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Below you will find a listing of current Centers for Medicare & Medicaid Services (CMS) program information (transmittals, corrections/changes to existing Medicare guidelines, etc.) and general updates to this Web site.
Note: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material which is copyrighted by the American Medical Association (AMA). You are forbidden to download the files unless you read, agree to and abide by the provisions of the copyright statement. Read the copyright statement now (you will be linked back to here).
2012 - May | April | March |
February |
January
2011 -
December |
November |
October |
September |
August |
July |
June |
May |
April |
March |
February |
January
May
10 May 2012
03 May 2012
April
26 April 2012
12 April 2012
05 April 2012
March
29 March 2012
22 March 2012
15 March 2012
13 March 2012
08 March 2012
- The Centralized Billing for Flu and Pneumococcal Vaccination Annual Notice has been published. (IOM, 100-04, Chapter 18)
- Common Working File (CWF) Northeast, Pacific and South Hosts Dark Day on Saturday, March 24, 2012
(TDL-12251)
On Saturday, March 24, 2012, the CWF Northeast, Pacific and South Hosts will be conducting a history purge. Due to the anticipated duration of this activity and to ensure the completion of weekly processing and scheduled data center maintenance, there will be a CWF Dark Day at the CWF Northeast, Pacific and South Hosts only on that Saturday. This means there will be no access to the Health Insurance Master Record (HIMR) query, which is usually available until noon on Saturdays.
All files received from satellites for Fridays cycle (March 23, 2012) will be completed prior to bringing CWF production down. If, for any reason, satellite files are received late Saturday morning, they will be processed by CWF after the history purge has been completed.
01 March 2012
February
16 February 2012
09 February 2012
02 February 2012
January
26 January 2012
19 January 2012
12 January 2012
05 January 2012
- Quarterly Provider Update (QPU)
(IOM Pub 100-09-Chapter 6 Section 50.2.4.3)
The Quarterly Provider Update (QPU) is a listing of the regulations and program instructions issued by CMS that impact Medicare providers. The QPU is maintained by CMS and available to providers through the CMS Web site.
Providers may elect to join a CMS electronic mailing list, to be notified periodically, of additions to the QPU. CMS publishes this Update at the beginning of each quarter to inform the public about the following:
- Regulations and major policies currently under development during this quarter.
- Regulations and major policies completed or cancelled.
- New/Revised manual instructions
The page may be found at: http://www.cms.hhs.gov/QuarterlyProviderUpdates/
Visit the QPU Whats New page at https://www.cms.gov/QuarterlyProviderUpdates/02_Spotlight.asp
December
28 December 2011
21 December 2011
15 December 2011
08 December 2011
- Medicares Acceptance of Voluntary Refunds, Annual Notice
(IOM, Publication 100-06, Chapter 5, Section 410-10)
The acceptance of a voluntary refund as repayment for the claims specified in no way affects or limits the rights of the Federal Government, or any of its agencies or agents, to pursue any appropriate criminal, civil, or administrative remedies arising from or relating to these or any other claims.
- SE1137 Additional Health Insurance Portability and Accountability Act (HIPAA) 837 5010 Transitional Changes and Further Modifications to the Coordination of Benefits Agreement (COBA) National Crossover Process
- MM7637 Screening for Depression in Adults
- MM7628 Reasonable Charge Update for 2012 for Splints, Casts, and Certain Intraocular Lenses
01 December 2011
November
29 November 2011
22 November 2011
- Change Request 7177 has been rescinded and is replaced by Change Request 7681.
- Attention Providers:
(Per Change Request 7573)
We encourage you to visit the Medicare Learning Network (http://www.cms.gov/MLNGenInfo/ )--the place for official CMS Medicare fee-for-service provider educational information. There you can find one of our most popular products, MLN Matters national provider education articles. These articles help you understand new or changed Medicare policy and how those changes affect you. A full array of other educational products (including Web-based training courses, hard copy and downloadable publications, and CD-ROMs) are also available and can be accessed at: http://www.cms.gov/MLNProducts/ . You can also find other important physician Web sites by visiting the Physician Center Web page at: http://www.cms.gov/center/physician.asp.
- To Our J14 Medical Community:
(Change Requests 7573 and 7412)
The Medicare Physician Fee Schedule Database (MPFSDB) and the Anesthesia files are available on our web site. Please go to
http://www.medicarenhic.com/ne_prov/fee_sched.shtml to view the file for your Area and a short message from the Centers for Medicare & Medicaid Services (CMS).
Any future updates released by CMS will be posted as soon as they are available.
The Annual Participation Open Enrollment Period also has begun. To view the pertinent documents, please go to http://www.medicarenhic.com/ne_prov/fee_sched.shtml where you will find the CMS Announcement and the Medicare Participating Physician or Supplier Agreement (Form CMS 460). The mailing address is listed immediately below the forms on the same web page.
Reminder: Any participating health professional who is not changing their participation status does not need to take any action during the Annual Open Enrollment Period.
17 November 2011
09 November 2011
03 November 2011
- MM7575 Influenza Vaccine Payment Allowances - Annual Update for 2011-2012 Season
- MM7363 Additional Provider and Supplier Enrollment Requirements for Fixed Wing and Helicopter Air Ambulance Operators
- MM7561 Format Revisions to the Special Incentive Remittance Advice Used to Report Quarterly Incentive Payments for Health Professional Shortage Areas (HPSAs), the Primary Care Incentive Payment Program (PCIP), and the HPSA Surgical Incentive Payment Program (HSIP)
- MM7580 New Influenza Virus Vaccine Code
- Revised: SE1126 Further Details on the Revalidation of Provider Enrollment Information
- SE1134 Medicare Payments for Diagnostic Radiology Services in Emergency Departments
- SE1136 2011-2012 Seasonal Influenza (Flu) Resources for Health Care Professionals
- MM7624 January 2012 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
- Revised: MM7350 Implementation of Provider Enrollment Provisions in CMS-6028-FC
- CMS Technical Direction Letter (TDL)-12038
Hospital Routine Services Under Arrangement Requirement
On August 18, 2011, the Centers for Medicare & Medicaid Services (CMS) issued the Fiscal Year (FY) 2012 Inpatient Prospective Payment System (IPPS) final rule. The final rule included a provision limiting the circumstances under which a hospital may furnish services under arrangement. Under the revised policy, only therapeutic and diagnostic services may be furnished outside of the hospital under arrangement; routine services (for example, bed, board, and nursing services) must be provided by the hospital. Under the policy, routine services that are furnished in the hospital to its inpatients are considered as being provided by the hospital. If services are provided outside of the hospital, the services are considered as being provided under arrangement.
We recognize that hospitals may need more time to restructure existing arrangements and establish operational protocols necessary to comply with the requirement that only therapeutic and diagnostic services may be furnished outside of the hospital under arrangement and that routine services must be provided by the hospital. CMS expects that during FY 2012, hospitals will work towards ensuring compliance with the new requirements. CMS will continue to work with these hospitals to communicate the requirements of this provision and to provide continued guidance. Beginning with the FY 2013, all hospitals will need to be in full compliance with the modified under arrangement provisions.
October
27 October 2011
20 October 2011
- 2012 Fee Schedule / Open Enrollment Period Postcards
Per Change Request 7412, NHIC, Corp. calls your attention to the following notice regarding the mailing of the 2012 Fee Schedule / Open Enrollment Period CDs. For this year, we will be mailing postcards, as instructed by the IOM section below. Watch for them in your mailbox!
Internet Only Manual (IOM) Pub. 100-04, Medicare Claims Processing Manual, Chapter 1, section 30.3.12.1:
Until 2004, the Medicare contractors mailed each provider a hardcopy package which included enrollment materials, a paper copy of the Medicare Physician Fee Schedule (MPFS), an Announcement document, the Medicare Participating Physician or Supplier Agreement (Form CMS-460), and a variety of provider education material about the Medicare program. Beginning with the 2005 mailing, CMS directed Medicare contractors to begin using a CD for the participation mailing because it was less expensive than mailing the hardcopy materials.
Beginning with the 2006 mailing, contractors placed the new Medicare fees on their Web sites and did not include the fees on the CDs due to frequent last minute changes to the MPFS. Removing the Medicare fees from the CD provided greater flexibility for updates late in the year due to legislative changes or CMS payment policy decisions.
Since the fee schedules are no longer included on the CD, and the educational materials, as well as the Form CMS-460, are also posted on contractors Web sites, the value of the CD to the provider community has diminished. Beginning 2011, CMS is directing contactors to produce a postcard mailing, instead of a CD, for eligible physicians, practitioners and suppliers.
- Revised: MM7489 Instructions to Accept and Process All Ambulance Transportation Healthcare Common Procedure Coding System (HCPCS) Codes
- 2012 Fee Schedule / Open Enrollment Period
(Change Request 7412; Internet Only Manual (IOM) Chapter 1, 30.3.12.1)
NHIC, Corp. reminds our medical community that the upcoming participation enrollment period documents and the upcoming Medicare Physician Fee Schedule (MPFS) and the Anesthesia Conversion Factor(s) will be published on the our web site after the physician fee schedule regulation is put on display.
When the files are ready, you may go to http://www.medicarenhic.com/ne_prov/fee_sched.shtml for this information.
- Revised: SE1110 Medicare Pilot Project for Electronic Submission of Medical Documentation (esMD) Data
- Revised: MM7558 Updates to the Internet Only Manual Publication 100-04, Chapter 15 Ambulance to include Medicare and Medicaid Extenders Act of 2010 (MMEA) Provisions
- SE1133 Predictive Modeling Analysis of Medicare Claims
- Revised: MM6421 Expansion of the Current Scope of Editing for Ordering/Referring Providers for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers' Claims Processed by Durable Medical Equipment Medicare Administrative Contractors (DME MACs)
06 October 2011
September
29 September 2011
22 September 2011
15 September 2011
08 September 2011
01 September 2011
August
25 August 2011
18 August 2011
11 August 2011
04 August 2011
July
28 July 2011
22 July 2011
- Common Working File Great Lakes and Northeast Hosts Dark Day on Saturday, July 23, 2011
CMS Technical Direction Letter (TDL)-11410
On Saturday, July 23, 2011, the Common Working File (CWF) Great Lakes and Northeast Hosts will be conducting a history purge. Due to the anticipated duration of this activity and to ensure the completion of weekly processing and scheduled data center maintenance, there will be a CWF dark day at the CWF Great Lakes and Northeast Hosts only on that Saturday. This means there will be no access to the Health Insurance Master Record (HIMR) query, which is usually available until noon on Saturdays.
All files received from satellites for Friday's cycle (July 22, 2011) will be completed prior to bringing CWF production down. If, for any reason, satellite files are received late Saturday morning, they will be processed by CWF after the history purge has been completed.
21 July 2011
07 July 2011
June
30 June 2011
23 June 2011
- Certification of Mammography Facilities (Annual Reminder)
IOM 100-04, Chapter 18, section 20.1
NHIC, Corp. reminds providers that Medicare will reimburse only FDA-certified mammography centers for mammography services.
We encourage you to inform your patients to use only centers that are certified.
We provide a direct link on our web site to the listing for all of these facilities in each state at: http://www.medicarenhic.com/ne_prov/billing_info.shtml.
Click on the Mammography Centers Certified link.
Please share this information with your patients.
- Unsolicited/Voluntary Refund Checks (Annual Reminder)
IOM 100-06, Chapter 5, section 410.10
NHIC, Corp. reminds you of the following statement from the CMS Internet Only Manual (IOM) regarding unsolicited/voluntary refund checks:
The acceptance of a voluntary refund as repayment for the claims specified in no way affects or limits the rights of the Federal Government, or any of its agencies or agents, to pursue any appropriate criminal, civil, or administrative remedies arising from or relating to these or any other claims.
For more information, please view the above-mentioned at: http://www.cms.hhs.gov/manuals/downloads/fin106c05.pdf
- Update Your Addresses! Do Not Forward (DNF) Annual Reminder Notice.
(IOM Pub. 100-04 Chapter 1 Section 80.5.1)
All providers must notify their Contractor (NHIC, Corp.) of any changes of address.
To do this:
1. Visit the CMS Enrollment website and download the Enrollment Form that pertains to you or your group or organization:
http://www.cms.hhs.gov/MedicareProviderSupEnroll/02_EnrollmentApplications.asp#TopOfPage
2. Update the form with your new information and mail it to:
NHIC, Corp.
Provider Enrollment
P.O. Box 3434
Hingham, MA 02044
NHIC, Corp. uses return service requested envelopes for certain mailings, and when an envelope is returned, we apply a Do Not Forward (DNF) flag to the providers Medicare Number. Once this happens, no additional checks will be generated until a properly completed change of address form is received and verified by NHIC, Corp. CMS requires corrections to all addresses before the contractor can remove the DNF flag and begin paying the provider or supplier again.
Protect yourself from payment delays by submitting your changes timely.
- MM7420 Guidelines to Allow Contractors to Develop and Utilize Procedures for Accepting and Processing Reopenings via a Secure Internet Portal/Application
- Rescinded: MM7456 Claim Status Category Code and Claim Status Code Update
- MM7435 New Waived Tests
- Revised: SE1035 Claims Modifiers for Use in the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program
16 June 2011
09 June 2011
May
26 May 2011
19 May 2011
12 May 2011
6 May 2011
- JSM/TDL 11264
CMS Message 201105-10
Medicare Part B Average Sales Price - Payments for Wilate and Flulaval
For the April 2011 Average Sales Price quarterly update, CMS is not publishing a payment limit for HCPCS code J7184 [Injection, Von Willebrand Factor Complex (Human), Wilate, Per 100 iu VWF:RCO] for claims with dates of service between Friday, April 1 and Thursday, June 30, 2011. A price for Wilate can be found on the April 2011 ASP Not Otherwise Classified (NOC) pricing file available on the CMS website. Additionally, as per updated CR #7234, CMS has updated the price for Q2036 (Flulaval vacc, 3 yrs & >, im) to $8.784 for the April 2011 ASP quarterly update. This updated price is effective for claims with dates of service on or after Friday, October 1, 2010. The revised price has been added to the October 2010 and January 2011 ASP pricing files.
These pricing files can be found on the CMS website at http://www.CMS.gov/McrPartBDrugAvgSalesPrice.
5 May 2011
April
28 April 2011
21 April 2011
14 April 2011
- Change Request 7177 has been rescinded and is replaced by Change Request 7681.
07 April 2011
March
31 March 2011
24 March 2011
17 March 2011
10 March 2011
03 March 2011
- Medicare NCCI - Medically Unlikely Edit (MUE) for FASLODEX (J9395)
JSM/TDL-11174
The Centers for Medicare & Medicaid Services has identified a Medicare claims processing issue with Healthcare Common Procedure Coding System (HCPCS) J9395 (Fulvestrant, 25 mg) (Faslodex) that began January 1, 2011. Payment for Faslodex is currently limited to a 250 mg dose but should be 500 mg, effective January 1, 2011, based on U.S. Food and Drug Administration (FDA) approved prescribing information. This will be corrected on April 1, 2011.
Provider Action
Providers may delay submission of their claims for a dosage greater than 250 mg until April 1, 2011, when the fix is in place to properly pay these claims. Alternatively, in this instance only, providers may submit their claims prior to April 1, 2011 by reporting J9395 on two lines of a claim utilizing modifier 59 with the code on one claim line, reporting ten units of service on each line, and be paid for the 500 mg dose of Faslodex.
If providers have had claims denied due to this issue, they may resubmit their claims using the alternative identified above or request a reopening after April 1, 2011.
Note: Due to NHIC system limitations, to have your claim paid, use modifier 76 in place of modifier 59.
- Revised: MM3834 Smoking and Tobacco-Use Cessation Counseling
- Revised: MM7018 Updates to the Medicare Claims Processing Manual (Publication 100-04, Chapter 15 (Ambulance)) to Correct Claims Billing Instructions as Well as to Update Fee Schedule Payment Rates Mandated by the Affordable Care Act of 2010
- Revised: MM6786 Screening for the Human Immunodeficiency Virus (HIV) Infection
- MM7307 Clarification to CR No. 6686 - Outpatient Mental Health Treatment Limitation
- Revised:MM7319 April Update to the Calendar Year (CY) 2011 Medicare Physician Fee Schedule Database (MPFSDB)
- Revised: MM7060 Incentive Payment Program for Primary Care Services, Section 5501(a) of The Affordable Care Act
February
24 February 2011
10 February 2011
03 February 2011
January
27 January 2011
20 January 2011
13 January 2011
06 January 2011
04 January 2011
- Face-to-Face Encounter Home Health Certification Requirement
(JSM/TDL-11111)
Section 6407 of the Affordable Care Act of 2010 established a physician face-to-face encounter requirement for certification of eligibility for Medicare home health services. The law requires that the certifying physician must document that he or she, or a non-physician practitioner (NPP) working with the physician, has seen the patient.
In the Home Health Prospective Payment System Rate Update for Calendar Year (CY) 2011, the Centers for Medicare & Medicaid Services (CMS) finalized its implementation approach for this law. Pursuant to 42 C.F.R. § 424.22(a)(1)(v) (75 Fed. Reg. 70464, November 17, 2010), the face-to-face encounter must occur within the 90 days prior to the start of care, or within the 30 days after the start of care. The regulation also states that the certifying physician must document the encounter as part of the certification itself or as a signed addendum to it. The documentation must include the date when the encounter occurred and a brief narrative which describes how the clinical findings of the encounter support the patients homebound status and need for skilled services. The rule requires such documentation be present on certifications for patients with starts of care on or after January 1, 2011.
Although many home health agencies and physicians are aware of and are able to comply with this policy, CMS is concerned that some home health agencies and physicians may need additional time to establish operational protocols necessary to comply with this new law. As such, CMS expects that during the first quarter of CY 2011, home health agencies and physicians who order home health services will collaborate and establish internal processes to ensure compliance. Beginning with the second quarter of CY2011, home health agencies will have fully established such internal processes and CMS will expect appropriate documentation of the encounter.
CMS will continue to address industry questions concerning the new requirement, and will update information on our Web site at http://www.cms.gov/center/hha.asp. We will also use other channels we have to communicate with providers to ensure information is widely distributed.
- Hospice Face-to-Face Encounter Requirement
(JSM/TDL-11112)
Section 3131(b) of the Affordable Care Act of 2010 requires a hospice physician or nurse practitioner (NP) to have a face-to-face encounter with every hospice patient prior to the patients 180th- day recertification, and each subsequent recertification. The provision applies to recertifications on and after January 1, 2011.
In the Home Health Prospective Payment System Rate Update for Calendar Year (CY) 2011, the Centers for Medicare & Medicaid Services (CMS) finalized its implementation approach for this hospice provision. The final rule, codified at 42 C.F.R. 418.22(a)(4) (75 Fed. Reg. 70463, November 17, 2010) states that the encounter must occur no more than 30 calendar days prior to the start of the hospice patients third benefit period. The regulation requires that the hospice physician or nurse practitioner attest that the encounter occurred, and the recertifying physician must include a narrative which describes how the clinical findings of the encounter support the patients terminal prognosis of 6 months or less. Both the narrative and the attestation must be part of, or an addendum to, the recertification.
Although many hospices are aware of and are able to comply with this policy, CMS is concerned that some hospices may need additional time to establish operational protocols necessary to comply with this new law. As such, CMS expects that during the first quarter of CY 2011, hospices will establish internal processes to ensure compliance. Beginning with the second quarter of CY 2011, hospices will have fully established such internal processes and CMS will expect appropriate documentation of the encounter.
CMS will address industry questions concerning the new requirement on our Web site at http://www.cms.gov/center/hospice.asp. We will also use other channels we have to communicate with providers to ensure information is widely distributed.
05/10/2012
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