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September 5, 2008 Part B Medicare Bulletin

Posted September 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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Beneficiary Submitted Claims

News Flash ― Physician Quality Reporting Initiative (PQRI) - The Centers for Medicare & Medicaid Services (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 Webpage 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, providers, and suppliers submitting claims to Medicare contractors (carriers, and Part A/B Medicare Administrative Contractors (A/B MACs)) for services provided to Medicare beneficiaries.

Provider Action Needed
Change Request (CR) 5683 updates the procedures for processing claims submitted by Medicare beneficiaries to carriers and/or A/B MACs and serves as a reminder to providers and suppliers that they are required by law to submit claims to Medicare for services they render to Medicare beneficiaries.. These updates do not apply to beneficiary claims submitted to Durable Medical Equipment (DME) MACs.

Background
All providers and suppliers are required to enroll in the Medicare program in order to receive payment. In addition, the Social Security Act (Section 1848 (g)(4)(A); http://www.ssa.gov/OP_Home/ssact/title18/1848.htm) requires all providers and suppliers to submit claims for services rendered to Medicare beneficiaries. The current manual requirement instructs Medicare contractors to provide education to the providers and suppliers explaining the statutory requirement, including possible penalties for repeatedly refusing to submit claims for services provided. Medicare contractors are also instructed to process beneficiary submitted claims for services that:

  1. Are not covered by Medicare
    (e.g., for hearing aids, cosmetic surgery, personal comfort services, etc., in accordance with its normal processing procedures; see 42 CFR 411.15; and
  2. Are covered by Medicare
    when the beneficiary has submitted a complete claim (Patient’s Request for Medical Payment Form CMS-1490S; http://www.cms.hhs.gov/CMSForms/CMSForms/) and all supporting documentation associated with the claim, including an itemized bill with the following information:
    • Date of service,
    • Place of service,
    • Description of illness or injury,
    • Description of each surgical or medical service or supply furnished,
    • Charge for each service,
    • The doctor’s or supplier’s name, address, and
    • The provider or supplier’s National Provider Identifier (NPI).

If an incomplete claim (or a claim containing invalid information) is submitted, the contractor will return the claim as incomplete with an appropriate letter. The Centers for Medicare & Medicaid Services (CMS) will be providing suggested language for that letter in a later Transmittal. In addition, contractors will manually return (to the beneficiary) beneficiary submitted claims when the beneficiary used Form CMS-1500 with instructions how to complete and return the appropriate beneficiary claims Form CMS-1490S for processing.

Note: CMS will be providing suggested language for the above mentioned letter in a later Transmittal.

When manually returning a beneficiary submitted claim (Form CMS-1490S) for a Medicare-covered service (because the claim is not complete or contains invalid information), the contractor will maintain a record of the beneficiary submitted claim for purposes of the timely filing rules in the event that the beneficiary re-submits the claim.

When returning a beneficiary submitted claim, the contractor will inform the beneficiary by letter that:

Medicare contractors should encourage beneficiaries to always seek non-emergency care from a provider or supplier that is enrolled in the Medicare program.

If a beneficiary receives services from a provider or supplier that refuses to submit a claim on the beneficiary’s behalf (for services that would otherwise be payable by Medicare), the beneficiary should:

  1. Notify the contractor in writing that the provider or supplier refused to submit a claim to Medicare, and
  2. Submit a complete Form CMS-1490S with all supporting documentation.

Upon receipt of both the beneficiary’s complaint that the provider/supplier refused to submit the claim, and the beneficiary’s claim Form CMS-1490S (and all supporting documentation), the contractor will process and pay the beneficiary’s claim if it is for a service that would be payable by Medicare were it not for the provider’s or supplier’s refusal to submit the claim and/or enroll in Medicare.

Contractors will maintain:

  1. Documentation of beneficiary complaints involving violations of the mandatory claims submission policy, and
  2. A list of the top 50 violators (by State) of the mandatory claim submission policy.

The instructions provided in CR 5683 do not apply to foreign claims, and they do not apply to beneficiary claims submitted to DME MACs (for durable medical equipment, prosthetics, orthotics and supplies). The processing of foreign claims will remain unchanged, and DME MACs should continue to follow procedures that are currently in place.

Additional Information
The official instruction, CR5683, issued to your carrier, A/B MAC, and DME MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1557CP.pdf
on the CMS Web site.

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

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Billing Unlisted Codes

Recently, an increasing number of claims for unlisted codes have been filed with neither a description of the unlisted code on the claim or in the medical record documentation.

In the event that a physician performs a procedure that does not have a designated CPT code, the physician should bill the procedure using an unlisted code. A description of the procedure should be listed in Item 19 of the CMS -1500 claim form or in the narrative of the EMC claim. This may facilitate processing by keeping the claim from being developed for further documentation. If the claim does have to be developed for additional documentation, the operative report should clearly indicate what the unlisted code is for by describing in detail the procedure performed. If the unlisted code being used is for a non-surgical procedure and no other instructions have been published pertaining to that procedure then the provider should submit supporting documentation with an explanation of what the unlisted code is for.

Other errors and tips to know when filing claims for unlisted codes include:

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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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Clarifications to Audiology Update Transmittal 1470

News Flash ― The Medicare Remit Easy Print brochure has been updated and is now available to order print copies or to download as a PDF file. This brochure provides an overview of free software that enables physicians and suppliers to view and print remittance information. To view the PDF file, go to http://www.cms.hhs.gov/MLNProducts/downloads/MedicareRemit_0408.pdf. Print copies may be ordered by visiting 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
Audiologists submitting claims to Medicare Administrative Contractors (A/B MACs) and carriers for services provided to Medicare beneficiaries.

Impact on Providers
This article is based on Change Request (CR) 6061, which alerts Audiologists who are not currently enrolled to the fact that they are required to obtain their NPI and use it on claims for services they render on or after October 1, 2008. An audiologist not previously enrolled with Medicare should initiate Medicare enrollment as soon as they obtain an NPI.

Background
Transmittal 1470, (CR5717) titled, “Update to Audiology Policies,” was issued February 29, 2008, with clarifications to the Medicare Claims Processing Manual. (An MLN Matters article related to CR5717 is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5717.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site.) In chapter 12, section 30.3, the manual instructions state, “. . . the audiologist’s NPI is required on all claims for services furnished by audiologists.” CR6061 responds to questions concerning CR5717.

Key Points

Additional Information
To see the official instruction (CR6061) issued to your Medicare A/B MACs and carriers visit http://www.cms.hhs.gov/Transmittals/downloads/R1550CP.pdf on the CMS Web site.

To learn more about the NPI and how to obtain your NPI, visit http://www.cms.hhs.gov/NationalProvIdentStand/06_implementation.asp on the CMS Web site. Information on enrolling as a Medicare provider is available at http://www.cms.hhs.gov/MedicareProviderSupEnroll/ on the CMS site.

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

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Comprehensive Error Rate Testing Consultation Services

The Centers for Medicare & Medicaid Services (CMS) uses the Comprehensive Error Rate Testing (CERT) program to measure and improve the quality and accuracy of Medicare claims submission, processing and payment. Under this program, numerous randomly selected claims are reviewed each year. The results of these reviews are used to characterize and quantify local, regional and national error rate patterns. CMS uses this information to address the error rate through appropriate educational programs.

One area showing an error rate pattern includes Consultation Codes (CPT Codes 99241 thru 99255). Consultation requirements are as follows:

NOTE: In both instances use the appropriate subsequent care or established patient visit code

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Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA)

News Flash ― Physician Quality Reporting Initiative (PQRI) - The Centers for Medicare & Medicaid Services (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 Webpage 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 28, 2008, to reflect changes to CR 6048, which CMS revised on July 25, 2008. The CR release date, transmittal number, and the Web address for accessing CR6048 were revised. All other information remains the same.

Provider Types Affected
Physicians, providers and suppliers submitting claims to Medicare contractors (carriers, Fiscal Intermediaries (FIs), Part A/B Medicare Administrative Contractors (A/B MACs), and/or Durable Medical Equipment (DME) MACs) for OSA-related services provided to Medicare beneficiaries.

Impact on Providers
Providers need to be aware that effective for claims with dates of service on and after March 13, 2008, Medicare will allow for coverage of CPAP therapy based upon a positive diagnosis of OSA by home sleep testing (HST), subject to the requirements of CR6048.

Background
The Centers for Medicare & Medicaid Services (CMS) reconsidered its 2005 National Coverage Determination (NCD) for CPAP Therapy for OSA to allow for coverage of CPAP based upon a diagnosis of OSA by HST.

Medicare previously covered the use of CPAP only in beneficiaries who had been diagnosed with moderate to severe OSA when ordered and prescribed by a licensed treating physician and confirmed by polysomnography (PSG) performed in a sleep laboratory in accordance with section 240.4 of the Medicare NCD Manual (see the Additional Information section of this article for the official instruction and the revised section of the NCD). Following the reconsideration of its coverage policy, CMS is revising the existing NCD on CPAP therapy for OSA as well as allowing coverage of CPAP based on a positive diagnosis of OSA by HST, subject to all the requirements of the new NCD, as outlined in CR6048. (Note that billing guidelines for capped rental equipment are contained in the Medicare Claims Processing Manual, Chapter 20, Section 30.5, which is available at http://www.cms.hhs.gov/manuals/downloads/clm104c20.pdf on the CMS Web site.)

As part of the NCD, apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation. The apnea hypopnea index (AHI) is equal to the average number of episodes of apnea and hypopnea per hour. The respiratory disturbance index (RDI) is equal to the average number of respiratory disturbances per hour.

Key Points of CR6048

  1. Coverage of CPAP is initially limited to a 12-week period for beneficiaries diagnosed with OSA as described below. CPAP is subsequently covered for those beneficiaries diagnosed with OSA whose OSA improves as a result of CPAP during this 12-week period.

NOTE: DME Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers are required to provide beneficiaries with necessary information and instructions on how to use Medicare-covered items safely and effectively. 42 CFR 424.57(c)(12). Failure to meet this standard may result in revocation of the DMEPOS supplier’s billing privileges. 42 CFR 424.57(d).

  1. CPAP for adults is covered when diagnosed using a clinical evaluation and a positive:
    • Polysomnography (PSG) performed in a sleep laboratory; or
    • Unattended home sleep monitoring device of Type II; or
    • Unattended home sleep monitoring device of Type III; or
    • Unattended home sleep monitoring device of Type IV, measuring at least 3 channels

NOTE: In general, pursuant to 42 CFR 410.32(a), diagnostic tests that are not ordered by the beneficiary’s treating physician are not considered reasonable and necessary. Pursuant to 42 CFR 410.32(b), diagnostic tests payable under the Medicare physician fee schedule that are furnished without the required level of supervision by a physician are not reasonable and necessary.

  1. A positive test for OSA is established if either of the following criteria using the Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) is met:
    • AHI or RDI greater than or equal to 15 events per hour, or
    • AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.

Note: The AHI is equal to the average number of episodes of apnea and hypopnea per hour. The RDI is equal to the average number of respiratory disturbances per hour.

  1. The AHI or RDI is calculated on the average number of events of per hour. If the AHI or RDI is calculated based on less than 2 hours of continuous recorded sleep, the total number of recorded events to calculate the AHI or RDI during sleep testing is at least the number of events that would have been required in a 2-hour period.
  2. CMS is deleting the distinct requirements that an individual have moderate to severe OSA and that surgery is a likely alternative.
  3. CPAP based on clinical diagnosis alone or using a diagnostic procedure other than PSG or Type II, Type III, or a Type IV HST measuring at least 3 channels is covered only when provided in the context of a clinical study and when that study meets the standards outlined in the NCD manual revision attached to CR6048. Medicare will process claims according to Coverage with Evidence Development (CED)/clinical trials criteria at section 310.1 of the NCD Manual and chapter 32 and sections 69.6-69.7 (Pub 100-04) of the Medicare Claims Processing Manual. These manuals are available at http://www.cms.hhs.gov/manuals/IOM/list.asp on the CMS Web site.

Note: The following HST portable monitoring G codes effective March 13, 2008, are provided for your information only, are not included in the CPAP for OSA NCD at section 240.4 of the NCD Manual, and do not necessarily convey coverage, which is determined at local contractor discretion.

G0398: Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation.
G0398 Short Descriptor: Home sleep test/type 2 Porta
G0399: Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation
G0399 Short Descriptor: Home sleep test/type 3 Porta
G0400: Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels
G0400 Short Descriptor: Home sleep test/type 4 Porta

Additional Information
To see the official instruction (CR6048) issued to your Medicare A/B MAC, FI , carrier, or DME MAC visit http://www.cms.hhs.gov/Transmittals/downloads/R91NCD.pdf on the CMS Web site.

If you have questions, please contact your Medicare A/B MAC, FI, carrier, 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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CR 5971 Clarification - Signature Requirements

News Flash ― Physician Quality Reporting Initiative (PQRI) - The Centers for Medicare & Medicaid Services (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 Webpage 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 other providers who bill Medicare Contractors (Carriers, Fiscal Intermediaries, Regional Home Health Intermediaries, Part A/B Medicare Administrative Contractors, including Durable Medical Equipment Medicare Administrative Contractors) for care provided to Medicare beneficiaries.

What You Need to Know
The purpose of this notice is to provide guidance to providers/suppliers and Medicare contractors on the use of stamped signatures. Note that stamped signatures are not acceptable on any medical record.

Background
The Centers for Medicare & Medicaid Services (CMS) has taken this step to ensure accurate application of Medicare’s program requirements throughout the nation. CMS has identified problems of noncompliance with existing statutes, regulations, rules, and other systematic problems relating to standards of practice for a valid physician’s signature on medical orders and related medical documents.

CR 5971 (Transmittal #248) was issued to prohibit the use of stamped signatures. These requirements are intended to apply all providers/suppliers. Stamped signatures are not acceptable on any medical record. Medicare will accept hand written, electronic signatures or facsimiles of original written or electronic signatures.

In addition, the Medicare Conditions of Participation (CoP) are requirements for ensuring health and safety. The CoPs define specific quality standards that providers must meet to participate in the Medicare program. A provider’s compliance with the CoPs is ultimately determined by the CMS regional office based on the State survey agency recommendation (per the Medicare Program Integrity Manual, Publication 100-8, chapter 3, section 3.4.2.1, which is available at http://www.cms.hhs.gov/manuals/downloads/pim83c03.pdf on the CMS Web site). Compliance with the CoPs and any related policies does not necessarily ensure that certain requirements for payment are being met.

Additional Information
The official instruction, CR 5971, issued to your carrier, FI, A/B MAC, and DME MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R248PI.pdf on the CMS Web site.

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

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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 Webpage 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 23, 2008, to reflect additional changes made to CR5993 on July 9. CR5993 was revised to correctly state the payment policy regarding emergency department visits on the same day as critical care services for the same patient by the same physician, to clarify reporting of services supplied to neonates, infants, and children by referring providers to consult the American Medical Association’s Current Procedural Terminology, and to correct the information on how to calculate critical care time from the paragraph before the table on page 6 of this article. There are additional minor clarifications.

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 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 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 additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of critical care. 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
There are some specific rules about physician services and time that you should know:

  1. 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 a qualified NPP, the service shall be billed 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:
    • the interpretation of cardiac output measurements (CPT 93561, 93562)
    • chest x-rays, professional component (CPT 71010, 71015, 71020)
    • blood draw for specimen (CPT 36415)
    • blood gases, and information data stored in computers (e.g., ECGs, blood pressures, hematologic data (CPT 99090))
    • gastric intubation (CPT 43752, 91105)
    • pulse oximetry (CPT 94760, 94761, 94762)
    • temporary transcutaneous pacing (CPT 92953)
    • ventilator management (CPT 94002 – 94004, 94660, 94662)
    • vascular access procedures (CPT 36000, 36410, 36415, 36591, 36600)

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 Medicare contractor 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 an inpatient hospital, 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:

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.

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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Important FDA Warning Regarding the Use of Fluoroquinolones:

Please take a moment to review the following important information from the FDA regarding the use of fluoroquinolones. Given that the target group is often also Medicare beneficiaries, I ask that you strongly consider this information.

FDA is notifying the makers of fluoroquinolone antimicrobial drugs for systemic use of the need to add a boxed warning to the prescribing information about the increased risk of developing tendonitis and tendon rupture in patients taking fluoroquinolones and to develop a Medication Guide for patients. The addition of a boxed warning and a Medication Guide would strengthen the existing warning information already included in the prescribing information for fluoroquinolone drugs.

Fluoroquinolones are associated with an increased risk of tendonitis and tendon rupture. This risk is further increased in those over age 60, in kidney, heart, and lung transplant recipients, and with use of concomitant steroid therapy. Physicians should advise patients, at the first sign of tendon pain, swelling, or inflammation, to stop taking the fluoroquinolone, to avoid exercise and use of the affected area, and to promptly contact their doctor about changing to a non-fluoroquinolone antimicrobial drug.

Selection of a fluoroquinolone for the treatment or prevention of an infection should be limited to those conditions that are proven or strongly suspected to be caused by bacteria.

For more information, visit: http://www.fda.gov/cder/drug/infopage/fluoroquinolones/default.htm.

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Important Information on the New Medicare Law – The Medicare Improvements for Patients and Providers Act of 2008

News Flash ― The Medicare Remit Easy Print brochure has been updated and is now available to order print copies or to download as a PDF file. This brochure provides an overview of free software that enables physicians and suppliers to view and print remittance information. To view the PDF file, go to http://www.cms.hhs.gov/MLNProducts/downloads/MedicareRemit_0408.pdf. Print copies may be ordered by visiting 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.

This article contains a compilation of messages that were issued on July 16, 2008.

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

Provider Action Needed
The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) was enacted on July 15, 2008. This legislation alters a number of Medicare policies, which have been the subject of a number of change requests (CRs) and MLN Matters articles published in recent months. The Centers for Medicare & Medicaid Services (CMS) is in the process of revising these previously issued CRs and MLN Matters articles as a result of this legislation. However, CMS feels it is important that physicians, providers and suppliers be aware of five critical issues immediately.

These five issues are:

Be sure your billing staff is aware of these changes.

Background
The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) was enacted on July 15, 2008. While MIPPA calls for numerous changes to the Medicare program, this special edition article covers five key provisions as noted above.

  1. New 2008 Medicare Physician Fee Schedule (MPFS) Payment Rates Effective for Dates of Service July 1, 2008 through December 31, 2008

As a result of this legislation, the mid-year 2008 MPFS rate of -10.6 percent has been replaced with the January-June 2008 0.5 percent update, retroactive to July 1, 2008.

Physicians, non-physician practitioners and other providers of services paid under the MPFS should begin to receive payment at the 0.5% update rates in approximately 10 business days, or less, for claims with dates of service on or after July 1, 2008. Medicare contractors are currently