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July 2012 J15 Part B Medicare Bulletin

Posted July 2, 2012

Table of Contents

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2nd Quarter 2012 Medical Review FAQs

The following items represent a variety of questions the Medical Review department has received. At least quarterly, CGS will address "Frequently Asked Questions" related to coverage and local medical review policy issues. Providers may submit questions to CGS through the Part B Online Help Center Coverage Requirements for Blepharoplasty (LCD L31828)

Blepharoplasty
CGS has an LCD L31828 that addresses coverage for blepharoplasty. To supplement this LCD CGS has created a blepharoplasty checklist which is located on the Medical Review page of the CGS website (www.cgsmedicare.com) scroll to the bottom of the medical review page for the link titled "checklist".

Billing for Drug Screens: G0431
Effective 04/01/2010 CMS implemented a new HCPCS code for drug screening; replacing the 80101 CPT code for Medicare use. CGS claim denial analysis and appeals data indicate an ongoing issue with the use of this code.

Beginning in calendar year 2011, G0431 is defined as: drug screen, qualitative: multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter

Correct Coding for Hydration Administration
Hydration is defined as the replacement of necessary fluids via an IV infusion which consists of pre-packaged fluids and electrolytes. Hydration services are reported by using CPT codes 96360 (initial 31 minutes to 1 hour) and 96361 (each additional hour). IV fluids reported for hydration lasting 30 minutes or less is not reported using infusion codes.

For hydration services to be reported using CPT codes, the hydration services must be medically necessary. Examples of hydration services that may be medically necessary

Services that would not be considered medically necessary hydration:

Coding for Impella® Heart Device
Recently CGS Administrators Medical Review Department has seen claims billed with the unlisted code 33799 for insertion of the Impella® Heart Device.

Per the manufacturer (Abiomed), the Impella® Heart Device/ Circulatory Support System is a: minimally invasive percutaneous catheter based support device, designed to provide partial circulatory support.

The Impella® is not a ventricular assist device designed to provide transition to transplant; it is designed to assist during revascularization procedures for a short term (6-8 hours).

CGS instructs providers to use CPT code 92970 to report the insertion of the Impella® device.
Impella® procedures coded under any other CPT code will be denied as a billing error.

Modifier-25 Use with "XXX" Global Surgery Codes
CGS Administrators has recently received a large volume of questions regarding the use of modifier-25 with CPT codes having a global surgery indicator of "XXX" (for example: injection and infusion codes). Payment for a service with an "XXX" global days indicator already includes the E&M component required to provide the service. The National Correct Coding Initiative states: Payment for XXX procedures performed by physicians include the inherent pre-procedure, intra-procedure, and post-procedure work usually performed each time the procedure is completed. This work should never be reported as a separate E&M code. Other "XXX" procedures are not usually performed by a physician and have no physician work relative value units associated with them. A physician should never report a separate E&M code with these procedures for the supervision of others performing the procedure or for the interpretation of the procedure."

Based on the definition of modifier-25; the only time an E&M service would be appropriate with an XXX procedure is if the E&M is significant and separate from the XXX service provided on the same day. The E&M may be related to the same diagnosis prompting the XXX procedure but can not include any work inherent in the performance, supervision or interpretation of the XXX procedure.

Documenting Surgical Debridement Services - Measurements Matter
The correct coding of surgical debridement services (CPT 11042-11047) requires documentation of the measurement of the devitalized tissue and the depth of tissue that is removed. The measurement and documentation should be part of your standard operating procedures for surgical debridement. Establishing such a process will help you avoid claims submission errors, denials for insufficient documentation, and potential overpayments.

One common error is reporting CPT 11043 when muscle and tendon are visible, but NOT actually surgically debrided. The potential exists for similar errors to occur when bone is visible, but not documented as being part of the surgical debridement procedure. It would not be appropriate to code CPT 11043 and 11044, respectively in these instances when they involve the same wound site. It is the deepest level of tissue removed from a uniquely identifiable wound that determines the correct code.

Documentation supporting the correct use of the surgical debridement "add-on" codes 11045 – 11047 communicating that > 20 square centimeters (cms2) of tissue were surgically debrided should reflect the actual area of devitalized tissue removed and not routinely set as being equal to the total area of the wounds in question. This latter point is particularly important in Electronic Health Records (EHRs) that are capable of automating the completion of key data elements based on certain pre-populated fields. For the purposes of CPT code selection and units, the wound measurements used are the amount debrided, not the total wound size, before or after debridement. Selecting CPT codes and units based on total wound size may result in incorrect coding and reimbursement.

By accurately documenting the size of the devitalized tissue, before and after the surgical debridement, and adhering to the coding and billing rules for surgical debridement services, you help ensure that claims payment errors are prevented and that the J15 AB MAC claims payment process is kept as efficient as possible.

Proper Billing for Critical Care Requires Time Documentation
The correct coding of the critical care codes requires that time involved be measured and recorded in "the physicians progress note".
CMS Pub 100.4 Chapter 12 Section 30.6.12E includes the following instruction:

E. Critical Care Services and Physician Time

Critical care is a time-based service, and for each date and encounter entry, the physician's progress note(s) shall document the total time that critical care services were provided.

F. Hours and Days of Critical Care that May Be Billed Critical care of less than 30 minutes total duration on a given calendar date is not reported separately using the critical care codes. This service should be reported using another appropriate E/M code such as subsequent hospital care.

The actual document is available at this web link:
Critical Care Billing

Signature Requirements Reminder
Consequences and Resolutions of missing or inappropriate signatures:

Internet Only Manuals (IOM) 100-08 Program Integrity Manual, Chapter 3 Section: 3.3.2.4

Documentation
There has been an increase in the number of errors found during a Comprehensive Error Rate Testing (CERT) review involving missing or insufficient documentation. To help assure that you are properly paid for the work you have done for Medicare patients here are a few things to remember:


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A Physician's Guide to Medicare's Home Health Certification, including the Face-to-Face Encounter - SE1219

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

News Flash –In response to shortage of liposomal doxorubicin (Doxil), the Food and Drug Administration is permitting the temporary importation of Lipodox, a brand of liposomal doxorubicin hydrochloride; visit http://www.FDA.gov/NewsEvents/Newsroom/PressAnnouncements/ucm292658.htm for additional information. The CMS HCPCS Quarterly Update includes two new codes (Q2048 and Q2049) for liposomal doxorubicin that will become effective Sun July 1. The code descriptors are worded in a manner that distinguishes Lipodox and Doxil. As of Sun July 1, HCPCS code J9001 will not be used for Medicare billing. CMS will release a Change Request (CR) with additional instructions in the near future.

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

  1. Requirements which must be met in order for a patient to qualify for Medicare's home health benefit.

The patient must:

2. Physician Home Health Certification Requirements

3. Timeframe for completion of the certification

4. Certification Content Requirements
The physician must certify that:

5. Face-to-Face Requirements

6. Face-to-Face Documentation Requirements

7. Who Can Perform the Face-to-Face Encounter?

8. Recertifications

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 your carrier or Medicare Administrative Contractor at their toll-free number, which may be found at http://www.cms.gov/Outreach-and-Education/Medicare-Learning- Network-MLN/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website.

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CGS J-15 A/B MAC to no longer require the use of the – JW modifier to track drug wastage

Based upon cooperative feedback from the provider community, CGS Administrators is rescinding the requirement to use the –JW modifier for the purpose of tracking drug wastage effective 01 June 2012. Providers are required to maintain documents that clearly show wastage and these documents must be provided when requested by any Medicare auditor or the HHS-OIG.

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CGS retirement of Local Coverage Determinations

Effective May 31, 2012 CGS is retiring the following Local Coverage Determinations for the states of Kentucky and Ohio. CGS will continue to monitor utilization for medical necessity but based on utilization data a Local Coverage Determination is no longer needed at this time.

LCD# - LCD Title
L31869 - Extracorporeal Shock Wave Therapy (ESWT) For Musculoskeletal Indications
L31874 - Infared Coagulation (IRC) of Hemorrhoids
L31875 - Intermittent Inotropic Infusion for the Treatment of Chronic Heart Failure in an Outpatient Setting
L31866 - Erectile Dysfunction, Evaluation and Treatment

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Coding for Impella® Heart Device

Recently CGS Administrators Medical Review Department has seen claims billed with the unlisted code 33799 for insertion of the Impella® Heart Device.

Per the manufacturer (Abiomed), the Impella® Heart Device/ Circulatory Support System is a: minimally invasive percutaneous catheter based support device, designed to provide partial circulatory support. The Impella® is not a ventricular assist device designed to provide transition to transplant; it is designed to assist during revascularization procedures for a short term (6-8 hours).

Because of the difference between circulatory transitional devices meeting the CPT code definition of 33975 (insertion of ventricular assist device, extracorporeal, single ventricle) and the short term use design of the Impella® device, CGS instructs providers to use CPT code 92970 to report the insertion of the Impella® device.

Impella® procedures coded under any other CPT code will be denied as a billing error.

Due to the short term nature of the Impella® device; there is no separate reimbursement for removal. The work associated with the removal is bundled into the fee schedule allowance for 92970; cardio assist-method of circulatory assist; internal.

Remember to accurately code the cardiac catheterization procedure performed and any other procedure (such as an angioplasty or stenting) performed during the same operative session.

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Correct Coding for Hydration Administration

Adapted from the AHA Coding Clinic, Volume 12; Number 1; First Quarter 2012

Hydration is defined as the replacement of necessary fluids via an IV infusion which consists of pre-packaged fluids and electrolytes. Hydration services are reported by using CPT codes 96360 (initial 31 minutes to 1 hour) and 96361 (each additional hour). IV fluids reported for hydration lasting 30 minutes or less is not reported using infusion codes.

For hydration services to be reported using CPT codes, the hydration services must be medically necessary. Examples of hydration services that may be medically necessary

Clinical Scenarios

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Documenting Surgical Debridement Services – Measurements Matter

The correct coding of surgical debridement services (CPT 11042-11047) requires documentation of both the measurement of the wound surface (devitalized tissue) area after debridement and the depth of tissue that is removed. The measurement and documentation should be part of your standard operating procedures for surgical debridement. Establishing such a process will help you avoid claims submission errors, denials for insufficient documentation, and potential overpayments.

One common error is reporting CPT 11043 when muscle and tendon are visible, but NOT actually surgically debrided. The potential exists for similar errors to occur when bone is visible, but not documented as being part of the surgical debridement procedure. It would not be appropriate to code CPT 11043 and 11044, respectively in these instances when they involve the same wound site. It is the deepest level of tissue removed from a uniquely identifiable wound that determines the correct code.

Documentation supporting the correct use of the surgical debridement "add-on" codes 11045 – 11047 communicating that > 20 square centimeters (cms2) of tissue were surgically debrided should reflect the actual area of devitalized tissue removed and not routinely set as being equal to the total area of the wounds in question. This latter point is particularly important in Electronic Health Records (EHRs) that are capable of automating the completion of key data elements based on certain pre-populated fields. For the purposes of CPT code selection and units, the wound measurements used are the amount debrided, not the total wound size, before or after debridement. Selecting CPT codes and units based on total wound size may result in incorrect coding and reimbursement.

By accurately documenting the size of the devitalized tissue, before and after the surgical debridement, and adhering to the coding and billing rules for surgical debridement services, you help ensure that claims payment errors are prevented and that the J15 AB MAC claims payment process is kept as efficient as possible.

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Evaluation and Management Services (E&M)

Established Patients and Requirements of Key Elements

Recently Medical Review at CGS has received questions concerning the requirements for the key elements (history, physical exam, and medical decision making) for E&M services involving an established patient. Discussion around the requirement of a physical exam has prompted the need for clarification of documentation requirements.

Per the CPT E&M parenthetical guidelines: "The first three components (under the service descriptors-defining the seven components used to determine level of E&M)-history, examination, and medical decision making; should be considered the key components in selecting the level of E&M services." Also in this section CPT states: for the categories and subcategories of established E&M codes "two of the three key components (history, exam, and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of E/M services; established..."

In the above citations, the requirements are "two of three requirements must meet or exceed"; meaning the components must all be present but one may be below the requirement described in the level description. CGS does not interpret this to mean one may be absent-on the contrary-in reviewing documentation and meeting medical necessity requirements it would be hard to establish medical decision making without an exam of some type. Medical decision making (at any level) refers to the complexity of establishing a diagnosis and/or selecting a management option. Without an exam, it would be difficult to establish the need for medical decision making above and beyond a 99211.

In support of this requirement, CPT and CMS indicate E&M code selection requires the inclusion of face-to-face services. CPT defines professional services as: those face-to-face services rendered by a physician (or non-physician practitioner-NPP) and reported by a specific E&M code. CMS publication 100-04 Claims Processing Manual Ch. 12 Section 30 refers to E&M services as those "face-to-face" services provided by a physician or NPP. For E&M services provided above the level of 99211, face-to-face time must be provided by the physician or non-physician practitioner.

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Health Care Provider Taxonomy Code Set

Under HIPAA code sets that characterize a general administrative situation rather than a medical condition or service are referred to as non-clinical or non- medical code sets. The Provider Taxonomy code set is an external non-medical data code set designed for use in classifying health care providers according to provider type or practitioner specialty in an electronic environment specifically within the American National Standards Institute (ANSI) Accredited Standards Committee (ASC) health care transaction.

The Health Care Provider Taxonomy Code (HPTC) is not required. However, if a HPTC is submitted it must be valid data from that code set. The HPTC is a named code set in the 837 professional implementation guide thus carriers must validate the inbound taxonomy codes against their internal HPTC tables.

The HPTCs are updated twice per year in April and October. The summary of changes is noted in the table below
TYPE OF CHANGE PROVIDER TAXONOMY VALUE CODE
New Codes (added 1/1/2012, effective 4/1/2012)
  • 207VF0040X
  • 2084B0040X
  • 2088F0040X
Revisions There were no revisions to the code sets for this update.

The HPTC code list is available from the National Uniform Claim Committee website: http://www.nucc.org/index.php?option=com_content&task=view&id=22&Itemid=41

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LCD for Polysomnography & Sleep Studies Revised

Effective July 1, 2011 the CGS Polysomnography & Sleep Studies LCD for KY & OH (L31855) has been revised to include the following information under the ‘Indications and Limitations' section; ‘Other Comments'; 5th paragraph (3rd bullet point) and 6th paragraph:

HST scoring must be performed by an individual certified by the Board of Registered Polysomnographic Technologists as a Registered Polysomnographic Technologist (RPSGT), or equivalent, or by a polysomnographic technician under the supervision of a RPSGT, or equivalent. RPSGTs and polysomnographic technicians must meet the standards for such individuals promulgated by the American Academy of Sleep Medicine Standards for Accreditation of Laboratories for Sleep Related Breathing Disorders, or by the Accreditation Commission for Health Care, Inc. Standards for Accreditation for Sleep Programs, and be licensed or certified by the state in which they practice, if such licensure or certification exists. The laboratory physician must review the entire raw data recording for every patient studied.

Please refer to the CGS Web site at:
http://www.cgsmedicare.com to view the policy.

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MM7260 - Modification to CWF, FISS, MCS and VMS to Return Submitted Information When There is a CWF Name and HIC Number Mismatch

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

News Flash:
REVISED product from the Medicare Learning Network® (MLN)
"CMS Website Wheel," Educational Tool, ICN 006212, Hard Copy.

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 or 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:

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 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 Centers for Medicare & Medicaid Services (CMS) website.

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

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MM7355 - Clarification of Medicare Conditional Payment Policy and Billing Procedures for Liability, No-Fault and Workers'
Compensation (WC) Medicare Secondary Payer (MSP) Claims

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

News Flash – Medicare is denying an increasing number of claims, because providers are not identifying, nor sending claims to, 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," Chapters 1, 3, and 5 and MLN Matters® Article SE1217 for additional guidance.

Clarification of Medicare Conditional Payment Policy and Billing Procedures for Liability, No-Fault and Workers' Compensation (WC) Medicare Secondary Payer (MSP) Claims

Note: This article was revised on May 30, 2012, to reflect the revised CR7355 issued on May 25. In the article, the CR release date, transmittal number, effective and implementation dates (see above), and the Web address for accessing CR7355 were revised. All other information is the same.

Provider Types Affected
This MLN Matters® article is intended for physicians, hospitals, Home Health Agencies, and other providers who bill Medicare Carriers, Fiscal Intermediaries (FIs) or Medicare Administrative Contractors (A/B/MACs); and suppliers who bill Durable Medical Equipment MACs (DME MACs) for Medicare beneficiary liability insurance (including self insurance), no-fault insurance, and WC
Medicare Second Payer (MSP) claims.

Provider Action Needed
This article provides clarifications in the procedures for processing liability insurance (including self- insurance), no-fault insurance and WC Medicare Secondary Payer (MSP) claims. Not following the procedures identified in this article may impact your reimbursement. Change Request (CR) 7355, from which this article is taken, clarifies the procedures you are to follow when billing Medicare for liability insurance (including self-insurance), no-fault insurance, or WC claims, when the liability insurance (including self-insurance), no-fault insurance, or WC carrier does not make prompt payment. It also includes definitions of the promptly payment rules and how contractors will identify conditional payment requests on MSP claims received from you. You should make sure that your billing staffs are aware of these Medicare instructions.

Background

CR7355, from which this article is taken: 1) Clarifies the procedures to follow when submitting liability insurance (including self-insurance), no-fault insurance and WC claims when the liability insurer (including self-insurance), no-fault insurer and WC carrier does not make prompt payment or cannot reasonably be expected to make prompt payment; 2) Defines the promptly payment rules; and 3) Instructs you how to submit liability insurance (including self-insurance), no-fault insurance and WC claims to your Medicare contractors when requesting Medicare conditional payments on these types of MSP claims.

The term Group Health Plan (GHP) as related to this MLN article means health insurance coverage that is provided by an employer to a Medicare beneficiary based on a beneficiary's own, or family member's, current employment status. The term Non-GHP means coverage provided by a liability insurer (including self-insurance), no-fault insurer and WC carrier where the insurer covers for services related to the applicable accident or injury.

Key Points

Conditional Medicare Payment Procedures

Medicare may not make payment on a MSP claim where payment has been made or can reasonably be expected to be made by GHPs, a WC law or plan, liability insurance (including self-insurance), or no-fault insurance.

Medicare can make conditional payments for both Part A and Part B WC, or no-fault, or liability insurance (including self insurance) claims if payment has not been made or cannot be reasonably expected to be made by the WC, or no-fault, or liability insurance claims (including self insurance) and the promptly period has expired. Note: If there is a primary GHP, Medicare may not pay conditionally on the liability, no-fault, or WC claim if the claim is not billed to the GHP first. The GHP insurer must be billed first and the primary payer payment information must appear on the claim submitted to Medicare.

These payments are made "on condition" that the trust fund will be reimbursed if it is demonstrated that WC, no-fault, or liability insurance is (or was) responsible for making primary payment (as demonstrated by a judgment; a payment conditioned upon the recipient's compromise, waiver, or release [whether or not there is a determination or admission of liability for payment for items or services included in a claim against the primary payer or the primary payer's insured]; or by other means).

"Promptly" Definition

No-fault Insurance and WC "Promptly" Definition
For no-fault insurance and WC, promptly means payment within 120 days after receipt of the claim
(for specific items and services) by the no-fault insurance or WC carrier. In the absence of evidence to the contrary, the date of service for specific items and service must be treated as the claim date when determining the promptly period. Further with respect to inpatient services, in the absence of evidence to the contrary, the date of discharge must be treated as the date of service when determining the promptly period.

Liability Insurance "Promptly" Definition
For liability insurance (including self-insurance), promptly means payment within 120 days after the earlier of the following:

The "Medicare Secondary Payer (MSP) Manual" (http://www.cms.gov/manuals/downloads/msp105c01.pdf), Chapter 1 (Background and Overview), Section 20 (Definitions), provides the definition of promptly (with respect to liability, no-fault, and WC) which all Medicare contractors must follow.

Note: For the liability situation, the MSP auxiliary record is usually posted to the Medicare's Common Working File (CWF) after the beneficiary files a claim against the alleged tortfeasor (the one who committed the tort (civil wrong)) and the associated liability insurance (including self-insurance). In the absence of evidence to the contrary, the date the general liability claim is filed against the liability insurance (including self-insurance) is no later than the date that the record was posted on Medicare's CWF. Therefore, for the purposes of determining the promptly period, Medicare contractors consider the date the Liability record was created on Medicare's CWF to be the date the general liability claim was filed.

How to Request a Conditional Payment
The following summarizes the technical procedures that Part A, and Part B and supplier contractors will use to identify providers' conditional payment requests on MSP claims.

Part A Conditional Payment Requests

Providers of Part A services can request conditional non-GHP payments from Part A contractors on the hardcopy Form CMS-1450, if you have permission from Medicare to bill hardcopy claims, or the 837 Institutional Electronic Claim, using the appropriate insurance value code (i.e., value code 14, 15 or 47) and zero as the value amount. Again, you must bill the non-GHP insurer, and the GHP insurer, if the beneficiary belongs to an employer group health plan, first before billing Medicare.

For hardcopy (CMS-1450) claims, Providers must identify the other payer's identity on line A of Form Locator (FL) 50, the identifying information about the insured is shown on line A of FL 58-65, and the address of the insured is shown in FL38 or Remarks (FL 80). All primary payer amounts and appropriate codes must appear on your claim submitted to Medicare.

For 837 Institutional Claims, Providers must provide the primary payer's zero value code paid amount and occurrence code in the 2300 HI. (The appropriate Occurrence code (2300 HI), coupled with the zeroed paid amount and MSP value code (2300 HI), must be used in billing situations where you attempted to bill a primary payer in non-GHP (i.e., Liability, no-fault and Workers' Compensation) situations, but the primary payer did not make a payment in the promptly period). Note: Beginning July 1, 2012 Medicare contractors will no longer be accepting 4010 claims; Providers must submit claims in the 5010 format beginning on this date.

Table 1 displays the required information of the electronic claim in which a Part A provider is requesting conditional payments.

Table 1 - Data Requirements for Conditional Payment for Part A Electronic Claims
Type of
Insurance
CAS Part A Value
Code (2300 HI)
Value Amount (2300 HI) Occurrence Code
(2300 HI)
Condition Code
(2300 HI)
No- Fault/Liability 2320 - valid
information why NGHP or GHP did not make payment
14 or 47 $0 01-Auto Accident &
Date
02-No-fault
Insurance Involved & Date
24 – Date Insurance
Denied
 
WC 2320 - valid
information why NGHP or GHP did not make payment
15 $0 04-Accident/Tort
Liability & Date
24 – Date Insurance
Denied
02-Condition is
Employment
Related

Part B Conditional Payment Requests (Table 2)
Since the electronic Part B claim (837 4010 professional claim) does not contain Value Codes or Condition Codes, the physician or supplier must complete the: 1) 2320AMT02 = $0 if the entire claim is a non-GHP claim and conditional payment is being requested for the entire claim; or 2) 2430 SVD02 for line level conditional payment requests if the claim also contains other service line activity not related to the accident or injury, so that the contractor can determine if conditional payment should be granted for Part B services related to the accident or injury.

For Version 4010, Physicians and other suppliers may include CP- Medicare Conditionally Primary, AP-auto insurance policy, or OT- other in the 2320 SBR05 field. The 2320 SBR09 may contain the claim filing indicator code of AM - automobile medical, LI - Liability, LM - Liability Medical or WC - Workers' Compensation Health Claim. Any one of these claim filing indicators are acceptable for the non-GHP MSP claim types.

The 2300 DTP identifies the date of the accident with appropriate value. The "accident related causes code" is found in 2300 CLM 11-1 through CLM 11-3. Note: Beginning July 1, 2012 Medicare contractors will no longer accept 4010 claims; Providers must submit claims in the 5010 format beginning on this date.

Table 2 displays the required information for a MSP 4010 Professional in which a physician/supplier is requesting conditional payments.

Table 2 - Data Requirements for Conditional Payments for MSP 4010 Professional Claims
Type of
Insurance
CAS Insurance
Type Code
(2320
SBR05)
Claim Filing
Indicator
(2320
SBR09)
Paid Amount
(2320 AMT or
2430 SVD02)
Insurance
Type Code (2000B SBR05)
Date of Accident
No- Fault/Liability 2320 or 2430 valid
information why
NGHP or GHP did not make payment
AP or CP AM, LI, or
LM
$0.00 14 2300 DTP 01 through 03 and 2300 CLM 11-1
through 11-3 with value
AA, AP or OA
WC 2320 or 2430 valid
information why
NGHP or GHP did not make payment
OT WC $0.00 15 2300 DTP 01 through 03 and 2300 CLM 11-1
through or 11-3 with value
EM

Please note that for 837 5010 Professional claims, the insurance codes changed and the acceptable information for Medicare conditional payment request is modified as displayed in Table 3.

Table 3 Data Requirements for Conditional Payment for 837 5010 Professional Claims
Type of
Insurance
CAS InsuranceType Code2320 SBR05 from previous payer(s) Claim Filing
Indicator (2320
SBR09)
Paid Amount
(2320 AMT or2430 SVD02)
Condition Code
(2300 HI)
Date of
Accident
No-
Fault/Liability
2320 or 2430 –
valid information why NGHP or GHP did not make payment
14 / 47 AM or LM $0.00   2300 DTP 01 through 03 and
2300 CLM 11-1 through 11-3 with value AA or OA
WC 2320 or 2430 –
valid information why NGHP or GHP did not make payment
15 WC $0.00 02-Condition is Employment
Related
2300 DTP 01 through 03 and 2300 CLM 11-1 through or 11-3 with value EM

Note: Medicare beneficiaries are not required to file a claim with a liability insurer or required to cooperate with a provider in filing such a claim, but they are required to cooperate in the filing of no- fault claims. If the beneficiary refuses to cooperate in filing of no-fault claims Medicare does not pay.

Situations Where a Conditional Payment Can be Made for No-Fault and WC Claims

Conditional payments for claims for specific items and service may be paid by Medicare where the following conditions are met:

Note: When a conditional payment is made to you, Medicare contractors will use Remittance Advice
Remark Code M32 to indicate a conditional payment is being made.

Situations Where a Conditional Payment Can be Made for Liability (includingSelf Insurance) Claims

Conditional payments for claims for specific items and service may be paid by Medicare where the following conditions are met:

Conditional Primary Medicare Benefits Paid When a GHP is a Primary Payer toMedicare

Conditional primary Medicare benefits may be paid if the beneficiary has GHP coverage primary to
Medicare and the following conditions are NOT present:

Situations Where Conditional Payment is Denied

Liability, No-Fault, or WC Claims Denied

  1. Medicare will deny claims when:
  1. Medicare will deny claims when:

Denial Codes
To indicate that claims were denied by Medicare because the claim was not submitted to the appropriate primary GHP for payment, Medicare contractors will use the following codes on the remittance advice sent to you:

Additional Information
You can find official instruction, CR7355, issued to your carrier, FI, RHHI, A/B MAC, or DME MAC by visiting http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R86MSP.pdf on the CMS website.

You will find the following revised Chapters of the "Medicare Secondary Payer Manual," as an attachment to that CR:

Chapter 1 (Background and Overview):

Chapter 3 (MSP Provider, Physician, and Other Supplier Billing Requirements):

Chapter 5 (Contractor Prepayment Processing Requirements):

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MM7629 - Handling Misdirected Claims for Part B Items and Services

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

News Flash – 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

Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers who bill Medicare carriers, Part A/B Medicare Administrative Contractors (A/B MACs) and Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for services provided to Medicare beneficiaries.

Provider Action Needed

STOP – Impact to You
Your misdirected claims for Part B items and services (those that you send to the wrong Medicare contractor) will be returned as unprocessable.

CAUTION – What You Need to Know
Change Request (CR) 7629, from which this article is taken, announces that effective July 20, 2012, your carrier or A/B MAC will return all misdirected claims as unprocessable; and your DME MAC will similarly return claims that should have been sent to a carrier or B MAC, as well as paper claims as that are sent to the wrong DME MAC.

GO – What You Need to Do
You should make sure that claims are submitted to the correct carrier, A/B MAC, or DME MAC. See the Background section for details.

Background
A "misdirected claim" is a claim that you submit to the wrong carrier, A/B MAC, or DME MAC. As each Fee-For-Service (FFS) claims administration contractor is assigned a specific geographic and subject matter jurisdiction for claims processing, you must submit your claims to the one having the appropriate jurisdiction.

Carriers and A/B MACs previously returned as unprocessible assigned claims for Part B items and services that were sent to the wrong carrier or A/B MAC, and denied such claims that were unassigned; and DME MACs denied paper claims if sent to the wrong DME MAC.

CR7629, from which this article is taken, implements new instructions on handling misdirected claims. Misdirected Carrier and A/B MAC Claims
With implementation of CR7629, carriers and A/B MACs will return all misdirected claims as unprocessable, regardless of their unassigned/assigned status. This includes: Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) claims that are appropriately billable to a A/B MAC or carrier, but are billed to the wrong one; and Misfiled claims for United Mine Workers of America (UMWA) and Railroad Beneficiaries (RRB) beneficiaries.

Specifically, when it receives a claim for Medicare payment for items/services that have been furnished outside of its payment jurisdiction (other than for RRB and UMWA beneficiaries), your Part A/B MAC or carrier will return it as unprocessable; using the following messages:

Note: These remittance and remark code messages remain the same, and Medicare Summary Notice messages have been removed.

Similarly, effective for claims received on and after July 20, 2012, when it receives a claim for Medicare payment for items or services that are in a DME MAC's payment jurisdiction (other than for RRB and UMWA beneficiaries), your A/B MAC or carrier will return it as unprocessable, using the same messages.

Additionally, while DME MACs will continue to follow existing procedures for misdirected beneficiary- submitted claims (CMS Form 1490S) and electronic claims; effective with implementation of CR7629, a paper claim (Form CMS -1500), sent to the wrong DME MAC will be returned as unprocessable, using the same messages.

Misdirected Railroad Beneficiaries (RRB) Beneficiary Claims
Effective July 20, 2012, when it receives a claim for an RRB beneficiary (and therefore should be processed by the RRB contractor), your carrier, A/B MAC, or DME MAC will return it as unprocessable using the following messages:

United Mine Workers of America (UMWA) Beneficiary Claims
Effective July 20, 2012, when it receives a claim for Medicare payment that should be processed by the UMWA, your carrier, A/B MAC, or DME MAC will return it as unprocessable using the following messages:

Please note that this new guidance does not apply to:

Additional Information
You can find the official instruction, CR7629, issued to your carrier, A/ B MAC, or DME MAC by visiting http://www.cms.hhs.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2474CP.pdf on the CMS website.

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

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MM7822 - July Quarterly Update for 2012 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

News Flash – 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, and MLN Matters® Article SE1217 for additional guidance.

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 Durable Medical Equipment, Prosthetics Orthotics, and Supplies (DMEPOS) items or services paid under the DMEPOS fee schedule.

Provider Action Needed
This article is based on Change Request (CR) 7822 and alerts providers and suppliers that the Centers for Medicare & Medicaid Services (CMS) issued instructions updating the DMEPOS fee schedule payment amounts. Be sure your billing staffs are aware of these changes.

Note: Claims for codes L6715 and L6880 with dates of service on or after January 1, 2012, that were previously processed, will be adjusted to reflect the newly established fees if you bring those claims to your contractor's attention.

Background
The DMEPOS fee schedules are updated on a quarterly basis, when necessary, in order to implement fee schedule amounts for new codes and to revise any fee schedule amounts for existing codes that were calculated in error. The quarterly update process for the DMEPOS fee schedule is documented in the "Medicare Claims Processing Manual," Chapter 23, Section 60 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf on CMS website.

Key Points of CR7822
Healthcare Common Procedure Coding System (HCPCS) codes L6715 and L6880 were added to the HCPCS file effective January 1, 2012. The fee schedule amounts for the aforementioned HCPCS codes are established as part of this update and are effective for claims with dates of service on or after January 1, 2012. These items were paid on a local fee schedule basis prior to implementation of the fee schedule amounts established in accordance with this update. Claims for codes L6715 and L6880 with dates of service on or after January 1, 2012, that have already been processed, may be adjusted to reflect the newly established fees if you bring those claims to your contractor's attention.

Per CR7679, the claims filling jurisdiction for the following HCPCS codes is changed from DME MAC to joint local carrier and DME MAC jurisdiction, effective January 1, 2012:

Additional Information
The official instruction, CR7822 issued to your FI, RHHI, A/B MAC, and DME/MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2467CP.pdf on the CMS website. If you have any questions, please contact your FI, RHHI, A/B MAC, or DME MAC at their toll-free number, which may be found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website.

Current and past DMEPOS Fee schedules can be viewed at https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html on the CMS website.

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MM7831 - Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - July 2012 Update

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

News Flash – Now Available!! The Medicare Billing Certificate Programs for Part A and Part B Providers. Learn about the Medicare Program and the specifics for your provider type with a special focus on Medicare billing, and receive a certificate in Medicare billing from CMS for successful completion of the program. Successful completion consists of completion of all required web-based training courses, required readings, and a 75-percent or higher score on the post-assessment. To participate in either the Part A or Part B provider type program, visit http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/index.htmland click on ‘Web-Based Training Modules' under ‘Related Links Inside CMS.'

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 or DME MACs) for services provided to Medicare beneficiaries.

Provider Action Needed
CR7831 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. CR7831 describes the Centers for Medicare & Medicaid Services (CMS) process for updating specific HCPCS codes.

Key Points of CR7831

Effective for claims with dates of service on or after July 1, 2012, the following HCPCS codes will no longer be payable for Medicare:
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)

Effective for claims with dates of service on or after July 1, 2012, the following HCPCS codes will be payable for Medicare:
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 your Medicare contractor at their toll-free number, which may be found at http://www.cms.hhs.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website.

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MM7834 - Modifying the Timely Filing Exceptions on Retroactive Medicare Entitlement and Retroactive Medicare Entitlement Involving State Medicaid Agencies

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

News Flash – In 2009, CMS implemented the Electronic Prescribing (eRx) Incentive Program, which is a program that uses incentive payments and payment adjustments to encourage the use of qualified electronic prescribing systems. From calendar year (CY) 2012 through 2014, a payment adjustment that increases each calendar year will be applied to an eligible professional's Medicare Part B Physician Fee Schedule (PFS) covered professional services for not becoming a successful electronic prescriber. The payment adjustment of 1.0 percent in 2012, 1.5 percent in 2013, and 2.0 percent in 2014 will result in an eligible professional or group practice participating in the eRx Group Practice Reporting Option (eRx GPRO) receiving 99.0 percent, 98.5 percent, and 98.0 percent respectively of their Medicare Part B Physician Fee Schedule (PFS) amount for covered professional services. CMS may exempt individual eligible professionals and group practices participating in eRx GPRO from the 2013 eRx payment adjustment if it is determined that compliance with the requirements for becoming a successful electronic prescriber would result in a significant hardship. To request a significant hardship, individual eligible professionals and group practices participating in eRx GPRO must submit their significant hardship exemption requests through the Quality Reporting Communication Support Page (Communications Support Page) on or between March 1 and June 30, 2012.

Modifying the Timely Filing Exceptions on Retroactive Medicare Entitlement
and Retroactive Medicare Entitlement Involving State Medicaid Agencies

Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs), carriers, A/B Medicare Administrative Contractors (MACs), and Durable Medical Equipment MACs for services provided to Medicare beneficiaries.

What You Need to Know
This article is based on Change Request (CR) 7834, which advises you that the Centers for Medicare& Medicaid Services (CMS) is revising the "Medicare Claims Processing Manual" to specify that, if a provider, supplier, or beneficiary is unable to provide the Medicare contractor with an official Social Security Administration (SSA) letter, the contractor must check the Common Working File (CWF) database in order to verify a beneficiary's retroactive Medicare entitlement date. Be sure that your staffs are aware of this change.

Background
The Medicare regulations at 42 Code of Federal Regulations (CFR), Section 424.44, specify the time limits for filing Part A and Part B Fee-For-Service claims. Section 424.44 also identifies certain exceptions to the claims filing time limit. If the requirements for satisfying a timely filing exception are met, an extension to file the claims may be granted.

Section 6404 of the Affordable Care Act reduced the maximum period for the submission of all Medicare Fee-For-Service claims to no more than 12 months, or one calendar year, after the date a service is furnished. Section 6404 also gave the Secretary of Health and Human Services the authority to create exceptions to the 12 month timely filing limit. As a result of this legislation, revisions were made to the timely filing regulations at 42 CFR, Section 424.44, and the relevant internet-only manual sections. (See Transmittal 2140/Change Request 7270, published on January 21, 2011, available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads//R2140CP.pdf, on the CMS website.)

The "Medicare Claims Processing Manual" currently requires that, in order to be granted a timely filing extension, the provider, supplier, or beneficiary must furnish an official letter from the SSA to the beneficiary in order to meet one of the conditions that the beneficiary was retroactively entitled to Medicare on or before the date of the furnished service. The purpose of CR 7834 is to revise sections 70.7, 70.7.2, and 70.7.3 of the manual to specify that, if an official SSA letter to the beneficiary is not submitted, Medicare contractors must check the CWF database and may interpret the CWF data in order to verify that the beneficiary was retroactively entitled to Medicare on or before the date of the furnished service.

Consequently, CR 7834 requires the Medicare contractors to accept the SSA letter or, in the absence of such letter, to check the CWF database for a beneficiary's date of Medicare entitlement. Contractors may interpret the CWF data in order to verify retroactive Medicare entitlement that may permit a claim to be processed after the 12 month timely filing limit.

Additional Information
The official instruction, CR7834, issued to your FI, RHHI, carrier, A/B MAC, and DME MAC regarding this change, may be viewed at http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2477CP.pdf on the CMS website.

If you have any questions, please contact your Medicare contractor at their toll-free number, which may be found at http://www.cms.hhs.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website.

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MM7854 - July 2012 Update of the Ambulatory Surgical Center (ASC) Payment System

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

News Flash – 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.

Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to Medicare contractors (carriers and A/B Medicare Administrative Contractors (MACs)) for services to Medicare beneficiaries.

Provider Action Needed

This article is based on Change Request (CR) 7854 which informs Medicare contractors about the changes to and billing instructions for various payment policies implemented in the July 2012 Ambulatory Surgical Center (ASC) update. CR7854 applies to chapter 14, section 10 of the Medicare Claims Processing Manual. Make sure that your billing staffs are aware of these changes. See the Background and Additional Information Sections of this article for further details regarding these changes.

Background

  1. New Category III CPT Codes that are Separately Payable Under the ASC Payment System Effective July 1, 2012

    The American Medical Association (AMA) releases Category III Current Procedural Terminology (CPT) codes in January, for implementation beginning the following July, and in July, for implementation beginning the following January. The mid-year implementation of category III CPT codes in ASCs began with the implementation of the revised ASC payment system in January 2008.

    For the July 2012 quarterly update, the Centers for Medicare & Medicaid Services (CMS) is implementing seven (7) Category III CPT codes that the AMA released in January 2012 for implementation on July 1, 2012. Five (5) of the seven (7) Category III CPT codes are separately payable under the ASC payment system. The Category III CPT codes and payment indicators are shown in Table 1 below. The payment rates, effective July 1, 2012, will be included in the July 2012 update of the ASC Payment system Addendum AA, which will be posted at http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/ASCPayment/11_Addenda_Updates.html and also in the July 2012 Ambulatory Surgical Center Fee Schedule (ASCFS) file.
Table 1 - Category III CPT Codes Implemented as of July 1, 2012
CPT Code Long Descriptor Short Descriptor ASC Payment Indicator (PI)
0302T Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation when performed and intra-operative interrogation and programming when performed; complete system (includes device and electrode) Icar ischm mntrng sys compl J8
0303T Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation when performed and intra-operative interrogation and programming when performed; electrode only Icar ischm mntrng sys eltrd G2
0304T Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation when performed and intra-operative interrogation and programming when performed; device only Icar ischm mntrng sys device J8
0307T Removal of intracardiac ischemia monitoring device Rmvl icar ischm mntrng dvce G2
0308T* Insertion of ocular telescope prosthesis including removal of crystalline lens Insj ocular telescope prosth G2

*Healthcare Common Procedure Coding System (HCPCS) code C9732 (Insertion of ocular telescope prosthesis including removal of crystalline lens) was deleted June 30, 2012, and replaced with CPT code 0308T effective July 1, 2012.

2. Instructions for Device Pass-Through Category C1840
Effective July1, 2012, device pass-through category C1840 must be billed with CPT code 0308T (Insertion of ocular telescope prosthesis including removal of crystalline lens) to receive pass-through payment, because C9732 is deleted effective June 30, 2012, and replaced with CPT code 0308T. The ASC Code Pair File will be revised for the July 2012 update to reflect this change.

3. Billing for Drugs, Biologicals, and Radiopharmaceuticals
a. Drugs and Biologicals with Payments Based on Average Sales Price (ASP) Effective July 1, 2012
Payment for separately payable drugs and biologicals based on the Average Sales Prices (ASPs) are updated on a quarterly basis as later quarter ASP submissions become available. In cases where adjustments to payment rates are necessary based on the most recent ASP submissions, we will incorporate changes to the payment rates in the July 2012 release of the ASC DRUG file. The updated payment rates, effective July 1, 2012, will be included in the July 2012 update of the ASC Payment system Addendum BB, which will be posted at http://www.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html on the CMS website.

b. New HCPCS Codes for Drugs and Biologicals Separately Payable under the ASC Payment System Effective July 1, 2012
Two drugs and biologicals have been granted ASC payment status effective July 1, 2012. These items, along with their descriptors and APC assignments, are identified in Table 2 below.

Table 2 – New Separately Payable Drugs and Biologicals Effective July 1, 2012
HCPCS Code Long Descriptor Short Descriptor ASC PI
C9368* Grafix core, per square centimeter Grafix core K2
C9369* Grafix prime, per square centimeter Grafix prime K2

NOTE: The HCPCS codes identified with an "*" indicate that these are new codes effective July 1, 2012.

c. New HCPCS Codes Effective July 1, 2012, for Separately Payable Drugs andBiologicals

Six (6) new HCPCS codes have been created for reporting certain drugs and biologicals (other than new pass-through drugs and biologicals listed above in Table 2) in the ASC payment system effective for services furnished on or after July 1, 2012. Five (5) of the six (6) HCPCS codes are separately payable under the ASC payment system. These codes are listed in Table 3 below and will be included in the July 2012 update of the ASC payment system Addendum BB which will be posted on the CMS web site and also in the July 2012 ASCFS file.

Table 3 -- New HCPCS Codes for Certain Drugs and Biologicals Effective July 1, 2012
HCPCS Code Long Descriptor Short Descriptor ASC PI
Q2045* Injection, human fibrinogen concentrate, 1 mg Human fibrinogen conc inj K2
Q2046** Injection, aflibercept, 1 mg Aflibercept injection K2
Q2048*** Injection, doxorubicin hydrochloride, liposomal, doxil, 10 mg Doxil injection K2
Q2049 Injection, doxorubicin hydrochloride, liposomal, imported lipodox, 10 mg Imported Lipodox inj K2
Q2034 Influenza virus vaccine, split virus, for intramuscular use (Agriflu) Agriflu vaccine L1

* Level II HCPCS code J1680 (Injection, human fibrinogen concentrate, 100 mg) will be replaced with HCPCS code Q2045 effective July 1, 2012. The ASC payment indicator for HCPCS code J1680 will change to E5, "Not payable by Medicare," effective July 1, 2012.

**Level II HCPCS code C9291 (Injection, aflibercept, 2 mg vial) will be deleted June 30, 2012, and replaced with HCPCS code Q2046 effective July 1, 2012.

***Level II HCPCS code J9001 (Injection, doxorubicin hydrochloride, all lipid formulations, 10 mg) will be replaced with HCPCS code Q2048 effective July 1, 2012. The ASC payment indicator for HCPCS code J9001 will change to E5, " Not payable by Medicare.," effective July 1, 2012.

d. Adjustment to the Payment Indicator for Certain HCPCS Codes Effective April 1,2012
Effective April 1, 2012, the status indicators for several HCPCS codes listed in Table 4 below will change from ASC PI=E5 (Not payable by Medicare) to ASC PI=K2 (Drugs and biologicals paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS rate.). For the remainder of CY 2012, these HCPCS codes will be separately paid and the price will be updated on a quarterly basis.

The payment rates for these HCPCS codes are listed in Table 4 below and have been included in the revised April 2012 ASC Drug file effective for services furnished on April 1, 2012, through the implementation of the July 2012 ASC quarterly update. Suppliers who have received an incorrect payment for dates of service between April 1, 2012, through June 30, 2012, may request contractor adjustment of the previously processed claims.

Table 4 -- Adjustment to ASC Payment Indicator for Certain Drugs and Biologicals Effective April 1, 2012
HCPCS Code Long Descriptor Short Descriptor ASC PI
Effective
4/1/12
90581 Anthrax vaccine, for subcutaneous or intramuscular use Anthrax vaccine sc or im K2
J2265 Injection, minocycline hydrochloride, 1 mg Minocycline
hydrochloride
K2
J8650 Nabilone, oral, 1 mg Nabilone oral K2
Q0174 Thiethylperazine maleate, 10 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Thiethylperazine maleate 10mg K2
Q4123 Alloskin rt, per square centimeter Alloskin K2
Q4125 Arthroflex, per square centimeter Arthroflex K2
Q4128 Flexhd or allopatch hd, per square centimeter Flexhd or allopatch hd K2
Q4129 Unite biomatrix, per sqaure centimeter Unite biomatrix K2

Additional Information
The official instruction, CR7854 issued to your carrier and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2479CP.pdf on the CMS website.

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

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Modifier-25 Use with "XXX" Global Surgery Codes

CGS Administrators has recently received a large volume of questions regarding the use of modifier-25 with CPT codes having a global surgery indicator of "XXX" (for example: injection and infusion codes). Payment for a service with an "XXX" global days indicator already includes the E&M component required to provide the service. For example: CMS Publication 100-4 Claims Processing Manual Section 30.5 states: Physician work related to hydration, injection, and infusion services involves the affirmation of the treatment plan and the supervision (pursuant to incident to requirements) of non-physician clinical staff.

This means payment for the work ordinarily provided by the physician or non-physician clinical staff to evaluate the patient before and after an injection/infusion service is already reflected in the fee schedule payment amount for the service. In situations where the pre/post infusion evaluation services are the only E&M component provided, no additional payment for an E&M may be made on the same date of service.

Conversely, when a separate and distinct E&M service is provided on the same date of service as an "XXX" global days code modifier-25 must be appended to avoid Correct Coding Initiative (CCI) edit denials. CMS Pub 100-4 Chapter 12 Section 30.5 also states: Physicians providing a chemotherapy administration service or a non-chemotherapy drug infusion service and evaluation and management services, other than CPT code 99211, on the same day must bill in accordance with §30.6.6 using modifier 25. The carriers pay for evaluation and management services provided on the same day as the chemotherapy administration services or a non-chemotherapy injection or infusion service if the evaluation and management service meets the requirements of section §30.6.6 even though the underlying codes do not have global periods.

Section 30.6.6 of the same manual states: Medicare requires that Current Procedural Terminology (CPT) modifier -25 should only be used on claims for evaluation and management (E/M) services, and only when these services are provided by the same physician (or same qualified non-physician practitioner) to the same patient on the same day as another procedure or other service.

These sections of the Claims Processing Manual affirm the requirement for appending modifier-25 to an E&M code when performed on the same date of service as a "XXX" CPT code in order to receive payment for the E&M.

Circumventing the CCI edit to maximize payment; i.e. having the patient come in on another day to bill for the E&M services separately, is inappropriate and considered "unbundling" of services. This billing pattern could result in prepayment medical review and/or referral to the Zone Program Integrity Contractor.

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New Physician Specialty Code for Sleep Medicine and Sports Medicine – MM7600

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

News Flash – Over the last year, the Centers for Medicare & Medicaid Services (CMS) has listened to your feedback about the Medicare online enrollment system, Provider Enrollment, Chain, and Ownership System (PECOS). As a result, we've made upgrades in order to reduce data entry time and increase access to information. Providers and staff using internet-based PECOS will now be able to digitally sign and certify your application and to see more information such as whether a request for revalidation has been sent to you by your Medicare contractor. You will be able to switch from Topic View to Fast Track View to review all of your enrollment information in a single screen. Overall, the system will be easier for you to use. Learn more about PECOS at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/InternetbasedPECOS.htmland be on the look-out for more enhancements in the coming months!

Note: This article was revised on May 9, 2012, to correct a typographical error in the second sentence of the "Provider Action Needed" Section. All other information is the same.

Provider Types Affected
This MLN Matters® Article is intended for physicians, non-physician practitioners, and suppliers who bill Medicare Carriers, Medicare Administrative Contractors (A/B MACs), or Durable Medical Equipment (DME) MACs for sleep medicine service and/or sports medicine services provided to Medicare beneficiaries.

Provider Action Needed
Effective April 2, 2012, you will need to use physician specialty code (C0) for sleep medicine services. In addition, claims submitted to DME MACs for sports medicine service should use the sports medicine specialty code of 23.
You should make sure that your billing staffs are aware of this new specialty code for sleep medicine services.

Background
Medicare physician and non-physician practitioner specialty codes describe the specific or unique types of medical services that physicians and non-physician practitioners provide. While physicians self-designate their Medicare physician specialty on the Medicare enrollment application (CMS-855I) or Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) when they enroll in the Medicare program, non-physician practitioners are assigned a Medicare specialty code when they enroll. The specialty code becomes associated with the claims submitted by physicians or non- physician practitioners. Medicare contractors also use specialty code data to develop claims processing edits.

New Specialty Code
CR 7600 announces that the Centers for Medicare & Medicaid Services (CMS) has established a new physician specialty code for Sleep Medicine. This new physician specialty code, which will be effective April 2, 2012, is C0. PECOS and your carrier or A/B MAC will recognize and use this new code as a valid primary and/or secondary specialty code for Sleep Medicine. Also, a new specialty code is established for sports medicine and that code is 23.

Additional Information
You can find more information about the new sleep medicine specialty code by going to CR7600, located at http://www.cms.hhs.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2462CP.pdf on the CMS website. A related transmittal that updates the "Medicare Financial Management Manual" is at http://www.cms.hhs.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R209FM.pdf on the CMS website.

If you have any questions, please contact your carrier or A/B MAC at their toll-free number, which may be found at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/index.html on the CMS website.

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Proper Billing for Critical Care Requires Time Documentation

The correct coding of the critical care codes requires that time be measured and recorded in "the physicians progress note".

CMS Pub 100.4 Chapter 12 Section 30.6.12E includes the following instruction:

E. Critical Care Services and Physician Time

Critical care is a time-based service, and for each date and encounter entry, the physician's progress note(s) shall document the total time that critical care services were provided.

F. Hours and Days of Critical Care that May Be Billed

Critical care of less than 30 minutes total duration on a given calendar date is not reported separately using the critical care codes. This service should be reported using another appropriate E/M code such as subsequent hospital care.

The actual document is available at this web link:

Critical Care Billing

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Results of Kentucky Progressive Corrective Action (PCA) for Emergency Department Visit Code 99285

AMA/CPT © 99285 Emergency Department Visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by urgency of the patient's clinical condition and/or mental status:

Please take a moment to review the following references and take advantage of our E&M checklists that are provided to help you optimize your coding, billing and documentation process.

Checklists
http://www.cgsmedicare.com/kyb/coverage/mr/Checklists.html
http://www.cgsmedicare.com/kyb/coverage/mr/PDF/DC_EM99285.pdf

Documentation Guidelines for Evaluation and Management Services
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//eval_mgmt_serv_guide-ICN006764.pdf

Medicare Claims Processing Manual
http://www.cms.gov/manuals/downloads/clm104c12.pdf

E/M Coding: Volume of Documentation versus Medical Necessity
http://www.cgsmedicare.com/kyb/coverage/mr/articles/em_volume.html

Medical Necessity for Evaluation and Management Services
http://www.cgsmedicare.com/kyb/claims/cert/articles/045.html

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Retiring the Bariatric Surgery LCD

L31852 Bariatric Surgery is being retired for J-15 effective May 31, 2012. A National Coverage Determination (100.1) exists on this topic and provides the coverage criteria. Coverage is not changed by this retirement of L31852 and the edits will remain in place.

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Revised 5/30/2012: SE1216 - Examining the Difference between a National Provider Identifier (NPI) and a Provider Transaction Access Number (PTAN)

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

News Flash – 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."

Note: This article was revised on May 30, 2012, to remove a sentence from the last paragraph on page2. All other information is the same.

Provider Types Affected
This MLN Matters® Special Edition Article is intended for physicians, providers, and suppliers who are enrolled in Medicare.

What You Need to Know
This article explains the difference between a National Provider Identifier (NPI) and a Provider Transaction Access Number (PTAN). There are no policy changes in this article.

Background

New Enrollees
All providers and suppliers who provide services and bill Medicare for services provided to Medicare beneficiaries must have an NPI. Upon application to a Medicare contractor, the provider or supplier will also be issued a Provider Transaction Access Number (PTAN). While only the NPI can be submitted on claims, the PTAN is a critical number directly linked to the provider or supplier's NPI.

Revalidation
Section 6401(a) of the Affordable Care Act established a requirement for all enrolled physicians, providers, and suppliers to revalidate their enrollment information under new enrollment screening criteria.

Providers and suppliers receiving requests to revalidate their enrollment information have asked the Centers for Medicare & Medicaid Services (CMS) to clarify the differences between the NPI and the PTAN.

National Provider Identifier (NPI)
The NPI is a national standard under the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification provisions.

Since May 23, 2008, Medicare has required that the NPI be used in place of all legacy provider identifiers, including the Unique Physician Identification Number (UPIN), as the unique identifier for all providers, and suppliers in HIPAA standard transactions.

You should note that individual health care providers (including physicians who are sole proprietors) may obtain only one NPI for themselves (Entity Type 1 Individual). Incorporated individuals should obtain one NPI for themselves (Entity Type 1 Individual) if they are health care providers and an additional NPI(s) for their corporation(s) (Entity Type 2 Organization). Organizations that render health care or furnish health care supplies may obtain NPIs (Entity Type 2 Organization) for their organizations and their subparts (if applicable).

For more information about the NPI, visit the NPPES website at https://nppes.cms.hhs.gov/NPPES/Welcome.doon the CMS website.

Provider Transaction Access Number (PTAN)
A PTAN is a Medicare-only number issued to providers by Medicare contractors upon enrollment to Medicare. When a Medicare contractor approves enrollment and issues an approval letter, the letter will contain the PTAN assigned to the provider.

Relationship of the NPI to the PTAN
The NPI and the PTAN are related to each other for Medicare purposes. A provider must have one NPI and will have one, or more, PTAN(s) related to it in the Medicare system, representing the provider's enrollment. If the provider has relationships with one or more medical groups or practices or with multiple Medicare contractors, separate PTANS are generally assigned.

Together, the NPI and PTAN identify the provider, or supplier in the Medicare program. CMS maintains both the NPI and PTAN in the Provider Enrollment Chain & Ownership System (PECOS), the master provider and supplier enrollment system.

Protect Your Information in PECOS
All providers and suppliers should carefully review their PECOS records in order to protect themselves and their practices from identity theft. PECOS should only contain active enrollment records that reflect current practice and group affiliations. You can review and update your PECOS records in the following ways:

The MLN fact sheet titled "How to Protect Your Identity Using the Provider Enrollment, Chain and Ownership System (PECOS)," provides guidelines and steps you can take to protect your identity while using Internet-based PECOS. This fact sheet is available at http://www.cms.gov/Outreach- and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/MedEnroll_ProtID_FactSheet_ICN905103.pdf on the CMS website.

Additional Information
MLN Matters® Special Edition Article SE1126 titled "Further Details on the Revalidation of Provider Enrollment Information," is available at http://www.cms.gov/Outreach-and-Education/Medicare- Learning-Network-MLN/MLNMattersArticles/downloads/SE1126.pdf on the CMS website.

"Medicare Provider–Supplier Enrollment National Educational Products," contains a list of products designed to educate Medicare Fee-For-Service (FFS) providers about important Medicare enrollment information, including how to use Internet-based PECOS to enroll in the Medicare Program and maintain their enrollment information. This resource is available at http://www.cms.gov/MedicareProviderSupEnroll/downloads/Medicare_Provider- Supplier_Enrollment_National_Education_Products.pdf on the CMS website.

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

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Revised: MM7499 - Reporting of Recoupment for Overpayment on the Remittance Advice (RA) with Patient Control Number

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

News Flash – Under the Affordable Care Act, Medicare beneficiaries may now receive coverage for an Annual Wellness Visit (AWV), which is a yearly office visit that focuses on preventive health. In addition, Medicare also provides coverage for the Initial Preventive Physical Examination (IPPE), commonly known as the "Welcome to Medicare" visit. To learn more about the AWV and the IPPE, please refer to the CMS Medicare Learning Network® publication at http://www.cms.gov/MLNProducts/downloads/mps_guide_web-061305.pdf on the Centers for Medicare & Medicaid Services (CMS) website.

Note: This article was revised on May 14, 2012, to reflect a revised CR7499 issued on May 10. The article was revised to show (above) the correct implementation date of October 1, 2012 for claims submitted to DME MACs. In addition, the transmittal number, release date, and the Web address for accessing CR7499 were revised. All other information is the same.

Provider Types Affected
This article is 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 MACs (DME MACs) and/or Regional Home Health Intermediaries (RHHIs)) for services provided to Medicare beneficiaries.

Provider Action Needed
This article is based on Change Request (CR) 7499 which instructs Medicare's claims processing systems maintainers to replace the Health Insurance Claim (HIC) number being sent on the ASC X12 Transaction 835) with the Patient Control Number received on the original claim, whenever the electronic remittance advice (ERA) is reporting the recovery of an overpayment.

Background
The Centers for Medicare & Medicaid Services (CMS) generates Health Insurance Portability and Accountability Act (HIPAA) compliant remittance advice that includes enough information to providers so that manual intervention is not needed on a regular basis. CMS changed reporting of recoupment for overpayment on the ERA)
as a response to provider request per CR6870 and CR7068. The MLN Matters article corresponding to CR6870 can be reviewed at http://www.cms.gov/MLNMattersArticles/downloads/MM6870.pdf and CR7068 can be reviewed at http://www.cms.gov/transmittals/downloads/R812OTN.pdf on the CMS website

It has been brought to the attention of CMS that providing the Patient Control Number as received on the original claim rather than the Health Insurance Claim (HIC)
number would:

CR7499 instructs the shared systems to replace the HIC number being sent on the ERA with the Patient Control Number, received on the original claim. The ERA will continue to report the HIC number if the Patient Control Number is not available. This would appear in positions 20-39 of PLB 03-2. A demand letter is also sent to the provider when the Accounts Receivable (A/R) is created. This document contains a claim control number for tracking purposes that is also reported in positions 1-19 of PLB 03-2 on the ERA.

Note: Instructions in CR7499 apply to the 005010A1 version of ASC X12 Transaction 835 only and do not apply to the Standard Paper Remit or the 004010A1 version of ASC X12 Transaction 835.

Additional Information
The official instruction, CR7499, issued to your carrier, FI, A/B MAC, DME MAC, or RHHI regarding this change may be viewed at http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R1088OTN.pdf on the CMS website.

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

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Revised: MM7610 - Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

News Flash –
REVISED products from the Medicare Learning Network® (MLN)·-
"Medicare Preventive Services Series: Part 2," Web-Based-Training Course

Screening for Sexually Transmitted Infections (STIs)

and High Intensity
Behavioral Counseling (HIBC) to Prevent STIs

Note: This article was revised on May 29, 2012, to reflect a revised CR7610 issued on May 23. In this article, the CR release date, transmittal number, and the Web address for accessing CR7610 were revised. All other information is the same.

Provider Types Affected
This MLN Matters® article is intended for all physicians, providers, and suppliers submitting claims to Medicare contractors (Fiscal Intermediaries (FIs), carriers, and A/B Medicare Administrative Contractors (MACs)) for Medicare beneficiaries.

Provider Action Needed
Effective for dates of service on or after November 8, 2011, the Centers for Medicare & Medicaid Services (CMS) will cover screening for Sexually Transmitted Infections (STIs) - specifically chlamydia, gonorrhea, syphilis, and hepatitis B - with the appropriate Food and Drug Administration (FDA) approved/cleared laboratory tests when ordered by the primary care provider. The tests must be used consistent with FDA approved labeling and in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations and performed by an eligible Medicare provider for these services.

In addition, Medicare will cover High Intensity Behavioral Counseling (HIBC) to prevent STIs. Ensure that your billing staffs are aware of these changes.

Background
Pursuant to Section 1861(ddd) of the Social Security Act, CMS may add coverage of "additional preventive services" through the National Coverage Determination (NCD) process. The preventive services must be:

CMS reviewed the USPSTF recommendations and supporting evidence for screening for STIs and HIBC to prevent STIs and determined that the criteria listed above were met, enabling CMS to cover these preventive services. Therefore, effective November 8, 2011, CMS will cover screening for the indicated STIs and HIBC to prevent STIs. The covered screening lab tests must be ordered by the primary care provider. The HIBC must be provided by primary care providers in primary care settings such as by the beneficiary's family practice physician, internal medicine physician, or nurse practitioner (NP) in the doctor's office.

A new Healthcare Common Procedure Coding System (HCPCS) code, G0445 (high-intensity behavioral counseling to prevent sexually transmitted infections, face-to-face, individual, includes: education, skills training, and guidance on how to change sexual behavior, performed semi-annually, 30 minutes), has been created for use when reporting HIBC to prevent STIs, effective November 8, 2011. This code is included in the January 2012 Medicare Physician Fee Schedule Database (MPFSDB) and Integrated Outpatient Code Editor (IOCE) updates.

This code may be paid on the same date of service as an annual wellness visit (AWV), evaluation and management (E&M) code, or during the global billing period for obstetrical care, but only one G0445 may be paid on any one date of service. If billed on the same date of service with an E&M code, the E&M code should have a distinct diagnosis code other than the diagnosis code used to indicate high/increased risk for STIs for the G0445 service. An E&M code should not be billed when the sole reason for the visit is HIBC to prevent STIs.

The use of the correct diagnosis code(s) on the claims is imperative to identify these services as preventive services and to show that the services were provided within the guidelines for coverage as preventive services. The patient's medical record must clearly support the diagnosis of high/increased risk for STIs and clearly reflect the components of the HIBC service provided – education, skills training, and guidance on how to change sexual behavior - as required for coverage.

The appropriate screening diagnosis code (ICD-9-CM V74.5 (screening bacterial – sexually transmitted) or V73.89 (screening, disease or disorder, viral, specified type NEC)), when used with the screening lab tests identified by Change Request (CR) 7610, will indicate that the test is a screening test covered by Medicare.

Diagnosis code V69.8 (other problems related to life style) is used to indicate that the beneficiary is at high/increased risk for STIs. Providers should also use V69.8 for sexually active adolescents when billing G0445 counseling services.

Diagnosis codes V22.0 (supervision of normal first pregnancy), V22.1 (supervision of other normal pregnancy), or V23.9 (supervision of unspecified high-risk pregnancy) are also to be used when appropriate.

For services provided on an annual basis, this is defined as a 12-month period.

Further Details
CMS will cover screening for Chlamydia (86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810, 87800 (used for combined Chlamydia and gonorrhea testing), gonorrhea (87590, 87591, 87850, 87800 (used for combined Chlamydia and gonorrhea testing), syphilis (86592, 86593, 86780), and hepatitis B (hepatitis B surface antigen) 87340, 87341)) with the appropriate FDA approved/cleared laboratory tests, used consistent with FDA-approved labeling and in compliance with the CLIA regulations, when ordered by the primary care provider, and performed by an eligible Medicare provider for these services. As per the requirements, the presence of V74.5 or V73.89 and V69.8, denoting STI screening and high-risk behavior, respectively, and/or V22.0, V22.1, or V23.9, denoting pregnancy as appropriate, must also be present on the claim for STI services along with one of the procedure codes above.

Screening for chlamydia and gonorrhea:

Screening for syphilis:

Screening for hepatitis B:

Coverage for HIBC

CMS will also cover up to two, individual, 20- to 30-minute, face-to-face counseling sessions annually for Medicare beneficiaries for HIBC to prevent STIs (G0445) for all sexually active adolescents and for adults at increased risk for STIs (V69.8), if referred for this service by a primary care provider and provided by a Medicare eligible primary care provider in a primary care setting. HIBC is defined as a program intended to promote sexual risk reduction or risk avoidance which includes each of these broad topics, allowing flexibility for appropriate patient-focused elements:

The high/increased risk individual sexual behaviors, based on the USPSTF guidelines, include any of the following:

Community social factors such as high prevalence of STIs in the community populations should also be considered in determining high/increased risk for chlamydia, gonorrhea, syphilis, and in recommending HIBC.

High/increased risk sexual behavior for STIs is determined by the primary care provider by assessing the patient's sexual history which is part of any complete medical history, typically part of an AWV or prenatal visit and considered in the development of a comprehensive prevention plan. The medical record should be a reflection of the service provided.

For the purposes of this NCD, a primary care setting is defined as the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Emergency departments, inpatient hospital settings, ambulatory surgical centers (ASCs), independent diagnostic testing facilities, skilled nursing facilities (SNFs), inpatient rehabilitation facilities, clinics providing a limited focus of health care services, and hospice are examples of settings not considered primary care settings under this definition.

For the purposes of this NCD, a "primary care physician" and "primary care practitioner" will be defined consistent with existing sections of the Social Security Act (Sections 1833(u)(6), 1833(x)(2)(A)(i)(I) and 1833(x)(2)(A)(i)(II)), as follows:

Billing Reminders

Additional Information
The official instruction, CR7610, was issued to your FI, carrier and A/B MAC regarding this change via two transmittals. The first updates the "Medicare Claims Processing Manual" and it is at http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2476CP.pdf on the CMS website. The second transmittal conveys the NCD and it is at http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R141NCD.pdf on the same site.

If you have any questions, please contact your FI, carrier or A/B MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/Outreach-and- Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website.

News Flash - It's Not too Late to Give and Get the Flu Vaccine. Take advantage of each office visit and protect your patients against the seasonal flu. Medicare will continue to pay for the seasonal flu vaccine and its administration for all Medicare beneficiaries through the entire flu season. The Centers for Disease Control and Prevention (CDC) also recommends that patients, healthcare workers and caregivers be vaccinated against the seasonal flu. Protect your patients. Protect your family. Protect yourself. Get the Flu Vaccine—Not the Flu. Remember: The flu vaccine plus its administration are covered Part B benefits. The flu vaccine is NOT a Part D-covered drug. For more information on coverage and billing of the flu vaccine and its administration, and related provider resources, visit 2011-2012 Provider Seasonal Flu Resources and Immunizations. For the 2011-2012 seasonal flu vaccine payment limits, visit http://www.CMS.gov/McrPartBDrugAvgSalesPrice/10_VaccinesPricing.asp on the Centers for Medicare & Medicaid Services (CMS) website.

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Revised: MM7819 - Coding Changes to Ultrasound Diagnostic Procedures for Transesophageal Doppler Monitoring

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

News Flash – Over the last year, the Centers for Medicare & Medicaid Services (CMS) has listened to your feedback about the Medicare online enrollment system, Provider Enrollment, Chain, and Ownership System (PECOS). As a result, we've made upgrades in order to reduce data entry time and increase access to information. Providers and staff using internet-based PECOS will now be able to digitally sign and certify your application and to see more information such as whether a request for revalidation has been sent to you by your Medicare contractor. You will be able to switch from Topic View to Fast Track View to review all of your enrollment information in a single screen. Overall, the system will be easier for you to use. Learn more about PECOS at http://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/MedicareProviderSupEnroll/InternetbasedPECOS.html and be on the look-out for more enhancements in the coming months!

Note: This article was revised on May 23, 2012, to delete a reference to fiscal intermediaries in the"Provider Types Affected" section. All other information is the same.

Provider Types Affected
This MLN Matters® Article is intended for providers billing Medicare contractors (Medicare Carriers
and/or A/B Medicare Administrative Contractors (A/B MACs)) for Transesophageal Doppler services used for cardiac monitoring of Medicare beneficiaries.

What You need to Know
This article is based on Change Request (CR) 7819, which informs you of the new code for Esophageal
Doppler monitoring.

Please note that no changes are being made to the current policy for Esophageal Doppler Monitoring. For a discussion of that policy, see the MLN Matters® article at http://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads//MM5608.pdf on the CMS website.

Additional Information
The official instruction, CR7819, issued to your carrier and A/B MAC regarding this change, may be viewed at http://www.cms.hhs.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2472CP.pdf on the CMS website. If you have any questions, please contact your carrier or A/B MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website.

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Revisions of the Financial Limitation for Outpatient Therapy Services - Section 3005 of the Middle Class Tax Relief and Job Creation Act of 2012 - MM7785

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

News Flash – 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/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html No Longer Available and start receiving updates immediately!

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 Change Request (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:

Change Request (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:

  1. The services are reasonable and necessary, and
  2. 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.

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:

Claims without at least one referring provider, including his/her NPI, will be returned as unprocessable with the following codes:

Additional Information
The official instruction, CR7785, issued to your carriers, FIs, A/B MACs, and RHHIs regarding this change may be viewed at http://www.cms.hhs.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2457CP.pdf on the CMS website.

If you have any questions, please contact your carriers, FIs, A/B MACs, or RHHIs at their toll-free number, which may be found at http://www.cms.hhs.gov/Outreach-and-Education/Medicare- Learning-Network-MLN/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website.

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SE1222 - Negative Pressure Wound Therapy Interpretive Guidelines

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

News Flash – 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."

Provider Types Affected
This MLN Matters® Special Edition Article is intended for 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 negative pressure wound therapy services provided to Medicare beneficiaries.

What You Need to Know
This article is intended to provide interpretive guidance to Centers for Medicare & Medicaid Services (CMS) approved accrediting organizations to use in their accreditation of suppliers that provide Negative Pressure Wound Therapy (NPWT) equipment to Medicare beneficiaries. These guidelines also apply to suppliers that are furnishing NPWT equipment to Medicare beneficiaries. SE1222 is also intended to assist the supplier in understanding their responsibilities related to this equipment in order to be in compliance with CMS Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) quality standards.

Background
(NPWT is defined as the application of sub-atmospheric pressure to a wound to remove exudate and debris from the wound(s). NPWT is delivered to a qualified wound through an integrated system that includes:

In these systems, the exudate is completely removed from the wound site to the collection chamber.

This Special Edition article, while assisting the supplier of NPWT to fulfill all Centers for Medicare &
Medicaid Services (CMS) Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
(DMEPOS) quality standards, does not contain a detailed discussion of all coverage and documentation requirements pertinent to this subject. Please consult the appropriate Local Coverage Determination (LCD) (or Local Coverage Article) more complete information using the Medicare Coverage Database Quick Search at http://www.cms.gov/medicare-coverage-database/overview- and-quick-search.aspx on the CMS website. Some of the more pertinent LCDs, per DME MAC Jurisdiction, are as follows:

Jurisdiction A:

L11500 (Local Coverage Determination (LCD) for Negative Pressure Wound Therapy Pumps)

See http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=11500&ContrId=137&ver=35&ContrVer=1&Date=&DocID=L11500&bc=iAAA AAgAAAAA& on the CMS website.

A35347 (Local Coverage Article for Negative Pressure Wound Therapy Pumps - Policy Article - Effective October 2011)

See http://www.cms.gov/medicare-coverage-database/details/article- details.aspx?articleId=35347&ver=17&ContrId=137&ContrVer=1&LCDId=11500&Date=&DocID= L11500&IsPopup=y& on the CMS website.

Jurisdiction B:

L27025 (Local Coverage Determination (LCD) for Negative Pressure Wound Therapy Pumps)

See http://www.cms.gov/medicare-coverage-database/details/lcd- details.aspx?LCDId=27025&ContrId=138&ver=12&ContrVer=1&Date=&DocID=L27025&bc=iAAA AAgAAAAA& on the CMS website.

A47111 (Local Coverage Article for Negative Pressure Wound Therapy Pumps - Policy Article - Effective October 2011)

See http://www.cms.gov/medicare-coverage-database/details/article- details.aspx?articleId=47111&ver=8&ContrId=138&ContrVer=1&CntrctrSelected=138*1&Date=& DocID=A47111&bc=hAAAAAgAAAAA& on the CMS website.

Jurisdiction C:

L5008 (Local Coverage Determination (LCD) for Negative Pressure Wound Therapy Pumps)

See http://www.cms.gov/medicare-coverage-database/details/lcd- details.aspx?LCDId=5008&ContrId=140&ver=46&ContrVer=2&CntrctrSelected=140*2&Cntrctr=1
40&name=CGS+Administrators%2c+LLC+(18003%2c+DME+MAC)&LCntrctr=140*2&bc=AgACA AIAAAAA& on the CMS website.

A35363 (Local Coverage Article for Negative Pressure Wound Therapy Pumps - Policy Article - Effective October 2011)

See http://www.cms.gov/medicare-coverage-database/details/article- details.aspx?articleId=35363&ver=19&ContrId=140&ContrVer=2&CntrctrSelected=140*2&Date=
&DocID=A35363&bc=hAAAAAgAAAAA&on the CMS website.

Jurisdiction D:

L11489 (Local Coverage Determination (LCD) for Negative Pressure Wound Therapy Pumps)

See http://www.cms.gov/medicare-coverage-database/details/lcd- details.aspx?LCDId=11489&ContrId=139&ver=39&ContrVer=1&Date=&DocID=L11489&bc=iAAA AAgAAAAA& on the CMS website.

A35425 (Local Coverage Article for Negative Pressure Wound Therapy Pumps - Policy Article)

See http://www.cms.gov/medicare-coverage-database/details/article- details.aspx?articleId=35425&ver=17&ContrId=139&ContrVer=1&LCDId=11489&Date=&DocID= L11489&IsPopup=y& on the CMS website.

Note: These interpretive guidelines do not address clinical aspects of NPWT, nor do they intend to assign clinical responsibilities to DMEPOS suppliers that provide the NPWT equipment to Medicare beneficiaries.

In addition to the LCDs and Articles, following are some guidelines for the CMS DMEPOS Quality
Standards that CMS uses to ascertain compliance with standards:

I. Supplier Business Services Requirements

Consumer Services

CMS DMEPOS Quality Standard: Suppliers shall provide information and telephone number(s) for customer service, regular business hours, after-hours access, equipment and/or item(s) repair, and emergency coverage.

Interpretive Guidelines:

Suppliers shall demonstrate that they have provided the beneficiary/caregiver with the following information:

  1. How to contact the supplier for equipment problems both during business hours and after hours through a 24/7 support function provided by the manufacturer or supplier;
  2. How to access supplier staff for 24/7 technical product consultation; and
  3. That they shall call their physician or 911 if a medical emergency arises.

Product Safety

CMS DMEPOS Quality Standards: Suppliers shall implement a program that promotes the safe use of equipment and item(s) and minimizes safety risks, infections, and hazards both for its staff and for beneficiaries:

Suppliers shall implement and maintain a plan for identifying, monitoring and reporting equipment and item(s) failure, repair and preventive maintenance provided to beneficiaries.

Interpretive Guideline:

II. Supplier Product-Specific Service Requirements

Intake & Assessment

CMS DMEPOS Quality Standard: The supplier shall consult with the prescribing physician as needed to confirm the order and to recommend any necessary changes, refinements, or additional evaluations to the prescribed equipment, item(s), and/or service(s).

Interpretive Guidelines:

The supplier shall:

CMS DMEPOS Quality Standard: The supplier shall review the beneficiary's record as appropriate and incorporate any pertinent information, related to the beneficiary's condition(s) which affect the provision of the DMEPOS and collaboration with the prescribing physician.

Interpretative Guidelines:

The supplier shall:

  1. Confirm that the wound type or risk factors in the patient record are not among those listed in the most recent public health notification of the U.S Food and Drug Administration. Refer to the FDA's link for all of the specific clinical information at http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalPr oducts/ucm190704.htm on the Internet.
  2. Confirm that if the wound type or any of the risk factors included in the patient's record are also in the most recent guidance issued by the FDA, there is a written approval from the patient's physician that the NPWT equipment is appropriate for this patient.
  3. Not supply the NPWT equipment to a beneficiary without the physician's written approval.

Delivery & Set-up

CMS DMEPOS Quality Standard: Suppliers shall deliver and set-up, or coordinate set-up with another supplier, all equipment and item(s) in a timely manner as agreed upon by the beneficiary and/or caregiver, supplier, and prescribing physician.

Interpretive Guidelines:

Suppliers shall:

  1. Coordinate the delivery of the equipment with the home health care providers' home visit, if there is a Home Health Agency (HHA) involved in the patient's care.
  2. Deliver the NPWT pump, dressings, and supplies prior to a beneficiary's discharge from the hospital, if the patient is being discharged from an acute care facility.

CMS DMEPOS Quality Standard: Suppliers shall provide all equipment and item(s) that are necessary to operate the equipment or item(s) and perform any further adjustments as applicable.

Interpretive Guidelines:

The supplier shall demonstrate that they have (prior to home delivery):

  1. Performed quality checks on pumps, tubing, dressings, drapes, containers, and canisters per the manufacturer maintenance schedule, before delivery;
  2. Confirmed that each NPWT component is operational and that equipment and supplies are available and complete prior to setup or at the time of setup;
  3. Confirmed that all of the supplies are within expiration date;
  4. Confirmed that the number and sizes of dressings are correct and the packaging is sterile;
  5. Confirmed that the correct pump, containers/canisters, dressing, tubing is used for the specific brand of equipment according to manufacturer requirements;
  6. Confirmed that clamps are available if required;
  7. Confirmed that the exudate collection containers or canister are specific to the NPWT system being used;
  8. Confirmed that the beneficiary has sufficient number of exudate collection containers to meet his/her wound needs based on the patient's history of drainage amount;
  9. Confirmed that the alarms are setup and working properly, capable of sounding an audible alarm and/or visual alarm, dependent upon the pump type when desired pressures are not being achieved (that is, where there is a leak in the dressing seal) or the wound drainage container/canister is full or the battery is low;
  10. Confirmed that the pump and the wound system (stationary or portable) are operational during use.

CMS DMEPOS Quality Standard: Suppliers shall provide, or arrange for, loaner equipment equivalent to the original equipment during any repair period except for orthotics and prosthetics.

Interpretive Guidelines:

The supplier shall demonstrate that they have:

  1. Performed or arranged maintenance and repairs or replacement of the pump and supplies;
  2. Given information to the beneficiary and/or caregiver(s) on how to obtain service for purchased equipment.

Training/Instruction to Beneficiary and/or Caregiver(s)

CMS DMEPOS Quality Standards: Suppliers shall provide or coordinate the provision of, appropriate information related to the set-up, features, routine use, troubleshooting, cleaning, infection control practices and maintenance of all equipment and item(s) provided.

Suppliers shall provide relevant information and/or instructions about infection control issues related to the use of all equipment and item(s) provided.

Interpretive Guidelines:

Suppliers shall demonstrate that they have provided training to the beneficiary/caregiver:

Follow-up

CMS DMEPOS Quality Standard: Suppliers shall provide follow-up services to the beneficiary and/or caregiver(s), consistent with the type(s) of equipment, item(s) and service(s) provided, and recommendations from the prescribing physician or healthcare team member(s).

Interpretive Guidelines:
supplier shall have an on-going individualized service plan with a defined frequency that addresses, defines or confirms;

  1. The ongoing operation and maintenance of the equipment, operation and maintenance of the equipment;
  2. The frequency for scheduled/planned delivery or supply of additional supplies
  3. That the beneficiary is using the equipment per the physicians order
  4. The supplier picks up the equipment when it is no longer needed per the physicians orders.

Additional Information
If you have any questions, please contact your DME MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website.

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Urgent Notice to all Cardiology Practices Billing for Impella® Heart Device Insertion

Earlier this month, CGS Administrators published instructions for the coding of the Impella® Heart Device. CGS is rescinding these instructions and providing new instructions for coding this device insertion. Please do not code this procedure with 92970. Beginning immediately, please use unlisted code 33999, unlisted procedures, cardiac surgery, to represent this procedure. For faster processing of these claims, please place: insertion of Impella® Heart Device in the electronic notepad or claim comments.

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