Medicare Bulletin - July 2014 · MEDICARE BULLETIN GR 2014-07 JULY 2014 2 ... SE1418: Proper Use of...

Reaching Out to the Medicare

Community

KEN

TU

CK

Y &

OH

IO PA

RT

BMedicare BulletinJurisdiction 15

JULY 2014 • WWW.CGSMEDICARE.COM

© 2014 Copyright, CGS Administrators, LLC.

www.cgsmedicare.com

Medicare BulletinJurisdiction 15

KE

NT

UC

KY

& O

HIO

PA

RT

B

Bold, italicized material is excerpted from the American Medical Association Current Procedural Terminology CPT codes. Descriptions and other data only are copyrighted 2009 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

MEDICARE BULLETIN • GR 2014-07 JULY 2014 2

Articles contained in this edition are current as of May 28, 2014.

KENTUCKY & OHIO

AdministrationMM8711: Implement Operating Rules - Phase III ERA EFT: CORE 360 Uniform Use of Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC) Rule - Update from CAQH CORE - June 1, 2014 version 3.0.5 8Incarcerated Beneficiary Claims and Adjustments: Refunds and Deductibles 19MM8456 Rescinded: Modifying the Daily Common Working File (CWF) to Medicare Beneficiary Database (MBD) File to Include Diagnosis Codes on the Health Insurance Portability and Accountability Act Eligibility Transaction System (HETS) 270/271 Transactions 23Provider Contact Center Reminders 26MM8662: Quarterly Update to the Correct Coding Initiative (CCI) Edits, Version 20.3, Effective October 1, 2014 27MM8684: Claim Status Category and Claim Status Codes Update 28

SE1418: Proper Use of Modifier 59 31

AmbulanceAmbulance Services: Incomplete Documentation 6

Coverage, LCDs, & NCDsMM8401 Revised: Mandatory Reporting of an 8-Digit Clinical Trial Number on Claims 12MM8757: Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS) 24

Fee SchedulesMM8664 Revised: April Update to the Calendar Year (CY) 2014 Medicare Physician Fee Schedule Database (MPFSDB) 14MM8786: July 2014 Update of the Ambulatory Surgical Center (ASC) Payment System 29

Home Health & HospiceCare Plan Oversight Services for Patients Receiving Care through Home Health Agencies or Hospices 17

Incentive ProgramsMM8667: Posting the Limiting Charge after Applying the Electronic Health Record (EHR) and Physician Quality Reporting System (PQRS) Negative Adjustments 20

Injections & DrugsMM8748: July 2014 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files 3MM8620 Revised: CWF Editing for Vaccines Furnished at Hospice - Correction 7

Laboratory & PathologyLaboratory Services: Medical Necessity and National Coverage Determinations (NCDs) 4MM8695 Revised: Calendar Year (CY) 2014 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment - REVISION 9

Preventive ServicesPreventive and Screening Services: Overview of Coverage under Medicare 11

RadiologyMM8468 Rescinded: Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors 4

NEWS FLASH

News Flash Items 36

http://www.cms.gov/MLNGenInfo

KE

NT

UC

KY

& O

HIO

PA

RT

B

This newsletter should be shared with all health care practitioners and managerial members of the provider/supplier staff. Newsletters issued after January 1997 are available at no cost from our website at http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.

MEDICARE BULLETIN • GR 2014-07 JULY 2014

RETURN TO TABLE OF CONTENTS

3

Kentucky and Ohio

MM8748: July 2014 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

The Centers for Medicare & Medicaid Services (CMS) has issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/2014-MLN-Matters-Articles.html

MLN Matters® Number: MM8748Related CR Release Date: April 25, 2014Related CR Transmittal #: R2936CP

Related Change Request (CR) #: CR 8748 Effective Date: July 1, 2014Implementation Date: July 7, 2014

Provider Types Affected

This MLN Matters® Article is intended for physicians, providers, and suppliers who submit claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment Medicare Administrative Contractors (DME MACs), and/or Home Health and Hospices (HH&H) MACs for services provided to Medicare beneficiaries.

Provider Action Needed

MACs will use the July 2014 Average Sales Price (ASP) and not otherwise classified (NOC) drug pricing files to determine the payment limit for claims for separately payable Medicare Part B drugs processed or reprocessed on or after July 1, 2014, with dates of service July 1, 2014, through September 30, 2014.

Change Request (CR) 8748, from which this article is taken, instructs MACs to implement the July 2014 ASP Medicare Part B drug pricing file for Medicate Part B drugs, and if they are released by the Centers for Medicare & Medicaid Services (CMS), to also implement the revised April 2014, January 2014, October 2013, and July 2013 ASP drug pricing files. Make sure your billing personnel are aware of these changes.

Background

The ASP methodology is based on quarterly data submitted to the Centers for Medicare & Medicaid Services (CMS) by manufacturers. CMS supplies the MACs with the ASP and NOC drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE) through separate instructions that can be located in the “Medicare Claims Processing Manual” (Chapter 4, Section 50 (Outpatient PRICER)) at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf on the CMS website.

The following table shows how the quarterly payment files will be applied:

Files Effective for Dates of ServiceJuly 2014 ASP and ASP NOC July 1, 2014, through September 30, 2014April 2014 ASP and ASP NOC April 1, 2014, through June 30, 2014January 2014 ASP and ASP NOC January 1, 2014, through March 31, 2014October 2013 ASP and ASP NOC October 1, 2013, through December 31, 2013July 2013 ASP and ASP NOC July 1, 2013, through September 30, 2013

http://www.cgsmedicare.com

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/2014-MLN-Matters-Articles.html


http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf


KE

NT

UC

KY

& O

HIO

PA

RT

B




4

Additional Information

The official instruction, CR 8748 issued to your MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2936CP.pdf on the CMS website.

Kentucky and Ohio

MM8468 Rescinded: Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors

The Centers for Medicare & Medicaid Services (CMS) has rescinded the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/2014-MLN-Matters-Articles.html

MLN Matters® Number: MM8468 RESCINDEDRelated CR Release Date: February 6, 2014Related CR Transmittal #: R2873CP/R162NCDRelated Change Request (CR) #: CR 8468

Effective Date: June 11, 2013Implementation Date: Non-sharedSystem Edits, July 7, 2014: Shared System Edits

Note: This article was rescinded and replaced by MLN Matters® article MM8739. The related CR8468 was also rescinded and replaced by CR8739. MM8739 is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8739.pdf on the Centers for Medicare & Medicaid Services website.

Kentucky and Ohio

Laboratory Services: Medical Necessity and National Coverage Determinations (NCDs)

Claims for the following CPT codes are often denied as “not medically necessary” (remark code CO-50). This includes claims for which additional supporting documentation was requested and reviewed.

yy 84443: Thyroid stimulating hormoneyy 83036: Glycosylated hemoglobinyy 85025: Complete blood countyy 80061: Lipid panel

The Centers for Medicare & Medicaid Services (CMS) created 23 National Coverage Determinations (NCDs) for specific clinical laboratory tests, including the tests listed above. Whereas most NCDs describe covered indications and limitations in narrative form, laboratory NCDs list specific ICD-9 codes that fall into 3 categories:

yy Covered ICD-9 codesyy Non-covered ICD-9 codesyy Codes that do not support medical necessity

Before Submitting Claims

yy Refer to the ICD-9 code lists for the applicable NCD.

y� Download the ICD-9 code lists for each NCD from the CMS website (http://www.cms.gov/Medicare/Coverage/CoverageGenInfo/LabNCDs.html): under Downloads, select Lab Code List.


http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2936CP.pdf




http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8739.pdf


http://www.cms.gov/Medicare/Coverage/CoverageGenInfo/LabNCDs.html


KE

NT

UC

KY

& O

HIO

PA

RT

B




5

yy If the patient’s condition is on the non-covered list or list of codes that do not support medical necessity, you may consider asking the patient to sign an Advance Beneficiary Notice of Noncoverage (ABN).

y� Refer to the CGS Modifier Tool, HCPCS modifier GA, for more information, and to the CMS resources in the Reference section of this article for further guidance on issuing these notices.

yy Remember to double-check medical records to ensure that valid orders and signatures are present.

Current list of Lab NCDs: AlphabeticalNCD# Title CPT Codes Included190.25 Alpha-fetoprotein 82105

190.15 Blood Counts85004 85013 85018 85027 8504885007 85014 85025 85032 8504985008

190.20 Blood Glucose TestingNCD 190.20A: 82948 82962NCD 190.20B: 82947

190.26 Carcinoembryonic Antigen 82378190.19 Collagen Crosslinks, Any Method 82523190.24 Digoxin Therapeutic Drug Assay 80162190.34 Fecal Occult Blood Test 82272190.32 Gamma Glutamyl Transferase 82977190.21 Glycated Hemoglobin/Glycated Protein 82985 83036190.33 Hepatitis Panel/Acute Hepatitis Panel 80074190.27 Human Chorionic Gonadotropin 84702

190.14 Human Immunodeficiency Virus (HIV) Testing (Diagnosis)86689 86702 87390 87534 8753786701 86703 87391 87535 87538

190.13 Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring) 87536 87539

190.23 Lipid Testing

NCD 190.23A: 83700 83704 83701NCD 190.23B: 80061 83718

82465 84478190.16 Partial Thromboplastin Time (PTT) 85730190.31 Prostate Specific Antigen 84153190.17 Prothrombin Time (PT) 85610190.18 Serum Iron Studies 82728 83540 83550 84466190.22 Thyroid Testing 84436 84439 84443 84479190.28 Tumor Antigen by Immunoassay (CA 125) 86304190.29 Tumor Antigen by Immunoassay (CA 15-3/CA 27.29) 86300190.30 Tumor Antigen by Immunoassay (CA 19-9) 86301190.12 Urine Culture, Bacterial 87086 87088

Reference:

yy CMS Lab NCD Web page (http://www.cms.gov/Medicare/Coverage/CoverageGenInfo/LabNCDs.html)yy CMS Beneficiary Notices Initiative (BNI) Web pageyy Additional guidance: Medicare Claims Processing Manual (Pub. 100-04), chapter 30, section 50 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c30.pdf)






KE

NT

UC

KY

& O

HIO

PA

RT

B




6

y� Prohibition on issuing “routine notices” and “blanket notices”: sections 40.3.6 and 40.3.6.2y� Beneficiary’s refusal to sign ABN: section 50.6.5.B y� Guidance for repetitive services: section 50.7.1.B

yy CMS Medicare Learning Network publication, “Advance Beneficiary Notice of Noncoverage (ABN)” (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ABN_Booklet_ICN006266.pdf)

Kentucky and Ohio

Ambulance Services: Incomplete Documentation

This article highlights current Comprehensive Error Rate Testing (CERT) denials for Ambulance Services. In all of these instances, the reason for denial was incomplete documentation, even after multiple attempts were made to obtain more information. Although your organization may not have had claims denied for this reason, CGS strongly encourages all ambulance providers to review these examples and be aware of common documentation errors.

yy Missing Physician Certification Statement (PCS) for non-emergent BLS transport, or documentation of attempts to obtain certification for submitted date of service 09/21/2012. Received the transport record only. The CERT contractor requested additional documents; however, no further documentation was received.yy Submitted BLS ambulance service with HCPCS modifier EJ modifier- residence/ domiciliary to non hospital based dialysis) and 3 units for mileage. Missing the ambulance record that contains the pickup address and the destination address and the total loaded miles for the transport to the Dialysis Center. Submitted documentation consists of ambulance transport record, unsigned Patient Evaluation Form for 01/08/2013 (after date of service), billing form, beneficiary signed consent, Physicians Certification Statement for ambulance transport for dialysis which is signed 09/15/12 (for 90 days). CGS called the provider in order to obtain documentation to support the pickup point with full address and the delivery address as well as the mileage billed. No documentation to support addresses for pickup and destination was submitted.yy This claim was submitted for Ambulance Service, Basic Life Support with HCPCS modifier RH for date of service 09/29/2012. Missing documentation to support why patient was transported by ambulance for a non-emergent problem and why other means of transportation was not used. Documentation received initially includes hospital face sheet and EMS Report for 09/29/2012 which documents chief complaint: constipated, paid. Findings: “32 y/o male patient met us at the door to his apartment. Patient stated he had not had a bowel movement for at least a day and that he had lower right quadrant abdominal pain… felt he was constipated after having difficulty producing stool.” The CERT contractor requested additional documentation and received a duplicate EMS report and ED note stating: “32 y/o male presents with constipation. He is seen here frequently for constipation and urinary retention. He has no abdominal pain at this time. There is no nausea, vomiting, diarrhea or GI bleed.” There was inadequate documentation to support medical necessity of the billed service.yy Submitted basic life support emergency ambulance transport service with HCPCS modifier RH for date of service 11/10/2012. Missing copy of the beneficiary’s signature to authorize accepting of assignment and claim submission for this date of service, or that of his or her representative if the beneficiary was unable to sign the claim form; and authenticated ambulance transport record for submitted date of service supporting BLS emergency ambulance transport. Submitted records include unsigned transport data flow sheets dated 11/09/2012 and 11/10/2012, beneficiary’s name not listed. The CERT contractor requested additional documentation; none was submitted. Documentation is insufficient to support this claim per Medicare guidelines.


http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ABN_Booklet_ICN006266.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ABN_Booklet_ICN006266.pdf

KE

NT

UC

KY

& O

HIO

PA

RT

B




7

References:

yy CGS Ambulance Checklist (http://www.cgsmedicare.com/kyb/coverage/mr/PDF/Ambulance.pdf)yy CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 10 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c10.pdf): Ambulance Servicesyy Requirements for Physician Certification Statements: Code of Federal Regulations - 42 CFR 410.40(d)(3) (http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AmbulanceFeeSchedule/Downloads/cfr410_40.pdf)yy CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 15: Ambulance (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ clm104c15.pdf)yy Form: Physician Certification Statement (http://www.cgsmedicare.com/ohb/pubs/news/2014/0214/cope24601.html) (you may use this form or create your own, as long as it meets Medicare requirements)

Kentucky and Ohio

MM8620 Revised: CWF Editing for Vaccines Furnished at Hospice - Correction

The Centers for Medicare & Medicaid Services (CMS) has issued the following revision to a Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/2014-MLN-Matters-Articles.html

MLN Matters® Number: MM8620 RevisedRelated CR Release Date: April 28, 2014Related CR Transmittal #: R1373OTN

Related Change Request (CR) #: CR 8620 Effective Date: October 1, 2013Implementation Date: April 7, 2014

Note: This article was revised on May 1, 2014, to reflect the revised CR8620 issued on April 28. In the article, we added a reference to Home Health and Hospice MACs. Also, the CR transmittal number, the CR release date, and the Web address for accessing the CR are revised. All other information remains the same.


This MLN Matters® Article is intended as an update for non-hospice providers furnishing vaccines to hospice beneficiaries and submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs.


The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 8620 to alert providers that any provider may furnish vaccines to hospice beneficiaries. Be sure your billing staffs are aware of this change.

Background

When CR 8098, Transmittal 1298, was published, effective October 1, 2013, it denied claims for vaccines furnished to hospice patients that were provided by anyone other than the patient’s hospice provider. This was to enforce the statement in the ‘Medicare Claims Processing Manual,” chapter 18, section 10.2.4 that vaccines “may be covered when furnished by the hospice.” CMS has determined that this enforcement is too restrictive, since the manual does not say “only when furnished by the hospice.” CR 8620 removes the changes made to Medicare systems in CR 8098, in order to allow any provider to furnish vaccines to hospice beneficiaries.


http://www.cgsmedicare.com/kyb/coverage/mr/PDF/Ambulance.pdf

http://www.cgsmedicare.com/kyb/coverage/mr/PDF/Ambulance.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c10.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c10.pdf

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AmbulanceFeeSchedule/Downloads/cfr410_40.pdf

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AmbulanceFeeSchedule/Downloads/cfr410_40.pdf



http://www.cgsmedicare.com/ohb/pubs/news/2014/0214/cope24601.html




KE

NT

UC

KY

& O

HIO

PA

RT

B




8

Key Points

yy Your MAC will allow professional claims for vaccines (Influenza, PPV, and Hepatitis B) and vaccine administration containing modifier GW when the date of service falls within a hospice election. Your MAC will adjust vaccine claims with dates of service on or after October 1, 2013, which were previously rejected due to a hospice election, if you bring such claims to your MAC’s attention.


The official instruction, CR 8620, issued to your MAC regarding this change is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1373OTN.pdf on the CMS website.

Kentucky and Ohio

MM8711: Implement Operating Rules - Phase III ERA EFT: CORE 360 Uniform Use of Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC) Rule - Update from CAQH CORE - June 1, 2014 version 3.0.5


MLN Matters® Number: MM8711Related CR Release Date: May 2, 2014Related CR Transmittal #: R1378OTN

Related Change Request (CR) #: CR 8711 Effective Date: September 2, 2014Implementation Date: September 2, 2014


This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.

What You Need to Know

This article is based on Change Request (CR) 8711, which instructs the MACs to update the Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC) Rule. If you use Medicare’s PC Print or Medicare Remit Easy Print (MREP) software, you will need to obtain the new version after it is updated on October 6, 2014. Make sure that your billing staffs are aware of these changes.

Background

The Department of Health and Human Services (HHS) adopted the Phase III Council for Affordable Quality Healthcare (CAQH) CORE Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) Operating Rule Set that must be implemented by January 1, 2014, under the Affordable Care Act.

Health Insurance Portability and Accountability Act (HIPAA) amended the Social Security Act by adding Part C—Administrative Simplification—to Title XI of the Social Security Act, requiring the Secretary of HHS (the Secretary) to adopt standards for certain transactions to enable health information to be exchanged more efficiently and to achieve greater uniformity in the transmission of health information.


http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1373OTN.pdf




KE

NT

UC

KY

& O

HIO

PA

RT

B




9

Through the Affordable Care Act, Congress sought to promote implementation of electronic transactions and achieve cost reduction and efficiency improvements by creating more uniformity in the implementation of standard transactions. This was done by mandating the adoption of a set of operating rules for each of the HIPAA transactions. The Affordable Care Act defines operating rules and specifies the role of operating rules in relation to the standards.

CAQH CORE will publish the next version of the Code Combination List on or about June 1, 2014. This update is based on March 1, 2014, CARC and RARC updates as posted at the Washington Publishing Company (WPC) website. (Visit http://www.wpc-edi.com/ reference for CARC and RARC updates and http://www.caqh.org/CORECodeCombinations.php for CAQH CORE defined code combination updates.)

Note: Per the Affordable Care Act mandate, all health plans including Medicare must comply with CORE 360 Uniform Use of CARCs and RARCs (835) rule or CORE developed maximum set of CARC/RARC/Group Code for a minimum set of four Business Scenarios. Medicare can use any code combination if the business scenario is not one of the four CORE defined business scenarios but for the four CORE defined business scenarios, Medicare must use the code combinations from the lists published by CAQH CORE.


The official instruction, CR 8711, issued to your MAC regarding this change, is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1378OTN.pdf on the Centers for Medicare & Medicaid Services (CMS) website.

If you have any questions, please contact your MAC at their toll-free number. That number is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html under - How Does It Work?

Kentucky and Ohio

MM8695 Revised: Calendar Year (CY) 2014 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment - REVISION


MLN Matters® Number: MM8695 RevisedRelated CR Release Date: May 2, 2014Related CR Transmittal #: R2948CP

Related Change Request (CR) #: CR 8695 Effective Date: January 1, 2014Implementation Date: On or before June 30, 2014

Note: This article was revised on May 6, 2014, to reflect the revised CR8695 issued on May 2. The article is revised to reflect an implementation date on or before June 30, 2014. Also, the CR release date, transmittal number, and the Web address for accessing the CR were changed. All other information remains the same.


This MLN Matters® article is intended for clinical diagnostic laboratories who submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.


http://www.wpc-edi.com/

http://www.caqh.org/CORECodeCombinations.php



http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html




KE

NT

UC

KY

& O

HIO

PA

RT

B




10

What You Need to Know

This MLN Matters® article is based on Change Request (CR) 8695 which provides instructions for the revised CY 2014 clinical laboratory fee schedule, including several codes that were inadvertently left off of the previous CY 2014 fee schedule files. These codes, which were intended to be included on the original CY 2014 clinical laboratory fee schedule file, were recently given a “QW” modifier to both identify the codes and to determine payment for tests performed by a laboratory having only a certificate of waiver under CLIA. Also, CR8695 corrects a technical oversight that led to the misstatement of several prices on the fee schedule. Those prices reflected on this file created for CR8695 are now correct. Be sure your billing staffs are aware of these updates.

Background

CR 8695 provides instructions for the revised Calendar Year (CY) 2014 clinical laboratory fee schedule.

Access to Data File

The revised CY 2014 clinical laboratory fee schedule data file will be available on the Internet on or after February 28, 2014, at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/index.html on the CMS website.

Other interested parties, such as the Medicaid State agencies, the Indian Health Service, the United Mine Workers, and the Railroad Retirement Board, will also use the Internet to retrieve the CY 2014 clinical laboratory fee schedule which will be available in multiple formats including Excel, text, and comma delimited.

Mapping Information

Existing codes that have been recalculated so that their national limitation amount (NLA) and/or price for each MAC is correct. These codes are 80160, 82017, 82136, 82139,82261, 82270, 82271, 82271QW, 82272, 82272QW, 82274, 82274QW, 82379, 83013, 83080, 85576, 85576QW, 86355, 86357, 86359, 86367, G0123, G0328, and G0328QW.

Existing Code Pricing

yy Existing code 86152 is priced at the 2013 contractor gap filled rate.yy Existing code 86294QW is priced at 100 percent of the midpoint in the NLA pricing.


Note that your MAC will not automatically adjust claims processed prior to implementation of CR8695. However, if you have claims that need adjustment, your MAC will adjust those claims that you bring to their attention.

The official instruction, CR 8695, issued to your MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2948CP.pdf on the Centers for Medicare & Medicaid Services (CMS) website.

If you have any questions, please contact your MAC at their toll-free number. That number is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html under - How Does It Work.


http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/index.html

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/index.html





KE

NT

UC

KY

& O

HIO

PA

RT

B




11

Kentucky and Ohio

Preventive and Screening Services: Overview of Coverage under Medicare

Medicare covers a variety of preventive and screening services. Some preventive services require that certain criteria or frequency requirements be met.

yy The CMS Preventive Services Web page (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html) provides helpful information regarding all potentially covered preventive services for Medicare beneficiaries. This Web page is a great starting point for further research about specific types of preventive services that may be covered under Medicare.

yy Refer to this handy CMS Medicare Learning Network Preventive Services Quick Reference Chart (http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf) for a summary of preventive services and applicable criteria for coverage.

Flu and Pneumonia Vaccines

Medicare pays for a seasonal flu shot for Medicare fee-for-service beneficiaries. There is no coinsurance amount and flu shots are not subject to the annual deductible, if the vaccine is provided by a Medicare-enrolled provider. In general, Medicare covers a pneumonia vaccine once in a patient’s lifetime. Additional vaccinations may be covered based on risk or if the beneficiary’s vaccination status is uncertain.

Helpful resources from the CMS Medicare Learning network include:

yy Mass Immunizers and Roster Billing (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Mass_Immunize_Roster_ Bill_factsheet_ICN907275.pdf)yy Preventive Immunizations (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Preventive-Immunizations- ICN907787.pdf)

Annual Wellness Visit (AWV) and Initial Preventive Physical Examination (IPPE)

Medicare covers an Annual Wellness Visit (AWV) for beneficiaries who are no longer within 12 months of the effective date of their initial Medicare Part B coverage period and who have not received either an Initial Preventive Physical Examination (IPPE) or AWV within the past 12 months. Requirements for the initial AWV are different from requirements for subsequent AWVs.

Medicare also covers an Initial Preventive Physical Examination (IPPE) for all newly-enrolled beneficiaries, within 12 months of the effective date of their first Medicare Part B coverage. The IPPE is a one-time benefit per beneficiary. The IPPE includes seven required components and is not the same as a “routine physical exam.”

Helpful resources include the following publications from the CMS Medicare Learning Network:

yy Providing the Annual Wellness Visits (AWV) (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AnnualWellnessVisit-ICN907786.pdf)yy Quick reference chart: The ABCs of Providing the Annual Wellness Visit (AWV) (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AWV_Chart_ICN905706.pdf)yy Required components for IPPEs and how to help beneficiaries prepare: Expanded Benefits: Initial Preventive Physical Examination; Ultrasound Screening for Abdominal


http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html

http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf

http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Mass_Immunize_Roster_Bill_factsheet_ICN907275.pdf



http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Preventive-Immunizations-ICN907787.pdf



http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AnnualWellnessVisit-ICN907786.pdf



https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AWV_Chart_ICN905706.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AWV_Chart_ICN905706.pdf

KE

NT

UC

KY

& O

HIO

PA

RT

B




12

Aortic Aneurysm; Cardiovascular Screening Blood Tests (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Expanded_Benefits.pdf)yy The ABCs of Providing the Initial Preventive Physical Examination (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MPS_QRI_IPPE001a.pdf)

Screening for Alcohol Abuse

Medicare covers annual screening for alcohol misuse. Medicare also covers up to 4 “brief face-to-face counseling interventions” in a 12-month period for those who screen positive.

Refer to these CMS Medicare Learning Network publications for more information:

yy Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Reduce-Alcohol-Misuse-ICN907798.pdf)

Depression Screening

Medicare covers annual screening for depression, up to 15 minutes, for Medicare beneficiaries, in primary care settings that have staff-assisted depression care support in place to ensure accurate diagnosis, effective treatment, and follow-up. Other requirements also apply. For more information, refer to the CMS Medicare Learning Network publication “Screening for Depression” (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Screening-for-Depression-Booklet-ICN907799.pdf).

Other Screening

Other helpful resources from the CMS Medicare Learning Network include:

yy Various publications available in the CMS Medicare Learning Network catalog (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MLNCatalog.pdf) (refer to the catalog for the most up-to-date materials)yy For help explaining coverage of preventive services to your Medicare patients, refer to the Medicare.gov (http://www.medicare.gov/coverage/preventive-and-screening-services.html) website.

Kentucky and Ohio

MM8401 Revised: Mandatory Reporting of an 8-Digit Clinical Trial Number on Claims


MLN Matters® Number: MM8401 RevisedRelated CR Release Date: May 13, 2014Related CR Transmittal #: R2955CP

Related Change Request (CR) #: CR 8401 Effective Date: January 1, 2014Implementation Date: January 6, 2014

Note: This article was revised on June 9, 2014, to emphasize that coding “CT” in front of the clinical trial number applies ONLY to paper claims. The “CT” is not to be coded on electronic claims. All other information remains the same.


http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Expanded_Benefits.pdf



http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MPS_QRI_IPPE001a.pdf



http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Reduce-Alcohol-Misuse-ICN907798.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Reduce-Alcohol-Misuse-ICN907798.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Screening-for-Depression-Booklet-ICN907799.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Screening-for-Depression-Booklet-ICN907799.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MLNCatalog.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MLNCatalog.pdf

http://www.medicare.gov/coverage/preventive-and-screening-services.html

http://www.medicare.gov/coverage/preventive-and-screening-services.html



KE

NT

UC

KY

& O

HIO

PA

RT

B




13


This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare contractors (Fiscal Intermediaries (FIs), carriers, Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) and A/B MACs) for items and services provided in clinical trials to Medicare beneficiaries.


This article is based on CR 8401, which informs you that, effective January 1, 2014, it will be mandatory to report a clinical trial number on claims for items and services provided in clinical trials that are qualified for coverage as specified in the “Medicare National Coverage Determination (NCD) Manual,” Section 310.1.

The clinical trial number to be reported is the same number that has been reported voluntarily since the implementation of CR 5790, dated January 18, 2008. That is the number assigned by the National Library of Medicine (NLM) http://clinicaltrials.gov website when a new study appears in the NLM Clinical Trials data base.

Make sure that your billing staffs are aware of this requirement.

Background

CR 5790, Transmittal 310, dated January 18, 2008, titled “Requirements for Including an 8- Digit Clinical Trial Number on Claims” is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R310OTN.pdf on the CMS website. The MLN Matters® Article for CR5790 is available at http://www.cms.gov/Outreachand-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM5790.pdf on the CMS website.

This number is listed prominently on each specific study’s page and is always preceded by the letters ‘NCT.’

The Centers for Medicare & Medicaid Services (CMS) uses this number to identify all items and services provided to beneficiaries during their participation in a clinical trial, clinical study, or registry. Furthermore, this identifier permits CMS to better track Medicare payments, ensure that the information gained from the research is used to inform coverage decisions, and make certain that the research focuses on issues of importance to the Medicare population.

Suppliers may verify the validity of a trial/study/registry by consulting CMS’s clinical trials/registry website at http://www.cms.gov/Medicare/Medicare-General-Information/MedicareApprovedFacilitie/index.html on the CMS website.

For institutional claims that are submitted on the electronic claim 837I, the 8-digit number should be placed in Loop 2300 REF02 (REF01=P4) when a clinical trial claim includes:

yy Condition code 30;yy ICD-9 code of V70.7/ICD-10 code Z00.6 (in either the primary or secondary positions) andyy Modifier Q0 and/or Q1, as appropriate (outpatient claims only).

For professional claims, the 8-digit clinical trial number preceded by the 2 alpha characters of CT (use CT only on paper claims) must be placed in Field 19 of the paper claim Form CMS-1500 (e.g., CT12345678) or the electronic equivalent 837P in Loop 2300 REF02(REF01=P4) (do not use CT on the electronic claim, e.g., 12345678) when a clinical trial claim includes:

yy ICD-9 code of V70.7/ICD-10 code Z00.6 (in either the primary or secondary positions) and

yy Modifier Q0 and/or Q1, as appropriate (outpatient claims only).

Medicare Part B clinical trial/registry/study claims with dates of service on and after January 1, 2014, not containing an 8-digit clinical trial number will be returned as unprocessable to the provider for inclusion of the trial number using the messages listed below.


http://clinicaltrials.gov



http://www.cms.gov/Outreachand-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM5790.pdf

http://www.cms.gov/Outreachand-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM5790.pdf

http://www.cms.gov/Medicare/Medicare-General-Information/MedicareApprovedFacilitie/index.html

http://www.cms.gov/Medicare/Medicare-General-Information/MedicareApprovedFacilitie/index.html

KE

NT

UC

KY

& O

HIO

PA

RT

B




14

yy Claim Adjustment Reason Code (CARC) 16: “Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either National Council for Prescription Drug Programs (NCPDP) Reject Reason Code, or Remittance Advice Remark Code (RARC) that is not an ALERT.)”yy RARC MA50: “Missing/incomplete/invalid Investigational Device Exemption number for FDA-approved clinical trial services.”yy RARC MA130: “Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.”yy Group Code-Contractual Obligation (CO).

Note: This is a reminder/clarification that clinical trials that are also investigational device exemption (IDE) trials must continue to report the associated IDE number on the claim form as well.


The official instruction, CR 8401, issued to your Medicare contractor regarding this change, may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2955CP.pdf on the CMS website.

See MLN Matters® Article SE1344 (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1344.pdf) for information on an interim alternative method of satisfying the requirement in CR 8401 for providers who do not have the ability to submit the clinical trial number for trial related claims.


Kentucky and Ohio

MM8664 Revised: April Update to the Calendar Year (CY) 2014 Medicare Physician Fee Schedule Database (MPFSDB)


MLN Matters® Number: MM8664 RevisedRelated CR Release Date: April 22, 2014Related CR Transmittal #: R2934CP

Related Change Request (CR) #: CR 8664 Effective Date: January 1, 2014Implementation Date: April 7, 2014

Note: This article was revised on May 16, 2014, to reflect the revised CR8664 issued on April 22. The article is revised to adjust table 2 on page 3 to clarify the effective dates for HCPCS code 77293 to be from January 1 to December 31, 2014. The CR release date, transmittal number, and the Web address for accessing the CR are revised. All other information remains the same.


This MLN Matters® Article is intended for physicians, other providers, and suppliers who submit claims to Medicare Claims Administration Contractors (carriers, Fiscal Intermediaries (FIs), A/B Medicare Administrative Contractors (MACs), Home Health and Hospices (HHHs), and/or Regional HH Intermediaries (RHHIs)) for services provided to Medicare beneficiaries.




http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1344.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1344.pdf





KE

NT

UC

KY

& O

HIO

PA

RT

B




15


This article is based on Change Request (CR) 8664 which amends the payment files that were issued to Medicare contractors based upon the CY 2014 MPFS, Final Rule and passage of the “Protecting Access to Medicare Act of 2014,” which the President signed on April 1, 2014. Make sure that your billing staffs are aware of these changes.

Background

The Social Security Act (Section 1848(c)(4); see http://www.ssa.gov/OP_Home/ssact/title18/1848.htm on the Internet) authorizes the Centers for Medicare & Medicaid Services (CMS) to establish ancillary policies necessary to implement relative values for physicians’ services.

In order to reflect appropriate payment policy as included in the CY 2014 MPFS Final Rule, the MPFSDB has been updated with April changes, and those necessitated by “Protecting Access to Medicare Act of 2014,” which the President signed on April 1, 2014. This law extends the 0.5% update through December 31, 2014. Since the Act extends the MPFSDB policies to all of CY 2014, the April update payment files that were previously created to be effective from January 1, 2014 to March 31, 2014, can now be used by MACs to be effective from January 1, 2014 to December 31, 2014.

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

CR 8664 Summary of Changes

The summary of changes for the April 2014 update consists of the following:

1. Short Description Corrections for HCPCS codes G0416 - G0419HCPCS Code Old Short Description Revised 2014 Short DescriptionG0416 Sat biopsy prostate 1-20 spc Biopsy prostate 10-20 spcG0417 Sat biopsy prostate 21-40 Biopsy prostate 21-40G0418 Sat biopsy prostate 41-60 Biopsy prostate 41-60G0419 Sat biopsy prostate: >60 Biopsy prostate: >60

2. Adjust the Facility and Non-Facility PE RVUs for HCPCS code 77293-Global and 77293-TC via CMS update files.

HCPCS Mod Status DescriptionNon- Facility PE RVUs

Facility PE RVUs Global

77293 A Respirator motion mgmt simul 9.96 NA ZZZ Jan 1 to March 31, 201477293 TC A Respirator motion mgmt simul 9.16 NA ZZZ Jan 1 to March 31, 2014

77293 A Respirator motion mgmt simul 10.72 NA ZZZCorrection April 1, 2014. RVU change effective January 1 to December 31, 2014.

77293 TC A Respirator motion mgmt simul 9.92 NA ZZZCorrection April 1, 2014. RVU change effective January 1 to December 31, 2014.

3. HCPCS code G9361 will be added to your Medicare contractor’s systems.HCPCS Code G9361Procedure Status MShort Descriptor Doc comm risk calcEffective Date 01/01/2014Work RVU 0Full Non-Facility PE RVU 0Full Non-Facility NA Indicator (blank)Full Facility PE RVU 0


http://www.ssa.gov/OP_Home/ssact/title18/1848.htm

http://www.ssa.gov/OP_Home/ssact/title18/1848.htm

KE

NT

UC

KY

& O

HIO

PA

RT

B




16

3. HCPCS code G9361 will be added to your Medicare contractor’s systems.HCPCS Code G9361Full Facility NA Indicator (blank)Malpractice RVU 0Multiple Procedure Indicator 9Bilateral Surgery Indicator 9Assistant Surgery Indicator 9Co-Surgery Indicator 9Team Surgery Indicator 9PC/TC 9Site of Service 9Global Surgery XXXPre 0.00Intra 0.00Post 0.00Physician Supervision Diagnostic Indicator 09Diagnostic Family Imaging Indicator 99Non-Facility PE used for OPPS Payment Amount 0.00

Facility PE used for OPPS Payment Amount 0.00MP Used for OPPS Payment Amount 0.00Type of Service 9

Long Descriptor

Medical indication for induction [Documentation of reason(s) for elective delivery or early induction (e.g., hemorrhage and placental complications, hypertension, preeclampsia and eclampsia, rupture of membranes-premature, prolonged maternal conditions complicating pregnancy/delivery, fetal conditions complicating pregnancy/delivery, malposition and malpresentation of fetus, late pregnancy, prior uterine surgery, or participation in clinical trial)]

4. Correct the Physician Supervision of Diagnostic Procedures indicator for the TC’s of the following codes, effective January 1, 2014.HCPCS Code

Physician Supervision of Diagnostic Procedures (Phys Diag Supv)

Effective Date

70450-TC Ct head/brain w/o dye - Phys Diag Supv Correction (TC) 01 01/01/201470460-TC Ct head/brain w/dye - Phys Diag Supv Correction (TC) 02 01/01/201470551-TC Mri brain stem w/o dye - Phys Diag Supv Correction (TC) 01 01/01/201470552-TC Mri brain stem w/dye - Phys Diag Supv Correction (TC) 02 01/01/201470553-TC Mri brain stem w/o & w/dye - Phys Diag Supv Correction (TC) 02 01/01/201472141-TC Mri neck spine w/o dye - Phys Diag Supv Correction (TC) 01 01/01/201472142-TC Mri neck spine w/dye - Phys Diag Supv Correction (TC) 02 01/01/201472146-TC Mri chest spine w/o dye - Phys Diag Supv Correction (TC) 01 01/01/201472147-TC Mri chest spine w/dye - Phys Diag Supv Correction (TC) 02 01/01/201472148-TC Mri lumbar spine w/o dye - Phys Diag Supv Correction (TC) 01 01/01/201472149-TC Mri lumbar spine w/dye - Phys Diag Supv Correction (TC) 02 01/01/201472156-TC Mri neck spine w/o & w/dye - Phys Diag Supv Correction (TC) 02 01/01/201472157-TC Mri chest spine w/o & w/dye - Phys Diag Supv Correction (TC) 02 01/01/201472158-TC Mri lumbar spine w/o & w/dye - Phys Diag Supv Correction (TC) 02 01/01/201472191-TC Ct angiograph pelv w/o&w/dye - Phys Diag Supv Correction (TC) 02 01/01/201474174-TC Ct angio abd&pelv w/o&w/dye - Phys Diag Supv Correction (TC) 02 01/01/201474175-TC Ct angio abdom w/o & w/dye - Phys Diag Supv Correction (TC) 02 01/01/201493880-TC Extracranial bilat study - Phys Diag Supv Correction (TC) 01 01/01/201493882-TC Extracranial uni/ltd study - Phys Diag Supv Correction (TC) 01 01/01/2014


KE

NT

UC

KY

& O

HIO

PA

RT

B




17

4. Correct the Physician Supervision of Diagnostic Procedures indicator for the TC’s of the following codes, effective January 1, 2014.HCPCS Code

Physician Supervision of Diagnostic Procedures (Phys Diag Supv)

Effective Date

77001-TC Fluoroguide for vein device - Phys Diag Supv Correction (TC) 03 01/01/201477002-TC Needle localization by xray - Phys Diag Supv Correction (TC) 03 01/01/201477003-TC Fluoroguide for spine inject - Phys Diag Supv Correction (TC) 03 01/01/2014


The official instruction, CR 8664, issued to your MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2934CP.pdf on the CMS website.

If you have any questions, please contact your DME MAC at their toll-free number. That number is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html under - How Does It Work.

Kentucky and Ohio

Care Plan Oversight Services for Patients Receiving Care through Home Health Agencies or Hospices

Care Plan Oversight (CPO) is physician supervision of patients under either the home health or hospice benefit where the patient requires complex or multi-disciplinary care requiring ongoing physician involvement. Medicare does not pay for care plan oversight services for nursing facility or skilled nursing facility patients. This article describes criteria for coverage as well as important information about submitting the hospice’s or home health agency’s (HHA’s) NPI on claims for CPO.

Applicable Codes HCPCS Code Short Description NotesG0179 MD re-certification HHA PT May be submitted per certification periodG0180 MD certification HHA patient May be submitted per certification periodG0181 Home health care supervision Requires 30 minutes or more of physician or NPP’s time within a calendar monthG0182 Hospice care supervision Requires 30 minutes or more of physician or NPP’s time within a calendar month

Note: The types of services that are included in CPO are included in the narrative descriptions for each HCPCS code.

Criteria for Coverage

The Centers for Medicare & Medicaid Services (CMS) Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, section 180.G lists criteria for coverage of CPO under Medicare:

1. The beneficiary requires complex or multi-disciplinary care modalities requiring the physician’s ongoing involvement in the beneficiary’s plan of care.

2. CPO services are furnished during the period in which the beneficiary was receiving Medicare-covered home health agency (HHA) or hospice services.

3. The physician who submits the claim for CPO must be the same physician that signed the home health or hospice plan of care.

4. The physician furnished at least 30 minutes of CPO within the calendar month. Time counted toward CPO may not include time spent by a nurse or time spent consulting with a nurse.






KE

NT

UC

KY

& O

HIO

PA

RT

B




18

5. Time counted toward hospital discharge management (CPT codes 99238-99239) or discharge from observation (CPT code 99217) may not also be counted toward CPO. Services that are separately documented and that are provided after the patient is physically discharged may be counted toward CPO.

6. The physician provided a covered service that required a face-to-face encounter (i.e., Evaluation & Management (E/M) service) with the beneficiary within the 6 months immediately preceding the CPO service. EKG, lab, and surgical services do not meet this face-to-face encounter requirement.

7. The CPO service may not be routine post-operative care provided during the global surgery period by the surgeon.

8. For home health CPO, the physician may not have a “significant financial or contractual interest in the home health agency.” For hospice CPO, the physician may not be employed by or volunteer as medical director of the hospice.

9. CPO services must be submitted by the same physician that provided the services.10. Services provided “incident to” a physician’s service may not be counted toward the

30-minute requirement for CPO. 11. The same physician may not submit a claim for both CPO and end stage renal disease

(ESRD) capitation payment for the same beneficiary during the same month.12. The physician must document, in the patient’s medical record, the services furnished to

the patient and date and length of time associated with these services.

CPO: Home Health

Medicare pays separately for the services involved in physician certification/re-certification and development of a plan of care for Medicare covered home health services when certain criteria are met.

yy Submit HCPCS code G0180 when the patient has not received Medicare covered home health services for at least 60 days. The initial certification (HCPCS code G0180) cannot be submitted for the same date of service as the supervision service HCPCS code (G0181). yy Submit HCPCS code G0179 for re-certification after a patient has received services for at least 60 days (or one certification period).

y� HCPCS code G0179 may be reported only once every 60 days, except in the rare situation when the patient starts a new episode before 60 days elapses and requires a new plan of care to start a new episode.

yy Special notes regarding certification and re-certification of home health care:

y� Physicians play a key role in determining and documenting the medical necessity for home health care for Medicare beneficiaries. As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face encounters (FTF) with your patients regarding home health care.y� For more information about required documentation for home health certification and re-certification, please refer to the CGS Web article “Face to Face Documentation for Home Health Certification: Important Information for Certifying Physicians and Non-physician Practitioners (NPPs)” (http://www.cgsmedicare.com/ohb/pubs/news/2013/0613/cope22407.html).

CPO: Hospice

Submit HCPCS code G0182 for CPO services provided to patients that have elected hospice benefits under Medicare and who are in a Medicare-approved hospice.

Claim Submission:

yy The patient does not have to be present in order for CPO services to be provided and claims submitted to Medicare.




KE

NT

UC

KY

& O

HIO

PA

RT

B




19

yy The HHA or Hospice Provider Number is required on claims for CPO (HCPCS codes G0181 and G0182).

y� Electronic claims: submit the HHA’s or hospice’s NPI, as appropriate, in loop 2300, ref segment, with qualifier 1J.y� Paper claims: submit the HHA’s or hospice’s NPI, as appropriate, in Item 23.

yy Dates of service:

y� For HCPCS codes G0181 and G0182, submit the first and last date during which documented care planning services were actually provided during the calendar month.

- Do not submit the first and last calendar date of the month unless services were provided on those dates

- Submit the claim after the end of the month in which the service is performed - Report care planning only once per calendar month - Report only one month of services per line item

y� For HCPCS codes G0179 and G0180, submit the date physician signed the certification or re-certification.

yy Place of service: Submit the place of service code that corresponds to where the CPO services were provided. yy Submit CPT codes 99201-99263 and 99281-99357 only when there has been a face-to-face meeting/encounter.

Documentation:

yy Claims for care plan oversight services will be denied when review of the beneficiary’s claims history shows that there was no covered physician service requiring a face-to-face encounter by the same physician during the six months preceding the provision of the first care plan oversight service. yy Medical records for these service must indicate:

y� For HCPCS codes G0181 and G0182, the physician spent 30 minutes or more for countable care planning activities y� The specific service furnished, including the date and length of time

Reference:

yy CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, section 30, sub-section G (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf)yy CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12, section 180 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ clm104c12.pdf)yy CGS Web article “Face to Face Documentation for Home Health Certification: Important Information for Certifying Physicians and Non-physician Practitioners (NPPs)” (http://www.cgsmedicare.com/ohb/pubs/news/2013/0613/cope22407.html)

Kentucky and Ohio

Incarcerated Beneficiary Claims and Adjustments: Refunds and Deductibles

Between June 3 and August 31, 2013, some Informational Unsolicited Responses (IURs) incorrectly indicated that beneficiaries were incarcerated and that claims for services rendered to them should be denied.

The Healthcare Integrated General Ledger Accounting System (HIGLAS) has issued refunds on these erroneous incarcerated beneficiary IURs. These refunds were made without regard to the


http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf


KE

NT

UC

KY

& O

HIO

PA

RT

B




20

then-current status of the Medicare deductible, as well as without verifying whether the provider had subsequently resubmitted and been paid for the cancelled claim, or had been issued a refund upon appeal.

In accordance with CMS Change Request 8536, CGS will be reconciling Fiscal Intermediary Shared System (FISS) and Multi-Carrier System (MCS) history, researching potential overpayment situations, and generating accounts receivable and overpayment demand letters where appropriate. However, updated remittance advices (RAs) will not be issued, nor will revisions be posted to history on Medicare Summary Notices (MSNs).

There could be situations where the cancellation of the original claim resulted in the cancellation of a previously assessed deductible, but the provider was paid for the deductible on the HIGLAS refund, and the deductible was not subsequently satisfied. Where the beneficiary has supplemental insurance and the trading partner has chosen to accept adjustments, CMS will be forwarding notice of this action to the trading partner.

However, there could be situations where the supplemental insurer refuses to process the deductible claim without an RA or MSN. Please contact the CGS in writing in these situations to request written confirmation of the situation, and CGS will provide this information.

Written Correspondence AddressPart A

1.866.590.6703

CGS J15 Part A PCC PO Box 20200 Nashville, TN 37202

Part B

1.866.276.9558

J15 — Part A/ B Correspondence CGS Administrators, LLC PO Box 20018 Nashville, TN 37202

Home Health & Hospice

1.877.299.4500

J15 — HHH Correspondence CGS Administrators, LLC PO Box 20014 Nashville, TN 37202

Kentucky and Ohio

MM8667: Posting the Limiting Charge after Applying the Electronic Health Record (EHR) and Physician Quality Reporting System (PQRS) Negative Adjustments


MLN Matters® Number: MM8667Related CR Release Date: May 16, 2014Related CR Transmittal #: R1384OTN

Related Change Request (CR) #: CR 8667 Effective Date: January 1, 2015Implementation Date: October 6, 2014


This MLN Matters® Article is intended for Medicare eligible professionals (EPs) submitting professional claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.




KE

NT

UC

KY

& O

HIO

PA

RT

B




21


This article is based on Change Request (CR) 8667, whose purpose is to place the Electronic Health Record (EHR) and Physician Quality Reporting System (PQRS) Negative Adjustment Limiting Charge amounts on MAC websites and hard copy disclosure reports. EPs under the Medicare EHR Incentive Program include: Doctor of medicine or osteopathy, Doctor of oral surgery or dental medicine, Doctor of podiatry, Doctor of optometry, and Chiropractor. Be sure your billing staffs are aware of these changes.

Background

Electronic Health Record (EHR)

Beginning January 1, 2015, Section 1848(a)(7) of the Social Security Act as amended by Section 4101(b) of the HITECH Act, requires that EPs that are not meaningful EHR users are subject to the EHR negative adjustment.

Specifically, section 1848(a)(7) of the Act states that: “If the eligible professional is not a meaningful EHR user (as determined under subsection (o)(2)) for an EHR reporting period for the year, the fee schedule amount for such services furnished by such professional during the year (including the fee schedule amount for purposes of determining a payment based on such amount) shall be equal to the applicable percent of the fee schedule amount that would otherwise apply to such services under this subsection (determined after application of paragraph (3) but without regard to this paragraph).”

Physician Quality Reporting System (PQRS)

Beginning on January 1, 2015, Section 1848(a)(8) of the Social Security Act, as added by section 3002(b) of the Affordable Care Act, requires that EPs who do not satisfactorily report data on quality measures for covered professional services for the quality reporting period of the year are subject to the PQRS negative adjustment.

Specifically, section 1848(a)(8) of the Act states that: “If the eligible professional does not satisfactorily submit data on quality measures for covered professional services for the quality reporting period for the year (as determined under subsection (m)(3)(A)), the fee schedule amount for such services furnished by such professional during the year (including the fee schedule amount for purposes of determining a payment based on such amount) shall be equal to the applicable percent of the fee schedule amount that would otherwise apply to such services under this subsection (determined after application of paragraphs (3), (5), and (7), but without regard to this paragraph).”

The negative payment adjustment applies to all EPs, regardless of whether the EP elects to be “participating” or “non-participating” for purposes of Medicare payments.

Non-participating (Non-Par) EPs in the Medicare program may choose either to accept or not accept assignment on Medicare claims on a claim-by-claim basis. If EPs choose not to accept assignment, they may not charge the beneficiary more than the Medicare limiting charge for unassigned claims for Medicare services. The limiting charge is 115 percent of the MPFS amount. The beneficiary is not responsible for billed amounts in excess of the limiting charge for a covered service.

Non-participating EPs that do not accept assignment on a claim may choose to collect the entire limiting charge amount up front from the beneficiary at the time of service.

Submission of a non-par, non-assigned Medicare Physician Fee Schedule (MPFS) service with a charge in excess of the Medicare limiting charge amount constitutes a violation of the limiting charge. A physician or supplier who violates the limiting charge is subject to a civil monetary penalty of not more than $10,000, an assessment of not more than 3 times the amount claimed for each item or service, and possible exclusion from the Medicare program. Therefore, it is crucial that EPs are provided with the correct limiting charge they may bill for a MPFS service.


KE

NT

UC

KY

& O

HIO

PA

RT

B




22

Your MAC will list and display the limiting charge amount after applying the EHR and PQRS negative adjustment on their website. Specifically, they will add the following to their website:

yy EHR Limiting Charge;yy PQRS Limiting Charge;yy EHR/2014 eRx Limiting Charge;yy EHR + PQRS Limiting Charge; andyy EHR/2014 eRx + PQRS Limiting Charge.

Examples

Non-Par Non-Assigned Claim No EHR/PQRS Adjustment:

Original Fee Schedule Amount: $1005% non-PAR status: $5 (100 x .05)Adjustment Total $5.00MPFS Allowed Amount $100-$5.00= $95.00Limiting Charge Allowed= $95.00 x 115%= $109.25

Non-Par Non-Assigned Claim with EHR Adjustment:

Original Fee Schedule Amount: $1005% non-PAR status: $5 (100 x .05)1% EHR negative adjustment $.95 (95 x.01)Adjustment Total $5.95MPFS Allowed Amount $100-$5.95= $94.05Limiting Charge Allowed= $94.05 x 115%= $108.16

Non-Par Non-Assigned Claim with PQRS Adjustment:

Original Fee Schedule Amount: $1005% non-PAR status: $5 (100 x .05)1.5% PQRS negative adjustment $1.43 (95 x.015)Adjustment Total $ 6.43MPFS Allowed Amount $100-$6.43= $93.57Limiting Charge Allowed= $93.57 x 115%= $107.61

Non-Par Non-Assigned Claim with EHR + e-prescribing:

Original Fee Schedule Amount: $1005% non-PAR status: $5 (100 x .05)2% PQRS negative adjustment $1.90 (95 x.02)Adjustment Total $ 6.90MPFS Allowed Amount $100-$6.90= $93.10Limiting Charge Allowed= $93.10 x 115%= $107.07

Non-Par Non-Assigned Claim with EHR without 2014 e-Prescribing Adjustment + PQRS:

Original Fee Schedule Amount: $1005% non-PAR status: $5 (100 x .05)1% EHR negative adjustment $.95 (95 x .01)EHR Adjustment Total $5.95MPFS Allowed Amount $100-$5.95= $94.051.5% PQRS negative adjustment $1.41 ($94.05 x .015)PQRS Adjustment Total $94.05-$1.41=$92.64MPFS Allowed Amount $92.64Limiting Charge Allowed= $92.64 x 115%= $106.54


KE

NT

UC

KY

& O

HIO

PA

RT

B




23

Non-Par Non-Assigned Claim with EHR with 2014 e-Prescribing Adjustment + PQRS:

Original Fee Schedule Amount: $1005% non-PAR status: $5 (100 x .05)2% EHR negative adjustment $1.90 (95 x .02)EHR Adjustment Total $6.90MPFS Allowed Amount $100-$6.90= $93.101.5% PQRS negative adjustment $1.40 (93.10 x .015)PQRS Adjustment Total $93.10-$1.40=$91.70MPFS Allowed Amount $91.70Limiting Charge Allowed= $91.70 x 115%= $105.46


Information about the EHR Incentive Programs is available at http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html on the Centers for Medicare & Medicaid Services (CMS) website.

Information about “Physician Quality Reporting System (PQRS) Payment Adjustment Information” is available at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Payment-Adjustment-Information.html on the CMS website.

The official instruction, CR 8667, issued to your MAC regarding this change, may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1384OTN.pdf on the CMS website.

If you have any questions, please contact your MAC at their toll-free number. That number is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html under - How Does It Work. You can also find a link to your MAC’s website at this page.

Kentucky and Ohio

MM8456 Rescinded: Modifying the Daily Common Working File (CWF) to Medicare Beneficiary Database (MBD) File to Include Diagnosis Codes on the Health Insurance Portability and Accountability Act Eligibility Transaction System (HETS) 270/271 Transactions

The Centers for Medicare & Medicaid Services (CMS) has rescinded the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/2014-MLN-Matters-Articles.html

MLN Matters® Number: MM8456 RescindedRelated CR Release Date: May 16, 2014Related CR Transmittal #: R1386OTN

Related Change Request (CR) #: CR 8456 Effective Date: October 1, 2014Implementation Date: October 6, 2014

Note: This article was rescinded on May 20, 2014, as a result of a revision to CR8456, issued on May 16. The CR revision eliminated the need for provider education. As a result, this article is rescinded.


http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Payment-Adjustment-Information.html

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Payment-Adjustment-Information.html







KE

NT

UC

KY

& O

HIO

PA

RT

B




24

Kentucky and Ohio

MM8757: Percutaneous Image-Guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS)


MLN Matters® Number: MM8757Related CR Release Date: May 16, 2014Related CR Transmittal #: R167NCD and R2959CP

Related Change Request (CR) #: CR 8757 Effective Date: January 9, 2014Implementation Date: October 6, 2014


This MLN Matters® Article is intended for providers submitting claims to Medicare Administrative Contractors (MACs) for services furnished to Medicare beneficiaries.


Effective for claims with dates of service on and after January 9, 2014, Medicare will only allow coverage with evidence development (CED) for percutaneous image-guided lumbar decompression (PILD) for lumbar spinal stenosis (LSS) for beneficiaries enrolled in an approved clinical trial.

Background

PILD is a procedure that was proposed as a treatment for symptomatic LSS unresponsive to conservative therapy. PILD is a posterior decompression of the lumbar spine performed under indirect image guidance without any direct visualization of the surgical area. It is generally described as a non-invasive procedure using specially designed instruments to percutaneously remove a portion of the lamina and debulk the ligamentum flavum. The procedure is performed under x-ray guidance (e.g., fluoroscopic, CT) with the assistance of contrast media to identify and monitor the compressed area via epiduragram.

The Centers for Medicare & Medicaid Services (CMS) currently does not cover PILD; and moreover, after careful consideration, determines that PILD for lumbar spinal stenosis LSS is not reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act (the Act).

However, CMS has determined that effective for claims with dates of service on or after January 9, 2014, Medicare will cover PILD only when it is provided in a clinical study under section 1862(a)(1)(E) of the Act, through CED, for beneficiaries with LSS who are enrolled in an approved clinical study that meets the criteria described in the National Coverage Determinations (NCD) Manual at NCD150.13.

Specific Payment Actions

yy On or after January 9, 2014, effective for hospital outpatient procedures on type of bill (TOB) 13X or 85X, and for professional claims billed with a place of service (POS) 22 (outpatient) or 24 (ambulatory surgical center), Medicare will allow CED for PILD (procedure code 0275T) for LSS, ICD-9 diagnosis range 724.01-724.03, or ICD-10 diagnosis range M48.05-M48.07, only when billed with:

a. Diagnosis code ICD-9 V70.7 (ICD-10 Z00.6) and condition code 30 either in the primary or secondary positions; and

b. Modifier Q0; and




KE

NT

UC

KY

& O

HIO

PA

RT

B




25

c. An 8-digit clinical trial number listed at http://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/PILD.html on the CMS CED website.

yy On or after January 9, 2014, effective for hospital outpatient procedures on type of bill (TOB) 13X or 85X, your MAC will reject claims for PILD, procedure code 0275T for LSS, ICD-9 diagnosis range 724.01-724.03, or ICD-10 diagnosis range M48.05-M48.07, when billed without:

a. Diagnosis code ICD-9 V70.7 (ICD-10 Z00.6) in either the primary/secondary positions;

b. Modifier Q0, condition code 30 (institutional claims only); and,c. An 8-digit clinical trial number listed on the CMS website.

When rejecting these claims, they will use:

a. Claims Adjustment Reason Code (CARC): 50 -These are non-covered services because this is not deemed a “medical necessity” by the payer;

b. Remittance Advice Remarks Code (RARC) N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp. If you do not have Web access, you may contact the contractor to request a copy of the NCD; and

c. Group Code – Contractual Obligation (CO).

yy MACs will return the professional PILD claim as unprocessable when billed with a diagnosis code other than 724.01-724.03 (ICD-9) or M48.05-M48.07 (ICD-10), using:

a. CARC B22: “This payment is adjusted based on the diagnosis;”b. RARC N704: “Alert: You may not appeal this decision but can resubmit this claim/

service with corrected information if warranted.”; andc. Group Code-Contractual Obligation (CO).

yy MACs will return the professional PILD claim as unprocessable when billed in a place of service other than 22 (outpatient) or 24 (ambulatory surgical center), using:

a. CARC 58: “Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service;”

b. RARC N704: “Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted.”; and

c. Group Code-Contractual Obligation (CO).

yy MACs will return the professional PILD claim as unprocessable if it does not contain the required clinical trial diagnosis code V70.7 (ICD-9) or Z00.6 (ICD-10) in either the primary/secondary positions, using:

a. CARC B22: “This payment is adjusted based on the diagnosis;”b. RARC M76: “Missing/incomplete/invalid diagnosis or condition;”c. RARC N704: “Alert: You may not appeal this decision but can resubmit this claim/

service with corrected information if warranted.”; andd. Group Code-Contractual Obligation (CO).

yy MACs will return the professional PILD claim as unprocessable when billed without Modifier Q0, using:

a. CARC 4: “The procedure code is inconsistent with the modifier used or a required modifier is missing;”

b. RARC N657: “This should be billed with the apporpriate code for these services.”;c. RARC N704: “Your claim contains incomplete and/or invalid information, and no

appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information;” and

d. Group Code-Contractual Obligation (CO).


http://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/PILD.html

http://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/PILD.html

http://www.cms.hhs.gov/mcd/search.asp

KE

NT

UC

KY

& O

HIO

PA

RT

B




26

yy MACs will accept the numeric, 8-digit clinical trial identifier number preceded by the two alpha characters of “CT” when placed in Field 19 of paper Form CMS-1500, or when entered WITHOUT the “CT” prefix in the electronic 837P in Loop 2300 REF02 (REF01=P4). NOTE: The “CT” prefix is required on a paper claim, but it is not required on an electronic claim. For PILD claims submitted without a clinical trial identifier number, they will follow the requirements outlined in CR8401, Mandatory Reporting of an 8-Digit Clinical Trial Number on Claims, released on October 30, 2013. You can find the associated MLN Matters® article at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8401.pdf on the CMS website.

MACs will not search their files to adjust claims already processed, but will adjust claims that you bring to their attention.

Finally, you should note that endoscopically assisted laminotomy/laminectomy, which requires open and direct visualization, as well as other open lumbar decompression procedures for LSS, are not within the scope of this NCD.


The official instruction, CR8757, issued to your MAC, consists of two transmittals. The first updates the “Medicare National Coverage Determinations Manual” and it is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R167NCD.pdf on the CMS website. The second transmittal updates the “Medicare Claims Processing Manual” and it is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2959CP.pdf on the same site.

Kentucky and Ohio

Provider Contact Center Reminders

Your questions are important to us, and CGS’s Provider Contact Centers (PCCs) strive to provide the most accurate and consistent information to our provider community. There may be times when we receive a question that requires additional research before an accurate response can be provided by the Customer Service Representative.

Please be advised that every effort is taken to research your questions and to return your call as soon as possible. However, the Centers for Medicare & Medicaid Services (CMS) does allow PCCs up to 10 business days to research and return your call. This information can be found in the CMS Medicare Contractor Beneficiary and Provider Communications Manual (Pub. 100-09) Chapter 6, Section 60.2.5 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/com109c06.pdf).

As a reminder, CGS offers the Interactive Voice Response (IVR) Unit and the myCGS Web portal for eligibility/claim status information.

yy IVR User Guide - http://www.cgsmedicare.com/kyb/claims/ivr/PartB_IVR_user_guide.pdfyy myCGS – http://www.cgsmedicare.com/kyb/index.html# (KY) and http://www.cgsmedicare.com/ohb/index.html# (OH)




http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R167NCD.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R167NCD.pdf



http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/com109c06.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/com109c06.pdf

http://www.cgsmedicare.com/kyb/claims/ivr/PartB_IVR_user_guide.pdf

http://www.cgsmedicare.com/kyb/index.html

http://www.cgsmedicare.com/ohb/index.html

http://www.cgsmedicare.com/ohb/index.html

KE

NT

UC

KY

& O

HIO

PA

RT

B




27

Kentucky and Ohio

MM8662: Quarterly Update to the Correct Coding Initiative (CCI) Edits, Version 20.3, Effective October 1, 2014


MLN Matters® Number: MM8662Related CR Release Date: May 23, 2014Related CR Transmittal #: R2969CP



This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries.


This article is based on Change Request (CR) 8662 which informs Medicare contractors about the release of the latest package of CCI edits, Version 20.3, which will be effective October 1, 2014. Make sure that your billing staffs are aware of these changes.

Background

The Centers for Medicare & Medicaid Services (CMS) developed the National CCI edits to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment in Part B claims. The coding policies developed are based on coding conventions defined in the American Medical Association’s Current Procedural Terminology manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practice, and review of current coding practice.

Version 20.3 will include all previous versions and updates from January 1, 1996, to the present. In the past, CCI was organized in two tables: Column 1/Column 2 Correct Coding Edits and Mutually Exclusive Code (MEC) Edits. In order to simplify the use of NCCI edit files (two tables), on April 1, 2012, CMS consolidated these two edit files into the Column One/Column Two Correct Coding edit file. Separate consolidations have occurred for the two practitioner NCCI edit files and the two NCCI edit files used for OCE. It will only be necessary to search the Column One/Column Two Correct Coding edit file for active or previously deleted edits. CMS no longer publishes a Mutually Exclusive edit file on its website for either practitioner or outpatient hospital services, since all active and deleted edits will appear in the single Column One/Column Two Correct Coding edit file on each website. The edits previously contained in the Mutually Exclusive edit file are NOT being deleted but are being moved to the Column One/Column Two Correct Coding edit file.


For additional information, refer to the CMS NCCI webpage at http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html on the CMS website.

The official instruction, CR 8662 issued to your MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2969CP.pdf on the CMS website.




http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html




KE

NT

UC

KY

& O

HIO

PA

RT

B




28

If you have any questions, please contact your MAC at their toll-free number, which may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html on the CMS website.

Kentucky and Ohio

MM8684: Claim Status Category and Claim Status Codes Update





This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and Home Health & Hospice MACs (HH&H MACs), for services to Medicare beneficiaries.


This article is based on Change Request (CR) 8684 which informs the MACs of the changes to Claim Status Category Codes and Claim Status Codes. Make sure that your billing personnel are aware of these changes.

Background

The Health Insurance Portability and Accountability Act (HIPAA) requires all health care benefit payers to use only Claim Status Category Codes and Claim Status Codes approved by the national Code Maintenance Committee in the X12 276/277 Health Care Claim Status Request and Response format adopted as the standard for national use (e.g. previous HIPAA named versions included 004010X093A1, more recent HIPAA named versions). These codes explain the status of submitted claim(s). Proprietary codes may not be used in the X12 276/277 to report claim status. The National Code Maintenance Committee meets at the beginning of each X12 trimester meeting (February, June, and October) and makes decisions about additions, modifications, and retirement of existing codes. The codes sets are available at http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-category-codes/ and http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/ on the Internet.

All code changes approved during the June 2014 committee meeting will be posted on these sites on or about July 1, 2014. Included in the code lists are specific details, including the date when a code was added, changed, or deleted.

These code changes will be used in the editing of all X12 276 transactions processed on or after the date of implementation and are to be reflected in X12 277 transactions issued on and after the date of implementation of CR8684.


The official instruction, CR8684 issued to your MAC regarding this change is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2967CP.pdf on the CMS website.


http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html

http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html



http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-category-codes/

http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-category-codes/

http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/

http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/



KE

NT

UC

KY

& O

HIO

PA

RT

B




29


Kentucky and Ohio

MM8786: July 2014 Update of the Ambulatory Surgical Center (ASC) Payment System



Related Change Request (CR) #: CR 8786 Effective Date: July 1, 2014Implementation Date: July 7, 2014


This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for Ambulatory Surgical Center (ASC) services to Medicare beneficiaries.


This article is based on Change Request (CR) 8786 and is a recurring update that describes changes to and billing instructions for various payment policies implemented in the July 2014 ASC update as well as updates to the Healthcare Common Procedure Coding System (HCPCS). Make sure your billing staff is aware of the changes.

Key Points of CR8786

One new brachytherapy sourceshown below, is assigned for payment under the ASC Payment System.

New Brachytherapy Source Code Effective July 1, 2014HCPCS CY2014 Short Descriptor CY2014 Long Descriptor ASC Payment Indicator (PI)

C2644 Brachytx cesium-131 chloride Brachytherapy source, cesium-131 chloride solution, per millicurie H2

New Category III CPT Codes

The American Medical Association (AMA) releases Category III Current Procedural Terminology (CPT) codes twice per year: in January, for implementation beginning the following July, and in July, for implementation beginning the following January. For the July 2014 update, the Centers for Medicare & Medicaid Services (CMS) is implementing 27 Category III CPT codes that the AMA released in January 2014 for implementation on July 1, 2014. Four of the 27 Category III CPT codes are separately payable under the ASC payment system and are shown below. Payment rates for these services can be found in the July 2014 ASC Update addenda that are posted at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html on the CMS website.

Category III CPT Codes Implemented as of July 1, 2014CPT Code Short Descriptor Long Descriptor July 2014 ASC PI

0348T RSA spine exam Radiologic examination, radiostereometric analysis (RSA); spine, (includes, cervical, thoracic and lumbosacral, when performed) Z2






http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html


KE

NT

UC

KY

& O

HIO

PA

RT

B




30

Category III CPT Codes Implemented as of July 1, 2014CPT Code Short Descriptor Long Descriptor July 2014 ASC PI

0349T RSA upper extr exam Radiologic examination, radiostereometric analysis (RSA); upper extremity(ies), (includes shoulder, elbow and wrist, when performed) Z2

0350T RSA lower extr examRadiologic examination, radiostereometric analysis (RSA); lower extremity(ies), (includes hip, proximal femur, knee and ankle, when performed)

Z2

0356T Insrt drug device for iop Insertion of drug-eluting implant (including punctal dilation and implant removal when performed) into lacrimal canaliculus, each R2

Billing for Drugs, Biologicals, and Radiopharmaceuticals

Payments for separately payable drugs and biologicals based on Average Sales Price (ASP) 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, CMS will incorporate changes to the payment rates in the July 2014 release of the ASC Drug File. The updated payment rates below, effective July 1, 2014, will be included in the July 2014 update of the ASC 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.

New HCPCS Codes Effective July 1, 2014, for Certain Drugs and Biologicals Separately Payable Under ASC Payment SystemHCPCS Code CY2014 Short Descriptor CY2014 Long Descriptor ASC PIC9022 Injection, elosulfase alfa Injection, elosulfase alfa, 1mg K2C9134 Factor XIII A-subunit recomb Factor XIII (antihemophilic factor, recombinant), Tretten, per 10 i.u. K2Q9970* Inj Ferric Carboxymaltos 1mg Injection, ferric carboxymaltose, 1 mg K2

* HCPCS code C9441 (Injection, ferric carboxymaltose, 1 mg) will be deleted and replaced with HCPCS code Q9970 effective July 1, 2014.

Updated Payment Rates for Certain HCPCS Codes Effective October 1, 2013, Through December 31, 2013

The payment rate for one HCPCS code, was incorrect in the October 2013 ASC Drug File. The corrected payment rate is listed below. Suppliers who think they may have received an incorrect payment for dates of service October 1, 2013, through December 31, 2013, may request that their MAC adjust the previously processed claims.

Updated Payment Rates for Certain HCPCS Codes Effective October 1, 2013, Through December 31, 2013HCPCS Code Short Descriptor Corrected Payment Rate ASC PIJ2788 Rho d immune globulin 50 mcg 25.15 K2

Updated Payment Rates for Certain HCPCS Codes Effective January 1, 2014, Through March 31, 2014

The payment rate for one HCPCS code was incorrect in the January 2014 ASC Drug File. The corrected payment rate is listed below. Suppliers who think they may have received an incorrect payment for dates of service January 1, 2014, through March 31, 2014, may request that their MAC adjust the previously processed claims.

Updated Payment Rates for Certain HCPCS Codes Effective January 1, 2014, Through March 31, 2014HCPCS Code Short Descriptor Corrected Payment Rate ASC PIJ0775 Collagenase, clost hist inj 38.49 K2




KE

NT

UC

KY

& O

HIO

PA

RT

B




31

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


The official instruction, CR8786 issued to your MAC regarding this change is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2970CP.pdf on the CMS website.


Kentucky and Ohio

SE1418: Proper Use of Modifier 59


MLN Matters® Number: SE1418Related CR Release Date: N/ARelated CR Transmittal #: N/A

Related Change Request (CR) #: N/A Effective Date: N/AImplementation Date: N/A


This MLN Matters® Special Edition Article is intended for physicians and providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.


This special edition article is being provided by the Centers for Medicare & Medicaid Services (CMS) to clarify the proper use of Modifier 59. The article only clarifies existing policy. Make sure that your billing staffs are aware of the proper use of Modifier 59.

Background

The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure (PTP) edits that define when two Healthcare Common Procedure Coding System (HCPCS)/ Current Procedural Terminology (CPT) codes should not be reported together either in all situations or in most situations.

For PTP edits that have a Correct Coding Modifier Indicator (CCMI) of “0,” the codes should never be reported together by the same provider for the same beneficiary on the same date of service. If they are reported on the same date of service, the column one code is eligible for payment and the column two code is denied.

For PTP edits that have a CCMI of “1,” the codes may be reported together only in defined circumstances which are identified on the claim by the use of specific NCCI-associated modifiers. (Refer to the National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 1, for general information about the NCCI program, PTP edits, CCMIs, and NCCI-associated modifiers. This manual can be retrieved from the download section at http://www.









KE

NT

UC

KY

& O

HIO

PA

RT

B




32

cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html on the Centers for Medicare & Medicaid Services (CMS) website.)

One function of NCCI PTP edits is to prevent payment for codes that report overlapping services except in those instances where the services are “separate and distinct.” Modifier 59 is an important NCCI-associated modifier that is often used incorrectly.

The CPT Manual defines modifier 59 as follows:

Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.

Modifier 59 and other NCCI-associated modifiers should NOT be used to bypass a PTP edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used.

1. Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.

One of the common uses of modifier 59 is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are performed at different anatomic sites, are not ordinarily performed or encountered on the same day, and that cannot be described by one of the more specific anatomic NCCI-associated modifiers – i.e., RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, or RI. (See examples 1, 2, and 3.) From an NCCI perspective, the definition of different anatomic sites includes different organs or, in certain instances, different lesions in the same organ. However, NCCI edits are typically created to prevent the inappropriate billing of lesions and sites that should not be considered to be separate and distinct. Modifier 59 should only be used to identify clearly independent services that represent significant departures from the usual situations described by the NCCI edit. The treatment of contiguous structures in the same organ or anatomic region does not constitute treatment of different anatomic sites. For example:

- Treatment of the nail, nail bed, and adjacent soft tissue (See example 4.) - Treatment of posterior segment structures in the eye (See example 5.) - Arthroscopic treatment of structures in adjoining areas of the same shoulder

(See example 6.)

2. Modifier 59 is used appropriately when the procedures are performed in different encounters on the same day.



KE

NT

UC

KY

& O

HIO

PA

RT

B




33

Another common use of modifier 59 is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are performed during different patient encounters on the same day and that cannot be described by one of the more specific NCCI-associated modifiers – i.e., 24, 25, 27, 57, 58, 78, 79, or 91. (See example 7) As noted in the CPT definition, modifier 59 should only be used if no other modifier more appropriately describes the relationship of the two procedure codes.

3. Modifier 59 is used inappropriately if the basis for its use is that the narrative description of the two codes is different.

One of the common misuses of modifier 59 is related to the portion of the definition of modifier 59 allowing its use to describe a “different procedure or surgery.” The code descriptors of the two codes of a code pair edit usually represent different procedures, even though they may be overlapping. The edit indicates that the two procedures should not be reported together if performed at the same anatomic site and same patient encounter as those procedures would not be considered to be “separate and distinct.” The provider should not use modifier 59 for such an edit based on the two codes being “different procedures.” (See example 8.) However, if the two procedures are performed at separate anatomic sites or at separate patient encounters on the same date of service, modifier 59 may be appended to indicate that they are different procedures on that date of service.

4. Other specific appropriate uses of modifier 59

There are three other limited situations in which two services may be reported as separate and distinct because they are separated in time and describe non-overlapping services even though they may occur during the same encounter, i.e.:

A. Modifier 59 is used appropriately for two services described by timed codes provided during the same encounter only when they are performed sequentially. There is an appropriate use for modifier 59 that is applicable only to codes for which the unit of service is a measure of time (e.g., per 15 minutes, per hour). If two timed services are provided in time periods that are separate and distinct and not interspersed with each other (i.e., one service is completed before the subsequent service begins), modifier 59 may be used to identify the services. (See example 9.)

B. Modifier 59 is used appropriately for a diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure. When a diagnostic procedure precedes a surgical procedure or non-surgical therapeutic procedure and is the basis on which the decision to perform the surgical procedure is made, that diagnostic test may be considered to be a separate and distinct procedure as long as (a) it occurs before the therapeutic procedure and is not interspersed with services that are required for the therapeutic intervention; (b) it clearly provides the information needed to decide whether to proceed with the therapeutic procedure; and (c) it does not constitute a service that would have otherwise been required during the therapeutic intervention. (See example 10.) If the diagnostic procedure is an inherent component of the surgical procedure, it should not be reported separately.

C. Modifier 59 is used appropriately for a diagnostic procedure which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure. When a diagnostic procedure follows the surgical procedure or non-surgical therapeutic procedure, that diagnostic procedure may be considered to be a separate and distinct procedure as long as (a) it occurs after the completion of the therapeutic procedure and is not interspersed with or


KE

NT

UC

KY

& O

HIO

PA

RT

B




34

otherwise commingled with services that are only required for the therapeutic intervention, and (b) it does not constitute a service that would have otherwise been required during the therapeutic intervention. (See example 11.) If the post-procedure diagnostic procedure is an inherent component or otherwise included (or not separately payable) post-procedure service of the surgical procedure or non-surgical therapeutic procedure, it should not be reported separately.

Use of Modifier 59 does not require a different diagnosis for each HCPCS/CPT coded procedure. Conversely, different diagnoses are not adequate criteria for use of modifier 59. The HCPCS/CPT codes remain bundled unless the procedures are performed at different anatomic sites or separate patient encounters or meet one of the other three scenarios described above.

Examples of Modifier 59 Usage

Following are some examples developed to help guide physicians and providers on the proper use of Modifier 59 (Please remember that Medicare policy is that Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.):

Example 1: Column 1 Code/Column 2 Code - 17000/11100

yy CPT Code 17000 – Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), all benign or premalignant lesions (eg, actinic keratoses) other than skin tags or cutaneous vascular proliferative lesions; first lesionyy CPT Code 11100 – Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion

Modifier 59 may be reported with code 11100 if the procedures are performed at different anatomic sites on the same side of the body and a specific anatomic modifier is not applicable. If the procedures are performed on different sides of the body, modifiers RT and LT or another pair of anatomic modifiers should be used, not modifier 59.

Example 2: Column 1 Code/Column 2 Code 47370/76942

yy CPT Code 47370 – Laparoscopy, surgical, ablation of one or more liver tumor(s); radiofrequencyyy CPT Code 76942 – Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation

CPT code 76942 should not be reported and Modifier 59 should not be used if the ultrasonic guidance is for needle placement for the laparoscopic liver tumor ablation procedure. Code 76942 may be reported with modifier 59 if the ultrasonic guidance for needle placement is unrelated to the laparoscopic liver tumor ablation procedure.

Example 3: Column 1 Code/Column 2 Code 93453/76000

yy CPT Code 93453 – Combined right and left heart catheterization including intraprocedural injections(s) for left ventriculography, imaging supervision and interpretation, when performedyy CPT Code 76000 – Fluoroscopy (separate procedure), up to one hour physician time, other than 71023 or 71034 (eg, cardiac fluoroscopy)

CPT code 76000 should not be reported and Modifier 59 should not be used for fluoroscopy that is used in conjunction with a cardiac catheterization procedure. Modifier 59 may be reported with code 76000 if the fluoroscopy is performed for a procedure unrelated to the cardiac catheterization procedure.


KE

NT

UC

KY

& O

HIO

PA

RT

B




35


yy CPT Code 11055 - Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesionyy CPT Code 11720 – Debridement of nail(s) by any method(s); one to five

CPT code 11720 should not be reported and Modifier 59 should not be used if a nail is debrided on the same toe from which a hyprkeratotic lesion has been removed. Modifier 59 may be reported with code 11720 if multiple nails are debrided and a corn that is on the same foot and that is not adjacent to a debrided toenail is pared.

Example 5: Column 1 Code/Column 2 code - 67210/67220

yy CPT Code 67210 – Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; photocoagulationyy CPT Code 67220 – Destruction of localized lesion of choroid (eg, choroidal neovascularization); photocoagulation (eg, laser), 1 or more sessions

CPT code 67220 should not be reported and Modifier 59 should not be used if both procedures are performed during the same operative session because the retina and choroid are contiguous structures of the same organ.


yy CPT Code 29827 – Arthroscopy, shoulder, surgical; with rotator cuff repairyy CPT Code 29820 – Arthroscopy, shoulder, surgical; synovectomy, partial

CPT code 29820 should not be reported and Modifier 59 should not be used if both procedures are performed on the same shoulder during the same operative session because the shoulder joint is a single anatomic structure. If the procedures are performed on different shoulders, modifiers RT and LT should be used, and not Modifier 59.


yy CPT Code 93015 – Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and reportyy CPT Code 93040 – Rhythm ECG, one to three leads; with interpretation and report

Modifier 59 may be reported if the rhythm ECG is performed at a different encounter than the cardiovascular stress test. If a rhythm ECG is performed during the cardiovascular stress test encounter, CPT code 93040 should not be reported and Modifier 59 should not be used. In this case, the procedures are performed in different encounters on the same day.

Example 8: Column 1 Code/Column 2 code - 34833/34820

yy CPT code 34833 - Open iliac artery exposure with creation of conduit for delivery of aortic or iliac endovascular prosthesis, by abdominal or retroperitoneal incision, unilateralyy CPT code 32550 - Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral

CPT code 34833 is followed by a CPT Manual instruction that states: “(Do not report 34833 in addition to 34820).” Although the CPT code descriptors for 34833 and 34820 describe different procedures, they should not be reported together for the same side. Modifier 59 should not be appended to either code to report the two procedures for the same side of the body. If the two procedures were performed on different sides of the body, they may be reported with modifiers LT and RT as appropriate. However, the use is inappropriate if the basis for its use is that the narrative description of the two codes is different.


KE

NT

UC

KY

& O

HIO

PA

RT

B




36


yy CPT Code 97140 – Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutesyy CPT Code 97530 – Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes

Modifier 59 may be reported if the two procedures are performed in distinctly different 15 minute intervals. CPT code 97530 should not be reported and Modifier 59 should not be used if the two procedures are performed during the same 15 minute time interval. In this case, the procedures are performed in different encounters on the same day.


yy CPT Code 37220 – Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplastyyy CPT Code 75710 – Angiography, extremity, unilateral, radiological supervision and interpretation

Modifier 59 may be reported with CPT code 75710 if a diagnostic angiography has not been previously performed and the decision to perform the revascularization is based on the result of the diagnostic angiography. The CPT Manual defines additional circumstances under which diagnostic angiography may be reported with an interventional vascular procedure on the same artery. Modifier 59 is used appropriately for a diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure.

Example 11: Column 1 Code/Column 2 Code

yy CPT Code 32551 – Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, openyy CPT Code 71020 – Radiologic examination, chest, 2 views, frontal and lateral

Modifier 59 may be reported if, later in the day following the insertion of a chest tube, the patient develops a high fever and a chest x-ray is performed to rule out pneumonia. CPT code 71020 should not be reported and Modifier 59 should not be used for a chest x-ray that is performed following insertion of a chest tube in order to verify correct placement of the tube. Modifier 59 is used appropriately for a diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure.


The CMS webpage on the National Correct Coding Initiative Edits is available at http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html on the CMS website.

The CPT Manual includes the definition of Modifier 59, as well as CPT codes used with Modifier 59. The manual is available at http://www.ama-assn.org/ama on the American Medical Association (AMA) website.

Kentucky and Ohio

News Flash Items

yy New product from the Medicare Learning Network® (MLN)

y� “Provider Compliance Tips for Computed Tomography (CT Scans)” (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-



http://www.ama-assn.org/ama

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/ICN907793.html?DLPage=1&DLFilter=Provider%20Compliance%20Tips&DLSort=0&DLSortDir=ascending


KE

NT

UC

KY

& O

HIO

PA

RT

B




37

Publications-Items/ICN907793.html?DLPage=1&DLFilter=Provider%20Compliance%20Tips&DLSort=0&DLSortDir=ascending) - Fact sheet (ICN 907793) EPUB, QRy� “Annual Wellness Visit,” (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimedia-Items/2013-05-29-awv.html) Podcast, ICN 908726, Downloadable only.y� “Information on the National Physician Payment Transparency Program: Open Payments,” (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimedia-Items/ICN908961-Podcast.html) Podcast, ICN 908961, downloadable only.y� “Medicare Quarterly Provider Compliance Newsletter [Volume 4, Issue 3]” Educational Tool, ICN 909006 (http://cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909006.pdf), downloadable

yy REVISED product from the Medicare Learning Network® (MLN)

y� “Contractor Entities At A Glance: Who May Contact You About Specific Centers for Medicare & Medicaid Services (CMS) Activities” (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ContractorEntityGuide_ICN906983.pdf) Educational Tool, ICN 906983, downloadabley� “Intensive Behavioral Therapy (IBT) for Obesity,” (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ICN907800.pdf) Booklet, ICN 907800, downloadable)y� “Improving Quality of Care for Medicare Patients: Accountable Care Organizations,” Fact Sheet, ICN 907407, downloadable (http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO_Quality_Factsheet_ICN907407.pdf)y� “HIPAA EDI Standards,” Web-based Training (WBT) (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/WebBasedTraining.html)

The CGS Listserv Notification Service is the primary means used by CGS to communicate with Kentucky and Ohio Medicare Part B providers. The ListServ is a free email notification service that provides you with prompt notification of Medicare news including policy, benefits, claims submission, claims processing and educational events. Subscribing for this service means that you will receive information as soon as it is available, and plays a critical role in ensuring you are up-do-date on all Medicare information.

Consider the following benefits to joining the CGS ListServ Notification Service:

yy It’s free! There is no cost to subscribe or to receive information. yy You only need a valid e-mail address to subscribe. yy Multiple people/e-mail addresses from your facility can subscribe. We recommend that all staff (clinical, billing, and administrative) who interact with Medicare topics register individually. This will help to facilitate the internal distribution of critical information and eliminates delay in getting the necessary information to the proper staff members.

STAY INFORMEDJoin the CGS ListServ Notification Service&

To subscribe to the CGS ListServ Notification Service, go to http://www.cgsmedicare.com/medicare_dynamic/ls/001.asp and complete the required information.




http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimedia-Items/2013-05-29-awv.html

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimedia-Items/2013-05-29-awv.html

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimedia-Items/ICN908961-Podcast.html

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimedia-Items/ICN908961-Podcast.html

http://cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909006.pdf



http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ContractorEntityGuide_ICN906983.pdf



http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ICN907800.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ICN907800.pdf

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO_Quality_Factsheet_ICN907407.pdf



http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/WebBasedTraining.html

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/WebBasedTraining.html

http://www.cgsmedicare.com/medicare_dynamic/ls/001.asp

http://www.cgsmedicare.com/medicare_dynamic/ls/001.asp

Medicare Bulletin - July 2014 · MEDICARE BULLETIN GR 2014-07 JULY 2014 2 ... SE1418: Proper Use of...

Documents

Transcript of Medicare Bulletin - July 2014 · MEDICARE BULLETIN GR 2014-07 JULY 2014 2 ... SE1418: Proper Use of...