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February 2012 Home Health & Hospice Medicare Bulletin

Posted February 1, 2012

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2012 ICD-10-CM Code Updates Now Available from CMS

CMS has posted the 2012 ICD-10-CM code updates to the CMS web site, including the 2012 ICD-10-CM index and tabular, code titles, addendum, General Equivalence Mappings (GEMs), and reimbursement mappings files.  The 2012 ICD-10-CM files contain information on the new diagnosis coding system, ICD-10-CM, that is being developed as a replacement for ICD-9-CM, Volumes 1 and 2.  These files are available on the 2012 ICD-10-CM and GEMs web page at http://www.cms.gov/ICD10/11b14_2012_ICD10CM_and_GEMs.asp.  To access the files, scroll to the bottom of the page to the “Downloads” section.

The 2012 ICD-10-PCS (procedure) files were posted in June on the 2012 ICD-10-PCS and GEMs web page at http://www.cms.gov/ICD10/11b15_2012_ICD10PCS.asp. 

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Availability of the Provider Contact Center (PCC)

Medicare is a continuously changing program, and it is important that we provide correct and accurate answers to your questions.  To better serve the provider community, the Centers for Medicare & Medicaid Services (CMS) allows the provider contact centers the opportunity to offer training to our customer service representatives (CSRs).  Listed below is the date and time the home health and hospice PCC (1.877.299.4500 and 1.866.539.5592) will be closed for training.

closed for training

CSR Training Date

Time

February 20, 2012 (Federal Holiday)

8:00 am – 4:30 p.m. (Central Time)

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Electronic Funds Transfer (EFT)

Existing regulations at 42 CFR 424.510(e)(1)(2) require that at the time of enrollment, enrollment change request or revalidation, providers and suppliers that expect to receive payment from Medicare for services provided must also agree to receive Medicare payments through Electronic Funds Transfer (EFT).  Section 1104 of the Affordable Care Act further expands Section 1862 (a) of the Social Security Act by mandating Federal payments to providers and suppliers only by electronic means.  As part of Medicare’s revalidation efforts, all suppliers and providers who are not currently receiving EFT payments will be identified, and required to submit the CMS 588 EFT form with the Provider Enrollment Revalidation application.  For more information about provider enrollment revalidation, review the Medicare Learning Network’s Special Edition Article #SE1126, titled “Further Details on the Revalidation of Provider Enrollment Information” at: http://www.cms.gov/MLNMattersArticles/downloads/SE1126.pdf

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Get the Flu Vaccine – Not the Flu

It’s a busy time of year.  Make each office visit an opportunity to remind your patients about the importance of getting the seasonal flu vaccination and a one-time pneumococcal vaccination.  Medicare pays for these vaccinations for all beneficiaries with no co-pay or deductible.  The Centers for Disease Control and Prevention also recommends that healthcare workers and caregivers be vaccinated against the seasonal flu.  Protect your patients. Protect your family. Protect yourself.  Get the Flu Vaccine – Not the Flu.  Remember: The flu vaccine plus its administration are covered Part B benefits.  The flu vaccine is NOT a Part D-covered drug. For more information on coverage and billing of the flu vaccine and its administration, and related educational provider resources, visit the following CMS web pages Medicare Learning Network® Preventive Services and Immunizations.  Get the Flu Vaccine -- Not the Flu.  For the 2011-2012 seasonal flu vaccine payment limits, visit: http://www.CMS.gov/McrPartBDrugAvgSalesPrice/10_VaccinesPricing.asp

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MM7323—Home Health Advance Beneficiary Notice, (HHABN), Form CMS-R-296

The Centers for Medicare & Medicaid Services (CMS) has provided the following Medicare Learning Network® (MLN) Matters article.  This MLN Matters article and other CMS articles can be found on the CMS web site at: http://www.cms.gov/MLNMattersArticles/

MLN Matters® Number: MM7323
Related Change Request (CR) #: CR 7323
Related CR Release Date: December 1, 2011
Effective Date: February 3, 2012
Related CR Transmittal #: R2362CP
Implementation Date: February 3, 2012

Provider Types Affected
Home health agencies (HHAs) who bill Medicare regional home health intermediaries (RHHIs) for their services.

Provider Action Needed
STOP – Impact to You
This article is based on CR 7323 which implements the revised HHABN and its instructions.

CAUTION – What You Need to Know
CR 7323 revises the “Medicare Claims Processing Manual” (Pub. 100-04, Chapter 30, Section 60 and its subsections) incorporating edits to simplify presentation of previously released information.  There have been no recent changes to the existing HHABN policy or the HHABN notice.

GO – What You Need to Do
See the “Background” and “Additional Information” sections of this article for further details regarding these changes.  Advise appropriate HHA staff of the availability of this updated resource for HHABN policy and issuance information.

Background
HHAs have issued HHABNs since 2002 that are related to the absence or cessation of Medicare coverage when a beneficiary had liability protection under Section 1879 of the Social Security Act (the Act) (See http://www.ssa.gov/OP_Home/ssact/title18/1879.htm on the Internet).  The HHABN gained additional notification capabilities in 2006 following the U.S. Court of Appeals decision in the case LUTWIN V. THOMPSON.

Subsequent to that decision, the HHABN was modified so that it could also be used by HHAs to notify beneficiaries receiving home health services of any changes made to their plan of care in accordance with the HHA conditions of participation (COPs) in Section 1891 of the Social Security Act.

Highlights of CR 7323 Changes to Section 60
This article is based on CR 7323 which revises the currently published HHABN section contained in the “Medicare Claims Processing Manual” (Pub. 100-04, Chapter 30, Section 60). The revised Section 60 is included as an attachment to CR 7323, and the following are highlights of the revisions:

Additional Information
The official instruction, CR 7323, issued to your RHHIs regarding this change may be viewed at http://www.cms.gov/transmittals/downloads/R2362CP.pdf on the CMS web site.  You will find the HHABN notice and instructions at http://www.cms.gov/BNI/03_HHABN.asp on the CMS web site.

If you have any questions, please contact a CGS Customer Service Representative by calling the appropriate telephone number found on the Customer Service Telephone Numbers web page at: http://www.cgsmedicare.com/hhh/help/telephone_numbers.html

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MM7397 (Revised)—Pharmacy Billing for Drugs Provided "Incident To" a Physician Service

The Centers for Medicare & Medicaid Services (CMS) has issued a revision to the MM7397 article entitled, “Pharmacy Billing for Drugs Provided "Incident To" a Physician Service” which was published in the November 2011 HH+H Bulletin.  This MLN Matters article and other CMS articles can be found on the CMS web site at: http://www.cms.gov/MLNMattersArticles/

MLN Matters® Number: MM7397 Revised
Related Change Request (CR) #: 7397
Related CR Release Date: December 15, 2011
Effective Date: January 1, 2013
Related CR Transmittal #: R2368CP
Implementation Date: January 1, 2013

Note: This article was revised on December 16, 2011, to reflect the revised CR 7397 issued on December 15.  The effective and implementation dates were changed.  Also, the CR release date, transmittal number, and the web address for accessing CR 7397 were revised.  All other information remains the same.

Provider Types Affected
Pharmacies that submit claims for drugs to Medicare contractors (fiscal intermediaries (FIs), carriers, regional home health intermediaries (RHHIs), A/B Medicare administrative contractors (A/B MACs), and durable medical equipment MACs) are affected.

What You Should Know
This article is based on CR 7397, which clarifies policy with respect to restrictions on pharmacy billing for drugs provided “incident to” a physician service. The CR also clarifies policy for the local determination of payment limits for drugs that are not nationally determined.

This article notes that CR 7397 rescinds and fully replaces CR 7109. Please be sure your staffs are aware of this update.

Background
Pharmacies billing drugs
Pharmacies may bill Medicare Part B for certain classes of drugs, including immunosuppressive drugs, oral anti-emetic drugs, oral anti-cancer drugs, and drugs self-administered through any piece of durable medical equipment.

The DME MAC, A/B MAC, or carrier will make payment to the pharmacy for these drugs, when deemed to be covered and reasonable and necessary.  All bills submitted to the DME MAC, A/B MAC, or carrier must be submitted on an assigned basis by the pharmacy.

When drugs may not be billed by pharmacies to Medicare Part B
Pharmacies, suppliers and providers may not bill Medicare Part B for drugs dispensed directly to a beneficiary for administration “incident to” a physician service, such as refilling an implanted drug pump.  These claims will be denied.

Pharmacies may not bill Medicare Part B for drugs furnished to a physician for administration to a Medicare beneficiary. When these drugs are administered in the physician’s office to a beneficiary, the only way these drugs can be billed to Medicare is if the physician purchases the drugs from the pharmacy. In this case, the drugs are being administered “incident to” a physician’s service and pharmacies may not bill Medicare Part B under the “incident to” provision.

Payment limits
The payment limits for drugs and biologicals that are not included in the average sales price (ASP) Medicare Part B Drug Pricing File or Not Otherwise Classified (NOC) Pricing File are based on the published Wholesale Acquisition Cost (WAC) or invoice pricing, except under the Outpatient Prospective Payment System (OPPS) where the payment allowance limit is 95 percent of the published average wholesale price (AWP).  In determining the payment limit based on WAC, the payment limit is 106 percent of the lesser of the lowest-priced brand or median generic WAC.

Medicare contractors will not search their files to either retract payment for claims already paid or to retroactively pay claims, but will adjust claims brought to their attention.

Additional Information
The official instruction, CR 7397 issued to your Medicare contractor regarding this issue may be viewed at http://www.cms.gov/Transmittals/downloads/R2368CP.pdf on the CMS web site.

If you have any questions, please contact a CGS Customer Service Representative by calling the appropriate telephone number found on the Customer Service Telephone Numbers web page at: http://www.cgsmedicare.com/hhh/help/telephone_numbers.html

The following manual sections regarding billing drugs and biological and “incident to” services may be helpful:

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MM7567 (Revised)—Update to Medicare Deductible, Coinsurance and Premium Rates for 2012

The Centers for Medicare & Medicaid Services (CMS) has issued a revision to the MM7567 article entitled, “Update to Medicare Deductible, Coinsurance and Premium Rates for 2012” which was published in the January 2011 HH+H Bulletin. This MLN Matters article and other CMS articles can be found on the CMS web site at: http://www.cms.gov/MLNMattersArticles/

MLN Matters® Number: MM7567 Revised
Related Change Request (CR) #: CR 7567
Related CR Release Date: December 16, 2011
Effective Date: January 1, 2012
Related CR Transmittal #: R74GI
Implementation Date: January 3, 2012

Note: This article was revised on December 19, 2011, to reflect a revised CR 7567 issued on December 16, 2011.  In the article, the CR release date, transmittal number, and the web address for accessing CR7567 were revised.  All other information is the same.

Provider Types Affected
Physicians, providers, and suppliers submitting claims to Medicare contractors (carriers, fiscal intermediaries (FIs), A/B Medicare administrative contractors (A/B MACs), and/or regional home health intermediaries (RHHIs)) for services provided to Medicare beneficiaries.

Provider Action Needed
This article is based on CR 7567, which provides the Medicare rates for deductible, coinsurance, and premium payment amounts for Calendar Year (CY) 2012.  Be sure billing staffs are aware of these updates.

Background
2012 Part A - Hospital Insurance (HI)
Beneficiaries who use covered Part A services may be subject to deductible and coinsurance requirements.  A beneficiary is responsible for an inpatient hospital deductible amount, which is deducted from the amount payable by the Medicare program to the hospital, for inpatient hospital services furnished in a spell of illness.  When a beneficiary receives such services for more than 60 days during a spell of illness, he or she is responsible for a coinsurance amount equal to one-fourth of the inpatient hospital deductible per-day for the 61st-90th day spent in the hospital.

Note: An individual has 60 lifetime reserve days of coverage, which they may elect to use after the 90th day in a spell of illness. The coinsurance amount for these days is equal to one-half of the inpatient hospital deductible.

In addition, a beneficiary is responsible for a coinsurance amount equal to one-eighth of the inpatient hospital deductible per day for the 21st through the 100th day of Skilled Nursing Facility (SNF) services furnished during a spell of illness.  The 2012 inpatient deductible is $1,156.00.  The coinsurance amounts are shown below in the following table:

The coinsurance amounts are shown below in the following table:

Hospital Coinsurance

Skilled Nursing Facility Coinsurance

Days 61-90

Days 91-150 (Lifetime Reserve Days)

Days 21-100

$289.00

$578.00

$144.50

Most individuals age 65 and older, and many disabled individuals under age 65, are insured for Health Insurance (HI) benefits without a premium payment.  The Social Security Act provides that certain aged and disabled persons who are not insured may voluntarily enroll, but are subject to the payment of a monthly premium.  Since 1994, voluntary enrollees may qualify for a reduced premium if they have 30-39 quarters of covered employment.  When voluntary enrollment takes place more than 12 months after a person’s initial enrollment period, a 2-year 10% penalty is assessed for every year they had the opportunity to (but failed to) enroll in Part A.  The 2012 Part A premiums are as follows:

The 2012 Part A premiums are as follows:

Voluntary Enrollees Part A Premium Schedule for 2012

Base Premium (BP)

$451.00 per month

Base Premium with 10% Surcharge

$496.10 per month

Base Premium with 45% Reduction

248.00 per month (for those who have 30-39 quarters of coverage)

Base Premium with 45% Reduction and 10% Surcharge

$272.80 per month

2012 Part B - Supplementary Medical Insurance (SMI)
Under Part B of the Supplementary Medical Insurance (SMI) program, all enrollees are subject to a monthly premium.  Most SMI services are subject to an annual deductible and coinsurance (percent of costs that the enrollee must pay), which are set by statute.  When Part B enrollment takes place more than 12 months after a person’s initial enrollment period, there is a permanent 10 percent increase in the premium for each year the beneficiary could have enrolled and failed to enroll.

In addition, some beneficiaries may pay higher premiums based on their incomes.  These amounts change each year.  There may be a late-enrollment penalty.

Additional Information
The official instruction, CR 7567, issued to your carriers, FIs, A/B MACs, and RHHIs regarding this change may be viewed at http://www.cms.gov/Transmittals/downloads/R74GI.pdf on the CMS web site.

If you have any questions, please contact a CGS Customer Service Representative by calling the appropriate telephone number found on the Customer Service Telephone Numbers web page at: http://www.cgsmedicare.com/hhh/help/telephone_numbers.html

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MM7638—April 2012 Quarterly Update for the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program

The Centers for Medicare & Medicaid Services (CMS) has provided the following Medicare Learning Network® (MLN) Matters article.  This MLN Matters article and other CMS articles can be found on the CMS web site at: http://www.cms.gov/MLNMattersArticles/

MLN Matters® Number: MM7638
Related Change Request (CR) #: 7638
Related CR Release Date: December 2, 2011
Effective Date: April 1, 2012
Related CR Transmittal #: R2363CP
Implementation Date: April 2, 2012

Provider Types Affected
This article is for providers and suppliers submitting claims to the durable medical equipment Medicare administrative contractors (DME MACs), or Medicare regional home health intermediaries (RHHIs) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) provided to Medicare beneficiaries.

Provider Action Needed
This article is based on CR 7638, which provides the DMEPOS April 2012 quarterly update. This update implements necessary changes to the Healthcare Common Procedure Coding System (HCPCS), ZIP code, and single payment amount files effective April 1, 2012.  Be sure your billing staff is aware of these changes.

Background
Section 302 of the Medicare Modernization Act of 2003 (MMA) established requirements for a new competitive bidding program for certain DMEPOS.  Under the program, DMEPOS suppliers compete to become Medicare contract suppliers by submitting bids to furnish certain items in competitive bidding areas, and the CMS awards contracts to enough suppliers to meet beneficiary demand for the bid items.  The new, lower payment amounts resulting from the competition replace the Medicare DMEPOS fee schedule amounts for the bid items in these areas.  All contract suppliers must comply with Medicare enrollment rules, be licensed and accredited, and meet financial standards.  The program sets more appropriate payment amounts for DMEPOS items while ensuring continued access to quality items and services, which will result in reduced beneficiary out-of-pocket expenses and savings to taxpayers and the Medicare program.

Under the MMA, the DMEPOS Competitive Bidding Program was to be phased in so that competition under the program would first occur in 10 areas in 2007.  As required by law, CMS conducted the Round One competition in 10 areas and for 10 DMEPOS product categories, and successfully implemented the program on July 1, 2008, for two weeks before the contracts were terminated by subsequent law.

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) temporarily delayed the program in 2008, terminated the Round One contracts that were in effect, and made other limited changes.  As required by MIPPA, CMS conducted the supplier competition again in 2009, referring to it as the Round One Rebid.

The Round One Rebid Competitive Bidding Program was implemented on January 1, 2011, in CBAs defined by ZIP codes within nine of the largest Metropolitan Statistical Areas (MSAs).  The CBAs in the Round One Rebid include: Charlotte-Gastonia-Concord, NC-SC; Cincinnati-Middletown, OH-KY-IN; Cleveland-Elyria-Mentor, OH; Dallas-Fort Worth-Arlington, TX; Kansas City, MO-KS; Miami-Fort Lauderdale-Pompano Beach, FL; Orlando- Kissimmee, FL; Pittsburgh, PA; and Riverside-San Bernardino-Ontario, CA.

The Round One Rebid competitive bidding product categories are: Oxygen Supplies and Equipment; Standard Power Wheelchairs, Scooters, and Related Accessories; Group 2 Complex Rehabilitative Power Wheelchairs and Related Accessories; Mail-Order Diabetic Supplies; Enteral Nutrients, Equipment and Supplies; Continuous Positive Airway Pressure (CPAP) Devices, Respiratory Assist Devices, and Related Supplies and Accessories; Hospital Beds and Related Accessories; Walkers and Related Accessories; and, in the Miami-Fort Lauderdale-Pompano Beach CBA only, Support Surfaces (Group 2 Mattresses and Overlays).  A list of the HCPCS codes that are included in each of the Round One Rebid product categories can be accessed by visiting the Competitive Bidding Implementation Contractor’s (CBIC) web site at http://www.dmecompetitivebid.com/palmetto/cbic.nsf on the Internet.

MIPPA requires the competition for Round Two to occur in 2011 in 70 additional Metropolitan Statistical Areas (MSAs) and authorizes competition for national mail order items and services after 2010.  The Affordable Care Act expands the number of Round Two MSAs from 70 to 91 areas and mandates that all areas of the country are subject either to DMEPOS competitive bidding or payment rate adjustments using competitively bid rates by 2016.  You can find additional information on the DMEPOS Competitive Bidding Program at http://www.cms.gov/DMEPOSCompetitiveBid/ on the CMS web site.

Competitive Bidding ZIP Codes
For competitive bidding, ZIP codes designated as mail order only are assigned a separate CBA number from the standard CBA.  ZIP codes are established by the United States Postal Service (USPS).  The CBA numbers and associated names are as follows:

 

Public Use Files
The competitive bidding ZIP codes and single payment amounts per product category and CBA are available on the CBIC web site for interested parties like DMEPOS suppliers, State Medicaid agencies, and managed care organizations.  The CBIC web site can be accessed at http://www.dmecompetitivebid.com/palmetto/cbic.nsf or by going to http://www.cms.gov/DMEPOSCompetitiveBid/01_overview.asp on the CMS web site.  These files can be used to identify when a specific item furnished to a beneficiary is subject to the DMEPOS competitive bidding program.

Single Payment Amount
Currently, Medicare payment for most DMEPOS items is based on fee schedules in most areas of the country.  However, the Social Security Act (Section 1847; see http://www.ssa.gov/OP_Home/ssact/title18/1847.htm on the Internet) mandates that competitive bidding single payment amounts replace the current DMEPOS fee schedule payment amounts for competitively bid items in CBAs.  Therefore, the single payment amount is the Medicare allowed payment amount for competitively bid items for beneficiaries who reside in the Round One Rebid CBAs.  Medicare pays contract suppliers 80 percent of the single payment amount for each competitively bid item.  Beneficiaries are responsible for the remaining 20 percent of the single payment amount.  Payment for all claims is on an assignment-related basis.  In no case can a beneficiary be charged more than the 20 percent coinsurance payment for medically necessary items.  Single payment amounts remain the same throughout the term of suppliers’ contracts.

In the CBA pricing file and the single payment amount public use file, the rental single payment amounts for capped rental DME and rented enteral nutrition equipment are 10 percent of the purchase single payment amount.  This payment amount is for rental months one through three.  The rental single payment amounts for months 4 through 13 for capped rental DME and for months 4 through 15 for rented enteral nutrition equipment are equal to 75 percent of the single payment amounts paid in the first three rental months.  The changes to the power wheelchair payment rules made by section 3136 of the Affordable Care Act (see http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf on the Internet) do not apply to payment made for items furnished pursuant to competitive bidding contracts entered into prior to January 1, 2011, or for power wheelchairs in which the first rental month occurred before January 1, 2011.  Therefore, under the Round One Rebid Competitive Bidding Program, contract and grandfathered suppliers furnishing rented power wheelchairs will continue to be paid under the capped rental payment methodology using 10 percent of the purchase single payment amount (or fee schedule amount for grandfathered suppliers) for the first three months and 75 percent of the single payment amounts (or fee schedule amounts for grandfathered suppliers) paid in the first three rental months for months 4 through 13.  Similarly, the elimination of the lump sum purchase option for standard power wheelchairs, as required by the Section 3136 of the Affordable Care Act, does not apply to standard power wheelchairs furnished by contract suppliers under the Round One Rebid Program.

Payment for standard power wheelchairs will continue to be made to Round One Rebid contract suppliers on either a lump sum purchase or rental basis.

For inexpensive and/or routinely purchased DME items, the recorded single payment amount for rental is 10 percent of the purchase single payment amount.

For all equipment furnished on a purchase basis, the recorded single payment amount for purchased used equipment is 75 percent of the purchase single payment amount.

Also included in the CBA pricing file and the single payment amount file is the maintenance and servicing single payment amounts for rented enteral nutrition infusion pumps described by HCPCS code B9000 and B9002, made in accordance with the “Medicare Claims Processing Manual” (Chapter 20, Section 40.3; see http://www.cms.gov/Manuals/downloads/clm104c20.pdf on the CMS web site).  The maintenance and servicing single payment amounts are equal to 5 percent of the single payment amount purchase price for the infusion pump.

Key Points of CR7638
Updates to the ZIP Code Files:
There are no updates to these files at this time

Updates to the HCPCS and Single Payment Amount Files:
There are no updates to these files at this time.

Additional Information
If you have any questions, please contact a CGS Customer Service Representative by calling the appropriate telephone number found on the Customer Service Telephone Numbers web page at: http://www.cgsmedicare.com/hhh/help/telephone_numbers.html

The official instruction associated with this CR 7638 issued to your Medicare DME MAC or RHHI regarding this change may be viewed at http://www.cms.gov/Transmittals/downloads/R2363CP.pdf on the CMS web site.

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MM7660—Additional Instructions Regarding Demand Bills Under the Home Health Prospective Payment System

The Centers for Medicare & Medicaid Services (CMS) has provided the following Medicare Learning Network® (MLN) Matters article.  This MLN Matters article and other CMS articles can be found on the CMS web site at: http://www.cms.gov/MLNMattersArticles/

MLN Matters® Number: MM7660
Related Change Request (CR) #: CR 7660
Related CR Release Date: December 22, 2011
Effective Date: March 22, 2012
Related CR Transmittal #: R2374CP
Implementation Date: March 22, 2012

Provider Types Affected
Home health agencies (HHAs) who, under the Home Health Prospective Payment System (HHA PPS), bill regional home health intermediaries (RHHIs) for services provided to Medicare beneficiaries are affected.

Provider Action Needed
This article is based on CR 7660.  This CR provides additional instructions and clarifies two sections of Chapter 10 in the “Medicare Claims Processing Manual” (Pub. 100-04).  CMS recently discovered that Medicare’s instruction regarding the reporting of the Total Charges field on claims is in conflict with the requirements of the HIPAA standard 837 Institutional claim format.  The 837 requires that the Total Charges field (SV203) must always be reported, and that zero is an acceptable value.  Medicare’s instructions since 2000 have stated that the field may be zero or blank.

Note from CGS: CR 7660 also includes updated instructions in Chapter 10, Section 40.2 of the Medicare Claims Processing Manual (Pub. 100-04) for billing non-covered charges on home health claims and examples of situations where HHAs would need to bill non-covered charges, such as when therapy visits were provided prior to the required re-assessments being performed. 

A revised Chapter 10, Section 50 also provides additional billing instructions to assist providers in preparing demand bills when requests by the State Medicaid program do not correspond to dates of existing episodes of care. Please make sure that your billing staff is aware of these changes.

Background
Demand Billing
When (on a beneficiary’s behalf) a State Medicaid program requests a demand bill, regarding services which have been billed to Medicaid, the dates of service for which the State requests the demand bill might not correspond exactly to the episode periods billed to Medicare.  CR 7660 updates the “Medicare Claims Processing Manual” to provide additional billing instructions to help you prepare demand bills when these dates do not match.

When the Request Begins During a Non-Medicare Episode
Sometime later during the course of a Medicare-Medicaid dually-eligible patient’s episode of care (in which they were initially admitted to home care with the expectation that no services would be billed to Medicare), the State could request a demand bill.

A Medicare-Medicaid dually-eligible patient may be admitted to home care with the expectation that no services will be billed to Medicare.  Later, the State may request demand bills beginning during the course of that episode. This may occur when requests correspond to a calendar year. For example, the patient may be admitted in December and the request for demand bills is effective January 1.  In this case, the HHA should submit a demand bill to Medicare with episode dates corresponding to the OASIS assessment that began in December.  All services in the episode should be submitted as non-covered line items.  As with any demand bill, condition code 20 should be reported on this claim.

When the Request Applies to Services Immediately Following Medicare Discharge
A dually-eligible patient could be discharged from Medicare HH services before the end of a 60-day episode because the patient met their treatment goals or could remain under the care of the HHA receiving services billed to Medicaid.

If the State requests a demand bill for the services within the original Medicare 60-day episode, the HHA should submit an adjustment to their previously paid Medicare claim, using TOB 3x7, and the HHA should:

  1. Change the statement “Through” date to reflect the full 60-day period;
  2. Add the services provided during the demand bill request period as non-covered line items; and
  3. Submit the claim with condition code 20 and all of the non-covered line items for any episodes of continuous care within the demand bill request period.

Total Charge Reporting
As noted above, CMS recently discovered that Medicare’s instruction, regarding the reporting of the Total Charges field on claims, is in conflict with the requirements of the HIPAA standard 837 Institutional claim format.

Specifically, the 837 requires that the Total Charges field (SV203) must always be reported (and zero is an acceptable value,) while Medicare’s instructions since 2000 have said the field may be zero or blank.  CR 7660 corrects this discrepancy by stating that HHAs must report zero charges on the 0023 revenue code line.

Additional Information
You can find CR 7660, located http://www.cms.gov/Transmittals/downloads/R2374CP.pdf on the CMS web site.  You will find the updated “Medicare Claims Processing Manual”, Chapter 10 (Home Health Agency Billing), Sections 50 (Beneficiary-Driven Demand Billing Under HH PPS) and 40.2 (HH PPS Claims) as an attachment to that CR.

If you have any questions, please contact a CGS Customer Service Representative by calling the appropriate telephone number found on the Customer Service Telephone Numbers web page at: http://www.cgsmedicare.com/hhh/help/telephone_numbers.html

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MM7668—January 2012 Integrated Outpatient Code Editor (I/OCE) Specifications Version 13.0

The Centers for Medicare & Medicaid Services (CMS) has provided the following Medicare Learning Network® (MLN) Matters article.  This MLN Matters article and other CMS articles can be found on the CMS web site at: http://www.cms.gov/MLNMattersArticles/

MLN Matters® Number: MM7668
Related Change Request (CR) #: 7668
Related CR Release Date: December 16, 2011
Effective Date: January 1, 2012
Related CR Transmittal #: R2370CP
Implementation Date: January 3, 2012

Provider Types Affected
This article is for providers submitting claims to Medicare contractors (fiscal intermediaries (FIs), Medicare administrative contractors (MACs), and/or regional home health intermediaries (RHHIs)) for outpatient services provided to Medicare beneficiaries and paid under the Outpatient Prospective Payment System (OPPS) and for outpatient claims from any non-OPPS provider not paid under the OPPS, and for claims for limited services when provided in a home health agency not under the Home Health Prospective Payment System or claims for services to a hospice patient for the treatment of a non-terminal illness.

Provider Action Needed
This article is based on CR 7668, which describes changes to the I/OCE and OPPS to be implemented in the January 2012 OPPS and I/OCE updates.  Be sure your billing staff is aware of these changes.

Background
The full list of I/OCE specifications can now be found at http://www.cms.gov/OutpatientCodeEdit/ on the CMS web site.

A summary of the changes for January 2012 is within Appendix M of Attachment A of CR 7668 and that summary is captured in the following key points.

Additional Information
The official instruction, CR 7668 issued to your Medicare MAC, RHHI, or FI regarding this change may be viewed at http://www.cms.gov/Transmittals/downloads/R2370CP.pdf on the CMS web site.

If you have any questions, please contact a CGS Customer Service Representative by calling the appropriate telephone number found on the Customer Service Telephone Numbers web page at: http://www.cgsmedicare.com/hhh/help/telephone_numbers.html

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MM7672—January 2012 Update of the Hospital Outpatient Prospective Payment System (OPPS)

The Centers for Medicare & Medicaid Services (CMS) has provided the following Medicare Learning Network® (MLN) Matters article.  This MLN Matters article and other CMS articles can be found on the CMS web site at: http://www.cms.gov/MLNMattersArticles/

MLN Matters® Number: MM7672
Related Change Request (CR) #: CR 7672
Related CR Release Date: December 29, 2011
Effective Date: January 1, 2012
Related CR Transmittal #: R2376CP and R152BP
Implementation Date: January 3, 2012

Provider Types Affected
This article is for providers submitting claims to Medicare contractors (fiscal intermediaries (FIs), A/B Medicare administrative contractors (A/B MACs), and/or regional home health intermediaries (RHHIs)) for services subject to the Outpatient Prospective Payment System (OPPS) that are provided to Medicare beneficiaries.

Provider Action Needed
STOP – Impact to You
This article is based on CR 7672 which describes changes to the OPPS to be implemented in the January 2012 OPPS update.

CAUTION – What You Need to Know
CR 7672, from which this article is taken:

  1. Describes changes to, and billing instructions for, various payment policies implemented in the January 2012 OPPS update; and
  2. Implements several changes and clarifications in the manual requirements for the provision of hospital outpatient therapeutic services, finalized in the Calendar Year (CY) 2012 OPPS/Ambulatory Surgical Center (ASC) Final Rule.

 

GO – What You Need to Do
You should make sure your billing staffs are aware of these changes.

Background
CR 7672 describes changes to and billing instructions for various payment policies implemented in the January 2012 OPPS update.  The January 2012 Integrated Outpatient Code Editor (I/OCE) and OPPS Pricer will reflect the Healthcare Common Procedure Coding System (HCPCS), Ambulatory Payment Classification (APC), HCPCS Modifier, and Revenue Code additions, changes, and deletions identified in this CR.

The January 2012 revisions to I/OCE data files, instructions, and specifications are provided in CR 7668, “January 2012 Integrated Outpatient Code Editor (I/OCE) Specifications Version 13.0.”  (You can find the associated MLN Matters® article at http://www.cms.gov/MLNMattersArticles/downloads/MM7668.pdf on the CMS web site.)

Key changes to and billing instructions for various payment policies implemented in the October 2010 OPPS update are as follows:

Physician Supervision
In the “Medicare Benefit Policy Manual,” (Pub. 100-02) Chapter 6 (Hospital Services Covered Under Part B), Section 20.4.4 (Coverage of Outpatient Diagnostic Services Furnished on or After January 1, 2010), CMS is making several revisions to the standards governing the supervision of hospital or critical access hospital (CAH) outpatient therapeutic services.

Currently, CMS requires the direct supervision of outpatient therapeutic services except for nonsurgical extended duration therapeutic services, for which CMS allows general supervision during a portion of the service at the discretion of the supervising practitioner.

CR 7672 provides that (effective January 1, 2012) CMS may assign general or personal supervision for the duration of the service to certain hospital outpatient therapeutic services.  To enable such assignment, CMS is defining those levels of supervision using the definitions that are used in the Medicare Physician Fee Schedule.

CR 7672 also provides (as specified in CMS regulations), that in addition to providing direct supervision certain non-physician practitioners may also furnish the required general or personal supervision.

New Device Pass-Through Categories
The Social Security Act (the Act) (Section 1833(t)(6)(B); see  http://www.ssa.gov/OP_Home/ssact/title18/1833.htm on the Internet) requires that, under the OPPS, categories of devices be eligible for transitional pass-through payments for at least 2, but not more than 3 years.  Section 1833(t)(6)(B)(ii)(IV) of the Act requires that additional categories be created for transitional pass-through payment of new medical devices not described by existing or previously existing categories of devices.

CMS is establishing one new device pass-through category as of January 1, 2012.  Table 1, below, provides a listing of new coding, Status Indicator (SI), Ambulatory Payment Classification (APC), and payment information concerning the new device category for transitional pass-through payment.

Table 1
New Device Pass-Through Code

Table 1, below, provides a listing of new coding, Status Indicator (SI), Ambulatory Payment Classification (APC), and payment information concerning the new device category for transitional pass-through payment

HCPCS

Effective Date

SI

APC

Short Descriptor

Long Descriptor

APC for Device Offset from Payment

C1886

01-01-12

H

1886

Catheter, ablation

Catheter, extravascular tissue ablation, any modality (insertable)

0415

Device Offset from Payment for C1886
Section 1833(t)(6)(D)(ii) of the Act requires that CMS deduct, from pass-through payments for devices, an amount that reflects the portion of the APC payment amount determined to be associated with the cost of the device.  (Please see 2005 Federal Register, Vol. 70, page 68627-8 at http://www.gpoaccess.gov/fr/retrieve.html on the Internet).

CMS has determined that it is able to identify a portion of the APC payment amount associated with the cost of C1886 (Catheter, extravascular tissue ablation, any modality (insertable)), in APC 0415, Level II, Endoscopy, lower airway.  The device offset from payment represents this deduction from pass-through payments for category C1886, when it is billed with a service included in APC 0415.  The device offset amount for APC 0415, along with the device offsets for other APCs, is available under “Annual Policy Files” at http://www.cms.gov/HospitalOutpatientPPS/ on the CMS web site.

Revised Device Offset from Payment for Category C1840
Effective January 1, 2012, device pass-through category C1840 must be billed with procedure code C9732 (Insertion of ocular telescope prosthesis including removal of crystalline lens), (see New Procedure Code section below) to receive pass-through payment.  C9732 is assigned to APC 0234, Level IV Anterior Segment Eye Procedures.  Therefore, as of January 1, 2012, device C1840 will be used with an APC 0234 service.  The new device offset for CY 2012 for APC 0234, is available under “Annual Policy Files” at http://www.cms.gov/HospitalOutpatientPPS/ on the CMS web site.

New Procedure Code
CMS is establishing one new procedure code, effective January 1, 2012.  Table 2 provides a listing of the descriptor and payment information for this new code.

Table 2
New Procedure Code

Table 2 provides a listing of the descriptor and payment information for this new code

HCPCS

Effective Date

SI

APC

Short Descriptor

Long Descriptor

C9732

01-01-12

T

0234

Insert ocular telescope pros

Insertion of ocular telescope prosthesis including removal of crystalline lens

Billing Instructions for C9732 and C1840
Pass-through category C1840 (Lens, intraocular (telescopic)), is to be billed and paid for as a pass-through device only when provided with C9732 (Insertion of ocular telescope prosthesis including removal of crystalline lens) beginning on and after the effective date for C9732 of January 1, 2012.

Note: These billing instructions supersede prior billing instructions for C1830 provided in the October 2011 update of the OPPS, Transmittal 2296, CR 7545.

Billing for Thermal Anal Lesions by Radiofrequency Energy
For CY 2012, the CPT Editorial Panel created new CPT code 0288T (Anoscopy, with delivery of thermal energy to the muscle of the anal canal (e.g., for fecal incontinence)) to describe the procedure associated with radiofrequency energy creation of thermal anal lesions.  Prior to CY 2012, this procedure was described by HCPCS code C9716 (Creations of thermal anal lesions by radiofrequency energy).  In Addendum B of the CY 2012 OPPS/ASC final rule, both HCPCS code C9716 and 0288T were assigned to specific APCs.  Specifically, HCPCS code C9716 was assigned to APC 0150 (Level IV Anal/Rectal Procedures) and CPT code 0288T was assigned to APC 0148 (Level I Anal/Rectal Procedures).  Because HCPCS code C9716 is described by CPT code 0288T, CMS is deleting HCPCS code C9716 on December 31, 2011, since it will be replaced with CPT code 0288T effective January 1, 2012.  In addition, CPT code 0288T is being reassigned from APC 0148 to APC 0150 effective January 1, 2012.  This change will be reflected in the January 2012 OPPS I/OCE and OPPS Pricer. Table 3 below lists the final OPPS status indicator and APC assignment for HCPCS codes C9716 and 0288T.

Table 3 – CY 2012 OPPS Status Indicator and APC Assignment
for HCPCS Codes C9716 and 0288T

Table 3 below lists the final OPPS status indicator and APC assignment for HCPCS codes C9716 and 0288T
HCPCS Code

Short Descriptor

CY 2012 SI

CY 2012 APC

C9716

Radiofrequency energy to anu

D

N/A

0288T

Anoscopy w/rf delivery

T

0150

Cardiac Resynchronization Therapy Payment for CY 2012
Effective for services furnished on or after January 1, 2012, cardiac resynchronization therapy involving an implantable cardioverter defibrillator (CRT-D) will be recognized as a single, composite service combining implantable cardioverter defibrillator procedures and pacing electrode insertion procedures when performed on the same date of service.

CMS also is implementing claims processing edits that will return to providers incorrectly coded claims on which a pacing electrode insertion procedure described by CPT code 33225 (Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator (including upgrade to dual chamber system)) is billed without one of the primary CPT codes for insertion of an implantable cardioverter defibrillator or pacemaker as specified in the 2012 CPT code book.  CMS is adding new Section 10.2.2 to the “Medicare Claims Processing Manual”, (Pub. 100-04) Chapter 4, to reflect the implementation of this new composite service policy and claims processing edits for CPT code 33225.

Billing for Drugs, Biologicals, and Radiopharmaceuticals
Reporting HCPCS Codes for All Drugs, Biologicals, and Radiopharmaceuticals
Hospitals are strongly encouraged to report charges for all drugs, biologicals, and radiopharmaceuticals, regardless of whether the items are paid separately or packaged, using the correct HCPCS codes for the items used.  It is also of great importance that hospitals billing for these products make certain that the reported units of service of the reported HCPCS codes are consistent with the quantity of a drug, biological, or radiopharmaceutical that was used in the care of the patient.

More complete data from hospitals on the drugs and biologicals provided during an encounter would help improve payment accuracy for separately payable drugs and biologicals in the future.  CMS strongly encourages hospitals to report HCPCS codes for all drugs and biologicals furnished, if specific codes are available.  CMS realizes that this may require hospitals to change longstanding reporting practices.  Precise billing of drug and biological HCPCS codes and units, especially in the case of packaged drugs and biologicals for which the hospital receives no separate payment, is critical to the accuracy of the OPPS payment rates for drugs and biologicals each year.

CMS notes that it makes packaging determinations for drugs and biologicals annually based on charge information reported with specific HCPCS codes on claims, so the accuracy of OPPS payment rates for drugs and biologicals improves when hospitals report charges for all items and services that have HCPCS codes under those HCPCS codes, whether or not payment for the items and services is packaged or not. It is CMS’ standard rate-setting methodology to rely on hospital cost and charge information as it is reported to CMS by hospitals through the claims data and cost reports.  Precise billing and accurate cost reporting by hospitals allow CMS to most accurately estimate the hospital costs for items and services upon which OPPS payments are based.

CMS reminds hospitals that under the OPPS, if two or more drugs or biologicals are mixed together to facilitate administration, the correct HCPCS codes should be reported separately for each product used in the care of the patient.  The mixing together of two or more products does not constitute a “new” drug as regulated by the Food and Drug Administration (FDA) under the New Drug Application (NDA) process.  In these situations, hospitals are reminded that it is not appropriate to bill HCPCS code C9399. HCPCS code C9399 (Unclassified drug or biological) is for new drugs and biological that are approved by the FDA on or after January 1, 2004, for which a HCPCS code has not been assigned.

Unless otherwise specified in the long description, HCPCS descriptions refer to the non-compounded, FDA-approved final product.  If a product is compounded and a specific HCPCS code does not exist for the compounded product, the hospital should report an appropriate unlisted code such as J9999 or J3490.

New CY 2012 HCPCS Codes and Dosage Descriptors for Certain Drugs, Biologicals, and Radiopharmaceuticals
For CY 2012, several new HCPCS codes have been created for reporting drugs and biologicals in the hospital outpatient setting, where there have not previously been specific codes available. These new codes are listed in Table 4.

Table 4
New CY 2012 HCPCS Codes Effective for Certain Drugs, Biologicals, and Radiopharmaceuticals

New CY 2012 HCPCS Codes Effective for Certain Drugs, Biologicals, and Radiopharmaceuticals
CY 2012 HCPCS Code

CY 2012 Long Descriptor

CY 2012 SI

CY 2012 APC

A9585

Injection gadobutrol, 0.1 ml

N

N/A

C9287

Injection, brentuximab vedotin, 1 mg

G

9287

C9366

EpiFix, per square centimeter

G

9366

J0257

Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg

K

1415

J7180

Injection, factor xiii (antihemophilic factor, human), 1 i.u.

G

1416

J7326

Hyaluronan or derivative, gel-one, for intra-articular injection, per dose

K

1417

J8561

Everolimus, oral, 0.25 mg

K

1418

Q4122

Dermacell, per square centimeter

K

1419

Other Changes to CY 2012 HCPCS and CPT Codes for Certain Drugs, Biologicals, and Radiopharmaceuticals
Many HCPCS and CPT codes for drugs, biologicals, and radiopharmaceuticals have undergone changes in their HCPCS and CPT code descriptors that will be effective in CY 2012.  In addition, several temporary HCPCS C-codes have been deleted effective December 31, 2011, and replaced with permanent HCPCS codes in CY 2012.  Hospitals should pay close attention to accurate billing for units of service consistent with the dosages contained in the long descriptors of the active CY 2012 HCPCS and CPT codes.

Table 5 displays those drugs, biologicals, and radiopharmaceuticals that have undergone changes in either their HCPCS/CPT codes, their long descriptors, or both. Each product’s CY 2011 HCPCS/CPT code and CY 2011 long descriptor are noted in the two left hand columns, with the CY 2012 HCPCS/CPT code and long descriptor are noted in the adjacent right hand columns.

Table 5
Other CY 2012 HCPCS and CPT Code Changes for Certain Drugs, Biologicals, and Radiopharmaceuticals

Other CY 2012 HCPCS and CPT Code Changes for Certain Drugs, Biologicals, and Radiopharmaceuticals
CY 2011 HCPCS/
CPT code

CY 2011 Long Descriptor

CY 2012 HCPCS/
CPT Code

CY 2012 Long Descriptor

C9270

Injection, immune globulin (Gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg

J1557

Injection, immune globulin, (Gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 mg

C9272

Injection, denosumab, 1 mg

J0897

Injection, denosumab, 1 mg

C9273***

Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion

Q2043

Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion

C9274

Crotalidae Polyvalent Immune Fab (Ovine), 1 vial

J0840

Injection, crotalidae polyvalent immune fab (ovine), up to 1 gram

C9276

Injection, cabazitaxel, 1 mg

J9043

Injection, cabazitaxel, 1 mg

C9277

Injection, alglucosidase alfa (Lumizyme), 1 mg

J0221

Injection, alglucosidase alfa, (lumizyme), 10 mg

C9278*

Injection, incobotulinumtoxin A, 1 unit

J0588

Injection, incobotulinumtoxin A, 1 unit

Q2040*

Injection, incobotulinumtoxin A, 1 unit

J0588

Injection, incobotulinumtoxin A, 1 unit

C9280

Injection,eribulin mesylate, 1 mg

J9179

Injection, eribulin mesylate, 0.1 mg

C9281

Injection, pegloticase, 1 mg

J2507

Injection, pegloticase, 1 mg

C9282

Injection, ceftaroline fosamil, 10 mg

J0712

Injection, ceftaroline fosamil, 10 mg

C9283

Injection, acetaminophen, 10 mg

J0131

Injection, acetaminophen, 10 mg

C9284

Injection, ipilimumab, 1 mg

J9228

Injection, ipilimumab, 1 mg

C9365

Oasis Ultra Tri-Layer matrix, per square centimeter

Q4124

Oasis ultra tri-layer wound matrix, per square centimeter

C9406

Iodine I-123 ioflupane, diagnostic, per study dose, up to 5 millicuries

A9584

Iodine i-123 ioflupane, diagnostic, per study dose, up to 5 millicuries

J0220

Injection, alglucosidase alfa, 10 mg

J0220

Injection, alglucosidase alfa, 10 mg, not otherwise classified

J0256

Injection, alpha 1 - proteinase inhibitor - human, 10 mg

J0256

Injection, alpha 1 proteinase inhibitor (human), not otherwise specified, 10mg

J1561**

'Injection, immune globulin, (Gamunex), intravenous, non-lyophilized (e.g. liquid), 500 mg

J1561

Injection, immune globulin, (Gamunex/Gamunex-c/Gammaked), non-lyophilized (e.g., liquid), 500 mg

Q2044

Injection, belimumab, 10 mg

J0490

Injection, belimumab, 10 mg

Q2042

Injection, hydroxyprogesterone caproate, 1 mg

J1725

Injection, hydroxyprogesterone caproate, 1 mg

J7130

Hypertonic saline solution, 50 or 100 meq, 20 cc vial

J7131

Hypertonic saline solution, 1 ml

Q2041

Injection, von willebrand factor complex (human), wilate, 1 i.u. vwf:rco

J7183

Injection, von willlebrand factor complex (human), wilate, 1 i.u. vwf:rco

Q1079

Ondansetron hydrochloride 8 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0162

Ondansetron 1 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

*HCPCS code C9278 was replaced with HCPCS code Q2040 effective April 1, 2011. HCPCS code Q2040 was subsequently replaced with HCPCS code J0588, effective January 1, 2012.
** The short descriptor for HCPCS code J1561 has been revised from “Gamunex/Gamunex C” to “Gamunex, Gamunex-C, Gammaked” effective January 1, 2012.
*** HCPCS code C9273 was replaced with HCPCS code Q2043 effective July 1, 2011.

Drugs and Biologicals with Payments Based on Average Sales Price (ASP) Effective January 1, 2012
For CY 2012, payment for non-pass-through drugs, biologicals, and therapeutic radiopharmaceuticals is made at a single rate of ASP + 4 percent, which provides payment for both the acquisition cost and pharmacy overhead costs associated with the drug, biological or therapeutic radiopharmaceutical.  In CY 2012, a single payment of ASP + 6 percent for pass-through drugs, biologicals, and radiopharmaceuticals is made to provide payment for both the acquisition cost and pharmacy overhead costs of these pass-through items.  Payment for drugs and biologicals with pass-through status for the first quarter of CY 2012 is not made at the Part B Drug Competitive Acquisition Program (CAP) rate, as the CAP program was postponed beginning January 1, 2009.

Should the Part B Drug CAP program be reinstituted sometime during CY 2012, CMS would again use the Part B drug CAP rate for pass-through drugs and biologicals if they are a part of the Part B drug CAP program, as required by the statute.

In the CY 2012 OPPS/ASC final rule with comment period, CMS stated that payments for drugs and biologicals based on ASPs will be updated on a quarterly basis as later quarter ASP submissions become available.  Effective January 1, 2012, payment rates for many drugs and biologicals have changed from the values published in the CY 2012 OPPS/ASC final rule with comment period as a result of the new ASP calculations based on sales price submissions from the third quarter of CY 2011.

In cases where adjustments to payment rates are necessary, changes to the payment rates will be incorporated in the January 2012 release of the OPPS Pricer.  CMS is not publishing the updated payment rates in this instruction implementing the January 2012 update of the OPPS.  However, the updated payment rates effective January 1, 2012, can be found in the January 2012 update of the OPPS Addendum A and Addendum B at http://www.cms.gov/HospitalOutpatientPPS/AU/list.asp on the CMS web site.

Updated Payment Rates for Certain HCPCS Codes Effective October 1, 2011, through December 31, 2011
The payment rates for several HCPCS codes were incorrect in the October 2011 OPPS Pricer.  The corrected payment rates are listed in Table 6 and have been installed in the January 2012 OPPS Pricer, effective for services furnished on October 1, 2011, through implementation of the January 2012 update.  Your Medicare contractor will adjust any claims related to the changes shown in Table 6, provided you make the contractor aware of such claims.

Table 6
Updated payment Rates for Certain HCPCS Codes Effective
October 1, 2011, through December 31, 2011

 Your Medicare contractor will adjust any claims related to the changes shown in Table 6, provided you make the contractor aware of such claims

HCPCS Code

Status Indicator

APC

Short Descriptor

Corrected Payment Rate

Corrected Minimum Unadjusted Copayment

J9600

K

0856

Porfimer sodium injection

$19,143.46

$3,828.69

Q4121

K

1345

Theraskin

$20.77

$4.15

Correct Reporting of Biologicals When Used As Implantable Devices
When billing for biologicals where the HCPCS code describes a product that is only surgically implanted or inserted, whether the HCPCS code is identified as having pass-through status or not, hospitals are to report the appropriate HCPCS code for the product.  Units should be reported in multiples of the units included in the HCPCS descriptor.  Providers and hospitals should not bill the units based on the way the implantable biological is packaged, stored, or stocked.  The HCPCS short descriptors are limited to 28 characters, including spaces, so short descriptors do not always capture the complete description of the implantable biological. Therefore, before submitting Medicare claims for biologicals that are used as implantable devices, it is extremely important to review the complete long descriptors for the applicable HCPCS codes.  In circumstances where the implanted biological has pass-through status as a device, separate payment for the device is made.  In circumstances where the implanted biological does not have pass-through status, the OPPS payment for the implanted biological is packaged into the payment for the associated procedure.

When billing for biologicals where the HCPCS code describes a product that may either be surgically implanted or inserted or otherwise applied in the care of a patient, hospitals should not separately report the biological HCPCS codes, with the exception of biologicals with pass-through status, when using these items as implantable devices (including as a scaffold or an alternative to human or nonhuman connective tissue or mesh used in a graft) during surgical procedures.  Under the OPPS, hospitals are provided a packaged APC payment for surgical procedures that includes the cost of supportive items, including implantable devices without pass-through status.  When using biologicals during surgical procedures as implantable devices, hospitals may include the charges for these items in their charge for the procedure, report the charge on an uncoded revenue center line, or report the charge under a device HCPCS code (if one exists) so these costs would appropriately contribute to the future median setting for the associated surgical procedure.

Hospitals are reminded that HCPCS codes describing skin substitutes (Q4100 – Q4130) should only be reported when used with one of the CPT codes describing application of a skin substitute (15271-15278).  These Q codes for skin substitutes should not be billed when used with any other procedure besides the skin substitute application procedures.

Payment for Therapeutic Radiopharmaceuticals
Beginning in CY 2010, non-pass-through separately payable therapeutic radiopharmaceuticals are paid under the OPPS based upon the ASP.  If ASP data are unavailable, payment for therapeutic radiopharmaceuticals will be provided based on the most recent hospital mean unit cost data. Therefore, for January 1, 2012, the status indicator for separately payable therapeutic radiopharmaceuticals is “K” to reflect their separately payable status under the OPPS. Similar to payment for other separately payable drugs and biologicals, the payment rates for non-pass-through separately payable therapeutic radiopharmaceuticals will be updated on a quarterly basis.

Table 7 - Non-Pass-Through Separately Payable Therapeutic Radiopharmaceuticals for January 1, 2012

Similar to payment for other separately payable drugs and biologicals, the payment rates for non-pass-through separately payable therapeutic radiopharmaceuticals will be updated on a quarterly basis
CY 2012 HCPCS Code

CY 2012 Long Descriptor

Final CY 2012 APC

Final CY 2012 SI

A9517

Iodine I-131 sodium iodide capsule(s), therapeutic, per millicurie

1064

K

A9530

Iodine I-131 sodium iodide solution, therapeutic, per millicurie

1150

K

A9543

Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries

1643

K

A9545

Iodine I-131 tositumomab, therapeutic, per treatment dose

1645

K

A9563

Sodium phosphate P-32, therapeutic, per millicurie

1675

K

A9564

Chromic phosphate P-32 suspension, therapeutic, per millicurie

1676

K

A9600

Strontium Sr-89 chloride, therapeutic, per millicurie

0701

K

A9604

Samarium SM-153 lexidronam, therapeutic, per treatment dose, up to 150 millicuries

1295

K

Payment Offset for Pass-Through Diagnostic Radiopharmaceuticals
Effective for nuclear medicine services furnished on and after April 1, 2009, CMS implemented a payment offset for pass-through diagnostic radiopharmaceuticals under the OPPS. As discussed in the April 2009 OPPS CR6416, pass-through payment for a diagnostic radiopharmaceutical is the difference between the payment for the pass-through product and the payment for the predecessor product that, in the case of diagnostic radiopharmaceuticals, is packaged into the payment for the nuclear medicine procedure in which the diagnostic radiopharmaceutical is used. (You can find the associated MLN Matters® article at http://www.cms.gov/MLNMattersArticles/downloads/MM6416.pdf on the CMS web site).

Effective July 1, 2011, the diagnostic radiopharmaceutical reported with HCPCS code A9584 (Iodine i-123 ioflupane, diagnostic, per study dose, up to 5 millicuries) was granted pass-through status under the OPPS and assigned status indicator “G.”  HCPCS code A9584 will continue on pass-through status for CY 2012 and therefore, when HCPCS code A9584 is billed on the same claim with a nuclear medicine procedure, CMS will reduce the amount of payment for the pass-through diagnostic radiopharmaceutical reported with HCPCS code A9584 by the corresponding nuclear medicine procedure’s portion of its APC payment associated with “policy-packaged” drugs (offset amount) so no duplicate radiopharmaceutical payment is made.

The “policy-packaged” portions of the CY 2012 APC payments for nuclear medicine procedures may be found on the CMS web site at http://www.cms.gov/HospitalOutpatientPPS/04_passthrough_payment.asp#TopOfPage in the download file labeled 2012 OPPS Offset Amounts by APC.

CY 2012 APCs to which nuclear medicine procedures are assigned and for which CMS expects a diagnostic radiopharmaceutical payment offset could be applicable in the case of a pass-through diagnostic radiopharmaceutical are displayed in the following table:

Table 8
APCs to Which Nuclear Medicine Procedures are Assigned for CY 2012

APCs to Which Nuclear Medicine Procedures are Assigned for CY 2012

CY 2012 APC

CY 2012 APC Title

0308

Positron Emission Tomography (PET) Imaging

0377

Level II Cardiac Imaging.

0378

Level II Pulmonary Imaging.

0389

Level I Non-imaging Nuclear Medicine.

0390

Level I Endocrine Imaging.

0391

Level II Endocrine Imaging.

0392

Level II Non-imaging Nuclear Medicine.

0393

Hematologic Processing & Studies.

0394

Hepatobiliary Imaging.

0395

GI Tract Imaging.

0396

Bone Imaging.

0397

Vascular Imaging.

0398

Level I Cardiac Imaging.

0400

Hematopoietic Imaging.

0401

Level I Pulmonary Imaging.

0402

Level II Nervous System Imaging.

0403

Level I Nervous System Imaging.

0404

Renal and Genitourinary Studies.

0406

Level I Tumor/Infection Imaging.

0408

Level III Tumor/Infection Imaging.

0414

Level II Tumor/Infection Imaging.

Payment Offset for Pass-Through Contrast Agents
Effective for contrast-enhanced procedures furnished on or after January 1, 2010, CMS implemented a payment offset for pass-through contrast agents, for when a contrast-enhanced procedure that is assigned to a procedural APC with a “policy-packaged” drug amount greater than $20.00 (that is not an APC containing nuclear medicine procedures) is billed on the same claim with a pass-through contrast agent on the same date of service.  As discussed in the January 2010 OPPS CR6751, CMS will reduce the amount of payment for the contrast agent by the corresponding contrast-enhanced procedure’s portion of its APC payment associated with “policy-packaged” drugs (offset amount) so no duplicate contrast agent payment is made.  You can find the MLN Matters® article associated with this CR at http://www.cms.gov/MLNMattersArticles/downloads/MM6416.pdf on the CMS web site.

CY 2012 procedural APCs for which CMS expects a contrast agent payment offset could be applicable in the case of a pass-through contrast agent are identified in Table 9. Pass-through payment for a contrast agent is the difference between the payment for the pass-through product and the payment for the predecessor product that, in the case of a contrast agent, is packaged into the payment for the contrast-enhanced procedure in which the contrast agent is used.

For CY 2012, when a contrast agent with pass-through status is billed with a contrast-enhanced procedure assigned to any procedural APC listed in the table on the same date of service, a specific pass-through payment offset determined by the procedural APC to which the contrast-enhanced procedure is assigned will be applied to payment for the contrast agent to ensure that duplicate payment is not made for the contrast agent.

For CY 2012, HCPCS code C9275 (Injection, hexaminolevulinate hydrochloride, 100 mg, per study dose) will continue on pass-through status and will be subject to the payment offset methodology for contrast agents.  HCPCS code C9275 is assigned a status indicator of “G”.  Therefore, in CY 2012, CMS will reduce the payment that is attributable to the predecessor contrast agent that is packaged into payment for the associated contrast enhanced procedure reported on the same claim on the same date as HCPCS code C9275 if the contrast-enhanced procedure is assigned to one of the APCs listed in the table.

The “policy-packaged” portions of the CY 2012 APC payments that are the offset amounts may be found on the CMS web site at: http://www.cms.gov/HospitalOutpatientPPS/04_passthrough_payment.asp in the download file labeled 2012 OPPS Offset Amounts by APC.

Table 9
APCs to Which a Pass-Through Contrast Agent Offset May Be Applicable for CY 2011

APCs to Which a Pass-Through Contrast Agent Offset May Be Applicable for CY 2011
CY 2012 APC

CY 2012 APC Title

0080

Diagnostic Cardiac Catheterization

0082

Coronary or Non-Coronary Atherectomy

0083

Coronary Angioplasty, Valvuloplasty, and Level I Endovascular Revascularization

0093

Vascular Reconstruction/Fistula Repair without Device

0104

Transcatheter Placement of Intracoronary Stents

0128

Echocardiogram with Contrast

0152

Level I Percutaneous Abdominal and Biliary Procedures

0229

Level II Endovascular Revascularization of the Lower Extremity

0278

Diagnostic Urography

0279

Level II Angiography and Venography

0280

Level III Angiography and Venography

0283

Computed Tomography with Contrast

0284

Magnetic Resonance Imaging and Magnetic Resonance Angiography with Contrast

0333

Computed Tomography without Contrast followed by Contrast

0334

Combined Abdomen and Pelvis CT with Contrast

0337

Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast followed by Contrast

0375

Ancillary Outpatient Services When Patient Expires

0383

Cardiac Computed Tomographic Imaging

0388

Discography

0442

Dosimetric Drug Administration

0653

Vascular Reconstruction/Fistula Repair with Device

0656

Transcatheter Placement of Intracoronary Drug-Eluting Stents

0662

CT Angiography

0668

Level I Angiography and Venography

8006

CT and CTA with Contrast Composite

8008

MRI and MRA with Contrast Composite

Clarification of Coding for Drug Administration Services
As noted in CR 7271, in 2011 CMS revised the “Medicare Claims Processing Manual,” (Pub. 100-04) Chapter 4 (Part B Hospital (Including Inpatient Hospital Part B and OPPS), Section 230.2 (Coding and Payment for Drug Administration)), to clarify the correct coding of drug administration services.  Drug administration services are to be reported with a line-item date of services on the day they are provided.  In addition, CMS noted that beginning in CY 2007, hospitals should report only one initial drug administration service, including infusion services, per encounter for each distinct vascular access site, with other services through the same vascular access site being reported via the sequential, concurrent or additional hour codes.  CMS has subsequently become aware of new CPT guidance regarding the reporting of initial drug administration services in the event of a disruption in service; however, Medicare contractors are to continue to follow the guidance given in this manual.  (You can find the associated MLN Matters® article at http://www.cms.gov/MLNMattersArticles/downloads/MM7271.pdf on the CMS web site and this manual reference at http://www.cms.gov/manuals/downloads/clm104c04.pdf on the CMS web site).

Provenge Administration
Effective July 1, 2010, the autologous cellular immunotherapy treatment reported with HCPCS code C9273 (Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion) was granted pass-through status under OPPS and assigned status indicator “G.”  Effective July 1, 2011, this product was assigned to HCPCS code Q2043 (Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion) with status indicator “G.”  HCPCS code Q2043 will continue on pass-through status for CY 2012.

Please note that the HCPCS long descriptor for CY 2012 for HCPCS code Q2043 includes payment for the drug itself, as well “all other preparatory procedures,” referring to the transportation process of collecting immune cells from a patient during a non-therapeutic leukapheresis procedure, subsequently sending the immune cells to the manufacturing facility, and then transporting the immune cells back to the site of service to be administered to the patient.  Payment for Q2043 does not include OPPS payment for drug administration.

Billing for Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse – National Coverage Determination (NCD)
Effective for claims with dates of service on and after October 14, 2011, CMS will cover annual alcohol screening, and for those who screen positive, up to four, brief, face-to-face behavioral counseling interventions per year for Medicare beneficiaries, including pregnant women: 1) who misuse alcohol, but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence (defined as at least three of the following: tolerance, withdrawal symptoms, impaired control, preoccupation with acquisition and/or use, persistent desire or unsuccessful efforts to quit, sustains social, occupational, or recreational disability, use continues despite adverse consequences); and 2) who are competent and alert at the time that counseling is provided; and 3) whose counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting.  In outpatient hospital settings, as in any other setting, services covered under this NCD must be provided by a primary care provider.

To implement this recent coverage determination, CMS created two new G-codes to report annual alcohol screening and brief, face-to-face behavioral counseling interventions. The long descriptors for both G-codes appear in Table 10.

Table 10 – Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse

 The long descriptors for both G-codes appear in Table 10
CY 2012 HCPCS Code

CY 2012 Long Descriptor

CY 2012 Status Indicator

CY 2012 APC

G0442

Annual alcohol misuse screening, 15 minutes

S

0432

G0443

Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes

S

0432

Further reporting guidelines on Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse can be found in Pub. 100-03, “Medicare National Coverage Determinations Manual,” Chapter 1, Section 210.8 and Pub. 100-04, “Medicare Claims Processing Manual,” Chapter 18, Section 180, as well as in Transmittals 138, and 2358, CR7633 that was published on November 23, 2011. The related MLN Matters® on this NCD is at http://www.cms.gov/MLNMattersArticles/downloads/MM7633.pdf on the CMS web site.

Screening for Depression in Adults – NCD
Effective for claims with dates of service on and after October 14, 2011, Medicare covers annual screening for adults for depression in the primary care setting that have staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment, and follow-up.  For the purposes of this NCD, a primary care setting is defined as one in which there is provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.  Emergency departments, inpatient hospital settings, Ambulatory Surgical Centers (ASCs), independent diagnostic testing facilities, Skilled Nursing Facilities (SNFs), inpatient rehabilitation facilities, and hospices are not considered primary care settings under this definition.

To implement this recent coverage determination, CMS created a new G-code to report the annual depression screening. The long descriptor for the G-code appears in Table 11.

Table 11 – Annual Depression Screening

The long descriptor for the G-code appears in Table 11
CY 2012 HCPCS Code

CY 2012 Long Descriptor

CY 2012 Status Indicator

CY 2012 APC

G0444

Annual Depression Screening, 15 minutes

S

0432

Further reporting guidelines on depression screening can be found in Pub. 100-03, “Medicare National Coverage Determinations Manual,” Chapter 1, Section 210.9 and Pub. 100-04, “Medicare Claims Processing Manual,” Chapter 18, Section 190, as well as in Transmittals 139 and 2359, CR 7637 that was published on November 23, 2011. The MLN Matters® article on this NCD is at http://www.cms.gov/MLNMattersArticles/downloads/MM7637.pdf on the CMS site.

Billing for Sexually Transmitted Infections (STIs) Screening and High Intensity Behavioral Counseling (HIBC) to Prevent STIs – NCD
Effective for claims with dates of service on and after November 8, 2011, CMS will cover screening for chlamydia, gonorrhea, syphilis, and hepatitis B with the appropriate FDA approved/cleared laboratory tests, used consistent with FDA approved labeling and in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations, when ordered by the primary care provider, and performed by an eligible Medicare provider for these services. Also effective for claims with dates of service on and after November 8, 2011, CMS will cover up to two individual - 20 to 30 minute, face to face counseling sessions annually for Medicare beneficiaries for High Intensity Behavioral Counseling (HIBC) to prevent Sexually Transmitted Infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs, if referred for this service by a primary care provider and provided by a Medicare eligible primary care provider in a primary care setting. For the purposes of this NCD, a primary care setting is defined as the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.  Emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, clinics providing a limited focus of health care services, and hospice are examples of settings not considered primary care settings under this definition.

To implement this recent coverage determination, CMS created a new G-code to report HIBC to Prevent STIs. The long descriptor for the G-code appears in Table 12.

Table 12 –STIs Screening and HIBC to Prevent STIs

The long descriptor for the G-code appears in Table 12
CY 2012 HCPCS Code

CY 2012 Long Descriptor

CY 2012 Status Indicator

CY 2012 APC

G0445

High intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training and guidance on how to change sexual behavior; performed semi-annually, 30 minutes

S

0432

HCPCS code G0445 has been assigned to APC 0432 and given a status indicator assignment of “S.”  Further reporting guidelines on HIBC to Prevent STIs will be provided in a future CR.

CMS is deleting screening code G0450 (Screening for sexually transmitted infections, includes laboratory tests for Chlamydia, Gonorrhea, Syphilis, and Hepatitis B) previously released on the 2012 HCPCS tape, from the OPPS addenda, effective November 8, 2011. This screening service will now be identified using ICD-9 screening and diagnosis codes. Coding and billing instructions will be issued in an upcoming CR.

Billing for Intensive Behavioral Therapy for Cardiovascular Disease – NCD
Effective for claims with dates of service on and after November 8, 2011, CMS will cover intensive behavioral therapy for cardiovascular disease (referred to below as a CVD risk reduction visit), which consists of the following three components: 1) encouraging aspirin use for the primary prevention of cardiovascular disease when the benefits outweigh the risks for men age 45-79 years and women 55-79 years; 2) screening for high blood pressure in adults age 18 years and older; and 3) intensive behavioral counseling to promote a healthy diet for adults with hyperlipidemia, hypertension, advancing age, and other known risk factors for cardiovascular and diet-related chronic disease.  Effective for claims with dates of service on and after November 8, 2011, CMS covers one face-to-face CVD risk reduction per year for Medicare beneficiaries who are competent and alert at the time that counseling is provided, and whose counseling is furnished by a qualified primary care physician or other primary care practitioner in a primary care setting.  For the purposes of this NCD , a primary care setting is defined as one in which there is provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.  Emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, and hospices are not considered primary care settings under this definition.

To implement this recent coverage determination, CMS created a new G-code to report the CVD risk reduction visit.  The long descriptor for the G-code appears in Table 13.

Table 13 – Intensive Behavioral Therapy for Cardiovascular Disease

The long descriptor for the G-code appears in Table 13
CY 2012 HCPCS Code

CY 2012 Long Descriptor

CY 2012 Status Indicator

CY 2012 APC

G0446

Intensive behavioral therapy to reduce cardiovascular disease risk, individual, face-to-face, annual, 15 minutes

S

0432

Further reporting guidelines on intensive behavioral therapy for cardiovascular disease can be found in Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, section 210.11 and Pub. 100-04, Medicare Claims Processing Manual, chapter 18, section 160, as well as in Transmittals 137 and 2357, CR 7636 that was published on November 23, 2011. The MLN Matters® article on this NCD is at http://www.cms.gov/MLNMattersArticles/downloads/MM7636.pdf on the CMS site.

Intensive Behavioral Therapy for Obesity – NCD
Effective for claims with dates of service on and after November 29, 2011, Medicare beneficiaries with obesity (BMI ≥ 30 kg/m2), who are competent and alert at the time that counseling is provided and whose counseling is furnished by a qualified primary care physician or other primary care practitioner in a primary care setting are eligible for: 1) One face to face visit every week for the first month; 2) One face to face visit every other week for months 2-6; and 3) One face to face visit every month for months 7-12.

To implement this recent coverage determination, CMS created a new G-code to report counseling for obesity.  The long descriptor for the G-code appears in Table 14.

Table 14 – Intensive Behavioral Therapy for Obesity

The long descriptor for the G-code appears in Table 14
CY 2012 HCPCS Code

CY 2012 Long Descriptor

CY 2012 Status Indicator

CY 2012 APC

G0447

Face-to-face behavioral counseling for obesity, 15 minutes

S

0432

Further reporting guidelines on intensive behavioral therapy for obesity will be provided in a future CR.

CMS is deleting screening code G0449 (Annual face to face obesity screening, 15 minutes) previously released on the 2012 HCPCS tape, from the OPPS addenda, effective November 29, 2011.  This screening service will now be identified using ICD-9 screening and diagnosis codes. Coding and billing instructions will be issued in an upcoming CR.

Payment Window for Outpatient Services Treated as Inpatient Services
CMS is revising its billing instructions to clarify that in situations where there is no Part A coverage for the inpatient stay, there is no inpatient service into which outpatient services (i.e., services provided to a beneficiary on the date of an inpatient admission or during the 3 calendar days (or 1 calendar day for a non-IPPS hospital) prior to the date of an inpatient admission) must be bundled.  Therefore services provided to the beneficiary prior to the point of admission (i.e., the admission order) may be separately billed to Part B as the outpatient services that they were. See the “Medicare Claims Processing Manual”, (Pub. 100-04) Chapter 4, Section 10.12 and Chapter 1, Section 50.3.2 for the updated billing guidelines.

Partial Hospitalization APCs
For CY 2012, CMS is updating the four PHP per diem payment rates based on the median costs calculated using the most recent claims data for each provider type: two for CMHCs (for Level I and Level II PH services based on only CMHC data), and two for hospital-based PHPs (for Level I and Level II services based on only hospital-based data).  The APCs for the CMHCs are: APC 0172 (Level I Partial Hospitalization (3 services)) and APC 0173 (Level II Partial Hospitalization (4 or more services)).  The APCs for the hospital-based PHPs are: APC 0175 (Level I Partial Hospitalization (3 services)) and APC 0176 (Level II Partial Hospitalization (4 or more services)).

When a Community Mental Health Center (CMHC) provides three services of partial hospitalization services and meets all other partial hospitalization payment criteria, the CMHCs would be paid through APC 0172.  Similarly, when a hospital-based PHP provides three services of partial hospitalization services and meets all other partial hospitalization payment criteria, the hospital-based PHP would be paid through APC 0175.  When the CMHCs provide four or more services of partial hospitalization services and meet all other partial hospitalization payment criteria, the CMHC would be paid through APC 0173 and the hospital-based PHP providing four or more services would be paid through APC 0176.  The tables below provide the updated per diem payment rates:

Table 15
CY 2011 Median Per Diem Costs for CMHC PHP Services Plus Transition

 The tables below provide the updated per diem payment rates
APC

Group Title

Median Per Diem Costs Plus Transition

0172

Level I Partial Hospitalization (3 services) for CMHCs

$97.64

0173

Level II Partial Hospitalization (4 or more services) for CMHCs

$113.83

Table 16
CY 2011 Median Per Diem Costs for Hospital-Based PHP Services

Median Per Diem Costs for Hospital-Based PHP Services
APC

Group Title

Median Per Diem Costs

0175

Level I Partial Hospitalization (3 services) for hospital-based PHPs

$160.74

0176

Level II Partial Hospitalization (4 or more services) for hospital-based PHPs

$191.16

Molecular Pathology Procedure Test Codes
The American Medical Association’s (AMA) CPT Editorial Panel created 101 new molecular pathology procedure test codes for CY 2012.  These new codes are in the following CPT code range: 81200-81299, 81300-81383, and 81400-81408.  For payment purposes under the hospital OPPS these test codes will be assigned to status indicator “E” (Not recognized by Medicare for outpatient claims; alternate code for the same item or service may be available) effective January 1, 2012. These new codes will be listed in the January 2012 OPPS Addendum B, which can be downloaded from http://www.cms.gov/HospitalOutpatientPPS/AU/list.asp on the CMS web site.

Please note that each of the new molecular pathology procedure test code represents a test that is currently being utilized and which may be billed to Medicare.  When these types of tests are billed to Medicare, CMS understand that existing CPT test codes are “stacked” to represent a given test.  For example, Laboratory A has a genetic test that is generally billed to Medicare in the following manner – 83891 (one time) + 83898 (multiple times) + 83904 (multiple times) + 83909 (multiple times) + 83912 (one time) – in order to represent the performance of the entire test.  If the new CPT test coding structure were active, Laboratory A would bill Medicare the new, single CPT test code that corresponds to the test represented by the “stacked” codes in the example above rather than billing each component of the test separately.

Effective January 1, 2012, under the hospital OPPS, hospitals are advised to report both the existing CPT “stacked” test codes that are required for payment and the new single CPT test code that would be used for payment purposes if the new CPT test codes were active.  Referring to the example above, Laboratory A would report the existing stacked set of codes that are required to receive payment [i.e., 83891 (one time) + 83898 (multiple times) + 83904 (multiple times) + 83909 (multiple times) + 83912 (one time)] along with the new, single CPT test code that corresponds to the test represented by the “stacked” test codes.

Use of Modifiers for Discontinued Services (Modifiers 52, 53, 73, and 74)
CMS is revising the guidance related to use of modifiers for discontinued services in the “Medicare Claims Processing Manual”, Chapter 4, Section 20.6.4.

Changes to OPPS Pricer Logic

  1. Rural sole community hospitals (SCH) and Essential Access Community Hospitals (EACHs) will continue to receive a 7.1 percent payment increase for most services in CY 2012.  The rural SCH and EACH payment adjustment excludes drugs, biologicals, items and services paid at charges reduced to cost, and items paid under the pass-through payment policy in accordance with Section 1833(t)(13)(B) of the Social Security Act, as added by Section 411 of Pub. L. 108-173.
  2. New OPPS payment rates and copayment amounts will be effective January 1, 2012.  All copayments amounts will be limited to a maximum of 40 percent of the APC payment rate. Copayment amounts for each service cannot exceed the CY 2012 inpatient deductible.
  3. For hospital outlier payments under OPPS, there will be no change in the multiple threshold of 1.75 for 2012.  This threshold of 1.75 is multiplied by the total line-item APC payment to determine eligibility for outlier payments.  This factor also is used to determine the outlier payment, which is 50 percent of estimated cost less 1.75 times the APC payment amount. The payment formula is (cost-(APC payment x 1.75))/2.
  4. However, there will be a change in the fixed-dollar threshold in CY 2012. The estimated cost of a service must be greater than the APC payment amount plus $1,900 in order to qualify for outlier payments.  The previous fixed-dollar threshold for CY 2011 was $2,025.
  5. For outliers for CMHCs (bill type 76x), there will be no change in the multiple threshold of 3.4 for 2012.  This threshold of 3.4 is multiplied by the total line-item APC payment for APC 0173 to determine eligibility for outlier payments.  This multiple amount is also used to determine the outlier payment, which is 50 percent of estimated costs less 3.4 times the APC payment amount.  The payment formula is (cost-(APC 0173 payment x 3.4))/2.
  6. Effective January 1, 2012, 4 devices are eligible for pass-through payment in the OPPS Pricer logic.  Categories C1749 (Endoscope, retrograde imaging/illumination colonoscope device (implantable)) and C1830 (Powered bone marrow biopsy needle) have an offset amount of $0 because CMS is not able to identify portions of the APC payment amounts associated with the cost of the devices.  Category C1840 (Lens, intraocular (implantable)) and C1886 (Catheter, extravascular tissue ablation, any modality (insertable)) have offset amounts included in the Pricer for CY2012.  Pass-through offset amounts are adjusted annually.  For outlier purposes, when C1749 is billed with a service included in APC 0143 or APC 0158 it will be associated with specific HCPCS in those APCs for outlier eligibility and payment.
  7. Effective January 1, 2012, the OPPS Pricer will apply a reduced update ratio of 0.980 to the payment and copayment for hospitals that fail to meet their hospital outpatient quality data reporting requirements or that fail to meet CMS validation edits.  The reduced payment amount will be used to calculate outlier payments.
  8. Effective January 1, 2012, there will be 1 diagnostic radiopharmaceutical receiving pass-through payment in the OPPS Pricer logic.  For APCs containing nuclear medicine procedures, the Pricer will reduce the amount of the pass-through diagnostic radiopharmaceutical payment by the wage-adjusted offset for the APC with the highest offset amount when the radiopharmaceutical with pass-through appears on a claim with a nuclear procedure.  The offset will cease to apply when the diagnostic radiopharmaceutical expires from pass-through status.  The offset amounts for diagnostic radiopharmaceuticals are the “policy-packaged” portions of the CY 2012 APC payments for nuclear medicine procedures and may be found on the CMS web site.
  9. Effective January 1, 2012, there will be 1 contrast agent receiving pass-through payments in the OPPS Pricer logic.  For a specific set of APCs identified elsewhere in this update, Pricer will reduce the amount of the pass-through contrast agent by the wage-adjusted offset for the APC with the highest offset amount when the contrast agent with pass-through status appears on a claim on the same date of service with a procedure from the identified list of APCs with procedures using contrast agents.  The offset will cease to apply when the contrast agent expires from pass-through status.  The offset amounts for contrast agents are the “policy-packaged” portions of the CY 2012 APC payments for procedures using contrast agents and may be found on the CMS web site.
  10. Pricer will update the payment rates for drugs, biologicals, therapeutic radiopharmaceuticals, and diagnostic radiopharmaceuticals with pass-through status when those payment rates are based on ASP on a quarterly basis.
  11. Effective January 1, 2012, CMS is adopting the FY 2012 IPPS post-reclassification wage index values with application of out-commuting adjustment authorized by Section 505 of Pub. L. 108-173 to non-IPPS hospitals discussed below.

Coverage Determinations
The fact that a drug, device, procedure, or service is assigned a HCPCS code and a payment rate under the OPPS does not imply coverage by the Medicare program, but indicates only how the product, procedure, or service may be paid if covered by the program.  Fiscal intermediaries (FIs)/Medicare administrative contractors (MACs) determine whether a drug, device, procedure, or other service meets all program requirements for coverage.  For example, FIs/MACs determine that it is reasonable and necessary to treat the beneficiary’s condition and whether it is excluded from payment.

Additional Information
You can find the official instruction, CR 7672, was issued to your FI, A/B MAC, or RHHI via two transmittals.  The first transmittal revises the “Medicare Benefit Policy Manual” and it is at http://www.cms.gov/Transmittals/downloads/R152BP.pdf on the CMS web site.  The second transmittal updates the “Medicare Claims Processing Manual” at http://www.cms.gov/Transmittals/downloads/R2376CP.pdf on the same site.

You will find the revised “Medicare Benefit Policy Manual,” Chapter 6 (Hospital Services Covered Under Part B), Sections 20.4.4 (Coverage of Outpatient Diagnostic Services Furnished on or After January 1, 2010) and 20.5.2 (Coverage of Outpatient Therapeutic Services Incident to a Physicians Service Furnished on or After January 1, 2010); and the revised “Medicare Claims Processing Manual,” Chapter 1 (General Billing Requirements), Section 50.3.2 (Policy and Billing Instructions for Condition Code 44), and Chapter 4 (Part B Hospital (Including Inpatient Hospital Part B and OPPS), Sections 10.2.2 (Cardiac Resynchronization Therapy), 10.12 (Payment Window for Outpatient Services Treated as Inpatient Services), 20.6.4 (Use of Modifiers for Discontinued Services), and 10.2.1 (Healthcare Common Procedure Coding System (HCPCS) and Diagnosis Codes) as an attachment to that CR.

If you have any questions, please contact a CGS Customer Service Representative by calling the appropriate telephone number found on the Customer Service Telephone Numbers web page at: http://www.cgsmedicare.com/hhh/help/telephone_numbers.html

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MM7683—Claim Adjustment Reason Code (CARC), Remittance Advice Remark Code (RARC), Medicare Remit Easy Print (MREP), and PC Print Update

The Centers for Medicare & Medicaid Services (CMS) has provided the following Medicare Learning Network® (MLN) Matters article.  This MLN Matters article and other CMS articles can be found on the CMS web site at: http://www.cms.gov/MLNMattersArticles/

News Flash – New product from the Medicare Learning Network® (MLN)

MLN Matters® Number: MM7683
Related Change Request (CR) #: CR 7683
Related CR Release Date: December 22, 2011
Effective Date: April 1, 2012
Related CR Transmittal #: R3372CP
Implementation Date: April 2, 2012

Provider Types Affected
Physicians, providers, and suppliers submitting claims to Medicare contractors (carriers, durable medical equipment Medicare administrative contractors (DME MACs), fiscal intermediaries (FIs), A/B Medicare administrative contractors (A/B MACs), and/or regional home health intermediaries (RHHIs)) for services provided to Medicare beneficiaries.

Provider Action Needed
STOP –– Impact to You
This article is based on CR 7683 which updates Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Medicare Remit Easy Print (MREP), and PC Print for Medicare.

CAUTION –– What You Need to Know
CR 7683 instructs Medicare contractors and the Shared System Maintainers (SSMs) to make programming changes to incorporate new, modified, and deactivated CARCs and RARCs that have been added since the last recurring code update CR.  It also instructs Fiscal Intermediary Standard System (FISS) and VIPs Medicare System (VMS) to update PC Print and Medicare Remit Easy Print (MREP) software.  Be sure your billing staff is aware of these changes.

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

Background
The Health Insurance Portability and Accountability Act (HIPAA) of 1996, instructs health plans to be able to conduct standard electronic transactions adopted under HIPAA using valid standard codes.  Medicare policy states that Claim Adjustment Reason Codes (CARCs) are required in the remittance advice and coordination of benefits transactions.  Medicare policy further states that appropriate Remittance Advice Remark Codes (RARCs) that provide either supplemental explanation for a monetary adjustment or policy information that generally applies to the monetary adjustment are required in the remittance advice transaction.  For transaction 835 (Health Care Claim Payment/Advice) and standard paper remittance advice, CARCs and RARCs must be used to report payment adjustments, appeal rights, and related information. If there is any adjustment, appropriate Group Code must be reported as well.  Additionally, for transaction 837 COB, CARC must be used.  

The CARC and RARC changes that impact Medicare are usually requested by the CMS staff in conjunction with a policy change.  Medicare contractors and Shared System Maintainers (SSMs) are notified about these changes in the corresponding instructions from the specific CMS component that implements the policy change, in addition to the regular code update notification.  If a modification has been initiated by an entity other than CMS for a code currently used by Medicare, then Medicare contractors must either use the modified code or another code if the modification makes the modified code inappropriate to explain the specific reason for adjustment.

Medicare contractors will stop using codes that have been deactivated on or before the effective date specified in the comment section (as posted on the Washington Publishing Company (WPC) web site) if they are currently being used.  In order to comply with any deactivation, Medicare may have to stop using the deactivated code in original business messages before the actual “Stop Date” posted on the WPC web site because the code list is updated three times a year and may not align with the Medicare release schedule.  Note that a deactivated code used in derivative messages must be accepted even after the code is deactivated if the deactivated code was used before the deactivation date by a payer who adjudicated the claim before Medicare. Medicare contractors must stop using any deactivated reason and/or remark code past the deactivation date whether the deactivation is requested by Medicare or any other entity.  

The regular code update CR will establish the implementation date for all modifications, deactivations, and any new code for Medicare contractors and the SSMs.  If another specific CR has been issued by another CMS component with a different implementation date, the earlier of the two dates will apply for Medicare implementation.  If any new or modified code has an effective date past the implementation date specified in CR 7683, Medicare contractors must implement on the date specified on the WPC web site.  

The discrepancy between the dates may arise because the WPC web site gets updated only 3 times a year and may not match the CMS release schedule.

CR7683 lists only the changes that have been approved since the last code update CR (CR 7514 Transmittal 2304), and does not provide a complete list of codes in these two code sets. You must get the complete list for both CARC and RARC from the WPC web site that is updated three times a year – around March 1, July 1, and November 1 – to get the comprehensive lists for both code sets, but the implementation date for any new or modified or deactivated code for Medicare contractors is established by this recurring code update CR published three or four times a year according to the Medicare release schedule (see above for exception).

The WPC web site (at http://www.wpc-edi.com/Reference on the Internet) has four listings available for both CARC and RARC:

NOTE: In case of any discrepancy in the code text as posted on WPC web site and as reported in any CR, the WPC version is implemented by Medicare.

Claim Adjustment Reason Code (CARC)
A national code maintenance committee maintains the health care Claim Adjustment Reason Codes (CARCs).  The Committee meets at the beginning of each X12 trimester meeting (January/February, June and September/October) and makes decisions about additions, modifications, and retirement of existing reason codes.  The updated list is posted three times a year around early March, July, and November.  To access the updated list see http://www.wpc-edi.com/Reference on the Internet

The new codes usually become effective when approved unless mentioned otherwise.  Any modification or deactivation becomes effective on a future date to provide lead time for implementing necessary programming changes.  Exception: The effective date for a modification may be as early as the approval or publication date if the requester can provide enough justification to have the modification become effective earlier than a future date.  A health plan may decide to implement a code deactivation before the actual effective date posted on WPC web site as long as the deactivated code is allowed to come in on Coordination of Benefits (COB) claims if the previous payer(s) has (have) used that code prior to the deactivation date.  In most cases Medicare will stop using a deactivated code before the deactivation becomes effective per the WPC web site to accommodate the Medicare release schedule.  The following new Claim Adjustment Reason Codes were approved by the Code Committee in October, and must be implemented, if appropriate, by April 2, 2012.

New Codes – CARC:
Code

Current Narrative

Effective Date

238

Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period (use Group Code PR).

3/1/2012

239

Claim spans eligible and ineligible periods of coverage. Rebill separate claims (use Group Code OA).

3/1/2012

 

Modified Codes – CARC:
Code

Modified Narrative

Effective Date

18

Exact duplicate claim/service (Use with Group Code OA).

1/1/2013
Deactivated Codes – CARC:
Code

Current Narrative

Effective Date

141

Claim spans eligible and ineligible periods of coverage.

7/1/2012

Remittance Advice Remark Codes (RARC):
CMS is the national maintainer of the remittance advice remark code list.  This code list is used by reference in the ASC X12 N transaction 835 (Health Care Claim Payment/Advice) version 004010A1 and 005010A1 Implementation Guide (IG)/Technical Report (TR) 3. Under HIPAA, all payers, including Medicare, have to use reason and remark codes approved by X12 recognized code set maintainers instead of proprietary codes to explain any adjustment in the claim payment. CMS as the X12 recognized maintainer of RARCs receives requests from Medicare and non- Medicare entities for new codes and modification/deactivation of existing codes.  Additions, deletions, and modifications to the code list resulting from non-Medicare requests may or may not impact Medicare.  Remark and reason code changes that impact Medicare are usually requested by CMS staff in conjunction with a policy change.

CR 7683 contains no new, modified, or deactivated RARC codes.

Additional Information
The official instruction, CR 7683, issued to your carriers, DME MACs, FIs, A/B MACs, and RHHIs regarding this change may be viewed at http://www.cms.gov/Transmittals/downloads/R2372CP.pdf on the CMS web site.

If you have any questions, please contact a CGS Customer Service Representative by calling the appropriate telephone number found on the Customer Service Telephone Numbers web page at: http://www.cgsmedicare.com/hhh/help/telephone_numbers.html

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Part A and HH&H DDE User Access Issues

If you are a J15 home health and hospice provider who currently uses a Direct Data Entry (DDE) function to check eligibility, claims status, or enter or modify claims (ELGA, ELGH, FISS, etc.) and you experience any security issues with that access or need to have your password reset, please email the CGS Security Administration Team at cgs.medicare.opid@cgsadmin.com. Please include the user ID that is experiencing problems and the first and last name of the user to which that ID is assigned in your email request.

For all GPNet access and password issues, please continue to call the J15 EDI Helpdesk for assistance at 866.758.5666.

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Prohibition on Balance Billing Qualified Medicare Beneficiaries (QMBs)

MLN Matters® Special Edition Article #SE1128 at http://www.cms.gov/MLNMattersArticles/downloads/SE1128.pdf titled “Prohibition on Balance Billing Qualified Medicare Beneficiaries (QMBs),” reminds affected providers about their responsibilities to QMBs. This article is intended to help providers avoid inappropriately billing QMBs for Medicare cost-sharing, including deductible, coinsurance, and copayments.

 

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Provider Revalidation Deadline Fast Approaching

All home health agencies, for which CGS is their audit intermediary, were mailed a provider enrollment revalidation request on either December 20, 2011, or December 29, 2011.  This revalidation is required by section 6401 (a) of the Patient Protection and Affordable Care Act (the Affordable Care Act), and impacts home health and hospice agencies that were enrolled in the Medicare program prior to March 25, 2011.

Providers will need to complete the CMS-855A form using either internet-based PECOS or the paper form and submit it to CGS prior to the deadline. 

NOTE: As mentioned, CGS mailed revalidation letters dated December 20, 2011.  A letter was mailed to the provider’s special payments address, and a second letter was sent to the provider’s practice location address.  Letters mailed to the practice location address were inadvertently mailed to the wrong provider’s address.  Therefore, CGS re-sent the letters, which were dated December 29, 2011.  Due to this error, the due date for providers to submit the enrollment revalidation will be 60 days from the postmark of the reissued letter (December 29, 2011).

Therefore, for revalidation letters mailed on December 20th and December 29th, the deadline for responding is February 27, 2012.

The letters were mailed to the provider’s special payments address when sending revalidation letters to providers.  In addition, a second revalidation letter was sent to the provider’s practice location address.  If the practice location address and the special payment address were the same, the second letter was sent to the provider’s correspondence address.  The letters were mailed in yellow envelopes to help distinguish them from other mailings received from CGS.

Please review the CGS Provider Enrollment Revalidation Frequently Asked Questions at https://www.cgsmedicare.com/hhh/education/faqs/PER.html and Provider Enrollment Revalidation web page http://www.cgsmedicare.com/hhh/enrollment/Revalidation.html for additional information and resources to assist you in responding to the revalidation request.

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SE1135—Guidance on Completing the CMS-855A Enrollment Form

The Centers for Medicare & Medicaid Services (CMS) has provided the following Special Edition (SE) Medicare Learning Network® (MLN) Matters article.  This Special Edition MLN Matters article and other CMS articles can be found on the CMS web site at: http://www.cms.gov/MLNMattersArticles/

MLN Matters® Number: SE1135
Related Change Request (CR) #: N/A
Related CR Release Date: N/A
Effective Date: N/A
Related CR Transmittal #: N/A
Implementation Date: N/A

Provider Types Affected
This MLN Matters® Special Edition Article is intended for hospitals and other providers that complete the CMS-855A enrollment application.  Specifically, this article applies to the following health care organizations:

 

What You Need to Know
CMS is issuing this article solely as an educational guide to improve compliance with documentation requirements for the Medicare Enrollment Application for Institutional Providers, Form CMS-855A (07/11).  This article presents a brief guide that you may use when completing the CMS-855A application.  Please note that use of this guide is not mandatory and does not ensure Medicare enrollment.

Background
Getting Started

What do I need to have to fill out the CMS-855A?

You should have the following before you start to fill out the application:

Where can I get a copy of the CMS-855A application?

You may download and view the application at https://www.cms.gov/cmsforms/downloads/cms855a.pdf on the CMS web site.

What are the sections of the application?

Below are the sections and brief explanations on filling them out.

Section 1 –Basic Information

Section 1A – Reason for Application

This section identifies the purpose of the application submission.  Only one reason should be selected.  Here is a description of the possible submission reasons:

Section 1B – Check all that apply
If Section 1A reports a change in Medicare enrollment information, indicate the sections in which the information is changing.  Please remember that you are responsible for disclosing changes timely.

Section 2 – Identifying Information

Section 2A – Type of Provider
Indicate the type of provider enrolling/enrolled.

Section 2B – Identification Information

In this section, you should do the following:

 

Section 2C – Correspondence Address
Provide an address where the applicant can be contacted directly.  Be sure to include the entire ZIP code (ZIP Code + 4).  This address cannot be the address of a billing agency, provider’s representative or the chain home office.

Section 2D – Accreditation
Indicate whether the facility is accredited.  If accredited, provide the date of accreditation, name of accrediting body, and type of accreditation or accreditation program.

Section 2E – Comments
Provide any comments, if needed, to clarify a unique enrollment situation.

Section 2F – Change of Ownership (CHOW) Information
You should complete this section if the type of CHOW transaction described in the instructions on page 4 of the CMS-855A has occurred.  The information provided in this section should be that of the seller/former owner.

Section 2G – Acquisitions/Mergers
You should complete this section only if an acquisition/merger – as that term is described in the instructions on page 5 of the CMS-855A - has occurred.

Section 2H – Consolidations
Complete this section only if a consolidation – as that term is described in the instructions on page 5 of the CMS-855A – has occurred.

Section 3 – Final Adverse Actions/Convictions
Final adverse actions include, but are not limited to, felony convictions, licensure suspensions or revocations, or exclusions from participation in a federal or state health care program.  A complete list of reportable adverse actions can be found on page 16 of the CMS-855A application.  (You may download and view the CMS-855A at http://www.cms.gov/cmsforms/downloads/cms855a.pdf on the CMS web site.)

Section 4 – Practice Location Information

Section 4A – Practice Location Information
All practice locations must be disclosed in this section.  Please list the primary practice location first, and list the PTAN or CCN (if assigned) and NPI combination for each practice location.  If a location has multiple NPIs, list each of the NPIs for the location in this section.

Identify the type of practice location for Hospitals and Home Health Agencies (HHAs); for Hospitals this includes provider types such as Swing-Bed Unit; Hospital - Psychiatric Unit or a Hospital — Rehabilitation Unit.

Section 4B – Where do you want Remittance Notices or Specials Payments Sent?
Medicare will issue payments via Electronic Funds Transfer (EFT).  Therefore, this address will be used for all other payment information (i.e., remittance notices, special payments).

Section 4C – Where do you keep patients’ medical records?
This section captures any address in which patient medical records are stored.  If this section is not competed, you are indicating that all records are stored at the practice locations reported in Sections 4A or 4D.

Section 4D – Base of Operations Address for Mobile or Portable Providers
This section captures the location, if applicable, where personnel are dispatched, where mobile/portable equipment is stored, and where vehicles are parked when not in use.

Section 4E – Vehicle Information
This section captures vehicle information, if applicable, for mobile health care services that are rendered inside the vehicle, like a van, mobile home, or trailer.

Section 4F – Geographic Location for Mobile or Portable Providers where the Base of Operations and/or Vehicle Renders Services
For Home Health Agencies (HHAs) and mobile or portable providers, this section captures geographic areas where health care services are rendered.

Section 5 – Ownership Interest and/or Managing Control Information (Organizations)
Check the box Not Applicable if Section 5 does not apply to the provider listed in Section 2.

Section 5A – Organization with Ownership Interest and/or Managing Control – Identification Information
If the provider identified in Section 2 is owned and/or operated by another organization, please provide identifying information and check type of organization in Sections 5A1 and 5A2.

Section 5A – Ownership/Managing Control Identification Information
You must report all organizations that have any of the following interests in the enrolling provider.  Check the types of interest that the entity has in the provider and complete all information for each type of ownership and/or managing control applicable:

For each organization, be sure to:

If a federal, state, county, city, or other level of government or Indian tribe will be legally and financially responsible for Medicare payments received, the name of that agency or organization must be listed as an owner and an attestation statement signed by an authorized official (as indicated in Section 15 of the CMS-855A) must be submitted.

If the provider is a non-profit, charitable or religious entity and is operated and/or managed by a Board of Trustees or governing body, the name of the Board of Trustees or governing body should be reported in this section.  The organization is listed in Section 5.  The individuals on the Board or governing body are listed in Section 6.

If applicable, the chain home office must be listed in Section 5 as well as in Section 7.

Note that the following data elements in Section 5 need not be completed:

Section 5B – Adverse Legal History
Final adverse actions include, but are not limited to, felony convictions, licensure suspensions or revocations, or exclusions from participation in a federal or state health care program.  A complete list of reportable final adverse actions can be found on page 16 of the CMS-855A application.  (You may view the CMS-855A at http://www.cms.gov/cmsforms/downloads/cms855a.pdf on the CMS web site.)

Section 6 – Ownership Interest and/or Managing Control information (Individuals)

Section 6A – Individuals with Ownership Interest and/or Managing Control – Identification Information
This section captures information on individuals with ownership interest and/or managing control of the provider.

Note that the following data elements in Section 6 need not be completed:

Section 6B – Adverse Legal History
Final adverse actions include, but are not limited to, felony convictions, licensure suspensions or revocations, and exclusions from participation in a federal or state health care program.  A complete list of reportable final adverse actions can be found on page 16 of the CMS 855A application.

Section 7 – Chain Home Office Information
This section applies to providers that are part of a chain organization.  It should be completed in its entirety for providers enrolling in a chain, disassociating from a current chain or changing from one chain to another.

Section 8 – Billing Agency Information
A billing agency is a company or individual that will process and submit claims on your behalf.

Section 12 – Special Requirements for Home Health Agencies (HHAs)
Check the box Not Applicable if this section does not apply to you.

Section 13 – Contact Person
This is the only person with whom the Medicare contractor can discuss this application, with the exception of the authorized or the delegated official.  Multiple individuals can be listed in this section.

Section 15 – Certification Statement
This section is signed by the authorized official of the organization.  Authorized officials must be identified in Section 6 of the application. A provider can have as many authorized officials as it desires, but must have at least one.

Section 16 – Delegated Official(s) (Optional)

(Note: Authorized and delegated officials must be identified in Section 6 of the application.)

Section 17 – Supporting Documents
Certain documents must be submitted with your application:

What are some tips for completing the EFT Authorization Agreement - Form CMS-588?
Below are some tips for completing the CMS-588.  You may download and view this form at http://www.cms.gov/cmsforms/downloads/CMS588.pdf on the CMS web site.

Additional Information
For more information about Medicare enrollment, visit the Medicare Provider-Supplier Enrollment web page at http://www.cms.gov/MedicareProviderSupEnroll on the CMS web site.

If you have any questions, please contact a CGS Customer Service Representative by calling the appropriate telephone number found on the Customer Service Telephone Numbers web page at: http://www.cgsmedicare.com/hhh/help/telephone_numbers.html

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SE1138—Non-Specific Procedure Code Description Requirement for HIPAA Version 5010 Claims

The Centers for Medicare & Medicaid Services (CMS) has provided the following Special Edition (SE) Medicare Learning Network® (MLN) Matters article.  This Special Edition MLN Matters article and other CMS articles can be found on the CMS web site at: http://www.cms.gov/MLNMattersArticles/

MLN Matters® Number: SE1138
Related Change Request (CR) #: N/A
Related CR Release Date: N/A
Effective Date: N/A
Related CR Transmittal #: N/A
Implementation Date: N/A

Provider Types Affected
This MLN Matters® Special Edition Article is intended for all physicians, providers, and suppliers who bill Medicare contractors (carriers, fiscal intermediaries (FIs), Medicare administrative contractors (A/B MACs), home health and hospice MACs (HH+H MACs), and durable medical equipment MACs (DME MACs)) for services provided to Medicare beneficiaries.

What You Need to Know
The Office of E-Health Standards and Services (OESS) announced on November 17, 2011, that although the 5010/D.0 compliance date of January 1, 2012, will not change, HIPAA enforcement of compliance with the standards will be deferred until March 31, 2012.

The 5010 versions of the institutional and professional claim implementation guides mandate that when claims use non-specific procedure codes a corresponding description of the service is now required.

HIPAA compliant claim when Non-Specific Procedure codes are used.  Please ensure these implementation guide requirements are followed when submitting a HIPAA compliant claim for all Non-Specific Procedure codes.

Background
The HIPAA Version 5010 implementation guide describes Non-Specific Procedure Codes as codes that may include, in their descriptor, terms such as: “Not Otherwise Classified (NOC); Unlisted; Unspecified; Unclassified; Other; Miscellaneous; Prescription Drug Generic; or Prescription Drug, Brand Name”.  If a procedure code containing any of these descriptor terms is billed, a corresponding description of that procedure is required; otherwise, the claim is not HIPAA compliant.  Note that there is no crosswalk of non-specified procedure codes with corresponding descriptions.

Detailed information regarding this new requirement can be found in the 837I and 837P implementation guides (837I – 005010X223A2 and 837P – 005010X222A1).  If the corresponding non-specific procedure code description is not submitted, the transaction does not comply with the implementation guide and is not, therefore, HIPAA compliant.  Note that the non-specific procedure code’s descriptor terms as listed above do not constitute a description of the procedure, drug, or service.  For example, simply using Not Otherwise Classified as the description does not pass editing and the claim will be rejected.

Additional Information
A complete listing of Not Otherwise Classified (NOC) Code Set is available at http://www.cms.gov/ElectronicBillingEDITrans/40_FFSEditing.asp on the CMS web site.

For 5010/D.O implementation information and deadlines, refer to MLN Matters® Special Edition Article #SE1131, which is available at http://www.cms.gov/MLNMattersArticles/downloads/SE1131.pdf on the CMS web site.

If you are not ready, consider contacting your Medicare contractor to receive the free Version 5010 software (PC-Ace Pro32) and begin testing now.  Or, consider contracting with a Version 5010 compliant clearinghouse who can translate the non-compliant transactions into compliant 5010 transactions.

If you are billing Part B and DME claims, you may download the free Medicare Remit Easy Print (MREP) software to view and print compliant HIPAA 5010 835 remittance advices.  This software is available at http://www.cms.gov/AccesstoDataApplication/02_MedicareRemitEasyPrint.asp on the CMS web site.  Part A billers may download the free PC-Print software to view and print a compliant HIPAA 5010 835 remittance advice from their A/B MACs web site.

Contact your respective professional associations and other payers for guidance and resources in order to meet their deadlines.

Please note, CR 7392, “Common Edits and Enhancements Module (CEM) and Receipt, Control, and Balancing Updates,” dated July 21, 2011, established the requirements that all procedures shall comply with the HIPAA 5010 version claim process.  CR 7392 was implemented by Medicare contractors on October 1, 2011, and does not override any previous claims processing instructions.

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SE1142—Preventive Services Educational Resources for Health Care Professionals

The Centers for Medicare & Medicaid Services (CMS) has provided the following Special Edition (SE) Medicare Learning Network® (MLN) Matters article.  This Special Edition MLN Matters article and other CMS articles can be found on the CMS web site at: http://www.cms.gov/MLNMattersArticles/

MLN Matters® Number: SE1142
Related Change Request (CR) #: NA
Related CR Release Date: NA
Effective Date: NA
Related CR Transmittal #: NA
Implementation Date: NA

Provider Types Affected
This MLN Matters® Special Edition Article is intended for all Medicare Fee-For-Service (FFS) physicians, non-physician practitioners, providers, suppliers, and other health care professionals who order, refer, or provide Medicare-covered preventive services to Medicare beneficiaries.

What You Need to Know

Introduction
Medicare covers a wide variety of preventive services and screenings for eligible beneficiaries.

Educational Products for Health Care Professionals
The Medicare Learning Network® (MLN) offers a variety of educational products to help you understand coverage, coding, reimbursement, and billing information related to these services.

Annual Wellness Visit (AWV). It is available as a downloadable PDF at http://www.cms.gov/MLNProducts/downloads/AWV_Chart_ICN905706.pdf on the CMS web site.

To view the downloadable PDFs for these products, visit the Preventive Services Educational Products PDF page at http://www.cms.gov/MLNProducts/Downloads/education_products_prevserv.pdf on the CMS web site.

Under the Affordable Care Act, CMS has the authority to cover additional preventive services that meet certain criteria through the National Coverage Determination Process.  In addition to the web sites above, please visit the CMS press release web page at http://www.cms.gov/apps/media/press_releases.asp on the CMS web site.  

Beneficiary Information
Please visit the Medicare.gov web page at http://www.medicare.gov for beneficiary-related information and resources you may share with your Medicare patients.

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Subscribe to the MLN Matters Electronic Mailing List

Looking for the latest new and revised MLN Matters® articles?  Subscribe to the MLN Matters® electronic mailing list!  For more information about MLN Matters® and how to register for this service, go to http://www.cms.gov/MLNMattersArticles/downloads/What_Is_MLNMatters.pdf  and start receiving updates immediately!

In addition CGS also has an electronic mailing list.  We encourage anyone at your facility who needs to know Medicare information to subscribe to it, as it is the primary means of communicating with home health and hospice providers who submit their billing transactions to us. To subscribe, access the Join the ListServ Notification Service web page at https://www.cgsmedicare.com/medicare_dynamic/ls/001.asp. To edit or update your ListServ Profile, access the web page at http://www.cgsmedicare.com/medicare_dynamic/ls/reminder.asp

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Vaccinate Early to Protect Against the Flu / 2011-2012 Influenza Vaccine Prices Are Now Available

CDC recommends a yearly flu vaccination as the most important step in protecting against flu viruses. Remind your patients that annual vaccination is recommended for optimal protection.  Under Medicare Part B, Medicare pays for the flu vaccine and its administration for seniors and other Medicare beneficiaries with no co-pay or deductible. Take advantage of each office visit and start protecting your patients as soon as your 2011-2012 seasonal flu vaccine arrives.  And don’t forget to immunize yourself and your staff. Get the Flu Vaccination – Not the Flu.

CMS has posted the 2011-2012 seasonal influenza vaccine payment limits at: http://www.CMS.gov/McrPartBDrugAvgSalesPrice/10_VaccinesPricing.asp on the CMS web site.

Influenza vaccine is NOT a Part D-covered drug.  For information about Medicare’s coverage of the influenza vaccine, its administration, and educational resources for healthcare professionals and their staff, visit http://www.CMS.gov/MLNProducts/35_PreventiveServices.asp on the CMS web site

Note from CGS: Home health agencies are reimbursed for the administration of the flu vaccine under the Outpatient Prospective Payment System (OPPS) Ambulatory Payment Classification (APC) code 0350 that is assigned to HCPCS code G0008.  The reimbursement amount is adjusted for the geographic area where the flu shot was provided and other factors. The reimbursement for APC code 0350 for calendar year (CY) 2011 was $26.35.  For CY 2012, APC code 0350 will be $24.81.  Due to the adjustments under OPPS, the actual payment amount your HHA receives could be more or less than this amount. CGS is unable to provide the actual amount you will receive for the flu shot administration since this is based on OPPS processing.

CGS has published additional information regarding Medicare-covered immunizations provided by HHAs, which is available in the “Home Health Billing FAQs” http://www.cgsmedicare.com/hhh/education/faqs/hh_billing_faqs.html, the “Billing Individual Influenza and Pneumococcal Pneumonia Vaccines” http://www.cgsmedicare.com/hhh/education/materials/BIIPPV.html, and the “Roster Billing for Mass Influenza and Pneumococcal Pneumonia Vaccines” http://www.cgsmedicare.com/hhh/education/materials/RBMIPPV.html web pages. 

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