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August 5, 2008 Part B Medicare Bulletin

Posted August 5, 2008

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2008 Physician Quality Reporting Initiative (PQRI) Establishment of Alternative Reporting Periods and Reporting Criteria

News Flash ― Upcoming Training for the Medicare Part B Drugs Competitive Acquisition Program (CAP) - Noridian Administrative Services, the designated carrier for the CAP, offers interactive, online workshops about the CAP for Part B Drugs and Biologicals. These workshops train CAP vendors and elected physicians on a number of CAP topics and requirements such as billing for CAP claims, and NAS personnel are available to answer questions. Physicians and/or their staff are strongly encouraged to attend. Interested parties may view additional information about and register for these workshops at https://www.noridianmedicare.com/cap_drug/train/workshops/index.html on the Internet.

Note: This article was revised on July 2, 2008, to remove the phrase "on 15 consecutive patients" from the first two G code descriptions on page 8 of the article. All other information remains the same.

Provider Types Affected
Physicians and other practitioners who qualify as eligible professionals to participate in the Centers for Medicare & Medicaid Services (CMS) Physician Quality Reporting Initiative (PQRI)

What You Need to Know
CMS is taking steps to encourage physicians and other eligible professionals to participate in the Physician Quality Reporting Initiative (PQRI), a program designed to improve the quality of care provided to Medicare beneficiaries. CR 6104, from which this article is taken, announces the establishment of alternative reporting periods and alternative criteria for satisfactorily reporting quality measures for the 2008 PQRI.

Make sure that your billing staffs are aware of the PQRI reporting changes.

Background
The 2006 Tax Relief and Health Care Act (TRHCA) (P.L. 109-432) required the CMS to establish the PQRI, that included an incentive payment for eligible professionals who satisfactorily reported data on quality measures for covered services furnished to Medicare beneficiaries during the second half of 2007 (the 2007 reporting period).

Under this program, CMS paid eligible professionals, who satisfactorily reported such data, an incentive payment equivalent to 1.5% of their total allowed charges for Medicare Physician Fee Schedule (MPFS)-covered professional services (referred to as total allowed charges) furnished during the 2007 reporting period (July 1, 2007 – December 31, 2007). The statute defines satisfactory reporting to be reporting of up to 3 applicable measures in at least 80% of the cases in which such measures are reportable. A total of 74 clinical quality measures were available for reporting for 2007, which occurred only via claims.

TRHCA also required that CMS establish a PQRI measure set for 2008. The 2008 set:

The Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA – Public Law 110-173), enacted on December 29, 2007, authorizes CMS to make PQRI incentive payments for satisfactory reporting quality measures data for services furnished in 2008. For 2008, eligible professionals who meet the criteria for satisfactory submission of quality measures data on services furnished during the reporting period (January 1, 2008 – December 31, 2008) will earn an incentive payment of 1.5% of their total allowed charges for PFS covered professional services furnished during that same period (the 2008 calendar year).

MMSEA also requires that, for 2008 and 2009, the Secretary of Health and Human Services (HHS) establish alternative reporting periods and criteria for the satisfactory reporting of measure groups; and for satisfactorily reporting quality measures data through registries. Thus, in 2008, eligible professionals may earn the incentive payment based on data submitted through these alternative mechanisms. Also, please note that while TRHCA established a cap on incentive payments for 2007 (based on an average per measure payment amount) there is no cap on incentive payments under MMSEA for 2008 and 2009.

CR 6104, from which this article is taken announces the establishment of the MMSEA-mandated alternative reporting periods and alternative criteria for satisfactorily reporting 2008 PQRI quality measures.

Measures Groups
There are four measures "groups" for the 2008 PQRI: 1) Diabetes Mellitus; 2) End Stage Renal Disease; 3) Chronic Kidney Disease (CKD); and 4) Preventive Care. Each of the measure groups contains at least four PQRI measures.

The individual Diabetes Mellitus Measures are:

The individual ESRD measures are:

The individual measures for CKD are:

The individual measures in the Preventive Care group are:

Note: If you elect to report a group of measures, you must report all of the measures in the group that are applicable to the patient.

General Reporting Guidance for Professionals
CR 6104 also contains some general guidance about reporting PQRI measures that you may find to be helpful before the alternative reporting periods and criteria are described:

Guidance for Registries

Alternative Reporting Periods and Reporting Options
A description of the MMSEA-mandated alternative reporting periods and alternative criteria for satisfactorily reporting 2008 PQRI quality measures follows. There are two alternative reporting periods and nine options for the 2008 PQRI.

  1. The claims-based reporting mechanism for measures groups will be first available July 1, 2008, therefore the July 1, 2008 – December 31, 2008 reporting period applies only when using the claims-based option to report measure groups.
  2. Both reporting periods apply when using the registry-based option to report both measure groups and individual measures.

A description of each option follows:

Option 1 – Reporting individual measures using the claims-based option (reporting period January 1, 2008 – December 31, 2008)

If you elect the claims-based option to report individual measures, you must report 3 measures (or 1 – 2 measures if less than 3 measures apply to you) on 80% of applicable patient claims for 1 – 3 measures).

Option 2 – Reporting measure groups using the claims-based option (reporting period July 1, 2008 – December 31, 2008)

If you elect the claims-based option to report measure groups, you must report all of the measures in one measure group that apply to each of 15 consecutive patients. To start the count of the 15 consecutive patients, you should report the measure group specific "G code" on the claim for the first of these patients.

Option 3 – Reporting measure groups using the claims-based option (reporting period July 1, 2008 – December 31, 2008)

If you elect the claims-based option to report measures groups, you must report all measures in one measures group on 80% of patients for the applicable measures group during the reporting period. You should report the measures group specific "G code" or the claim to indicate the intent to report the measures group.

Option 4 – Reporting individual measures using the registry-based option (reporting period January 1, 2008 – December 31, 2008)

If you elect the registry-based option to report individual measures, you must report at least 3 measures on 80% of applicable Medicare FFS patients.

Option 5 – Reporting individual measures using the registry-based reporting option (reporting period July 1, 2008 – December 31, 2008)

If you elect the registry-based option to report individual measures, you must report at least 3 PQRI measures on 80% of applicable Medicare FFS patients

Option 6 – Reporting measure groups using the registry-based reporting option (reporting period July
1, 2008 – December 31, 2008)

If you elect to use the registry-based option to report measure groups, you must report all of the measures in one measure group that apply to each of 15 consecutive patients. The consecutive patients may include (but not be exclusively) non-Medicare patients. The reporting of a measures group specific "G-code" is not required for registry-based reporting.

Option 7 – Reporting measure groups using the registry-based reporting option (reporting period January 1, 2008 – December 31, 2008)

If you elect to use the registry-based option to report measure groups, you must report all of the measures in one measure group that apply to each of 30 consecutive patients. The consecutive patients may include (but not be exclusively) non-Medicare patients. The reporting of a measures group specific "G-code" is not required for registry-based reporting.

Option 8 – Reporting measure groups using the registry-based reporting option (reporting period July 1, 2008 – December 31, 2008)

If you elect to use the registry-based option to report measure groups, you must report all of the measures in one measure group on 80% of Medicare FFS patients for the applicable measures group on services provided during the reporting period. The reporting of a measures group specific "G-code" is not required for registry-based reporting.

Option 9 – Reporting measure groups using the registry-based option (reporting period January 1, 2008 – December 31, 2008)

If you elect to use the registry-based option to report measure groups, you must report all of the measures in one measure group on 80% of Medicare FFS patients for the applicable measures group for services provided during the reporting period. The reporting of a measures group specific "G-code" is not required for registry-based reporting.

HCPCS Codes
Effective for dates of service on or after July 1, 2008, Medicare carriers and A/B MACs will recognize the following Healthcare Common Procedure Coding System (HCPCS) codes, which will be included in the July Update to the 2008 MPFS Database. These codes are required for claims-submission of measures groups:

Note: The alternative reporting criteria for measure groups apply regardless of whether the measures are reported through claims-based submission or through registry-based reporting; however, these G-codes that are required for claims-submission of measures groups will not be implemented until July 1, 2008. Therefore, the July 1, 2008 – December 31, 2008 reporting period is the only available reporting period for measure groups data that you submit on claims.

Additional Information
You can find more information about the establishment of alternative reporting periods and criteria for the 2008 PQRI by going to CR 6104, located at http://www.cms.hhs.gov/Transmittals/downloads/R355OTN.pdf on the 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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Attention Stratus Users: Stratus "Change Data Type" Menu to Change

In the very near future, the appearance of the Stratus "Change Data Type" Menu will be changing.

Currently, the Change Data Type menu appears as illustrated below and includes options for sending and receiving NSF files (Options 1 and 3). These file formats are no longer used due to HIPAA guidelines. Files sent using these options have not been processed since the HIPAA contingency periods were lifted.

Choose a Data Type Value
1. SEND_PRODNSF
2. RECEIVE_ERL
3. RECEIVE_NSFERN
4. SEND_ANSI
5. RECEIVE_ANSI
6. RECEIVE_ACK
7. SEND_ANSITEST
8. RECEIVE_ANSITEST

99. Return to Main Menu

ENTER SELECTION:

Options 1 and 3 will be soon removed from this menu. Other options on the menu will retain their current numbering, so no changes will be necessary to any automatic script programming your software may include. The only changes to the menu will be the removal of options 1 and 3. It will appear similar to the illustration below once the changes are made:

Choose a Data Type Value
2. RECEIVE_ERL
4. SEND_ANSI
5. RECEIVE_ANSI
6. RECEIVE_ACK
7. SEND_ANSITEST
8. RECEIVE_ANSITEST

99. Return to Main Menu

ENTER SELECTION:

As always, if you have any questions, feel free to contact the appropriate EDI department for your area:

NC 866.352.1608
TN/ID 866.520.4022

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Cardiac Computed Tomographic Angiography (CTA)

News Flash — CMS' 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 page as we will continue to post new information and resources!

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 Cardiac CTA services provided to Medicare beneficiaries.

Provider Action Needed
This article is informational only and based on Change Request (CR) 6098 which announces that the Centers for Medicare & Medicaid Services (CMS), upon review of the available evidence, has determined that the coverage of cardiac computed tomographic angiography (CTA) to diagnosis coronary artery disease (CAD) will remain at local Medicare contractor discretion, and no national coverage determination (NCD) is appropriate at this time.

Background
CTA is a noninvasive method (using intravenous contrast) to visualize the coronary arteries (or other vessels) using high resolution, high speed computed tomography (CT).

After examining the medical evidence, CMS has determined that no NCD is appropriate at this time, effective March 12, 2008. Pursuant to the Social Security Act (Section 1862(a) (1) (A)), decisions should be made by local contractors through:

Therefore, all claims for CTA used to diagnose CAD will continue to be determined by local Medicare contractor discretion and section 220.1 of Publication 100-03 of the NCD Manual remains unchanged.

Additional Information
The official instruction, CR 6098, issued to your carrier, FI, and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R85NCD.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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Changes to the Laboratory National Coverage Determination (NCD) Edit Software
for July 2008

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."

Note: This article was revised on June 27, 2008, to reflect the re-issuance of CR6084 to show that Medicare contractors use the appropriate ICD-9-CM and CPT codes effective dates, which are October 1, 2007 for the ICD-9-CM codes and January 1, 2008, for the CPT codes. All other information remains the same.

Provider Types Affected
Clinical diagnostic laboratories billing Medicare contractors (carriers, Fiscal Intermediaries (FIs) and/or Part A/B Medicare Administrative Contractors (AB MACs)).

Provider Action Needed
This article is based on Change Request (CR) 6084 which announces the changes that will be included in the July 2008 quarterly release of the edit module for clinical diagnostic laboratory services. The last quarterly release of the edit module was issued in April 2007. CR 6084 incorporates all changes from April 2007 to the present and has no other changes.

Background
The National Coverage Determinations (NCDs) for clinical diagnostic laboratory services were developed by the laboratory negotiated rulemaking committee and published in a final rule on November 23, 2001. Nationally uniform software was developed and incorporated in the shared systems so that laboratory claims subject to one of the 23 NCDs were processed uniformly throughout the nation effective January 1, 2003.

In accordance with the Medicare Claims Processing Manual (Chapter 16, Section 120.2; see http://www.cms.hhs.gov/manuals/downloads/clm104c16.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site) the laboratory edit module is updated quarterly as necessary to reflect ministerial coding updates and substantive changes to the NCDs developed through the NCD process. These changes are a result of coding analysis decisions developed under the procedures for maintenance of codes in the negotiated NCDs and biannual updates of the ICD-9-CM codes.

CR 6084 announces changes to the laboratory edit module for changes in laboratory NCD code lists for July 2008 as described below. These changes become effective for services furnished on or after July 1, 2008.

Note: Medicare contractors use the appropriate effective dates for the ICD-9-CM and CPT codes, which are October 1, 2007 for the ICD-9-CM codes and January 1, 2008, for the CPT codes.

Contractors are not required to search their files to adjust affected claims between the July 1, 2007, and the July 1, 2008, quarterly clinical lab edit module updates.

CR 6084 reports the following changes effective July 1, 2008:

For HIV Testing:

For Blood Counts:

For Prothrombin Time:

For Serum Iron Studies:

For Glycated Hemoglobin/Glycated Protein:

For Thyroid Testing:

For Gamma Glutamyl Transferase:

For Hepatitis Panel/Acute Hepatitis Panel:

Delete ICD-9-CM code 999.3 from the list of ICD-9-CM codes covered by Medicare for the Hepatitis Panel/Acute Hepatitis Panel (190.33) NCD.

For Fecal Occult Blood Test:

Additional Information
The official instruction, CR 6084, issued to your carrier, FI, and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1531CP.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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Claim Status Category Code and Claim Status Code Update

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!

Provider Types Affected
Physicians, providers, and suppliers who bill Medicare contractors (carriers, fiscal intermediaries (FI), regional home health intermediaries (RHHI), Part A/B Medicare Administrative Contractors (A/B MAC), and Durable Medical Equipment Medicare Administrative Contractors (DME MAC) for services provided to Medicare beneficiaries.

What You Need to Know
CR 6090, from which this article is taken, reminds providers of the periodic updates to the Claim Status Codes and Claim Status Category Codes that Medicare contractors use with the Health Care Claim Status Request (ASC X12N 276), and the Health Care Claim Response (ASC X12N 277).

Background
The Claim Category and Claim Status Codes explain the status of submitted claims. The Health Insurance Portability and Accountability Act (HIPAA) requires all health care benefit payers to use only national Code Maintenance Committee-approved codes in the X12 276/277 Health Care Claim Status Request and Response format adopted as the standard for national use (004010X093A1).

The national Code Maintenance Committee meets at the beginning of each X12 trimester meeting (February, June, and October) to decide about additions, modifications, and retirement of existing codes. Included in the code lists are specific details, including the date when a code was added, changed, or deleted.

CR 6090, from which this article is taken, updates the changes in the Claim Status Codes and Claim Status Category Codes from the February 2008 committee meeting, which were posted at http://www.wpc-edi.com/content/view/180/223/ on February 29, 2008 (previously referenced by http://www.wpc-edi.com/codes). CR6090 reminds Medicare contractors that they must have completed the entry of all applicable code text changes and new codes, and terminated the use of deactivated codes by its implementation date (October 6, 2008). On and after this date, these code changes are to be used in editing of all X12 276 transactions processed, and to be reflected in the X12 277 transactions issued.

Additional Information
You can find the official instruction, CR6090, issued to your carrier, FI, RHHI, A/B MAC, or DME MAC by visiting http://www.cms.hhs.gov/Transmittals/downloads/R1533CP.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.

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Clinical Laboratory Fee Schedule - Medicare Travel Allowance Fees for Collection of 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
Clinical laboratories submitting claims to Medicare contractors (carriers, Fiscal Intermediaries (FIs), and/or Part A/B Medicare Administrative Contractors (A/B MACs)) for clinical laboratory services provided to Medicare beneficiaries.

Provider Action Needed

STOP – Impact to You
This article is based on Change Request (CR) 5996 which clarifies payment of travel allowances, either on a per mileage basis (P9603) or on a flat rate basis (P9604) for Calendar Year (CY) 2008.

CAUTION – What You Need to Know
Note that Medicare contractors will not re-process claims that were processed before the new rates were implemented unless you bring such claims to their attention.

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

Background
Part B of Medicare covers 1) a specimen collection fee and 2) a travel allowance for a laboratory technician to draw the specimen from either a nursing home patient or homebound patient, and payment is made based on the clinical laboratory fee schedule. (See Section 1833(h)(3) of the Social Security Act at http://www.ssa.gov/OP_Home/ssact/title18/1833.htm on the Internet.) Furthermore, the travel codes allow for payment of the travel allowance either on a per mileage basis (P9603) or on a flat rate per trip basis (P9604), and payment of the travel allowance is made only if a specimen collection fee is also payable.

The travel allowance is intended to cover estimated travel costs of collecting the specimen (including the laboratory technician's salary and travel expenses), and Medicare contractors have the discretion to choose:

The per flat rate trip basis travel allowance (P9604) is $9.55, and the per mile travel allowance (P9603) is $0.955 cents per mile and is used in situations where the average trip to the patients' homes is:

The per mile allowance rate of $0.955 cents per mile was computed using the Federal mileage rate of $0.505 cents per mile for automobile expenses plus an additional $0.45 cents per mile to cover the technician's time and travel costs. Medicare contractors have the option of establishing a higher per mile rate in excess of the minimum of $0.955 cents per mile if local conditions warrant it.

The standard mileage rate for business is based on a study of the fixed and variable costs of operating an automobile, and the study is conducted on an annual basis for the Internal Revenue Service (IRS). CMS reviews the minimum mileage rate and updates it in conjunction with the clinical laboratory fee schedule as needed.

Under either method (i.e., flat rate allowance or per mile travel allowance), when one trip is made for multiple specimen collections (e.g., at a nursing home), the travel payment component is prorated based on the number of specimens collected on that trip (for both Medicare and non-Medicare patients) either at the time the claim is submitted by the laboratory or when the flat rate is set by the Medicare contractor.

Note: Because of confusion that some laboratories have had regarding the per mile fee basis and the need to claim the minimum distance necessary for a laboratory technician to travel for specimen collection, some Medicare contractors have established local policy to pay based on a flat rate basis only.

At no time will a laboratory be allowed to bill for more miles than are reasonable or for miles not actually traveled by the laboratory technician.

Additional Information
The official instruction, CR 5996, issued to your carrier, FI, and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1524CP.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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Comprehensive Error Rate Testing (CERT) May 2008 Report

The Comprehensive Error Rate Testing (CERT) Report was published May 2008 on the CERT Web site, http://www.cms.hhs.gov/cert/.

CIGNA Government Services wishes to thank all Part B providers and their staffs who responded and sent copies of documentation in response to CERT records requests. We recognize it is an additional task to include with the ongoing medical and administrative demands of a practice. Your cooperation helped to decrease the paid claim error rate, and helped us to pay you correctly for services you rendered to Medicare beneficiaries.

A brief summary of the National Top Errors is as follows:

No Documentation Errors

Insufficient Documentation

Medically Unnecessary

Incorrect Coding

Other Errors

Again, we would like to thank the entire provider community and staff members for past and future efforts directly contributing to the CERT error rate reductions. We do recognize and appreciate your labors. Congratulations!

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Critical Care Visits and Neonatal Intensive Care (Codes 99291 - 99292)

News Flash ― Physician Quality Reporting Initiative (PQRI) - The Centers for Medicare & Medicaid Services (CMS) is pleased to announce the 2007 PQRI Feedback Reports will be made available in mid-July on a secure Web site. More information on how to access 2007 PQRI Participant Feedback Reports will be posted on http://www.cms.hhs.gov/pqri on the CMS Web site. CMS will begin testing eleven new quality measures for possible adoption in the PQRI program in future years. To learn more about how you can help CMS test these measures, visit http://www.cms.hhs.gov/pqri on the CMS Web site and select the "Measures/Codes" link on the left side of the page. And as a reminder, all educational resources about the 2008 PQRI are available on the dedicated PQRI Web page on the CMS Web site. To access this Web page, visit http://www.cms.hhs.gov/pqri on the CMS Web site.

Note: This article was revised on July 10, 2008, to reflect changes made to CR5993 on July 9. CR5993 was revised to reflect longstanding policy regarding critical care services and other evaluation and management services on the same day, to correct information regarding calculation of critical care time to be consistent with the American Medical Association's Current Procedural Terminology, and to make minor clarifications in language related to time spent reviewing or discussing patient information and off the unit/floor and split/shared service discussions.

Provider Types Affected
Physicians and Qualified Non-Physician Practitioners (NPP) who bill Medicare carriers and Medicare Administrative Contractors (A/B MAC) for critical care services provided to Medicare beneficiaries.

What You Need to Know
CR 5993, from which this article is taken, revises the Medicare Claims Processing Manual Chapter 12 (Physicians/Nonphysician Practitioners), Section 30.6.12. (Critical Care Visits and Neonatal Intensive Care (Codes 99291 - 99292)), replacing all previous critical care payment policy language in the section and adding general Medicare evaluation and management (E/M) payment policies that impact payment for critical care services.

Specifically, CR 5993:

Make sure that your billing staffs are aware of these revisions.

Background
CR 5993, from which this article is taken, explains the definition of critical care services and how to correctly bill for these services. It discusses medically necessary services, full physician attention, counting the hours of critical care billing, performance of other evaluation and management (E/M) services on the same day as critical care services, group practice issues, services by a qualified nonphysician practitioner (NPP), bundled procedures, global surgery issues, ventilation management, teaching physician issues, physician services off the unit/floor, split/shared services, unbundled procedures, and inappropriate use of time and family counseling and discussions.

The following summarizes the information contained in CR 5993 and in Medicare Claims Processing Manual Chapter 12, Section 30.6.12, which is an attachment to CR5993.

Use of Critical Care Codes (CPT codes 99291-99292)
Critical care is defined as a physician's (or physicians') direct delivery of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition.

Critical care involves high complexity decision making to assess, manipulate, and support vital system functions to treat single, or multiple, vital organ system failure; and/or to prevent further life threatening deterioration of the patient's condition. Examples of vital organ system failure include (but are not limited to):

Although it typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present.

You should remember that providing medical care to a critically ill, injured, or post-operative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements. While critical care is usually given in a critical care area such as a coronary care unit, intensive care unit, respiratory care unit, or the emergency department, payment may also be made for critical care services that you provide in any location as long as this care meets the critical care definition.

When all these criteria are met, Medicare contractors (carriers and A/B MACs) will pay for critical care and critical care services that you report with CPT codes 99291 and 99292 (described below).

Critical Care Services and Medical Necessity
Critical care services must be reasonable and medically necessary. As explained above, critical care services encompass both the treatment of "vital organ failure" and "prevention of further life threatening deterioration in the patient's condition." Therefore, delivering critical care in a moment of crisis, or upon being called to the patient's bedside emergently, is not the only requirement for providing critical care service. Treatment and management of a patient's condition, in the threat of imminent deterioration; while not necessarily emergent, is required.

In this context, examples of patients whose medical conditions may warrant critical care services would include:

  1. An 81 year old male patient is admitted to the intensive care unit following abdominal aortic aneurysm resection. Two days after surgery he requires fluids and vasopressors to maintain adequate perfusion and arterial pressures. He remains ventilator dependent.
  2. A 67 year old female patient is three days status post mitral valve repair. She develops petechiae, hypotension, and hypoxia requiring respiratory and circulatory support.
  3. A 70 year old admitted for right lower lobe pneumococcal pneumonia with a history of COPD becomes hypoxic and hypotensive two days after admission.
  4. A 68 year old admitted for an acute anterior wall myocardial infarction continues to have symptomatic ventricular tachycardia that is marginally responsive to antiarrhythmic therapy.

You should not consider that the provision of care to a critically ill patient is automatically a critical care service just because the patient is critically ill or injured. To this point, each physician providing critical care services to a patient during the critical care episode of an illness or injury must be managing one or more of the critical illness(es) or injury(ies) in whole, or in part.

In this context, examples of scenarios in which a patient's medical condition may not warrant critical care services would include:

  1. A dermatologist evaluating and treating a rash on an ICU patient who is maintained on a ventilator and nitroglycerine infusion that are being managed by an intensivist.
  2. Daily management of a patient on chronic
    ventilator therapy unless the critical care is separately identifiable from the chronic long term management of the ventilator dependence.
  3. Management of dialysis or care related to dialysis
    for a patient receiving End Stage Renal Disease (ESRD) hemodialysis, unless the critical care is
    separately identifiable from the chronic long term management of the dialysis dependence (Refer to Medicare Claims Processing Manual, Chapter 8 (Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims), Section160.4 (Requirements for Payment).

Note: When a separately identifiable condition (e.g., management of seizures or pericardial tamponade related to renal failure) is being managed it may be billed as critical care, if critical care requirements are met. Modifier –25 (significant, separately identifiable evaluation and management services by the same physician on the day of the procedure) should be appended to the critical care code when applicable in this situation.

Similarly, examples of patients who may not satisfy Medicare medical necessity criteria for critical care payment would include:

You may also want to consult the American Medical Association (AMA) CPT Manual for the applicable codes and guidance for critical care services provided to neonates, infants and children. Critical care services provided in the outpatient setting (e.g., emergency department or office) for neonates and pediatric patients up through 24 months of age, use the hourly critical care codes 99291 and 99292.

For all other inpatient neonatal and pediatric critical care, refer to AMA CPT for guidance on the correct use of codes.

Critical Care Services and Full Attention of the Physician
The duration of critical care services that physicians should report is the time you actually spend evaluating, managing, and providing the critically ill, or injured, patient's care. Be aware that during this time, you cannot provide services to any other patient, but rather must devote your full attention to this particular critically ill patient.

This time must be spent at the patient's immediate bedside or elsewhere on the floor, or unit, so long as you are immediately available to the patient. For example, time spent reviewing laboratory test results or discussing the critically ill patient's care with other medical staff in the unit or at the nursing station on the floor would be reported as critical care, even when it does not occur at the bedside; if this time represents your full attention to the management of the critically ill/injured patient.

Note: Time spent off the unit or floor where the critically ill/injured patient is located (i.e., telephone calls, whether taken at home, in the office, or elsewhere in the hospital) floor may not be reported as critical care time because the physician is not immediately available to the patient. This time is regarded as pre- and post service work bundled in evaluation and management services. Critical Care Services and Qualified Non-Physician Practitioners (NPP).

Qualified NPPs may provide critical care services (and report for payment under their National Provider Identifier (NPI)), when these services meet the above critical care services definition and requirements.

Notes: 1) The critical care services that NPPs provide must be within the scope of practice and licensure requirements for the State in which they practice and provide the services; and 2) NPPs must meet the collaboration, physician supervision requirements, and billing requirements; and physician assistants (PA) must meet the general physician supervision requirements.

Critical Care Services and Physician Time
Critical care is a time- based service. Payment for critical care services is not restricted to a fixed number of hours, days, or physicians (on a per-patient basis) when such services meet medical necessity; and time counted toward critical care services may be continuous clock time or intermittent in aggregated time increments (e.g. 50 minutes of continuous clock time or five ten minute blocks of time spread over a given calendar date). Only one physician may bill for critical care services during any one single period of time even if more than one physician is providing care to a critically ill patient. For each medical encounter, the physician's progress notes must document the total time that critical care services are provided.

For Medicare Part B physician services, paid under the physician fee schedule, critical care is not a service that is paid on a "shift" basis or a "per day" basis. Documentation may be requested for any claim to determine medical necessity. Examples of critical care billing that may require further review could include:

Physicians assigned to a critical care unit (e.g., hospitalist, intensivist etc.) may not report critical care for patients based on a ‘per shift" basis. You should use CPT code 99291 (evaluation and management of the critically ill or critically injured patient, first 30-74 minutes) to report the first 30-74 minutes of critical care on a given calendar date of service. You can only use this code once per calendar date to bill for care provided for a particular patient by the same physician or physician group of the same specialty.

CPT code 99292 (critical care, each additional 30 minutes) is used to report each additional 30 minutes beyond the first 74 minutes of critical care. It may also be used to report the final 15 - 30 minutes of critical care on a given date. Critical care of less than 15 minutes beyond the first 74 minutes or less than 15 minutes beyond the final 30 minutes is not separately payable. Critical care of less than 30 minutes total duration on a given calendar date is not reported separately using the critical care codes. This service should be reported using another appropriate E/M code such as subsequent hospital care.

Table 1 (below) illustrates the correct reporting of critical care services, followed by a clinical example.

Table 1 Reporting of Critical Care Services
Total Duration of Critical Care Appropriate CPT Codes
Less than 30 minutes 99232 or 99233 or other appropriate E/M code
30-74 minutes 99291 x 1
75-104 minutes 99291 x 1 and 99292 x 1
105-134 minutes 99291 x1 and 99292 x 2
135-164 minutes 99291 x 1 and 99292 x 3
165-194 minutes 99291 x 1 and 99292 x 4
194 minutes or longer 99291 – 99292 as appropriate (per the above illustrations)

Clinical Example of Correct Billing of Time:
A patient arrives in the emergency department (ED) in cardiac arrest. The emergency department physician provides 40 minutes of critical care services. A cardiologist is called to the ED and assumes responsibility for the patient, providing 35 minutes of critical care services. The patient stabilizes and is transferred to the CCU. In this instance, the ED physician provided 40 minutes of critical care services and reports only the critical care code (CPT code 99291) and not also codes for emergency department services. Using CPT code 99291, the cardiologist may also report the 35 minutes of critical care services provided in the ED. Additional critical care services by the cardiologist in the CCU (on the same calendar date) using 99292 or another appropriate E/M code depending on the clock time involved.

Other Critical Care Issues

  1. There are some specific rules about physician services and time that you should know:
    Only one physician can bill for critical care during any one single period of time. Unlike other E/M services, critical care services reflect one physician's (or qualified non-physician practitioner's) care and management of a critically ill or critically injured patient for the specified reportable period of time. You cannot report a split/shared E/M service performed by a physician and a qualified NPP of the same group practice (or employed by the same employer) as a critical care service. The critical care service reported should reflect the evaluation, treatment and management of the patient by the individual physician or qualified non-physician practitioner and not representative of a combined service between a physician and a qualified NPP.

When CPT code requirements for time and critical care requirements are met for a medically necessary visit by an individual clinician the service shall be reported using the appropriate individual NPI number. Medically necessary visit(s) that do not meet these requirements shall be reported as subsequent hospital care services.

Please note that medically necessary service(s) that do not meet critical care criteria may be reported as subsequent hospital care services.

In denying a claim for a critical care service that is a split/shared service, carriers and A/B MACS will use the following messages:

Claims Adjustment Reason Code:
150 – Payment adjusted because the payer deems the information submitted does not support this level of service.

Remittance Advice Reason Code:
N180 – This item or service does not meet the criteria for the category under which it was billed.

Medicare Summary Notice:
17.11 – This item or service cannot be paid as billed.

For unassigned claims, Medicare contractors will use add-on message 16.34 – You should not be billed for this service. You are only responsible for any deductible and coinsurance amounts listed in the ‘you may be billed' column; or

For assigned claims, Medicare contractors will use add-on message 16.35 – You do not have to pay this amount.

  1. When performed on the day a physician bills for critical care, the following services are included in the critical care service, and should not be reported separately:

No other procedure codes are bundled into the critical care services. Therefore, other medically necessary procedure codes may be billed separately.

  1. Concurrent care by more than one physician (generally representing different physician specialties) is payable if the services all meet critical care requirements, are medically necessary, and are not duplicative (refer to Medicare Benefit Policy Manual, Chapter 15 (Covered Medical and Other Health Services), Section 30 (Physician Services) for concurrent care policy discussion).

Critically ill or injured patients may require the care of more than one physician medical specialty, but keep in mind that the critical care services provided by each physician must be medically necessary. Medicare will pay for non-duplicative, medically necessary critical care services provided by 1) physicians from the same group practice; or 2) from different group practices to the same patient.

Note: Physician specialty means the self-designated primary specialty by which the physician bills Medicare and is known to the carrier who adjudicates the claims. Physicians in the same group practice who have different medical specialties may bill and be paid without regard to their membership in the same group. For example, if a cardiologist and an endocrinologist are group partners and the critical care services of each are medically necessary and not duplicative the critical care services may be reported by each regardless of their group practice relationship.

Your medical record documentation must support that the critical care services each physician provided were necessary for treating and managing the patient's critical illness (es) or critical injury(ies). Each physician must accurately report the service(s) he/she provided to the patient in accordance with any applicable global surgery rules or concurrent care rules. (Refer to Medicare Claims Processing Manual, Chapter 12 (Physicians/Nonphysician Practitioners), and Section 40 (Surgeons and Global Surgery); and Medicare Benefit Policy Manual, Chapter 15 (Covered Medical and Other Health Services), and Section30 (Physician Services)).

You will need to follow these specific coding requirements.

Clinical Examples of Critical Care Services

  1. Two pulmonary specialists, who share a group practice, each provide critical care services (at different times during the same day) to a patient who has multiple organ dysfunction (including cerebral hematoma, flail chest and pulmonary contusion), is comatose, and has been in the intensive care unit for 4 days following a motor vehicle accident. Both physicians may report medically necessary critical care services provided at the different time periods. One physician would report CPT code 99291 for the initial visit and the second, as part of the same group practice, would report CPT code 99292 on the same calendar date if the appropriate time requirements are met.
  2. A 79 year old male comes to the emergency room with vague joint pains and lethargy. The ED physician evaluates him and phones his primary care physician to discuss his medical evaluation. His primary care physician visits the ER and admits him to the observation unit for monitoring, and diagnostic and laboratory tests; during which time he has a cardiac arrest. His primary care physician provides 50 minutes of critical care services, and admits him to the intensive care unit. On the same calendar day his condition deteriorates and he requires intermittent critical care services. In this scenario, the ED physician should report an emergency department visit and the primary care physician should report both an initial hospital visit and critical care services.
  1. When a patient requires critical care services upon presentation to a hospital emergency department, you may only report critical care codes 99291 - 99292. You may not also report an emergency department visit code.

However, when critical care services are provided on a day during which a hospital, emergency department, or office/outpatient evaluation and management service was furnished earlier on the same date at which time the patient did not require critical care, both the critical care and the previous evaluation and management service may be paid. Hospital emergency department services are not payable for the same calendar date as critical care services when provided by the same physician to the same patient. Physicians are advised to submit documentation to support a claim when critical care is additionally reported on the same calendar date as when other evaluation and management services are provided to a patient by the same physician or physicians of the same specialty in a group practice.

  1. Critical care services will not be paid on the same calendar date that the physician also reports a procedure code with a global surgical period, unless the critical care is billed with CPT modifier -25 to indicate that the critical care is a significant, separately identifiable, evaluation and management service that is above and beyond the usual pre and post operative care associated with the procedure that is performed.

Services such as endotracheal intubation (CPT code 31500) and the insertion and placement of a flow directed catheter e.g., Swan-Ganz (CPT code 93503) are not bundled into the critical care codes. Therefore, separate payment may be made for critical care in addition to these services if the critical care was a significant, separately identifiable service and it was reported with modifier -25. The time spent performing the pre, intra, and post procedure work of these unbundled services, e.g., endotracheal intubation, should be excluded from the determination of the time spent providing critical care.

This policy applies to any procedure with a 0, 10, or 90 day global period including cardiopulmonary resuscitation (CPR ― CPT code 92950). CPR has a global period of 0 days and is not bundled into critical care codes. Therefore, critical care maybe billed in addition to CPR if critical care was a significant, separately identifiable service and it was reported with modifier -25. The time spent performing CPR should be excluded from the determination of the time spent providing critical care. In this instance the physician who performs the resuscitation must bill for this service. Members of a code team cannot each bill Medicare Part B for this service.

When a physician, other than the surgeon, provides postoperative critical care services (for procedures with a global surgical period); no modifier is required unless all surgical postoperative care has been officially transferred from the surgeon to the physician performing the critical care services. In this situation, both the surgeon and intensivist, who are submitting claim, must use CPT modifiers "-54" (surgical care only) and "-55"(postoperative management only). Critical care services must meet all the conditions previously described, and the medical record documentation of the surgeon and physician who assumes a transfer (e.g., intensivist's), must both support claims for services when CPT modifiers -54 and -55 are used indicating the transfer of care from the surgeon to the intensivist.

  1. In addition to a global fee, critical care services provided during the preoperative portion and postoperative portions of the global period of procedures with 90 day global period in trauma and burn cases may be paid if the patient is critically ill and requires the full attention of the physician; and the critical care is unrelated to the specific anatomic injury or general surgical procedure performed.

Such patients may meet the definition of being critically ill and criteria for conditions where there is a high probability of imminent or life threatening deterioration in the patient's condition. Preoperatively, in order for these services to be paid, two reporting requirements must be met. Codes 99291 - 99292 and modifier -25 (significant, separately identifiable evaluation and management services by the same physician on the day of the procedure) must be used, and documentation identifying that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed must be submitted. An ICD-9-CM code in the range 800.0 through 959.9 (except 930.0 – 939.9), which clearly indicates that the critical care was unrelated to the surgery, is acceptable documentation.

Postoperatively, in order for these services to be paid, two reporting requirements must also be met. Codes 99291 - 99292 and modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period) must be used, and documentation that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed must be submitted.

An ICD-9-CM code in the range 800.0 through 959.9 (except 930.0 – 939.9), which clearly indicates that the critical care was unrelated to the surgery, is acceptable documentation.

Note: Medicare policy allows separate payment to the surgeon for postoperative critical care services during the surgical global period when the patient has suffered trauma or burns. When the surgeon provides critical care services during the global period, for reasons unrelated to the surgery, these are separately payable as well.

  1. Critical care CPT codes 99291 and 99292 include pre and post service work. Routine daily updates or reports to family members and or surrogates are considered part of this service.

However, time involved with family members or other surrogate decision makers, whether to obtain a history or to discuss treatment options (as described in CPT), may be counted toward critical care time when these specific criteria are met:

For such family discussions, the physician should document:

Telephone calls to family members and or surrogate decision-makers may be counted towards critical care time, only if they meet the same criteria as described in the aforementioned paragraph. Further, no other family discussions (no matter how lengthy) may be additionally counted towards critical care.

  1. A teaching physician, to bill for critical care services, must meet the requirements for critical care described above. For procedure codes determined on the basis of time, such as critical care, the teaching physician must be present for the entire period of time for which the claim is submitted. For example, payment will be made for 35 minutes of critical care services only if the teaching physician is present for the full 35 minutes. (See Medicare Claims Processing Manual, Chapter 12 (Physicians/Nonphysician Practitioners), Section 100.1.4 (Time-Based Codes).

Time spent teaching may not be counted towards critical care time. Nor, can the teaching physician bill, as critical care or other time-based services, for time spent by the resident (in the teaching physician's absence). Only time that the teaching physician spends alone with the patient (and that he/she and the resident spend together with the patient), can be counted toward critical care time.

A combination of the teaching physician's documentation and the resident's documentation may support critical care services. Provided that all requirements for critical care services are met, the teaching physician documentation may tie into the resident's documentation. The teaching physician may refer to the resident's documentation for specific patient history, physical findings and medical assessment.

However, the teaching physician medical record documentation must provide substantive information including:

The medical review criteria are the same for the teaching physician as for all physicians. (See Medicare Claims Processing Manual Chapter 12 (Physicians/Nonphysician Practitioners), Section 100.1.1 (Evaluation and Management (E/M) Services) for teaching physician documentation guidance).

The following is an example of acceptable teaching physician documentation:
"Patient developed hypotension and hypoxia; I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs, and oxygen. I reviewed the resident's documentation and I agree with the resident's assessment and plan of care." Conversely, the following is an example of unacceptable documentation from a teaching physician: "I came and saw (the patient) and agree with (the resident)."

  1. Medicare recognizes ventilator codes (CPT codes 94002 - 94004, 94660 and 94662) as physician services payable under the physician fee schedule. Medicare Part B under the physician fee schedule does not pay for ventilator management services in addition to an E/M service (e.g., critical care services, CPT codes 99291 - 99292) on the same day for the patient even when the E/M service is billed with CPT modifier -25.

Physicians should consult the American Medical Association (AMA) CPT Manual for the applicable codes and guidance for critical care services provided to neonates, infants and children. Critical care services provided in the outpatient setting (e.g., emergency department or office) for neonates and pediatric patients up through 24 months of age, use the hourly critical care codes 99291 and 99292. For all other inpatient neonatal and pediatric critical care, refer to AMA CPT for guidance on the correct use of codes.

Additional Information
You can find more information about critical care visits and neonatal intensive care (codes 99291 - 99292) by going to CR 5993, located at http://www.cms.hhs.gov/Transmittals/downloads/R1548CP.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site. Updated Medicare Claims Processing Manual Chapter 12 (Physicians/Nonphysician Practitioners), Section 30.6.12. (Critical Care Visits and Neonatal Intensive Care (Codes 99291 - 99292) is an attachment to that CR.

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

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Dear Physician Urologicals June 2008

June 20, 2008
Subject: Intermittent Urinary Catheterization

Dear Physician,

Recently Medicare changed the local coverage determination (LCD) for urological supplies. The previous policy covered "clean technique" for patients without a history of recurring urinary tract infections – allowing four intermittent catheters per month which were cleaned and re-used. Now any patient who utilizes intermittent catheterization can receive one sterile urological catheter and one packet of lubricant for each catheterization.

Because of this change in Medicare policy, medical equipment suppliers may be contacting you for new prescriptions for your patients. There are a couple of important points to keep in mind. First, the prescription should reflect the actual number of times that the patient actually catheterizes him/herself per day. For example, if the patient self-catheterizes four times per day, the prescription should be for approximately 120 catheters per month. Although the LCD says that Medicare will cover up to 200 intermittent catheters per month, this is a maximum number and most patients self-catheterize less than 6 times per day. It would be inappropriate to order 200 catheters per month for every patient. The prescription must be individualized for each patient.

The second important point is that you should clearly document in your chart the number of times per day that the patient performs self-catheterization. Just listing that value on the prescription or on a separate form provided by the supplier is not sufficient. In the case of an audit, we would look for documentation in the patient's medical record.

Thank you for your cooperation and your care of Medicare beneficiaries.

Sincerely,
Paul J. Hughes, MD
Medical Director, DME MAC Jurisdiction A

Robert D. Hoover, Jr., MD, MPH, FACP
Medical Director, DME MAC Jurisdiction C

Adrian M. Oleck, MD
Medical Director, DME MAC Jurisdiction B
Robert F. Szczys, MD
Medical Director, DME MAC Jurisdiction D

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Inappropriate Denials of Claims for Percutaneous Transluminal Angioplasty (PTA) of Carotid Arteries Concurrent with Stenting Based on Facility Recertification Due Dates

News Flash ― Physician Quality Reporting Initiative (PQRI) - The Centers for Medicare & Medicaid Services (CMS) is pleased to announce the 2007 PQRI Feedback Reports will be made available in mid-July on a secure Web site. More information on how to access 2007 PQRI Participant Feedback Reports will be posted on http://www.cms.hhs.gov/pqri on the CMS Web site. CMS will begin testing eleven new quality measures for possible adoption in the PQRI program in future years. To learn more about how you can help CMS test these measures, visit http://www.cms.hhs.gov/pqri on the CMS Web site and select the "Measures/Codes" link on the left side of the page. And as a reminder, all educational resources about the 2008 PQRI are available on the dedicated PQRI Web page on the CMS Web site. To access this Web page, visit http://www.cms.hhs.gov/pqri on the CMS Web site.

Provider Types Affected
Physicians and hospitals who submit claims to Medicare Carriers, fiscal intermediaries (FIs) and Part A/B Medicare Administrative Contractors (A/B MACs) for PTA services provided to Medicare beneficiaries.

What Providers Need to Know
Be aware that the Centers for Medicare & Medicaid Services (CMS) using Change Request (CR) 6046 reminds providers and Medicare contractors that certifying and recertifying facilities for Medicare payment is solely under CMS jurisdiction. When CMS certifies a facility, the facility name and effective date appear on a list of approved facilities located at
http://www.cms.hhs.gov/MedicareApprovedFacilitie/CASF/list.asp on the CMS Web site. If CMS disapproves a facility at any time, that facility is placed on a separate list of formerly approved facilities indicating the time period during which the facility was certified (also accessible on the above-noted Web site). Therefore, as long as a facility appears on the approved list, it is considered certified by CMS whether or not recertification is in pending status. Your Medicare contractors are expected to consult the two facility lists in determining certification status and they should not deny claims based on any other certification factors such as erroneously applied expiration date edits.

All requirements contained in CR 3811 and CR 5660 remain in effect. You may review related articles MM5660, which clarifies the national coverage determination (NCD) policy for PTA at
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5660.pdf on the CMS Web site, and MM3811, which outlines the initial NCD policy for PTA at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3811.pdf on the CMS Web site.

Background
This article is based on CR 6046 and in this article CMS states that it has come to their attention that some contractors are misapplying the initial certification and recertification requirements contained in CR 3811 and CR 5660, respectively, thereby inappropriately denying claims when a facility is not immediately recertified at the end of a 2-year period.

Effective March 17, 2005, CMS revised the NCD for PTA of the carotid artery concurrent with placement of an FDA-approved carotid stent for certain beneficiaries at high risk for carotid endarterectomy. On April 22, 2005, CMS issued change request (CR) 3811 to implement NCD 20.7, which included detailed steps facilities must follow to become certified by CMS to perform this procedure.

On April 30, 2007, as a result of a request for reconsideration of NCD 20.7, CMS posted a final decision that the current coverage policy would remain unchanged. CR 5660 was subsequently released on September 12, 2007, reiterating its decision. CR 5660 also made clarifying revisions to NCD 20.7 which included additional, detailed recertification steps