religious Non-Medical Health Care Institutions – A RNHCI provides care to beneficiaries in need of skilled nursing facility care or hospital care when the beneficiary's religious beliefs preclude admission to one of these institutional providers. This does not mean that the beneficiary will receive hospital or SNF care in the RNHCI, but that the beneficiary elected to pursue a religious approach to healing. Since the use of diagnoses or medical oversight is prohibited in a RNHCI, they are not candidates for any CMS existing PPS and continue to be paid using the TEFRA methodology.

Histocompatibility Lab - Histocompatibility Laboratories provide services related to tissue typing testing for possible organ recipients and donors to determine compatibility for an organ transplant. They operate on a cost reimbursement basis and bill transplant centers for their services.

E. The Geographic-Assignment Rule
Providers that are not within one of the categories described above (HH&H, DME, RRB, or specialty & demos) will be assigned to the MAC that covers the state where the provider is located. There are two exceptions.

First a qualified chain provider (QCP) may request that its member providers be serviced by a single A/B MAC - specifically, the A/B MAC that covers the state where the QCP's home office is located. The regulation at 42 CFR 421.404(b)(2) defines a qualified chain provider (QCP) as:

CMS may assign non-QCP providers, as well as End Stage Renal Disease (ESRD) providers to an A/B MAC outside of the prevailing geographic assignment rule only to support the implementation of the MACs or to serve some other compelling interest of the Medicare program.
The second exception is for providers that meet the "provider-based" criteria of 42 CFR 413.65. Provider-based entities (other than HH+H providers) will be assigned to the MAC that covers the state where the main ("parent") provider is assigned.

IV. Where will providers be assigned in the interim?
All existing providers with a Medicare claims history will remain in their current FI assignments until their workload is transferred to an A/B MAC. The "change of intermediary" process ended for individual providers in 2005, and ended for chain providers in 2007. A change of ownership now serves only to update CMS provider data with information about the new owner.

The workload currently serviced by a legacy FI will be absorbed by the incoming MAC within the 12 months following the award of MAC contract. In some situations the workload transition may be delayed by an award protest.

New providers enrolling with Medicare will be assigned to the FI or MAC that covers the state where the provider is physically located, with a few exceptions:

The other exceptions track the MAC-world assignment rules discussed in Sections III-A through III-D above.

V. How long will my interim assignment last?
An "out-of-jurisdiction provider" (OJP) is a provider that is not currently assigned to the A/B MAC or FI in accordance with Sections III-A through III-D above (including the geographic assignment rule.) For example, an individual, freestanding provider located in Oregon, but currently assigned to the Florida FI, would be an OJP.

New MACs will initially service some OJPs until CMS undertakes the final reassignment of all OJPs to their destination MACs based on the geographic assignment rule.

CMS will start the overall transfer of OJPs to their final destination MACs after two events have taken place. The first event is when all 15 A/B MACs have been awarded and implemented. The second event is when all the systems and contractors that support the claims processing, provider enrollment, and cost report auditing functions at the departure and destination MACs are capable of supporting the move.

Additional Information
For complete details regarding this CR please see the official instruction (CR5979) issued to your Medicare FI, A/B MAC, or RHHI. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R333OTN.pdf on the CMS Web site. To view any of the federal regulations cited in this article or in CR5979, visit http://www.cms.hhs.gov/Transmittals/downloads/R333OTN.pdf on the Internet.

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

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Attention Part B Medicare Providers: Provider Enrollment Training Now Available on the CGS Web site!

You asked for help, and CGS has delivered. We are happy to inform the Provider Community that we have added Provider Enrollment Online Education Courses to the CGS Web site.

These courses are designed to provide an overview of the enrollment process, help providers decide which application to complete based on their situation, and to assist providers in completing the CMS 855 Enrollment Applications.

These online education courses are available at the following links to the CIGNA Government Services Web site:
http://www.cignagovernmentservices.com/medicare_dynamic/Education/index.asp
http://www.cignagovernmentservices.com/partb/enrollment/index.html

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Average Sales Price (ASP) Updates

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 who submit claims to Medicare contractors (carriers, fiscal intermediaries (FIs), Part A/B Medicare Administrative Contractors (A/B MACs), and DME Medicare Administrative Contractors (DME MACs)) for services provided to Medicare beneficiaries.

Provider Action Needed
This article is based on Change Request (CR) 5798 and provides you with updates and additions to language in the Medicare Claims Processing Manual relating to the ASP drug pricing and payment methodology. This article is informational to advise providers that the information is now in the Medicare manual and this information has been supplied in prior MLN Matters articles.

Key Points
The Centers for Medicare & Medicaid Services (CMS) provides an ASP file to each FI, carrier, DME MAC, and A/B MAC for pricing drugs. Each FI, carrier, DME MAC, and A/B MAC must accept the ASP files made available by CMS for pricing bills/claims for any drug identified on the price files as these files are the single national payment limit established by CMS.

ASP Payment Methodology

Exceptions to the ASP Payment Methodology

Additional Information
You may see the official instruction (CR5798) issued to your Medicare contractor by visiting http://www.cms.hhs.gov/Transmittals/downloads/R1513CP.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.

The ASP methodology files are posted at
http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/ on the CMS Web site.

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Blood-Derived Products for Chronic, Non-Healing Wounds

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 submitting claims to Medicare contractors (carriers, Fiscal Intermediaries (FIs), and/or Part A/B Medicare Administrative Contractors (A/B MACs)) for services provided to Medicare beneficiaries.

Provider Action Needed

STOP – Impact to You
This article is based on Change Request (CR) 6043 which provides the Centers for Medicare & Medicaid Services (CMS) updated policy regarding autologous blood-derived products for chronic, non-healing wounds.

CAUTION – What You Need to Know
Effective March 19, 2008, CMS is maintaining its current non-coverage determination for autologous platelet rich plasma (PRP) for the treatment of chronic, non-healing cutaneous wounds, and issuing a non-coverage determination for acute surgical wounds when the autologous PRP is applied directly to the closed incision and for dehiscent wounds.

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

Background
In 1992, the Centers for Medicare & Medicaid Services (CMS) issued a national non-coverage determination for autologous, platelet-derived wound healing formulas intended to treat patients with chronic, non-healing wounds.

In December 2003, CMS issued a national non-coverage determination for use of autologous platelet rich plasma (PRP) for the treatment of chronic non-healing cutaneous wounds except for routine costs when used in accordance with the clinical trial policy defined in the Medicare National Coverage Determinations (NCD) Manual (Section 310.1; see http://www.cms.hhs.gov/manuals/downloads/ncd103c1_Part4TXT.pdf on the CMS Web site).

In April 2005, CMS issued an NCD to correct the erroneous potential for local coverage of becaplermin, a non-autologous growth factor for chronic non-healing subcutaneous wounds, stating that, because it is usually self-administered, it would remain nationally non-covered under Part B based on the Social Security Act (Section 1861(s)(2)(A) and (B); see http://www.ssa.gov/OP_Home/ssact/title18/1861.htm on the Internet).

On March 19, 2008, CMS issued a Decision Memorandum following a National Coverage Analysis to evaluate the use of autologous blood-derived products for the treatment of chronic, non-healing cutaneous wounds, specifically the use of autologous PRP for the treatment of acute wounds where PRP is applied directly to the closed incision site, or for dehiscent wounds.

CMS determined that the evidence is inadequate to conclude that autologous PRP for the treatment of chronic non-healing cutaneous wounds, acute surgical wounds when the autologous PRP is applied directly to the closed incision, or dehiscent wounds, improves health outcomes in the Medicare population.

Therefore, effective March 19, 2008, CMS is maintaining its current non-coverage determination for autologous PRP for the treatment of chronic, non-healing cutaneous wounds, and issuing a non-coverage determination for acute surgical wounds when the autologous PRP is applied directly to the closed incision and for dehiscent wounds. Effective for claims with dates of service on or after March 19, 2008, the use of autologous PRP for the treatment of acute surgical wounds where the PRP is applied directly to the closed incision, or dehiscent wounds, will be denied by Medicare contractors.

Additional Information
The official instruction, CR 6043, issued to your carrier, FI, and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R83NCD.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.

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CIGNA Government Services Allowable Amounts for the Drugs Emend and Treanda

***UPDATE***

Effective May 1st, 2008, the allowable amounts for the drugs Emend and Treanda are as follows:
  Participating Non-participating
fosaprepitant dimeglumine for Injection (Emend): $185.500 $176.225
bendamustine (Treanda) $1,908.000 $1,812.600

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Clinical Laboratory Fee Schedule - New Waived Tests

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. The Clinical Laboratory Fee Schedule Fact Sheet, is also available in print format. To place your order, visit http://www.cms.hhs.gov/mlngeninfo/, scroll down to "Related Links Inside CMS" and select "MLN Product Ordering Page."

Provider Types Affected
Clinical diagnostic laboratories that bill Medicare Carriers or Part A/B Medicare Administrative Contractors (A/B MACs) for laboratory tests.

What You Need to Know
CR 6021 announces the latest tests that the Food and Drug Administration (FDA) has approved (effective July 1, 2008) as waived tests under the Clinical Laboratory Improvement Amendments of 1988 (CLIA).

Please be aware that In order for a laboratory with a valid, current certificate of waiver to bill for these tests, the assigned Current Procedural Terminology (CPT) codes must contain the QW modifier. The new waived tests, CPT codes, and effective dates for each are provided in Table 1, below.

Make sure that your billing staffs are aware of these newly approved FDA waived tests under CLIA.

Background
Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations require that a laboratory facility be appropriately certified for each test that it performs. Further, these regulations require facilities with a Certificate of Waiver (COW) to perform only CLIA waived tests

Note: To ensure that Medicare only pays laboratories with a CLIA certificate of waiver for tests that are approved as waived complexity under the Clinical Laboratory Fee Schedule (CLFS), laboratory claims are currently edited at the CLIA certificate level.

In addition, the Centers for Medicare & Medicaid Service (CMS) is mandated by Section 1833(h) of the Social Security Act to add updated test codes to the CLFS, and CR 6021 announces the latest tests that the FDA has approved as waived tests under CLIA.

In order for a CLIA-enrolled, waived laboratory to bill for these tests, the Current Procedural Terminology (CPT) codes associated with them must contain a QW modifier. Table 1, below, lists the CPT codes, descriptions, and effective dates for these latest tests that the FDA has approved as waived tests under CLIA. Please note that the CPT codes for the tests in the table must have the modifier QW to be recognized as waived tests.

Table 1
FDA-Approved Waived Tests under CLIA
CPT Code Description
80047QW
dates of service on or after January 1, 2008 		Basic Metabolic Panel (Calcium, Ionized)
80048QW
dates of service on or after January 16, 2008 		Basic Metabolic Panel, (Calcium, total)
80051QW
dates of service on or after October 30, 2007 		Electrolyte Panel
80053QW
dates of service on or after January 16, 2008 		Comprehensive Metabolic Panel
82042QW
dates of service on or after October 4, 2006 		Albumin; Urine or Other source, Quantitative, Each Specimen
82150QW
dates of service on or October 4, 2006 		Amylase
82247QW
dates of service on or after October 4, 2006 		Bilirubin; Total
82977QW
dates of service on or after October 4, 2006 		Glutamyltransferase, Gamma (GGT)
84075QW
dates of service on or after October 4, 2006 		Phosphatase, Alkaline
84157QW
dates of service on or after October 4, 2006 		Protein, Total, Except by Refractometry; Other Source (e.g., Synovial Fluid, Cerebrospinal Fluid)
84520QW
dates of service on or after October 4, 2006 		Urea Nitrogen; Quantitative
87808QW
dates of service on or after January 1, 2007 		Infectious Agent Antigen Detection by Immunoassay with Direct Optical Observation; Trichomonas Vaginalis
87999QW
dates of service on or after July 1, 2007 		Unlisted Microbiology Procedure

Be aware that carriers and A/B MACS will not search their files to either retract payment or retroactively pay claim processed prior to implementation of CR6021, but they will adjust such claims if you bring them to their attention.

Additional Information
You can find the official instruction to your carrier or A/B MAC by going to CR 6021, located at http://www.cms.hhs.gov/Transmittals/downloads/R1527CP.pdf on CMS Web site.

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.

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Date of Service (DOS) for Clinical Laboratory and Pathology Specimens

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. The Clinical Laboratory Fee Schedule Fact Sheet, is also available in print format. To place your order, visit http://www.cms.hhs.gov/mlngeninfo/, scroll down to "Related Links Inside CMS" and select "MLN Product Ordering Page."

Provider Types Affected
Providers who submit claims to Medicare Administrative Contractors (A/B MACs), fiscal intermediaries (FIs) or carriers, for laboratory tests, or the technical component of physician pathology services, provided to Medicare beneficiaries.

Impact on Providers
This article is based on Change Request (CR) 6018 alerting providers that the Centers for Medicare & Medicaid Services (CMS) revised the DOS policy for clinical laboratory tests and added the technical component of physician pathology service effective January 1, 2009. These changes were announced in the final Medicare physician fee schedule rule published in the Federal Register on November 27, 2007 (42 CFR § 414.510).

Key Points of CR6018
The DOS policy as specified in 42 CFR § 414.510 for either a clinical laboratory test or the technical component of physician pathology service is as follows:

The following two exceptions apply to this DOS policy for either a clinical laboratory test or the technical component of physician pathology service:

  1. DOS for Tests/Services Performed on Stored Specimens:
    In the case of a test/service performed on a stored specimen, if a specimen was stored for less than or equal to 30 calendar days from the date it was collected, the DOS of the test/service must be the date the test/service was performed only if:
    • The test/service is ordered by the patient's physician at least 14 days following the date of the patient's discharge from the hospital;
    • The specimen was collected while the patient was undergoing a hospital surgical procedure;
    • It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted;
    • The results of the test/service do not guide treatment provided during the hospital stay; and
    • The test/service was reasonable and medically necessary for treatment of an illness.

If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have been archived and the DOS of the test/service must be the date the specimen was obtained from storage.

  1. DOS for Chemotherapy Sensitivity Tests/Services Performed on Live Tissue:
    In the case of a chemotherapy sensitivity test/service performed on live tissue, the DOS of the test/service must be the date the test/service was performed only if:

For purposes of applying the above exception, a "chemotherapy sensitivity test" is defined as a test that requires a fresh tissue sample to test the sensitivity of tumor cells to various chemotherapeutic agents. CMS identifies such tests through program instructions issued to the Medicare contractors.

Additional Information
For complete details regarding this CR please see the official instruction (CR6018) issued to your Medicare FI, A/B MAC, or carrier. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1515CP.pdf on the CMS Web site.

If you have questions, please contact your Medicare FI, 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.

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

News Flash ― Now available ― CMS' Newly Redesigned DMEPOS Competitive Bidding Web Page. This dedicated Web page provides one-stop shopping for Medicare providers, suppliers, and referral agents who want the most current and reliable information on this new program. Features include links to policy information such as the Metropolitan Statistical Areas and Product Categories included in Round One, Federal regulations, notices and manual instructions, provider educational products and resources, Frequently Asked Questions, and more. You can see the latest announcements and communications sent to the Medicare provider community here as well. The web address is: http://www.cms.hhs.gov/DMEPOSCompetitiveBid. We encourage you to bookmark this NEW page as we will continue to post new information and resources!

Note: This article was revised on June 2, 2008, to add the Web address for viewing the new Chapter 36 of the Medicare Claims Processing Manual. That chapter contains the initial, official manual instructions for the DMEPOS Competitive Bidding Program. All other information remains the same.

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:

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.

CMS has released a new Chapter 36 of the Medicare Claims Processing Manual. This chapter is part of CR5978 and contains the initial, official manual instructions for this program. The MLN Matters article related to CR5978 is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5978.pdf on the CMS Web site.

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/DMEPOSCompetitiveBid/ on the CMS Web site or http://www.dmecompetitivebid.com/ on the Internet for more details.

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From AdvanceMed Corporation: Place of Service Coding for Physician Services

Medicare has established facility versus non-facility rates for services performed by physicians. The non-facility rates such as place of service 11 (office) have a higher payment rate to adjust for overhead costs incurred by physicians. The facility rate such as place of service 22 (hospital) should be billed where a physician's office is located within the hospital. If the facility furnishes the office space at no charge to the provider, then the facility is entitled a facility fee from Part A and the Part B provider would not bill Place of Service (POS) 11.

Physicians are required to identify the place of service on the claims they submit to Medicare. This ensures that correct payment is made and duplicate payments to the facility and physician are avoided. For physicians to receive the higher non-facility payment for a service, the service must meet the requirements of 42 CFR §414.22(b)(5)(i)(B), which states in part:

The provider should refer to the National POS Code Set, which provides facility and non-facility designations for Medicare payment for services that are listed on the Physician Fee Schedule.

AdvanceMed conducted a study to identify Medicare Part B services submitted with place of service 11 (office) where a Part A facility fee was paid by Medicare for the same beneficiary on the same date of service. Claims data was compiled from January 1, 2004 through December 31, 2006 for paid services billed by Part B physicians for office visits and consultations. The Part B data was matched to the Part A data on the same beneficiary receiving a service from the same procedure code ranges in both the Part B office setting as well as the Part A outpatient setting. The paid services included the following Current Procedural Terminology (CPT) codes:

99201 – 99205
99211 – 99215
99241 - 99245

The results of this study identified numerous Medicare providers that met the above criteria. AdvanceMed has assessed overpayments and educated the providers that were discovered in the facility versus non-facility study.

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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 ― Now available ― CMS' Newly Redesigned DMEPOS Competitive Bidding Web Page. This dedicated Web page provides one-stop shopping for Medicare providers, suppliers, and referral agents who want the most current and reliable information on this new program. Features include links to policy information such as the Metropolitan Statistical Areas and Product Categories included in Round One, Federal regulations, notices and manual instructions, provider educational products and resources, Frequently Asked Questions, and more. You can see the latest announcements and communications sent to the Medicare provider community here as well. The Web address is: http://www.cms.hhs.gov/DMEPOSCompetitiveBid. We encourage you to bookmark this NEW page as we will continue to post new information and resources!

Note: This article was revised on June 2, 2008, to add the Web address for viewing the new Chapter 36 of the Medicare Claims Processing Manual. That chapter contains the initial, official manual instructions for the DMEPOS Competitive Bidding Program. All other information remains the same.

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
CMS has released a new Chapter 36 of the Medicare Claims Processing Manual. This chapter is part of CR5978 and contains the initial, official manual instructions for this program. The MLN Matters article related to CR5978 is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5978.pdf on the CMS Web site.

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.dmecompetitivebid.com/palmetto/cbic.nsf/DocsCat/Home on the Internet and at http://www.cms.hhs.gov/DMEPOSCompetitiveBid/ on the CMS Web site for more details.

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July Quarterly Update for 2008 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule

News Flash ― Now available ― CMS' Newly Redesigned DMEPOS Competitive Bidding Web Page. This dedicated Web page provides one-stop shopping for Medicare providers, suppliers and referral agents who want the most current and reliable information on this new program. Features include links to policy information such as the Metropolitan Statistical Areas and Product Categories included in Round One, Federal regulations, notices and manual instructions, provider educational products and resources, Frequently Asked Questions, and more. You can see the latest announcements and communications sent to the Medicare provider community here as well. The Web address is: http://www.cms.hhs.gov/DMEPOSCompetitiveBid. We ncourage you to bookmark this NEW page as we will continue to post new information and resources!

Note: This article was revised on June 2, 2008, to reflect an effective date (see above) of January 1, 2008. All other information remains the same.

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

Provider Action Needed
This article is based on Change Request (CR) 6022, which provides the quarterly update to the July 2008 DMEPOS fee schedules in order to implement fee schedule amounts for new codes and to revise any fee schedule amounts for existing codes that were calculated in error. Be sure your billing staffs are aware of these changes.

Background
This recurring update notification, CR6022, provides specific instructions regarding the July quarterly update for 2008 for the DMEPOS fee schedule. Payment on a fee schedule basis is required for durable medical equipment (DME), prosthetic devices, orthotics, prosthetics, and surgical dressings by §1834(a), (h), and (i) of the Social Security Act. Payment on a fee schedule basis is required for parenteral and enteral nutrition (PEN) by regulations contained at 42 CFR 414.102.

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

Key Points
The following Healthcare Common Procedure Coding System (HCPCS) codes were added to the HCPCS file effective January 1, 2008 and the fee schedule amounts for these HCPCS codes may be established as part of this update and are effective for claims with dates of service on or after January 1, 2008.

The following Healthcare Common Procedure Coding System (HCPCS) codes were added to the HCPCS file effective January 1, 2008
Code Description Code Description
A5083 Continent device, stoma absorptive cover for continent stoma. E0856 Cervical traction device, cervical collar with inflatable air bladder.
E2227 Manual wheelchair accessory, gear reduction drive wheel, each. E2228 Manual wheelchair accessory, wheel braking system and lock, complete, each.
E2397 Power wheelchair accessory, lithium-based battery, each. L3927 Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip),without joint/spring, extension/flexion (e.g. static or ring type), may include soft interface material, prefabricated, includes fitting and adjustment.
L7611 Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric. L7612 Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric
L7613 Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric L7614 Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric
L7621 Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined. L7622 Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined.
 
The fee schedule amounts for the following codes are being revised as part of this quarterly update to correct fee schedule calculation errors
Code Description Code Description
L3905 Wrist hand orthosis, includes one or more nontorsion joints, elastic bands. Turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment. L3806 Wrist hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material straps, custom fabricated, includes fitting and adjustment.
L3808 Wrist hand finger orthosis, rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment.    

Additional Information
For complete details regarding this CR please see the official instruction (CR6022) issued to your Medicare contractor. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1516CP.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.

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July Quarterly Update to 2008 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement

News Flash — Effective July 1, 2008, Medicare will begin implementation of a new program for purchasing DMEPOS for Medicare patients. For Medicare beneficiaries whose permanent residence is in 1 of the 10 metropolitan statistical areas (MSAs) affected by the first phase of this program, only contract suppliers, in most instances, will be eligible to provide competitive bid items and receive payment from Medicare. While new payment rules may not impact referral agents directly, they may impact your patients.

For more information on this program, please refer to MLN Matters articles located at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0805.pdf,
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0806.pdf, http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0807.pdf, or visit at http://www.cms.hhs.gov/CompetitiveAcqforDMEPOS/ on the CMS Web site.

Provider Types Affected
Providers submitting claims to Medicare contractors (carriers, Fiscal Intermediaries (FIs), and/or Part A/B Medicare Administrative Contractors (A/B MACs)) for services provided to Medicare beneficiaries in Skilled Nursing Facilities.

Provider Action Needed
This notification provides updates to the lists of Healthcare Common Procedure Coding System (HCPCS) codes that are subject to the consolidated billing provision of the SNF Prospective Payment System (PPS). CR 6009 adds HCPCS code J9303 (Injection, Panitumumab, 10MG) to the Major Category III.A. Chemotherapy services FI/A/B MAC Exclusion List retroactive to January 1, 2008.

Background
The Social Security Act (Section 1888) codifies the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) and Consolidated Billing (CB). The new coding identified in each update describes the same services that are subject to SNF PPS payment by law. No additional services are added by these routine updates; that is, new updates are required by changes to the coding system, not because the services subject to SNF CB are being redefined. Other regulatory changes beyond code list updates will be noted when and if they occur.

The Centers for Medicare & Medicaid Services (CMS) periodically updates the lists of HCPCS codes that are not subject to the consolidated billing provision of the SNF PPS. Services not appearing on this list submitted on claims to FIs/A/B MACs and carriers/A/B MACS, including DME MACs, will not be paid by Medicare to providers, other than a SNF, when included in SNF Consolidated Billing (CB).

For non-therapy services, SNF CB applies only when the services are furnished to a SNF resident during a covered Part A stay. However, SNF CB applies to physical and occupational therapies and speech-language pathology services whenever they are furnished to a SNF resident, regardless of whether Part A covers the stay. Services excluded from SNF PPS and CB may be paid to providers, other than SNFs, for beneficiaries, even when in a SNF stay. In order to assure proper payment in all settings, Medicare systems will edit for services provided to SNF beneficiaries both included and excluded from SNF CB.

CR 6009 adds HCPCS code J9303 to the Major Category III.A. Chemotherapy services FI/A/B MAC Exclusion List retroactive to January 1, 2008.

Medicare contractors will reopen and reprocess claims affected by this instruction when providers bring such claims to their contractor's attention.

Additional Information
The official instruction, CR 6009, issued to your carrier, FI, and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1501CP.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.

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

News Flash ― Effective July 1, 2008, Medicare will begin implementation of a new program for purchasing DMEPOS for Medicare patients. For Medicare beneficiaries whose permanent residence is in 1 of the 10 metropolitan statistical areas (MSAs) affected by the first phase of this program, only contract suppliers, in most instances, will be eligible to provide competitive bid items and receive payment from Medicare. While new payment rules may not impact referral agents directly, they may impact your patients. For more information on this program, please refer to MLN Ma