June 2012 Home Health & Hospice Medicare Bulletin
Posted June 4, 2012
Table of Contents
- June 2012 (565.3 K)
- All Medicare Provider and Supplier Payments to be Made by Electronic Funds Transfer
- Availability of the Provider Contact Center (PCC)
- Canceling Hospice Notices of Election (NOEs) and Benefit Periods (BPs)
- Comprehensive Error Rate Testing (CERT) Program – Recent Errors Identified
- Claims in a Suspended Status/Location (S/LOC)
- CMS.gov Website Upgrade Completed-Check your Bookmarks
- Consumers Can Now Compare Results from Home Health Agencies Patient Surveys
- Ensure Appropriate Reporting of Patient Status Code on Hospice Claims
- Home Health Billing Reminders to Reduce Errors for Reason Codes (RC) 38107 and 31755
- Home Health Claims Selected for Review with Dates of Service October 1, 2011 Through December 31, 2011
- MM7260—Modification to CWF, FISS, MCS and VMS to Return
Submitted Information When There is a CWF Name and HIC
Number Mismatch - MM7397 (Revised)—Pharmacy for Drugs Provided "Incident To" a Physician Service
- MM7473 (Revised)—Correction to Processing of Hospice Discharge Claims
- MM7755—Ensuring Hospice Certifying Physician Identifiers Are Fully Processed
- MM7775—Claim Adjustment Reason Code (CARC), Remittance Advice Remark Code (RARC), Medicare Remit Easy Print (MREP), and PC Print Update
- MM7785—Revisions of the Financial Limitation for Outpatient Therapy Services – Section 3005 of the Middle Class Tax Relief and Job Creation Act of 2012
- MM7792—New Occurrence Code to Report Date of Death
- MM7793—Claim Status Category and Claim Status Codes Update
- MM7794—New Influenza Virus Vaccine Code
- MM7797—General Update to Chapter 15 of the Program Integrity Manual (PIM) Part V
- MM7810— July 2012 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
- MM7831—Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2012 Update
- News Flash Messages from the Centers for Medicare & Medicaid Services (CMS)
- SE1211—Information on the Centers for Medicare & Medicaid Services (CMS) Fraud Prevention: Automated Provider Screening and National Site Visit Initiatives
- SE1215 —Information for Medicare Fee-For-Service Providers About the Middle Class Tax Relief and Job Creation Act of 2012
- SE1217—Guidance for Correct Claims Submission When Secondary Payers Are Involved
- SE1218—Redesigned Medicare Summary Notices
- SE1219—A Physician's Guide to Medicare's Home Health Certification, including the Face-to-Face Encounter
- Use an Individual NPI as the Ordering NPI when Billing Medicare for Part A Home Health Agency Services
All Medicare Provider and Supplier Payments to be Made by Electronic Funds Transfer
For Home Health and Hospice Providers
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 CMS's revalidation efforts, all suppliers and providers who are not currently receiving EFT payments are required to submit the CMS-588 EFT form with the Provider Enrollment Revalidation application, or at the time any change is being made to the provider enrollment record by the provider or supplier, or delegated official. For more information about provider enrollment revalidation, review the MLN Matters® Special Edition Article #SE1126, "Further Details on the Revalidation of Provider Enrollment Information" at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1126.pdf
Availability of the Provider Contact Center (PCC)
For Home Health and Hospice Providers
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).
| CSR Training Date | Time |
|---|---|
| June 12, 2012 | 8:00 – 10:00 a.m. (Central Time) |
| June 26, 2012 | 8:00 – 10:00 a.m. (Central Time) |
Canceling Hospice Notices of Election (NOEs) and Benefit Periods (BPs)
For Hospice Providers
The CGS Provider Contact Center has had a recent increase in calls from hospice providers who need assistance with canceling a hospice NOE or a hospice benefit period. The article serves as a reminder to hospice providers of the steps that are necessary to appropriately cancel an NOE or a benefit period from the Common Working File (CWF).
When an NOE is processed in the Fiscal Intermediary Standard System (FISS), and moves to a status/location (P B9997), the hospice election and benefit period dates are posted to the CWF. This established hospice benefit period then prevents other Medicare providers from billing for services that are related to the patient's terminal prognosis. Similarly, when a subsequent hospice claim, with a 'To" date that overlaps the end of the prior benefit period, is processed in FISS, a new benefit period is created at CWF.
If an NOE is submitted and processed in error, or it contained an incorrect admit date, the NOE must be canceled to remove the incorrect/inappropriate benefit period from the CWF. In order for the benefit period to be removed, a cancel NOE (type of bill 8XD) must be submitted.
NOTE: A cancel claim (8X8) DOES NOT remove hospice benefit periods from CWF.
| Data Element | Field Locator (FL) | FISS Page | Data Required |
|---|---|---|---|
| Type of bill | FL 4 | Page 01 | 8XD (X = 1 if non-hospital based) (X = 2 if hospital based) |
| From date | FL 6 | Page 01 | 'From' date on NOE being canceled |
| Admit date | FL 12 | Page 01 | 'Admit' date on NOE being canceled |
If any hospice claims have been processed based on the incorrect/inappropriate NOE, they will need to be canceled (type of bill 8X8) before the cancel NOE (8XD) can be submitted. Claims must be canceled sequentially in reverse order (cancel June's claim first, then cancel May's claim, then cancel April's claim, etc.). In addition, canceling a hospice claim DOES NOT remove the benefit period posted to CWF. Therefore, the benefit period will also need to be canceled.
| Data Element | Field Locator (FL) | FISS Page | Data Required |
|---|---|---|---|
| Type of bill | FL 4 | Page 01 | 8XD (X = 1 if non-hospital based) (X = 2 if hospital based) |
| From date | FL 6 | Page 01 | 'From' date of benefit period being canceled |
| Admit date | FL 12 | Page 01 | 'Admit' date of benefit period being canceled |
Once the cancel NOE/benefit periods (8XDs) have been processed in FISS (status/location P B9997), verify that the benefit periods have, in fact, been removed from the CWF. Once this is verified, a new NOE with the correct admit date may be submitted, if appropriate.
For additional information on canceling a hospice NOE or benefit period, refer to the CGS 'Canceling a Hospice Notice of Election or Benefit Period' web page, at http://www.cgsmedicare.com/hhh/education/materials/cancel_hos_notice.html
Comprehensive Error Rate Testing (CERT) Program – Recent Errors Identified
For Home Health and Hospice Providers
The Comprehensive Error Rate Testing (CERT) Program was established by the Centers for Medicare & Medicaid Services to assess the accuracy by which Medicare contractors, like CGS, process Medicare claims. Claims are randomly selected by the CERT contractor and documentation submitted by the provider is reviewed to determine whether the claim was paid correctly by the Medicare contractor.
The ultimate goal of the CERT program is to reduce the paid claims error rate. As a Medicare contractor, CGS is committed to educating our providers to help reduce the CERT error rate. We believe that by educating all providers on the errors identified, this will enable every CGS provider to understand the errors, and develop an internal process to prevent similar errors within your own organization.
Through analysis of recent CERT errors, we have identified some common trends among home health and hospice claims. For home health providers, the top error was associated with therapy visits, where the visits were not ordered, there was no documentation to support the therapy visit, or the therapy service provided was not skilled.
For hospice providers, the top error was associated with the certification/recertification, including a missing certification, an insufficiently documented certification, and an untimely certification.
Below is a summary of the most common errors identified and information on preventing similar errors within your agency. Please watch the Webinars and Teleconferences Calendar of Events web page at http://www.cgsmedicare.com/hhh/education/webinars.html for an upcoming CERT educational event.
Home Health Issue #1: Therapies - No Orders, No Skilled Service, No Documentation to Support Visit – 8 Errors
In four cases, therapy services were provided; however, there were no physician's orders/signed physician's orders. As a reminder, the Medicare Benefit Policy Manual (CMS Pub. 100-02), Ch. 7 § 30.2 states "The plan of care must be signed and dated by a physician as described who meets the certification and recertification requirements of 42 CFR 424.22 and before the claim for each episode for services is submitted for the final percentage payment. Any changes in the plan of care must be signed and dated by a physician."
In two cases, physical therapy visits were provided, however, the documentation did not support that a skilled service was provided. The Medicare home health benefit requires that, in order to bill for therapy services, the service must skilled. Per the Medicare Benefit Policy Manual (CMS Pub. 100-02), Ch. 7 § 40.2.1, "The service of a physical therapist, speech-language pathologist, or occupational therapist is a skilled therapy service if the inherent complexity of the service is such that it can be performed safely and/or effectively only by or under the general supervision of a skilled therapist. To be covered, the skilled services must also be reasonable and necessary to the treatment of the patient's illness or injury or to the restoration or maintenance of function affected by the patient's illness or injury."
In two cases, therapy visits were billed on claim; however the documentation did not support that a visit was provided. As a reminder, all visits billed to Medicare must be documented to substantiate the medical necessity of the service provided.
In all these cases, the errors identified with the therapy visits resulted in a downcoding of the Health Insurance Prospective Payment System (HIPPS) code, and, as a result, the provider's Medicare payment was reduced.
Home Health Issue #2: M2030 (Management of Injectable Meds) – 4 Errors
Errors for this reason were due to the responses to this OASIS item, which were inconsistent with the documentation submitted by the provider. In three of the cases, the OASIS was marked indicating the patient was receiving injectable medications. However, the documentation did not indicate that the beneficiary was receiving any injectable medications. In one case, the patient was receiving B12 injections; however these were administered in the physician's office, and therefore, should not have been reflected in the M2030 item. As a result of the errors with this OASIS items, the HIPPS codes were reduced, and partial Medicare payment was recouped.
Home Health Issue #3: Plan of Care Not Signed/Dated Before Claim Billed – 2 Errors
In both cases, the error resulted from the claim being billed to Medicare prior to the plan of care being signed and dated by the physician. As a reminder, the Medicare Claims Processing Manual (CMS Pub. 100-04), Ch. 10 §10.1.10.4 states "HHAs may not submit this claim until after all services are provided for the episode and the physician has signed the plan of care and any subsequent verbal order. Signed orders are required every time a claim is submitted, no matter what payment adjustment may apply." In both cases, Medicare payment was recouped in full.
Home Health Issue #4: Documentation Does Not Support Medical Necessity – 2 Errors
In one case, the patient was receiving home health care with a primary diagnosis of hypertension. However, no blood pressure parameters were noted in the plan of care (POC), and there were no changes to the Coumadin dosage. Documentation supported that the patient was stable with no changes in diagnosis, medications, treatment plan of care, and there was little risk of exacerbation. In the second case, the primary diagnosis was cellulitis. Documentation noted that an abscess was unchanged in 6 months, there were no signs/symptoms of infection, no falls were noted, and there was no new or changed medications or treatments. In both cases, Medicare payment was recouped in full.
Hospice Issue #1: Missing/Insufficient/Untimely Certification/Recertification – 4 Errors
All CERT errors for hospice providers were related to the hospice certification/recertification.
In two cases, the certification was not submitted with the documentation sent to the CERT review contractor. As a reminder, the Medicare Benefit Policy Manual (CMS Pub. 100-02), Ch. 9 §20.1 states "Written certification must be on file in the hospice patient's record prior to submission of a claim to the Medicare contractor."
In one case, the recertification was insufficiently documented, and lacked the specific clinical findings and explanation of why the clinical factors supported the six month prognosis. The Medicare Benefit Policy Manual (CMS Pub. 100-02), Ch. 9 §20.1 states:
"The written certification must include:
- The statement that the individual's medical prognosis is that their life expectancy is 6 months or less if the terminal illness runs its normal course;
- Specific clinical findings and other documentation supporting a life expectancy of 6 months or less; and
- The signature(s) of the physician(s), the date signed, and the benefit period dates that the certification or recertification covers.
- The physician's brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms.
- Documentation of the face-to-face encounter for patient's entering their 3rd or later benefit period."
In the final case, the physician's certification was not received until 2 weeks after hospice care began. According to the Medicare Benefit Policy Manual (CMS Pub. 100-02), Ch. 9 §20.1, the hospice must obtain oral or written certification of the terminal illness no later than 2 calendar days after hospice care is initiated, and must be signed prior to the submission of the claim.
CERT Web Page
A summary of all of the CERT-identified errors have been summarized on the "Summary of Common CERT Errors" web page, which is available at http://www.cgsmedicare.com/hhh/education/materials/CERT_Errors_Summary.html The page includes the provider type, type of bill, the error code assessed by CERT, and a summary of the error. Errors from the previous CERT report are also available to view using the "See previous CERT errors listing" link at the bottom of the webpage. Please take time to have your staff review this summary and identify any internal processes your organization can take to prevent your risk for similar errors within your agency.
As a reminder, providers have the ability to submit additional documentation at any time to substantiate the services billed. In addition, providers have their traditional Medicare appeal rights for any claims denied by CERT.
For additional information about CERT, refer to the CMS CERT Web page, at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/CERT/index.html
Appeal Rights for Claims with CERT Errors
As a reminder, providers have the right to appeal any claim which CERT found to be in error. For more information about the Medicare appeals process, refer to the "Appeals Overview' web page on CGS's website, at http://www.cgsmedicare.com/hhh/appeals/overview.html
Claims in a Suspended Status/Location (S/LOC)
For Home Health and Hospice Providers
CGS continues to receive a high volume of calls from home health and hospice providers regarding claims that are in a suspended S/LOC. These claims can be identified in the Fiscal Intermediary Standard System (FISS) by a status code beginning with an "S" (example: S B0100).
Generally, providers do not need to take action on claims in a suspended S/LOC. All Medicare billing transactions will temporarily suspend in different S/LOCs as they process through FISS.
| S/LOC | Definition | Provider Action Needed? |
|---|---|---|
| S B0100 | System processing | No |
| S B6001 | Claim has an Additional Development Request (ADR) and has been selected for Medical Review (MR) | Yes, providers should mail their medical documentation no later than 30 days after the request date. Additional information is available at http://www.cgsmedicare.com/hhh/education/materials/pdf/ADR_QRT.pdf |
| S B90XX (XX denotes a variety of location codes) | FISS is comparing the claim data to the beneficiary's eligibility information posted at the Common Working File (CWF) | No |
| S M0XXX (XX denotes a variety of location codes) | Billing transaction requires manual intervention by CGS staff | No. Suspended billing transactions that require CGS staff intervention may be suspended for up to 30 days. Claims with Medicare Secondary Payer (MSP) information may be suspended for more than 60 days. Providers may call the Provider Contact Center if their claim has been in the same "S MXXXX" S/LOC for longer than 30 days, or 60 days for MSP claims. |
| S M50MR | Claim will move from S B6001 to this S/LOC when the medical documentation has been received by CGS and is pending review by MR staff. | No. Review of ADR documentation may take up to 60 days to complete. Do not call CGS unless your claim has been in this S/LOC for more than 60 days. |
Suspended Claims That Have Processing Issues in FISS
Occasionally, there may be system problems that prevent Medicare billing transactions from processing appropriately. In these cases, billing transactions impacted by these issues may be suspended in FISS until a resolution is identified and implemented. CGS has a webpage, "Fiscal Intermediary Standard System Claims Processing Issues" available to assist providers in checking the status of known home health and hospice claims processing issues, including claims suspended in S BXXXX or S MXXXX S/LOCs. This page is available at http://www.cgsmedicare.com/hhh/claims/FISS_Claims_Processing_Issues.html Home health and hospice staff should refer to this resource before calling the Provider Contact Center with questions or status updates.
CMS.gov Website Upgrade Completed-Check your Bookmarks
For Home Health and Hospice Providers
CMS has completed the upgrades to the www.CMS.gov website. Bookmarked links to items posted in the "Downloads" sections on the CMS website have not been affected, but other bookmarked URLs are redirected to the index webpage for that topic. For example, if you bookmarked the page containing National Provider Calls and Events, you will be taken to the index page for National Provider Calls. On the index page, select the webpage you'd like to view from the left-hand side. Once you open the correct page, you can create a new bookmark. We appreciate your understanding and apologize for any inconvenience during this process.
Home Health:
http://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html
Hospice:
http://www.cms.gov/Center/Provider-Type/Hospice-Center.html
Consumers Can Now Compare Results from Home Health Agencies Patient Surveys
For Home Health and Hospice Providers
CMS to publicly report on consumer experiences with Medicare-certified home health agencies
Results from the CMS national survey that asks patients about their experiences with Medicare-certified home health agencies are now available on the agency's Quality Care Finder website, at http://www.medicare.gov/quality-care-finder/
CMS Acting Administrator Marilyn Tavenner announced the new tool offering prospective patients, their families and caregivers the chance to compare home health agencies by looking at patient survey results. The Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) Survey, which will be updated every four months with new survey data, will complement the clinical measures already available on the agency's "Home Health Compare" website.
The HHCAHPS is a survey that collects feedback on topics that patients have identified as important to them in determining which home health agencies provide high-quality care. For example, the survey asks patients about the care they received from their home health agency, including such topics as overall care; provider communication skills; whether care was provided in a courteous and respectful way; and whether the agency discussed medicines, pain, and home safety.
A prospective patient or caregiver will be able to review and compare feedback from other patients about Medicare-certified home health agencies' care of patients, communication between providers and patients, as well as the specific care issues identified on the survey. Ratings include an overall rating of home health care and a patient's willingness to recommend the agency to someone else.
The survey results are designed to create incentives for home health agencies to improve quality of care, as well as to give patients additional information so they are aware of the types of care they will receive from a particular agency. Additionally, public reporting enhances accountability in health care by increasing transparency.
For more information on the survey, visit the Home Health Care CAHPS Survey webpage, at https://homehealthcahps.org/
To access the survey data, visit the Quality Care Finder tool in Medicare.gov, at http://www.medicare.gov/quality-care-finder/index.html and click on Home Health Compare.
Full text of this excerpted CMS press release (issued April 19) can be accessed here.
Ensure Appropriate Reporting of Patient Status Code on Hospice Claims
For Hospice Providers
Based on calls CGS has received in our Provider Contact Center, the following article reminds hospice billers of a recent system change that has modified the reporting of hospice revocations to the Common Working File (CWF).
Change Request (CR) 7473, which became effective for services on/after January 1, 2012, now results in a revocation indicator posting to the CWF when the claim indicates the patient was discharged from the Medicare hospice benefit. Most often, this is reported through a patient status code (form locator (FL) 17) of a '01'. Therefore, claims with dates of service on/after January 1, 2012, that include a patient status code '01' will post a revocation indicator to the CWF, regardless of whether an occurrence code 42 is submitted on the claim.
As a result of this change, it is especially important to ensure the patient status code submitted on your claim is appropriate, and accurately reflects the patient's status as of the "TO" date on the claim. A patient status code '01' should never be used to indicate a patient transferring to another hospice agency, or a patient who passed away.
When a patient is transferring to another hospice agency, the "discharging" hospice agency should use a patient status code '50' (discharged/transfer to hospice – home) when transferring under routine or continuous home care, or a '51' (discharged/transfer to hospice – medical facility) when transferring under respite or general inpatient care.
| Patient Status Code | Used when the patient: | Impact on CWF Revocation Indicator |
|---|---|---|
| 01 | Discharged to home (i.e. discharged from the Medicare hospice benefit, including a revocation or patient no longer terminal) | Revocation indicator of "1" posted to CWF |
| 30 | Still a hospice patient | None |
| 40 | Expired at home | None |
| 41 | Expired at medical facility | None |
| 42 | Expired – place unknown | None |
| 50 | Transfers to another hospice while under routine or continuous care | None |
| 51 | Transfers to another hospice while under respite or general inpatient care | None |
Ensuring the appropriate patient status code is submitted on your hospice claims will prevent a revocation indicator from being posted to the CWF in error.
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
Home Health Billing Reminders to Reduce Errors for Reason Codes (RC) 38107 and 31755
For Home Health Providers
Home Health Billing Reminders to Reduce Errors for Reason Codes (RC) 38107 and 31755
Home Health Claims Selected for Review with Dates of Service October 1, 2011 Through December 31, 2011
For Home Health Providers
CMS issued V3210 of the home health (HH) prospective payment system (PPS) Grouper effective for dates of service October 1, 2011, and later. New Diagnosis codes 294.20 and 294.21 were not initially approved for addition to the V3210 of the HH PPS Grouper. In V3312, CMS has added these two diagnosis codes for dates of service October 1, 2011, and later. V3312 of the HH PPS Grouper which is effective January 1, 2012, will update the HH PPS Grouper so that OASIS records submitted with these diagnosis codes will result in the HH PPS Grouper producing the appropriate set of scores and HIPPS code for dates of service October 1, 2011, and later.
Regional Home Health Intermediaries (RHHIs) have received technical direction from CMS that provides the necessary information for their use in reviewing home health claims with a date of service between October 1, 2011, and December 31, 2011 that contain diagnosis codes 294.20 and 294.21.
Home Health agencies may want to review any claims with dates of service submitted from October 1, 2011, through December 31, 2011, to make a business decision as to whether or not to adjust the claim based upon a different HIPPS score determination made by V3312 of the HH PPS Grouper.
MM7260—Modification to CWF, FISS, MCS and VMS to Return Submitted Information When There is a CWF Name and HIC Number Mismatch
For Home Health and Hospice Providers
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 website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters® Number: MM7260
Related Change Request (CR) #: CR 7260
Related CR Release Date: April 26, 2012
Effective Date: October 1, 2012
Related CR Transmittal #: R2449CP
Implementation Date: October 1, 2012
Provider Types Affected
This MLN Matters® Article is intended all physicians, providers, and suppliers submitting claims to Medicare contractors (fiscal intermediaries (FIs), regional home health intermediaries (RHHIs), carriers, A/B Medicare administrative contractors (MACs) and durable medical equipment MACs (DME MACs) for Medicare beneficiaries.
Provider Action Needed
If Medicare systems reject a claim when the beneficiary name does not match the Health Insurance Claim Number (HICN), your Medicare contractor will return the claim to you as unprocessable with the identifying beneficiary information from the submitted claim as follows:
- Your contractor will return to provider (RTP) Part A claims.
- Your contractor will return as unprocessable Part B claims. Your contractor will use Reason Code 140 (Patient/Insured health identification number and name do not match).
When returning these claims as unprocessable, your contractor will utilize remittance advice codes MA130 and MA61. Also, based on CR 7260, you will receive the beneficiary name information you originally submitted when the claim is returned rather than the beneficiary data associated with the potentially incorrectly entered HICN. Previously, Medicare returned the name of the beneficiary that is associated with that HICN within its files.
If an adjustment claim is received where the beneficiary's name does not match the submitted HICN, your contractor will suspend the claim and, upon their review, either correct, develop, or delete the adjustment, as appropriate.
All providers should ensure that their billing staffs are aware of these changes.
Additional Information
The official instruction, CR 7260 issued to your FI, A/B MAC, and DME/MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2449CP.pdf on the CMS website.
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
MM7397 (Revised)—Pharmacy for Drugs Provided "Incident To" a Physician Service
For Home Health and Hospice Providers
The Centers for Medicare & Medicaid Services (CMS) has issued a revision to the MM7397 article entitled, "Pharmacy for Drugs Provided "Incident To" a Physician Service" which was published in the November 2011 and February 2012 HH+H Bulletins. This MLN Matters article and other CMS articles can be found on the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters® Number: MM7397 Revised
Related Change Request (CR) #: 7397
Related CR Release Date: April 4, 2012
Effective Date: January 1, 2013
Related CR Transmittal #: R2437CP
Implementation Date: January 1, 2013
Note: This article was revised on April 10, 2012, to reflect the revised CR 7397 issued on April 4. In this article, 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 (DME MACs) are affected.
What You Should Know
This article is based on Change Request (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.
- Claims for these drugs are generally submitted to the durable medical equipment Medicare administrative contractor (DME MAC). The carrier or A/B MAC will reject these claims as they need to be sent to the DME MAC.
- In the rare situation where a pharmacy dispenses a drug that will be administered through implanted DME and a physician's service will not be utilized to fill the pump with the drug, the claim is submitted to the A/B MAC or carrier.
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.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2437CP.pdf on the CMS website.
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:
- "Medicare Claims Processing Manual", Chapter 17, sections 20.1.3 and 50.B, available at http://www.cms.gov/manuals/downloads/clm104c17.pdf: and
- "Medicare Benefit Policy Manual", Chapter 15, sections 50.3 and 60.1, available at http://www.cms.gov/manuals/Downloads/bp102c15.pdf on the CMS website.
MM7473 (Revised)—Correction to Processing of Hospice Discharge Claims
For Hospice Providers
The Centers for Medicare & Medicaid Services (CMS) has issued a revision to the MM7473 article entitled, "Correction to Processing of Hospice Discharge Claims" which was published in the September 2011 HH+H Bulletin. This MLN Matters article and other CMS articles can be found on the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters® Number: MM7473 Revised
Related Change Request (CR) #: 7473
Related CR Release Date: July 29, 2011
Effective Date: January 1, 2012
Related CR Transmittal #: R2258CP
Implementation Date: January 3, 2012
Note: This article was revised on April 19, 2012, to emphasize that the implementation of this instruction is effective for claims on or after January 1, 2012. All other information is the same.
Provider Types Affected
This MLN Matters® Article is intended for hospice providers who bill Medicare regional home health intermediaries (RHHIs) or Medicare administrative contractors (A/B MACs) for hospice services provided to Medicare Beneficiaries.
Provider Action Needed
CR 7473, from which this article is taken, contains no new policy. The requirements of CR 7473 improve the implementation of longstanding policy under Medicare regulations at 42 CFR 418.26 and revise the Medicare system to ensure hospice discharge claims update the beneficiary's hospice benefit period correctly. Also, CR 7473 makes various revisions to chapter 11 of the Medicare Claims Processing Manual to remove outdated language and clarify existing instructions by adding more detailed instructions for hospices in coding claims.
See the Background Section of this article for further details regarding the improvements that are effective as of January 1, 2012, and make certain your billing staffs are aware of the changes.
Background
Medicare regulations at 42 CFR 418.26 outline three reasons for discharge from Hospice care:
- The beneficiary moves out of the hospice's service area or transfers to another hospice;
- The hospice determines that the beneficiary is no longer terminally ill; and
- The hospice determines the beneficiary meets their internal policy regarding discharge for cause.
Each of these discharge situations requires different coding on Medicare claims.
Reason 1: A beneficiary may move out of the hospice's service area either with, or without, a transfer to another hospice. In the case of a discharge when the beneficiary moves out of the hospice's service area without a transfer, the hospice uses the National Uniform Billing Committee (NUBC) approved discharge status code that best describes the beneficiary's situation. The hospice does not report occurrence code 42 on their claim. This discharge claim will terminate the beneficiary's current hospice benefit period as of the "Through" date on the claim. The beneficiary may re-elect the hospice benefit at any time as long as they remain eligible for the benefit.
In the case of a discharge when the beneficiary moves out of the hospice's service area and transfers to another hospice, the hospice uses discharge status code 50 or 51, depending on whether the beneficiary is transferring to home hospice or hospice in a medical facility. The hospice does not report occurrence code 42 on their claim. This discharge claim does not terminate the beneficiary's current hospice benefit period. The admitting hospice submits a transfer Notice of Election (type of bill 8xC) after the transfer has occurred and the beneficiary's hospice benefit is not affected.
Reason 2: In the case of a discharge when the hospice determines the beneficiary is no longer terminally ill, the hospice uses the NUBC approved discharge status code that best describes the beneficiary's situation. The hospice also reports occurrence code 42 on their claim and the date of their determination. This discharge claim will terminate the beneficiary's current hospice benefit period as of the occurrence code 42 date. This coding may also be used if the beneficiary has chosen to revoke their hospice election. The beneficiary may re-elect the hospice benefit if they are certified as terminally ill and eligible for the benefit again in the future.
Reason 3: In the case of a discharge for cause, the hospice uses the NUBC approved discharge status code that best describes the beneficiary's situation. The hospice does not report occurrence code 42 on their claim. Instead, the hospice reports condition code H2 to indicate a discharge for cause. The effect of this discharge claim on the beneficiary's current hospice benefit period depends on the discharge status.
If the beneficiary is transferred to another hospice (discharge status codes 50 or 51) the claim does not terminate the beneficiary's current hospice benefit period. The admitting hospice submits a transfer Notice of Election (type of bill 8xC) after the transfer has occurred and the beneficiary's hospice benefit is not affected. If any other appropriate discharge status code is used, this discharge claim will terminate the beneficiary's current hospice benefit period as of the "Through" date on the claim. The beneficiary may re-elect the hospice benefit if they are certified as terminally ill and eligible for the benefit again in the future and are willing to be compliant with care.
42 CFR 418.26 also specifies that any discharge from hospice care other than an immediate transfer to another hospice has the following effects:
- The beneficiary is no longer covered under Medicare for hospice care;
- The beneficiary resumes Medicare coverage of the benefits waived by their hospice election; and
- The beneficiary may at any time elect to receive hospice care if he or she is again eligible.
The Centers for Medicare & Medicaid Services (CMS) realizes that certain hospice discharge claims are not having the intended effects in Medicare systems. The requirements are intended to ensure all hospice discharge claims have the required effects on the coverage status of Medicare beneficiaries.
Key Points
Effective for claims with dates of service on or after January 1, 2012:
- Medicare contractors will set the revocation indicator on a beneficiary's hospice benefit period when a hospice claim is received with any discharge status code other than 30, 40, 41, 42, 50 or 51 and occurrence code 42 is not present.
- Medicare contractors will set the end date of the beneficiary's hospice benefit period to match the claim "Through" date when a hospice claim is received with any discharge status code other than 30, 40, 41, 42, 50 or 51 and occurrence code 42 is not present.
- Medicare contractors will set the end date of the beneficiary's hospice benefit period to match the occurrence code 42 date when a hospice claim is received with any discharge status code other than 30, 40, 41, 42, 50 or 51 and occurrence code 42 is present.
- Hospices must bill for their Medicare beneficiaries on a monthly basis. Monthly billing should conform to a calendar month (i.e. limit services to those in the same calendar month if services began mid-month) rather than a 30 day period which could span two calendar months.
Billing Medicare for Medicare Advantage (MA) Patients
Medicare hospices bill the Medicare fee-for-service contractor (RHHI or MAC) for beneficiaries who have coverage through Medicare Advantage just as they do for beneficiaries with fee-for-service coverage. Billing begins with a notice of election for an initial hospice benefit period and followed by claims with types of bill 81X or 82X. If the beneficiary later revokes election of the hospice benefit, a final claim indicating revocation, through use of occurrence code 42, should be submitted as soon as possible so that the beneficiary's medical care and payment is not disrupted.
Medicare physicians may also bill the Medicare fee-for-service contractor for beneficiaries who have coverage through Medicare Advantage as long as all current requirements for billing for hospice beneficiaries are met. These claims should be submitted with a GV or GW modifier as applicable. Medicare contractors process these claims in accordance with regular claims processing rules. When these modifiers are used, contractors are instructed to use an override code to assure such claims have been reviewed and should be approved for payment by the Common Working File in Medicare claims processing systems.
As specified above, by regulation, the duration of payment responsibility by fee-for-service contractors extends through the remainder of the month in which hospice is revoked by hospice beneficiaries. MA plan enrollees that have elected hospice may revoke hospice election at any time, but claims will continue to be paid by fee-for-service contractors as if the beneficiary were a fee-for-service beneficiary until the first day of the month following the month in which hospice was revoked.
Additional Information
The official instruction, CR 7473, issued to your RHHI and AB/MAC regarding this change may be viewed at http://www.cms.gov/Transmittals/downloads/R2258CP.pdf on the CMS website.
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
You may also want to review MLN Matters® Article MM7677 (http://www.cms.gov/MLNMattersArticles/downloads/MM7677.pdf), which requires hospices to (1) use occurrence code 42 only to indicate a discharge due to a patient revocation and not when a provider initiates the termination of hospice care; and (2) to use of condition code 52 to indicate a discharge due to the patient's unavailability.
MM7755—Ensuring Hospice Certifying Physician Identifiers Are Fully Processed
For Hospice Providers
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 website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters® Number: MM7755
Related Change Request (CR) #: 7755
Related CR Release Date: April 26, 2012
Effective Date: January 1, 2012
Related CR Transmittal #: R2448CP
Implementation Date: October 1, 2012
Provider Types Affected
This MLN Matters® Article is intended for hospice providers submitting claims to Medicare contractors (fiscal intermediaries (FIs), regional home health intermediaries (RHHIs) and A/B Medicare administrative contractors (MACs)) for services to Medicare beneficiaries.
Provider Action Needed
This article is based on Change Request (CR) 7755 which informs Medicare contractors about the requirements for hospice providers to code the National Provider Identifier (NPI) and name of the hospice physician responsible for certifying that the patient is terminally ill.
Hospice agencies are required to report the physician that certified the hospice patient's terminal illness on the claim when the certifying physician differs from the attending physician. The certifying physician is reported on the UB04 claim in the "Other Physician" field. With the implementation of the electronic claim 837I version 5010A2 format, the field for "other physician" is mapped to three possible physician identifying fields. Hospice agencies reporting the physician certifying the terminal illness using the electronic claim 837I version 5010A2 format should report this information in the 2310F loop of that claim. Be sure billing staff are aware of this requirement.
Additional Information
The official instruction, CR 7755 issued to your FI, RHHI, and A/B MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2448CP.pdf on the CMS website.
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
MM7775—Claim Adjustment Reason Code (CARC), Remittance Advice Remark Code (RARC), Medicare Remit Easy Print (MREP), and PC Print Update
For Home Health and Hospice Providers
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 website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters® Number: MM7775
Related Change Request (CR) #: CR 7775
Related CR Release Date: April 6, 2012
Effective Date: July 1, 2012
Related CR Transmittal #: R2442CP
Implementation Date: July 2, 2012
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, suppliers, and vendors representing physicians/providers/suppliers receiving remittance advice from 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 Change Request (CR) 7775 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
Change Request (CR) 7775 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 (CR 7683 Transmittal 2372 published on December 22, 2011). It also instructs Fiscal Intermediary Standard System (FISS) and VIPs Medicare System (VMS) to update PC Print and Medicare Remit Easy Print (MREP) software respectively. Be sure your billing staff is aware of these changes.
GO – What You Need to Do
If you use the MREP or PC Print software, be sure to download the updated software when available. 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) and 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 and coordination of benefits transactions. . For transaction 835 (Health Care Claim Payment/Advice) and standard paper remittance advice, valid CARCs and RARCs must be used to report payment adjustments, appeal rights, and related information. If there is any adjustment, the appropriate Group Code must be reported as well.
The CARC and RARC changes that impact Medicare are usually requested by the Centers for Medicare & Medicaid Services (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 for Medicare.
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) website). 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 website 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 7775, Medicare contractors must implement on the date specified on the WPC website.
The discrepancy between the dates may arise because the WPC website is updated only 3 times a year and may not match the CMS release schedule.
CR 7775 lists only the changes that have been approved since the last code update CR (CR 7683 Transmittal 2372), 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 website 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.
The WPC website (at http://www.wpc-edi.com/Reference on the Internet) has four listings available for both CARC and RARC:
- All: All codes including deactivated and to be deactivated codes are included in this listing.
- To Be Deactivated: Only codes to be deactivated at a future date are included in this listing.
- Deactivated: Only codes with prior deactivation effective date are included in this listing.
- Current: Only currently valid codes are included in this listing.
Note: In case of any discrepancy in the code text as posted on WPC website 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
Claim Adjustment Reason Code (CARC): 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. A health plan may decide to implement a code deactivation before the actual effective date posted on WPC website 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 website to accommodate the Medicare release schedule.
The following new Claim Adjustment Reason Codes were approved by the Code Committee in January, and must be implemented, if appropriate for Medicare, by July 2, 2012.
New Codes – CARC:
None
| Code | Modified Narrative | Effective Date |
|---|---|---|
| 109 | Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor. | 11/1/2012 |
| 239 | Claim spans eligible and ineligible periods of coverage. Rebill separate claims. | 11/1/2012 |
Deactivated Codes – CARC:
None
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. Medicare uses the standard code sets (CARC and RARC) for paper remittance advice as well.
| Code | Code Narrative | Effective Date |
|---|---|---|
| N547 | A refund request (Frequency Type Code 8) was processed previously. | 3/6/2012 |
| N548 | Alert: Patient's calendar year deductible has been met. | 3/6/2012 |
| N549 | Alert: Patient's calendar year out-of-pocket maximum has been met. | 3/6/2012 |
| N550 | Alert: You have not responded to requests to revalidate your provider/supplier enrollment information. Your failure to revalidate your enrollment information will result in a payment hold in the near future. | 3/6/2012 |
| N551 | Payment adjusted based on the Ambulatory Surgical Center (ASC) Quality Reporting Program. | 3/6/2012 |
| N552 | Payment adjusted to reverse a previous withhold/bonus amount. | 3/6/2012 |
| N553 | Payment adjusted based on a Low Income Subsidy (LIS) retroactive coverage or status change. | 3/6/2012 |
| Code | Modified Narrative | Effective Date |
|---|---|---|
| N4 | Missing/Incomplete/Invalid prior Insurance Carrier(s) EOB. | 3/6/2012 |
| N206 | The supporting documentation does not match the information sent on the claim. | 3/6/2012 |
Deactivated Codes – RARC:
None
Additional Information
The official instruction, CR 7775, issued to your carriers, DME MACs, FIs, A/B MACs, and RHHIs regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2442CP.pdf release on the CMS website.
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
MM7785—Revisions of the Financial Limitation for Outpatient Therapy Services – Section 3005 of the Middle Class Tax Relief and Job Creation Act of 2012
For Home Health Providers
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 website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters® Number: MM7785
Related Change Request (CR) #: CR 7785
Related CR Release Date: April 27, 2012
Effective Date: October 1, 2012
Related CR Transmittal #: R2457CP
Implementation Date: October 1, 2012
Provider Types Affected
This MLN Matters® article is intended for physicians, other suppliers and providers who submit claims to Medicare contractors (carriers, fiscal intermediaries (FIs), A/B Medicare administrative contractors (A/B MACs), and/or regional home health intermediaries (RHHIs)) for therapy services provided to Medicare beneficiaries.
Provider Action Needed
STOP –– Impact to You
This article is based on CR 7785, which extends the therapy cap exceptions process through December 31, 2012, adds therapy services provided in outpatient hospital settings other than Critical Access Hospitals (CAHs) to the therapy cap effective October 1, 2012, requires the National Provider Identifier (NPI) of the physician certifying therapy plan of care on the claim, and addresses new thresholds for mandatory medical review.
CAUTION –– What You Need to Know
The therapy cap amounts for 2012 are $1880 for occupational therapy services, and $1880 for the combined services for physical therapy and speech-language pathology. Suppliers and providers will continue to use the KX modifier to request an exception to the therapy caps on claims that are over these amounts. The use of the KX modifier indicates that the services are reasonable and necessary, and there is documentation of medical necessity in the patient's medical record. For services provided on or after October 1, 2012, and before January 1, 2013, there will be two new therapy services thresholds of $3700 per year: one annual threshold each for 1) Occupational Therapy (OT) services, and 2) Physical Therapy (PT) services and Speech-Language Pathology (SLP) services combined. Per-beneficiary services above these thresholds will require mandatory medical review.
GO – What You Need to Do
See the "Background" and "Additional Information" sections of this article for further details regarding these changes.
Background
The Balanced Budget Act of 1997 (see http://www.gpo.gov/fdsys/pkg/PLAW-105publ33/pdf/PLAW-105publ33.pdf on the Internet) enacted financial limitations on outpatient PT, OT, and SLP services in all settings except outpatient hospital. Exceptions to the limits were enacted by the Deficit Reduction Act (see http://www.gpo.gov/fdsys/pkg/PLAW-109publ171/pdf/PLAW-109publ171.pdf on the Internet), and have been extended by legislation several times.
The Middle Class Tax Relief and Job Creation Act of 2012 (MCTRJCA, Section 3005; see http://www.gpo.gov/fdsys/pkg/BILLS-112hr3630enr/pdf/BILLS-112hr3630enr.pdf on the Internet) extended the therapy caps exceptions process through December 31, 2012, and made several changes affecting the processing of claims for therapy services.
The therapy cap amounts for 2012 are:
- $1880 for OT services, and
- $1880 for the combined services for PT and SLP.
CR 7785 instructs Medicare suppliers and providers to continue to use the KX modifier to request an exception to the therapy cap on claims that are over these amounts. Note that use of the KX modifier is an attestation from the provider or supplier that:
- The services are reasonable and necessary, and
- There is documentation of medical necessity in the patient's medical record.
Therapy services furnished in an outpatient hospital setting have been exempt from the application of the therapy caps. However, MCTRJCA requires Original Medicare to temporarily apply the therapy caps (and related provisions) to the therapy services furnished in an outpatient hospital between October 1, 2012, and December 31, 2012.
Although the therapy caps are only applicable to hospitals for services provided on or after October 1, 2012, in applying the caps after October 1, 2012, claims paid for outpatient therapy services since January 1, 2012, will be included in the caps accrual totals.
In addition, MCTRJCA contains two requirements that become effective on October 1, 2012.
- The first of these requires that suppliers and providers report on the beneficiary's claim for therapy services the National Provider Identifier (NPI) of the physician (or Non-Physician Practitioner (NPP) where applicable) who is responsible for reviewing the therapy plan of care. For implementation purposes, the physician (or NPP as applicable) certifying the therapy plan of care is reported. NPPs who can certify the therapy plan of care include nurse practitioners, physician assistants and clinical nurse specialists.
- The second requires a manual medical review process for those exceptions where the beneficiary therapy services for the year reach a threshold of $3,700. The two separate thresholds triggering manual medical reviews build upon the separate therapy caps as follows:
- One for OT services, and
- One for PT and SLP services combined.
Although PT and SLP services are combined for triggering the threshold, medical review is conducted separately by discipline.
Claims with the KX modifier requesting exceptions for services above either threshold are subject to a manual medical review process. The count of services to which these thresholds apply begins on January 1, 2012. Absent Congressional action, manual medical review expires when the exceptions process expires on December 31, 2012.
Claims for services at or above the therapy caps or thresholds for which an exception is not granted will be denied as a benefit category denial, and the beneficiary will be liable. Although Medicare suppliers and providers are not required to issue an Advance Beneficiary Notice (ABN) for these benefit category denials, they are encouraged to issue the voluntary ABN as a courtesy to their patients requiring services over the therapy cap amounts ($1,880 for each cap in CY 2012) to alert them of their possible financial liability.
Key Billing Points
Remember the caps will apply to outpatient hospitals as detected via:
- Types of Bill (TOB) 12X (excluding CAHs with CMS Certification Numbers (CCNs) in the range of 1300-1399) or 13X;
- A revenue code of 042X, 043X, or 044X;
- Modifier GN, GO, or GP; and
- Date of service on or after October 1, 2012.
Other important points are as follows:
- The new thresholds will accrue for claims with dates of service from January 1, 2012, through December 31, 2012. Medicare will display the total amount applied toward the therapy caps and thresholds on all applicable inquiry screens and mechanisms.
- Providers should report the NPI of the physician/NPP certifying the therapy plan of care in the Attending Physician field on institutional claims for outpatient therapy services, for dates of service on or after October 1, 2012.
- In cases where different physicians/NPPs certify the OT, PT, or SLP plan of care, report the additional NPI in the Referring Physician field (loop 2310F) on institutional claims for outpatient therapy services for dates of service on or after October 1, 2012.
- On professional claims, providers are to report the physician/NPP certifying the therapy plan of care, including his/her NPI, for outpatient therapy services on or after October 1, 2012.
- For claims processing purposes, the certifying physician/NPP is considered a referring provider and such providers must follow the instructions in Chapter 15, Section 220.1.1 of the "Medicare Benefit Policy Manual" (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf) for reporting the referring provider on a claim.
- On electronic professional claims, report the referring provider, including NPI, per the instructions in the appropriate ASC X12 837 Technical Report 3 (TR3).
- For paper claims, report the referring provider, including NPI, per the instructions in Chapter 26, Section 10 of the "Medicare Claims Processing Manual" at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26.pdf on the CMS website.
Claims without at least one referring provider, including his/her NPI, will be returned as unprocessable with the following codes:
- Claim Adjustment Reason Code 165 (Referral absent or exceeded).
- Remittance Advice Remark Code of N285 (Missing/incomplete/invalid referring provider name) and/or N286 (Missing/incomplete/invalid referring provider number).
Note from CGS: HHAs are reminded that the therapy caps impact PT, OT, and SLP services that are furnished by the HHA to individuals who are not homebound or otherwise are not receiving services under a home health plan of care. For additional information, see the CGS "Home Health Outpatient Therapy Billing" webpage at http://www.cgsmedicare.com/hhh/education/materials/Home_Health_Outpatient_Therapy_Billing.html and the "Home Health Outpatient Therapies Coverage Guidelines" webpage at http://www.cgsmedicare.com/hhh/coverage/HH_Coverage_Guidelines/16A.html
Additional Information
The official instruction, CR 7785, issued to your carriers, FIs, A/B MACs, and RHHIs regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2457CP.pdf on the CMS website.
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
MM7792—New Occurrence Code to Report Date of Death
For Home Health and Hospice Providers
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 website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters® Number: MM7792
Related Change Request (CR) #: 7792
Related CR Release Date: April 27, 2012
Effective Date: October 1, 2012
Related CR Transmittal #: R1079OTN
Implementation Date: October 1, 2012
Provider Types Affected
This MLN Matters® Article is intended for providers and suppliers who bill Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs) or A/B Medicare Administrative Contractors (A/B MACs) for services provided to Medicare beneficiaries.
Provider Action Needed
This article is based on CR 7792, which announces that the National Uniform Billing Committee (NUBC) approved a new occurrence code to report date of death with an effective/ implementation date of October 1, 2012. Medicare systems will accept and process new occurrence code 55 used to report date of death. Be sure your staffs are aware of this change.
Background
The NUBC approved a new occurrence code to report date of death with an effective/ implementation date of October 1, 2012. Medicare systems will accept and process new occurrence code 55 used to report date of death. Occurrence code 55 and the date of death must be present when patient discharge status code 20 (expired), 40 (expired at home), 41 (expired in a medical facility), or 42 (expired – place unknown) is present.
Additional Information
The official instruction, CR 7792, issued to your FI, RHHI, or A/B MAC regarding this change, may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1079OTN.pdf on the CMS website.
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
MM7793—Claim Status Category and Claim Status Codes Update
For Home Health and Hospice Providers
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 website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters® Number: MM7793
Related Change Request (CR) #: CR 7793
Related CR Release Date: March 30, 2012
Effective Date: July 1, 2012
Related CR Transmittal #: R2436CP
Implementation Date: July 2, 2012
Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers who submit 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.
What You Need to Know
This article is based on CR 7793 which explains that the Health Insurance Portability and Accountability Act (HIPAA) requires all health care benefit payers to use only Claim Status Category Codes and Claim Status Codes approved by the national Code Maintenance Committee to report the status of submitted claim(s). Proprietary codes may not be used in the X12 276/277 to report claim status. The code sets are available at http://www.wpc-edi.com/content/view/180/223/ on the Internet. The code lists include the date when a code was added, changed, or deleted. All code changes approved during the June 2012 committee meeting will be posted on that site on or about July 1, 2012.
Background
HIPAA requires all health care benefit payers to use Claim Status Category Codes and Claim Status Codes to report the status of submitted claim(s). Only codes approved by the national Code Maintenance Committee in the X12 276/277 Health Care Claim Status Request and Response format are to be used. Proprietary codes may not be used in the X12 276/277 to report claim status.
The national Code Maintenance Committee meets at the beginning of each X12 trimester meeting (February, June, and October) and makes decisions about additions, modifications, and retirement of existing codes. The code sets are available at http://www.wpc-edi.com/content/view/180/223/ or http://www.wpc-edi.com/codes on the Internet. All code changes approved during the June 2012 committee meeting will be posted on that site on or about July 1, 2012. The code lists include specific details, including the date when a code was added, changed, or deleted. Your Medicare contractors must complete entry of all applicable code text changes and new codes, and terminated use of deactivated codes by July 2, 2012.
Additional Information
The official instruction, CR 7793, issued to your carriers, DME MACs, FIs, A/B MACs, and RHHIs regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2436CP.pdf on the CMS website.
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
MM7794—New Influenza Virus Vaccine Code
For Home Health and Hospice Providers
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 website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters® Number: MM7794
Related Change Request (CR) #: CR 7794
Related CR Release Date: April 26, 2012
Effective Date: July 1, 2012
Related CR Transmittal #: R2446CP
Implementation Date: October 1, 2012
Provider Types Affected
This MLN Matters® Article is intended for physicians and other providers who bill Medicare carriers, fiscal intermediaries (FI), Medicare Administrative Contractors (A/B MAC) and Regional Home Health Intermediaries (RHHI) for providing influenza virus vaccines to Medicare beneficiaries.
Provider Action Needed
Effective for claims with dates of service on or after July 1, 2012, Medicare will pay for influenza virus vaccine code Q2034. CR 7794, from which this article is taken, provides instructions for the payment of influenza virus vaccine code Q2034 for claims with dates of service on or after July 1, 2012, processed on or after October 1, 2012. Annual Part B deductible and coinsurance amounts do not apply. You should make sure that your billing staffs are aware of this new code for influenza virus vaccine.
Background
Effective July 1, 2012, your Medicare carrier, FI, A/B MAC, or RHHI will begin accepting influenza virus vaccine code Q2034 (for dates of service on or after that date); and will add it to existing influenza virus vaccine CWF edits. For professional claims, for dates of service of July 1, 2012, through September 30, 2012, your contractor will use local pricing guidelines to determine payment rates for Q2034. After September 30, 2012, professional claims will be paid using the Medicare Part B payment limit for Q2034 according to the established payment rate in the October 2012 Part B drug pricing file.
Processing Institutional Claims
Your contractor will pay for influenza virus vaccine code Q2034 based on reasonable cost to:
- Hospitals using type of bill (TOB) 12X and 13X; to:
- Skilled nursing facilities (SNF) using TOB 22X and 23X:
- Home health agencies (HHA) using TOB 34X;
- Hospital-based Renal Dialysis Facilities (RDF) using TOB 72X; and
- Critical access hospitals (CAH) using TOB 85X.
Your contractor will pay for influenza virus vaccine code Q2034 based on the lower of the actual charge or 95% of the Average Wholesale Price (AWP) to:
- Indian Health Service (IHS) hospitals using TOB 12X and 13X; and to:
- IHS CAHs using TOB 85X.
- Comprehensive Outpatient Rehabilitation Facilities (CORF) using TOB 75X; and
- Independent RDFs using TOB 72X.
Until systems are implemented, your contractor will hold institutional claims, containing code Q2034, with dates of service on or after July 1, 2012; and that are received before October 1, 2012. Upon implementation of CR 7794 on October 1, contractors will begin to process the held claims.
Additional Information
You can find more information about the new code for influenza virus vaccine (Q2034) by going to CR 7794, located at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2446CP.pdf on the CMS website.
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
MM7797—General Update to Chapter 15 of the Program Integrity Manual (PIM) Part V
For Home Health and Hospice Providers
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 website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters® Number: MM7797
Related Change Request (CR) #: CR 7797
Related CR Release Date: April 13, 2012
Effective Date: May 14, 2012
Related CR Transmittal #: R415PI
Implementation Date: May 14, 2012
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers that submit claims to Medicare carriers, fiscal intermediaries (FIs), Part A/B Medicare administrative contractors (A/B MACs) and home health & hospice Medicare administrative contractors (HHH MACs) for services provided to Medicare beneficiaries.
What You Need to Know
This article is based on CR 7797, which implements changes to Chapter 15 of the Program Integrity Manual (PIM)—Medicare Enrollment. CR 7797 focuses on the reasons for returning CMS-855 applications in Section 15.8.1 and the policies for rejecting CMS-855 applications in Section 15.8.2 of the PIM. Please make sure your staff is familiar with these changes.
Key Points
Providers and suppliers who bill Medicare Carriers, FIs, A/B MACs and HHH MACs should take note of the following:
- Your Medicare contractor may return a Form CMS-855 submission only in the following instances:
- The applicant sent its paper Form CMS-855 to the wrong contractor;
- The contractor received the application more than 60 days prior to the effective date listed on the application (though this does not apply to: (a) providers and suppliers submitting a Form CMS-855A application, (b) Ambulatory Surgical Centers (ASCs), or (c) Portable X-ray Suppliers (PXRSs);
- The contractor received an initial application from (a) a provider or supplier submitting a Form CMS-855A application, (b) an ASC, or (c) a PXRS, more than 180 days prior to the effective date listed on the application;
- An old owner or new owner in a Change of Ownership (CHOW) submitted its application more than 90 days prior to the anticipated date of the sale (though this only applies to Form CMS-855A applications);
- The contractor can confirm that the provider or supplier submitted an initial enrollment application prior to the expiration of the time period in which it is entitled to appeal the denial of its previously submitted application;
- The provider or supplier submitted an initial application prior to the expiration of a re-enrollment bar; and/or
- The application is not needed for the transaction in question.
Providers and suppliers who bill Medicare Carriers and A/B MACs take note of the following:
- If, under Section 15.8.2 of Chapter 15, a physician, non-physician practitioner, or physician or non-physician practitioner group fails to provide requested information regarding its Form CMS-855 submission within the designated timeframe, the contractor will reject (rather than deny) the application.
Additional Information
The official instruction, CR 7797, issued to your Medicare Carrier, FI, RHHI, or A/B MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R415PI.pdf on the CMS website. Attached to CR 7997 is the revised PIM Chapter, which further details the reasons for return/rejection.
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
MM7810 — July 2012 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
For Home Health and Hospice Providers
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 website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters® Number: MM7810
Related Change Request (CR) #: CR 7810
Related CR Release Date: April 6, 2012
Effective Date: July 1, 2012
Related CR Transmittal #: R2440CP
Implementation Date: July 2, 2012
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare contractors (carriers, fiscal intermediaries (FIs), A/B Medicare administrative contractors (A/B MACs), durable medical equipment Medicare administrative contractors (DME MACs), and/or regional home health intermediaries (RHHIs)) for services provided to Medicare beneficiaries.
Provider Action Needed
STOP – Impact to You
Medicare will use the July 2012 quarterly Average Sales Price (ASP) Medicare Part B drug pricing files to determine the payment limit for claims for separately payable Medicare Part B drugs processed or reprocessed on or after July 2, 2012, with dates of service July 1, 2012, through September 30, 2012.
CAUTION – What You Need to Know
Change Request (CR) 7810, from which this article is taken, instructs your Medicare contractors to download and implement the July 2012 Average Sales Price (ASP) Medicare Part B drug pricing file for Medicare Part B drugs and, if released by the Centers for Medicare & Medicaid Services (CMS), to also download and implement the revised April 2012, January 2012, October 2011, and July 2011 files.
GO – What You Need to Do
You should make sure that your billing staffs are aware of the release of these July 2012 ASP Medicare Part B drug files.
Background
The Average Sales Price (ASP) methodology is based on quarterly data submitted to CMS by manufacturers. CMS will supply Medicare contractors with the ASP and Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the OPPS are incorporated into the Outpatient Code Editor (OCE) through separate instructions that can be located in the "Medicare Claims Processing Manual" (Chapter 4 (Part B Hospital (Including Inpatient Hospital Part B and OPPS)), Section 50 (Outpatient PRICER); see http://www.cms.gov/manuals/downloads/clm104c04.pdf on the CMS website.)
The following table shows how the quarterly payment files will be applied:
| Files | Effective for Dates of Service |
|---|---|
| July 2012 ASP and ASP NOC | July 1, 2012, through September 30, 2012 |
| April 2012 ASP and ASP NOC | April 1, 2012, through June 30, 2012 |
| January 2012 ASP and ASP NOC | January 1, 2012, through March 31, 2012 |
| October 2011 ASP and ASP NOC | October 1, 2011, through December 31, 2011 |
| July 2011 ASP and ASP NOC | July 1, 2011, through September 30, 2011 |
Additional Information
You can find the official instruction, Change Request (CR) 7810, issued to your FI, carrier, A/B MAC, RHHI, or DME MAC by visiting http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2440CP.pdf on the CMS website.
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
MM7831—Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2012 Update
For Home Health and Hospice Providers
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 website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters® Number: MM7831
Related Change Request (CR) #: CR 7831
Related CR Release Date: April 26, 2012
Effective Date: July 1, 2012
Related CR Transmittal #: R2450CP
Implementation Date: July 2, 2012
Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to Medicare contractors (fiscal intermediaries (FIs), regional home health intermediaries (RHHIs), carriers, A/B Medicare administrative contractors (MACs) and durable medical equipment MACs (DME MACs) for services provided to Medicare beneficiaries.
Provider Action Needed
CR 7831 announces the quarterly updating of specific Healthcare Common Procedure Coding System (HCPCS) codes, effective for claims with dates of service on or after July 1, 2012. You should make sure that your billing staffs are aware of these HCPCS code changes.
Background
The HCPCS code set is updated on a quarterly basis. CR 7831 describes the Centers for Medicare & Medicaid Services (CMS) process for updating specific HCPCS codes.
Key Points of CR 7831
| HCPCS Code | Short Description | Long Description | MPFSDB* Status Indicator |
|---|---|---|---|
| J1680 | Human fibrinogen conc inj | INJECTION, HUMAN FIBRINOGEN CONCENTRATE, 100 MG | I |
| J9001 | Doxorubicin hcl liposome inj | INJECTION, DOXORUBICIN HYDROCHLORIDE, ALL LIPID FORMULATIONS, 10 MG | I |
* Medicare Physician Fee Schedule Data Base (MPFSDB)
| HCPCS Code | Short Description | Long Description | Type of Service (TOS) Code | MPFSDB Status Indicator |
|---|---|---|---|---|
| Q2034 | Agriflu vaccine | INFLUENZA VIRUS VACCINE, SPLIT VIRUS, FOR INTRAMUSCULAR USE (AGRIFLU) | V | X |
| Q2045 | Human fibrinogen conc inj | INJECTION, HUMAN FIBRINOGEN CONCENTRATE, 1 MG | 1,9 | E |
| Q2046 | Aflibercept injection | INJECTION, AFLIBERCEPT, 1 MG | 1,9 | E |
| Q2047 | Peginesatide injection | INJECTION, PEGINESATIDE, 0.1 MG (FOR ESRD ON DIALYSIS) | L | E |
| Q2048 | Doxil injection | INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL, DOXIL, 10 MG | 1,9 | E |
| Q2049 | Imported Lipodox inj | INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL, IMPORTED LIPODOX, 10 MG | 1,9 | E |
Additional Information
The official instruction, CR 7831, issued to your Medicare contractor regarding this change may be viewed at http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2450CP.pdf on the CMS website.
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
News Flash Messages from the Centers for Medicare & Medicaid Services (CMS)
For Home Health and Hospice Providers
- Home Health CAHPS Survey—All home health agencies (HHAs) must be participating in Home Health Care CAHPS (HHCAHPS) survey requirements for patients served in April 2012 and after, to be eligible for the full market basket payment increase for calendar year (CY) 2014. For the CY 2014 annual payment update, your agency needs to start HHCAHPS in May 2012, by providing a sample file of HHCAHPS-eligible patients who received services in your agency in April 2012.HHAs that fail to do so will have their CY 2014 payments reduced by 2 percent. CMS urges you to go to https://homehealthcahps.org to learn how to register for the HHCAHPS survey, and how to contract with an approved HHCAHPS survey vendor. HHAS may additionally email hhcahps@rti.org, or telephone 866-354-0985 for further assistance with HHCAHPS. HHAs can avoid payment reductions by participating in HHCAHPS Now!
- 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 website.
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 website - Opportunities for Providers and Patients Not Covered by Medicare as Result of Affordable Care Act—The Centers for Medicare & Medicaid Services (CMS) has posted online the Monday, June 20, letter from CMS Administrator, Donald M Berwick, MD, that highlights opportunities for providers, Medicare beneficiaries, and patients not covered by Medicare as a result of the Affordable Care Act. The letter was sent to Medicare Fee-For-Service providers by the Medicare Administrative Contractors (MACs) during the week of Monday, June 20, and can be found at http://www.CMS.gov/MLNProducts/35_PreventiveServices.asp on the CMS website.
- Has Medicare sent you a notice to revalidate your enrollment?—If you are not sure, you can find lists of providers sent notices to revalidate their Medicare enrollment by scrolling to the "Downloads" section at http://www.CMS.gov/MedicareProviderSupEnroll/11_Revalidations.asp on the Centers for Medicare & Medicaid Services (CMS) website. That site currently contains links to lists of providers sent notices from September 2011 through January 2012. Information on revalidation letters sent in February will be posted in late March. For ease of reference, the lists are in order by National Provider Identifier and the date the notice was sent.
- J12 MAC Now Diversified Service Options, Inc. —Effective January 1, 2012, Diversified Service Options, Inc., a wholly-owned subsidiary of Blue Cross and Blue Shield of Florida Inc., acquired Highmark Medicare Services from its parent company, Highmark Inc. As a result, Highmark Medicare Services changed its name to Novitas Solutions, Inc. Novitas will continue to be the Medicare Administrative Contractor (MAC) for the J12 jurisdiction and will also continue as the Section 1011 Administrative Contractor. In the near future, the Highmark website will be changing to http://www.Novitas-Solutions.com on the Internet.
- Reminder to Submit Claims to Appropriate Primary Payer—Medicare is denying an increasing number of claims, because providers are not identifying the correct primary payer prior to claims submission. Medicare would like to remind providers, physicians, and suppliers that they have the responsibility to bill correctly and to ensure claims are submitted to the appropriate primary payer. Please refer to the "Medicare Secondary Payer (MSP) Manual," Chapter 3, (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/msp105c03.pdf) and MLN Matters® Article SE1217 (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1217.pdf) for additional guidance.
- 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!
SE1211—Information on the Centers for Medicare & Medicaid Services (CMS) Fraud Prevention: Automated Provider Screening and National Site Visit Initiatives
For Home Health and Hospice Providers
The Centers for Medicare & Medicaid Services (CMS) has provided the following Special Edition Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters® Number: SE1211
Related Change Request (CR) #: 7669
Related CR Release Date: N/A
Effective Date: July 1, 2012
Related CR Transmittal #: N/A
Implementation Date: July 1, 2012
Provider Types Affected
This MLN Matters® Special Edition Article is intended for all providers and suppliers, who enroll in the Medicare program and submit fee-for-service (FFS) claims to fiscal intermediaries (FIs), carriers, A/B Medicare administrative contractors (MACs), and/or regional home health intermediaries (RHHIs), for services provided to Medicare beneficiaries.
What You Need to Know
This article provides you with the latest information about the Centers for Medicare & Medicaid Services (CMS) National Fraud Prevention Program (NFPP) initiative. The initiative includes additional tools to assist CMS in its efforts to prevent fraud and abuse in the Medicare program starting with the enrollment process itself. This article describes two new processes that CMS now employs as part of the provider enrollment process: (1) Automated provider screening, and (2) implementation of a new national site visit contractor that will conduct site visits to certain providers and suppliers. This NFPP is intended to protect the Medicare Program and to ensure that correct Program payment is made only for covered appropriate and reasonable services provided to Medicare beneficiaries by legitimate providers of care.
Key Information
National Fraud Prevention Program (NFPP)
The NFPP is an integral part of the CMS Fraud Prevention Initiative. The NFPP also enables CMS to proactively identify and respond to suspicious behavior, thus making the Agency more effective at fighting health care fraud than ever before. The NFPP focuses on two key program integrity gateways: provider enrollment and claims payment. By integrating these steps into one program, CMS can better ensure that it enrolls only qualified providers and pays only valid claims. CMS' comprehensive program integrity strategy is designed to stop fraudsters at every step of the process so CMS is now better able to:
- Identify and prevent bad actors from enrolling in Medicare;
- Identify and remove bad actors that are already in its programs; and
- Identify and prevent payment of fraudulent claims by responding with quick administrative action.
Automated Provider Screening: Ensuring Program Integrity at the Provider Enrollment Stage
CMS is implementing an Automated Provider Screening (APS) process that will screen providers and suppliers by automating data checks and developing methods to proactively identify fraud, waste, and abuse. APS will validate provider and supplier enrollment application information using various public and private databases as well as automatically check other referential databases. APS is expected to be fully implemented mid-2012 and it will:
- Reduce provider and supplier enrollment application processing time since there will be less manual review of the databases currently used in the verification process;
- On a continual basis, monitor the veracity and accuracy of all provider and supplier enrollment data including the status of licensure, sanctions or exclusions, and adverse legal actions;
- Assess the individual level of risk each provider and supplier presents to the Medicare program; and
- Be used by CMS and Medicare contractors (FIs, MACs, etc.) to verify, update, and act on relevant information found during the enrollment process-and on a continual enrollment basis.
APS is designed to ensure that Medicare enrolls only qualified providers and suppliers who meet and maintain compliance with its enrollment requirements.
National Site Visit Contractor: Ensuring Program Integrity at the Provider Enrollment Stage
CMS has implemented a site visit verification process using a National Site Visit Contractor (NSVC). The site visit verification process is a screening mechanism to prevent questionable providers and suppliers from enrolling in the Medicare program. The NSVC will conduct site visits for all providers and suppliers except for the Durable Medical Equipment (DMEPOS) which will continue to be conducted by the National Supplier Clearinghouse. The NSVC will verify enrollment related information during the site visit and collect specific information based on pre-defined checklists.
MSM Security Services, LLC was awarded the national site visit contract. MSM and its subcontractors, Computer Evidence Specialists, LLC (CES) and Health Integrity, LLC (HI) are authorized by CMS to conduct the provider and supplier site visits. Inspectors performing the site visits will be employees of MSM, CES or HI and shall possess a photo ID and a letter of authorization issued and signed by CMS that the provider or supplier may review.
Additional Information
To learn more about the predictive analytics process, refer to MLN Matters® Special Edition Article SE1133, titled "Predictive Modeling Analysis of Medicare Claims." The article is available at http://www.cms.gov/MLNMattersArticles/Downloads/SE1133.pdf on the CMS website.
To learn more about the CMS Fraud Prevention Initiative, visit the "Fraud Prevention Toolkit" web page at http://www.cms.gov/Partnerships/04_FraudPreventionToolkit.asp on the CMS website.
SE1215 —Information for Medicare Fee-For-Service Providers About the Middle Class Tax Relief and Job Creation Act of 2012
For Home Health and Hospice Providers
The Centers for Medicare & Medicaid Services (CMS) has provided the following Special Edition Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters® Number: SE1215
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 providers who provide Medicare-covered services in the fee-for-service (FFS) program.
What You Need to Know
On February 22, 2012, President Obama signed into law the Middle Class Tax Relief and Job Creation Act of 2012 (Job Creation Act). This law, which extended several provisions of the Temporary Payroll Tax Cut Elimination Act of 2011 (Continuation Act), contained several provisions that impact Medicare Fee-For-Service Providers, as outlined below.
Physician Payment Update
Section 3003 of the Jobs Creation Act extended the zero percent update for claims with dates of service on or after January 1, 2012, to February 29, 2012, all the way through December 31, 2012.
Note: The new law did NOT extend:
- Section 307 of the Continuation Act (the five percent physician fee schedule mental health add-on payment); or
- Section 309 of the Continuation Act (the special 2011 payment rates for bone mass measurements).
The Centers for Medicare & Medicaid Services (CMS) revised the 2012 Medicare Physician Fee Schedule (MPFS) to reflect the expiration of both of these provisions.
This provision does not affect claims with dates of service prior to March 1, 2012. Medicare contractors posted the new mental health and bone density rates no later than March 15, 2012.
Extension of Medicare Physician Work Geographic Adjustment Floor
Section 3004 of the law has extended the existing 1.0 floor on the physician work geographic practice cost index through December 31, 2012. As with the physician payment update, the revised 2012 MPFS will reflect this extension.
Extension of Medicare Modernization Act Section 508 Reclassifications
Section 3001 of the law extends Section 508 reclassifications and certain special exception wage indexes from December 1, 2011, through March 31, 2012.
This Section requires removing Section 508 and special exception wage date from the calculation of the reclassified wage index, if doing so raises the reclassified wage index for this period.
CMS shall assign all hospitals that receive Section 508 reclassifications and inpatient special exception reclassifications to a special wage index effective for October 2011 through March 2012.
CMS shall apply these provisions to both inpatient and outpatient hospital payments.
From January 1, 2012, through June 30, 2012, a special wage index will be applicable for affected hospital outpatient payments, special exception hospitals, and reclassified hospitals.
CMS shall make hospital inpatient and outpatient payments under both Section 302 of the Continuation Act and Section 3001 of the Job Creation Act by June 30, 2012.
Extension of Outpatient Hold Harmless Payments
Section 3002 of the law extends outpatient hold harmless payments through December 31, 2012, for:
- Rural hospitals, and
- Sole community hospitals with 100 or fewer beds.
Note: The law did NOT extend hold harmless payments for sole community hospitals with more than 100 beds. These payments expired February 29, 2012.
Extension of Exceptions Process for Medicare Therapy Services
Section 3005 of the law extends the exceptions process for outpatient therapy caps from March 1, 2012, through December 31, 2012, with some modifications to current therapy policies.
Outpatient therapy service providers must submit the KX modifier on their therapy claims when they are requesting an exception to the cap for medically necessary services that they furnished through December 31, 2012.
In addition, the new law includes changes related to therapy services that a therapist furnishes in a hospital Outpatient Department (OPD). These changes impact the annual therapy cap in 2012 as well as the applicability of the therapy cap exception process.
CMS will provide more information about the changes that affect hospital OPDs in the future. You can also find additional information about the exception process for therapy services in the "Medicare Claims Processing Manual," Pub. 100-04, Chapter 5, Section 10.3 at http://www.cms.gov/manuals/downloads/clm104c05.pdf on the CMS website.
CMS determines therapy caps on a calendar year basis. Therefore, all beneficiaries began a new cap for outpatient therapy services they received on January 1, 2012. For physical therapy and speech language pathology services combined, the 2012 limit for beneficiary-incurred expenses is $1,880.
There is a separate cap for occupation therapy services, which is also $1,880 for 2012.
Deductible and coinsurance amounts for therapy services count toward the accrued amount before a beneficiary reaches the cap and also apply for services above the cap where the provider used the KX modifier.
Section 3005 also mandates that Medicare perform an annual medical review of therapy services that a therapist furnished beginning on October 1, 2012, when the therapist requested an exception when the beneficiary reached a dollar aggregate threshold amount of $3,700, including OPD therapy services, for a year.
There are two separate $3,700 aggregate annual thresholds: one for physical therapy and speech-language pathology services, and another for occupational therapy services.
Finally, Section 3005 requires that claims for all therapy services that therapists furnish on or after October 1, 2012, include the National Provider Identifier (NPI) of the physician who reviews the therapy plan. CMS will issue additional information about all of these new requirements later this year.
Extension of Moratorium on Qualified Pathologists and Independent Laboratory Billing for the Technical Component of Physician Pathology Services Furnished to Hospital Patients
Section 3006 of the law extends the moratorium through June 30, 2012. Therefore, those qualified pathologists and independent laboratories that are eligible may continue to submit claims for the technical component of physician pathology services that they furnish to hospital patients, regardless of the beneficiary's hospitalization status (inpatient or outpatient) on the date they furnish the service.
This policy continues to be effective for claims with dates of service on or after March 1, 2012, through June 30, 2012.
Extension of Ambulance Add-On Payments
Section 3007 of the law extends the following Continuation Act ambulance payment provisions through December 31, 2012:
- The three percent increase in the ambulance fee schedule amounts for covered ground ambulance transports that originate in rural areas and the 2 percent increase for covered ground ambulance transports that originate in urban areas;
- The provision relating to air ambulance services that continues to treat any area that was designated as rural on December 31, 2006, as rural for purposes of payment under the ambulance fee schedule; and
- The provision relating to payment for ground ambulance services that increases the base rate for transports that originate in an area that is within the lowest 25th percentile of all rural areas arrayed by population density (known as the "super rural" bonus).
Suppliers of ambulance services that this provision affects may continue billing as usual.
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
SE1217—Guidance for Correct Claims Submission When Secondary Payers Are Involved
For Home Health and Hospice Providers
The Centers for Medicare & Medicaid Services (CMS) has provided the following Special Edition Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters® Number: SE1217
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 (SE) Article is intended for providers, physicians, and suppliers who bill Medicare contractors (Part A/B Medicare administrative contractors (A/B MACs), durable medical equipment Medicare administrative contractors (DME MACs), fiscal intermediaries (FIs), and carriers (hereafter referred to as Medicare contractors)) for services provided to Medicare beneficiaries.
Provider Action Needed
To ensure accurate claim submissions and timely payment, providers, physicians, and other suppliers should:
- Collect full beneficiary health insurance information upon each office visit, outpatient visit, and hospital admission.
- Identify the primary payer prior to submission of a claim, and bill the appropriate responsible payer for related services.
- Use specific and correct diagnosis codes, especially for accident related claims.
Remember: A properly filed claim prevents Medicare contractors from inappropriately denying claims and expedites the payment process.
Background
Collect full beneficiary health insurance information
It is the responsibility of all Medicare providers, physicians, and other suppliers to identify the correct primary payer by asking their patients or patients' representative questions concerning the beneficiary's Medicare Secondary Payer (MSP) status. The model hospital admissions questionnaire, published by the Centers for Medicare & Medicaid Services (CMS), may be used as a guide to collect this information from beneficiaries. This tool is available online in the "MSP Manual" in Chapter 3, Section 20.2.1 at http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/msp105c03.pdf on the CMS website. Physicians and other suppliers may also use this questionnaire to ensure MSP information is captured for use at the time of billing, so that the appropriate primary payer is billed before Medicare as required by law.
Identify and bill the correct primary payer
Medicare regulations require that all entities that bill Medicare for services or items rendered to Medicare beneficiaries must determine whether Medicare is the primary payer for those services or items before submitting a claim to Medicare. When another insurer is identified as the primary payer, bill that insurer first. After receiving the primary payer remittance advice, then bill Medicare as the secondary payer, if appropriate. If a patient is seen for multiple services, each service should be billed to the appropriate primary payer.
Accident Related Claims
If the beneficiary has an open MSP Liability (L), No-Fault (NF), or Workers' Compensation (WC) record, bill the L, NF, or WC insurer primary for accident-related claims first. DO NOT deny treatment.
To expedite processing and payment, the following steps should be followed:
- Submit the accident related claim to the L, NF, or WC insurer first. If the insurer denies the claim, then bill Medicare for payment. It is important that you include all necessary MSP payment information, as found on the primary payer's remittance advice (e.g., claim adjustment reason code specifying reason for denial), on the claim sent to Medicare. If the L, NF, or WC insurer did not make payment for the accident related services, Medicare will need this information to process your claim accordingly. If you follow these procedures, you do not need to wait 120 days to submit your claim to Medicare for payment.
- If the beneficiary has both a Group Health Plan (GHP) MSP coverage and L, NF, or WC coverage, you are required to submit a claim to the GHP insurer and the L, NF, or WC insurer before submitting the claim to Medicare. Once you receive the GHP remittance advice, include the GHP information along with the remittance advice information from the L, NF, and WC insurer with your claim to Medicare. If the claim is sent to Medicare without the GHP information, and there is an open GHP MSP record on file, Medicare will deny your claim.
- In situations where there is no L, NF, or WC accident or injury, but the beneficiary has employer GHP coverage that is primary to Medicare, you must submit the claim to the GHP insurer first before submitting the claim to Medicare for secondary payment.
If you believe a claim was inappropriately denied:
- Ensure that you have submitted a correctly completed claim to the appropriate payer(s).
- Contact your Medicare contractor if you still have reason to believe a claim was denied inappropriately.
- You may need to provide information to your Medicare contractor that demonstrates why the claim was denied inappropriately. For example, a diagnosis code may have been mistakenly applied to the beneficiary's L, NF, or WC MSP record. Indicate to the Medicare contractor that the service performed is not related to the accident or injury, and Medicare should adjust and pay the claim if it is a Medicare covered and payable service.
Contact the Coordination of Benefit Contractor (COBC) at 1-800-999-1118 if a beneficiary's MSP record needs to be updated.
- The COBC collects, manages, and maintains other insurance coverage for Medicare beneficiaries.
- Providers, physicians, or other suppliers may request an update to an MSP record if they have the appropriate documentation to substantiate the change. The documentation may need to be faxed to the COBC at 734-957-9598, or the beneficiary may need to be on the line to validate the change.
- Please do not call the COBC to adjust claims or about mistaken payments. They will not be able to assist you.
Key Points
- Collect full beneficiary health insurance information upon each office visit, outpatient visit, and hospital admission.
- Identify the primary payer prior to submission of a claim, and bill the appropriate responsible payer(s) for related services.
- For multiple services, bill each responsible payer(s) separately. Do not combine unrelated services on the same claim to Medicare. Consequently, if you render treatment to a beneficiary for accident related services and non-accident related services, do not submit both sets of services on the same claim to Medicare. Send separate claims to Medicare: one claim for services related to the accident and another claim for services not related to the accident.
- Providers, physicians, and other suppliers should always use specific diagnosis codes related to the accident or injury. Doing so will promote accurate and timely payments.
- Providers should report directly to the COBC any changes to beneficiary, spouse and/or family member's employment, accident, illness, or injury, Federal program coverage changes, or any other insurance coverage information.
Additional Information
- Specific claim-based issues or questions (including claim processing) should be addressed to the Medicare claims processing contractor. 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
- If you need to report new beneficiary coverage that may be primary to Medicare or have questions regarding MSP status or claims investigation activities, contact the COBC's toll-free lines. For more information on contacting the COBC or the Medicare Coordination of Benefits process, visit the Medicare Coordination of Benefits Web page at http://www.cms.hhs.gov/Medicare/Coordination-of-Benefits/COBGeneralInformation/index.html on the CMS website.
- The Medicare Learning Network (MLN) has a Medicare Secondary Payer Fact Sheet for Provider, Physician, and Other Supplier Billing Staff (ICN 006903) at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//MSP_Fact_Sheet.pdf on the CMS website. This fact sheet is designed to provide education on the MSP provisions. It includes information on MSP basics, common situations when Medicare may pay first or second, Medicare conditional payments, and the role of the COBC.
SE1218—Redesigned Medicare Summary Notices
For Home Health and Hospice Providers
The Centers for Medicare & Medicaid Services (CMS) has provided the following Special Edition Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html.
MLN Matters® Number: SE1218
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 informational in nature and is intended for all providers who provide Medicare-covered services in the Medicare fee-for-service (FFS) program.
Background
The Centers for Medicare & Medicaid Services (CMS) has announced the redesign of the statement that informs Medicare beneficiaries about their claims for Medicare benefits.
What You Need to Know
CMS will make the redesigned statement, known as the Medicare Summary Notice (MSN), available online. Starting in 2013, CMS will mail the MSN to beneficiaries quarterly.
The MSN redesign is part of a new initiative, "Your Medicare Information: Clearer, Simpler, At Your Fingertips". This initiative aims to make Medicare information clearer, more accessible, and easier for beneficiaries and their caregivers to understand.
CMS will take additional actions this year to make information about benefits, providers, and claims more accessible and easier to understand for people who have Medicare. This MSN redesign reflects more than 18 months of research and feedback from beneficiaries to provide enhanced customer service and respond to suggestions and input.
Features of the Redesigned MSN
The redesign of the MSN includes several features that are not available in the current MSN, including:
- A clear notice on how to check the form for important facts and potential fraud;
- An easy-to-understand snapshot of:
- The beneficiary's deductible status,
- A list of the providers they saw, and
- Whether Medicare approved their claims;
- Clearer language, including consumer-friendly descriptions for medical procedures;
- Definitions of all the column headers present in the form;
- Larger fonts to make it easier to read; and
- Information on preventive services available to Medicare beneficiaries.
For More Information
The redesigned MSN is available on www.mymedicare.gov, which is Medicare's secure online service for personalized information regarding Medicare benefits and services.
To see a side-by-side comparison of the former and redesigned MSNs, please visit http://www.cms.gov/apps/files/msn_changes.pdf on the CMS website.
To view the CMS press release on the MSN redesign, please visit: http://www.CMS.gov/apps/media/press/release.asp?Counter=4298 on the CMS website.
SE1219—A Physician's Guide to Medicare's Home Health Certification, including the Face-to-Face Encounter
For Home Health Providers
The Centers for Medicare & Medicaid Services (CMS) has provided the following Special Edition Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters® Number: SE1219
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 physicians who refer patients to home health, order home health services, and/or certify patients' eligibility for the Medicare home health benefit, home health agencies, and non-physician practitioners (NPPs).
What You Need to Know
- Requirements which must be met in order for a patient to qualify for Medicare's home health benefit.
The patient must:
- be confined to the home;
- be under the care of a physician;
- receive services under a plan of care established and periodically reviewed by a physician;
- be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology, or have a continuing need for occupational therapy.
- Physician Home Health Certification Requirements
- Physician must be Medicare-enrolled;
- When a resident is not Medicare-enrolled, the Medicare-enrolled teaching physician, who is supervising the resident, would sign the certification.
- The certifying physician must certify that the patient is receiving home health services under the care of a physician who is a doctor of medicine, osteopathy, or podiatric medicine; and
- The certifying physician must not have a financial relationship with the home health agency, as defined in 42 CFR 411.354, unless exceptions to the referral prohibition defined in Section1877 of the Social Security Act apply.
- Timeframe for completion of the certification
- Must be obtained when the plan of treatment is established, or as soon as possible thereafter;
- Must be signed and dated by the physician who established the plan; and
- Must be complete prior to the home health agency billing Medicare.
- Certification Content Requirements
The physician must certify that:
- Home health services are or were needed because the patient is homebound.
- The patient needs or needed skilled nursing services on an intermittent basis (other than solely venipuncture for the purposes of obtaining a blood sample), or physical therapy, or speech-language pathology services; or continues to need occupational therapy after the need for skilled nursing care, physical therapy, or speech-language pathology services ceased. Where a patient's sole skilled service need is for skilled oversight of unskilled services (management and evaluation of the care plan), the physician must include a brief narrative describing the clinical justification of this need as part of the certification and recertification, or as a signed addendum to the certification and recertification.
- A plan of care has been established and is periodically reviewed by a physician.
- The services are or were furnished while the patient is or was under the care of a physician.
- Face-to-Face Requirements
- For initial home health certifications, the certifying physician must document that the physician himself or herself, an allowed NPP, or a physician caring for the patient in an acute or post-acute facility who has privileges at the facility had a face-to-face encounter with the patient.
- The face-to-face encounter must occur within 90 days prior to the home health start of care date or within 30 days after the start of care.
- The face-to-face encounter can be performed via a telehealth service, in an approved originating site.
- Prior to billing, the home health agency should ensure that all certifications are complete, including that the face-to-face documentation that has been clearly titled, dated, and signed by the certifying physician.
- Face-to-Face Documentation Requirements
- Documentation must be clearly titled, dated, and signed by the certifying physician, whether as part of the certification form itself, or as an addendum. It must also include the date the face-to-face encounter was performed.
- Documentation includes a brief narrative which describes how the patient's clinical condition, as seen during that encounter, supports the patient's homebound status and need for skilled services.
- The face-to-face documentation must be that of the certifying physician, and cannot be altered/changed in any way by the home health agency.
- The face-to-face documentation is part of the certification, and the certification is required at the time the home health agency bills Medicare.
- The face-to-face documentation can include, or exist as, checkboxes so long as it comes from the certifying physician.
- If the physician who cared for the patient in the acute or post-acute facility chooses to use documentation that is compiled from the patient's medical record (e.g. a discharge summary) to inform the certifying physician of how the clinical findings of the face-to-face encounter support Medicare home health eligibility for that patient, the compiled documentation must be reflective of the clinical findings of that face-to-face encounter as observed by that physician caring for the patient in the acute or post-acute facility, thus serving as that physician's communication to the certifying physician. Further, if the certifying physician chooses to use the encounter documentation from the informing physician as his or her documentation of the face-to-face encounter, the certifying physician must sign and date the documentation, demonstrating that the certifying physician received that information from the physician who performed the face-to-face encounter, and that the certifying physician is using that discharge summary or documentation as his or her documentation of the face-to-face encounter. One physician signature, from the certifying physician, suffices if the face-to-face encounter documentation is co-located with the physician's certification of eligibility. Otherwise, if the face-to-face documentation is attached as an addendum to the certification (a separate document), the face-to-face documentation and certification each require a signature from the certifying physician.
- Electronic signatures are acceptable.
- Who Can Perform the Face-to-Face Encounter?
- Medicare-enrolled physicians who are also the certifying physician;
- The following physicians are allowed to perform the face-to-face encounter and inform the certifying physician:
- Physicians (Medicare-enrolled or otherwise) who cared for the patient in an acute or post-acute facility during a recent acute or post-acute stay and have privileges at the facility;
- Because residents (Medicare-enrolled or otherwise) do not have privileges at acute or post-acute facilities, if they are performing the encounter and informing the certifying physician, they must inform the certifying physician under the supervision of their teaching physician who must have such privileges.
- NPPs allowed to perform the face-to-face encounter include:
- A nurse practitioner or clinical nurse specialist working in collaboration with the certifying physician in accordance with State law;
- A certified nurse-midwife under the supervision of the certifying physician, as authorized by State law; and
- A physician assistant under the supervision of the certifying physician.
- NPPs are subject to the same financial restrictions with the home health agency as the certifying physician.
- Recertifications
- Face-to-face encounter documentation is only required for the initial certification.
- At the end of the 60-day episode, a decision must be made whether or not to recertify the patient for a subsequent 60-day episode.
Additional Information
A list of frequently asked questions is available at http://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html on the CMS website.
MLN Matters® Article #SE1038, which provides guidance for the original face-to-face implementation, is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1038.pdf on the CMS website.
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
Use an Individual NPI as the Ordering NPI when Billing Medicare for Part A Home Health Agency Services
To receive payment for home health services, any Medicare-enrolled home health agency must file claims containing the name and National Provider Identifier (NPI) of the physician who ordered the service. When billing for an ordered home health service:
- The individual physician must be enrolled in Medicare or in an opt-out status
- The NPI used for ordering must be for an individual physician (cannot be a group or organizational NPI).
- The individual physician must be of a specialist type that is eligible to order. These individuals include:
- Doctors of Medicine or Osteopathy
- Doctors of Podiatric Medicine
Failure to meet the requirements mentioned above will result in denied claims once the automatic edits are activated. For additional information, review the Medicare Learning Network's "Medicare Enrollment Guidelines for Ordering/Referring Providers" fact sheet, at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedEnroll_OrderReferProv_FactSheet_ICN906223.pdf
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