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This page contains announcements that were formerly on the What's New from CMS for Jurisdiction 14 Part B Medicare Administrative Contractor (MAC) page. These announcements cover a variety of topics that are important to the provider/supplier community.
December
29 December 2010
22 December 2010
- Revised: MM7234 – New HCPCS Q-codes for 2010-2011 Seasonal Influenza Vaccines
- Revised: MM7079 – Annual Wellness Visit (AWV), Including Personalized Prevention Plan Services (PPPS)
- Signature on Requisitions for Clinical Diagnostic Laboratory Tests
JSM/TDL-11097
In the November 29, 2010, Medicare Physician Fee Schedule final rule, the Centers for Medicare & Medicaid Services (CMS) finalized its proposed policy to require a physician’s or qualified nonphysician practitioner’s (NPP) signature on requisitions for clinical diagnostic laboratory tests paid under the clinical laboratory fee schedule effective January 1, 2011. A requisition is the actual paperwork, such as a form, which is provided to a clinical diagnostic laboratory that identifies the test or tests to be performed for a patient.
Although many physicians, NPPs, and clinical diagnostic laboratories may be aware of, and are able to comply with, this policy, CMS is concerned that some physicians, NPPs, and clinical diagnostic laboratories are not aware of, or do not understand, this policy. As such, CMS will focus in the first quarter of next year on developing educational and outreach materials to educate those affected by this policy. As they become available, we will post this information on our Web site at http://www.cms.hhs.gov/ClinicalLabFeeSched and use the other channels we have to communicate with providers to ensure this information is widely distributed. Once our first quarter educational campaign is fully underway, CMS will expect requisitions to be signed.
- Place of Service Indicator for HCPCS Codes G0339 and G0340
JSM/TDL-11066
The Pricing Indicator Code on the Alpha-Numeric HCPCS File has been changed from “00” to “13” for HCPCS codes G0339 and G0340. This change is effective for services furnished in CY 2006 – CY 2010.
Place of Service Indicator for HCPCS Codes G0339 and G0340
In calendar year (CY) 2006, the Status Code for Healthcare Common Procedure Coding System (HCPCS) codes G0339 (Image-guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment) and G0340 (Image-guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum five sessions per course of treatment) changed in the Medicare Physician Fee Schedule (PFS) Relative Value File from “X” (Exclusion by law. These codes represent an item or service that is not within the definition of physicians’ services for physician fee schedule payment purposes. No relative value units (RVUs) are shown for these codes, and no payment may be made under the physician fee schedule. (Examples are ambulance services and clinical diagnostic laboratory services.)) to “C” (Carriers price the code. Carriers will establish RVUs and payment amounts for these services, generally on an individual case basis following review of documentation, such as an operative report.)
While this change was accurately reflected in the annual published PFS Relative Value Files beginning in CY 2006, no corresponding change was made to the pricing indicator on the Alpha-Numeric HCPCS File. The Alpha-Numeric HCPCS File continued to show a HCPCS Pricing Indicator Code of “00” (Service not separately priced by part B) for HCPCS codes G0339 and G0340.
Therefore, we are issuing this Joint Signature Memorandum/Technical Direction Letter (JSM/TDL) to update the Alpha-Numeric HCPCS File for CYs 2006-2010 to reflect a HCPCS Pricing Indicator Code of “13” (Price established by carriers).
- SE1038 – Home Health Face-to-Face Encounter - A New Home Health Certification Requirement
16 December 2010
- Rescinded: MM7239 – Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens
- MM7012 – Waiver of Coinsurance and Deductible for Preventive Services, Section 4104 of The Affordable Care Act, Removal of Barriers to Preventive Services in Medicare
- MM7042 – Ambulance Inflation Factor (AIF) for CY 2011 and Productivity Adjustment
- SE1034 – Physicians and Non-Physician Practitioners (NPPs) Excluded from Deactivation in Medicare Due to Inactivity with Medicare
- Revised: MM6625 – Common Working File (CWF) Unsolicited Response Adjustments for Certain Claims Denied Due to an Open Medicare Secondary Payer (MSP) Group Health Plan (GHP) Record Where the GHP Record was Subsequently Deleted or Terminated
- Revised: MM7234 – New HCPCS Q-codes for 2010-2011 Seasonal Influenza Vaccines
- Skilled Nursing Facility and Nursing Facility Reporting of Physician Consultation Services
JSM/TDL 11080
The Centers for Medicare & Medicaid Services (CMS) would like to remind skilled nursing facilities (SNFs) and nursing facilities (NFs) of the evaluation and management (E&M) services coding policy that has been in effect since January 1, 2010. If a physician or nonphysician practitioner is furnishing that practitioner’s first E&M service for a Medicare beneficiary in a SNF or NF during the patient’s facility stay, even if that service is provided prior to the federally mandated visit, the practitioner may bill the most appropriate E&M code that reflects the services the practitioner furnished, whether that code be an initial nursing facility care code (current procedural terminology [CPT] codes 99304 –99306) or a subsequent nursing facility care code (CPT codes 99307 –99310) if documentation and medical necessity do not meet the requirements for billing an initial nursing facility care code. Prior to January 1, 2010, this service may have been reported and paid using a CPT consultation code under the Medicare Physician Fee Schedule. The CMS Internet-Only Manual (IOM) Publication 100-04, Medicare Claim Processing Manual, Chapter 12, Section 30.6.13 will be updated to reflect this policy. Additional information on reporting physician consultation services can be found in MLN Matters article SE1010 and may be viewed at: http://www.cms.gov/MLNMattersArticles/downloads/SE1010.pdf.
- MM7079 – Annual Wellness Visit (AWV), Including Personalized Prevention Plan Services (PPPS)
- Revised: MM7220 – Ventricular Assist Devices (VADs) as Destination Therapy
- Delay in Claim Editing for Ordering/Referring Providers
(JSM/TDL 11051)
The Centers for Medicare & Medicaid Services (CMS) previously announced that, beginning January 3, 2011, if certain Part B billed items and services require an ordering/referring provider and the ordering/referring provider is not on the claim, is not of a profession that is permitted to order/refer, or does not have an enrollment record in the Medicare Provider Enrollment, Chain and Ownership System (PECOS), the claim will not be paid. The automated edits will not be turned on effective January 3, 2011. We are working diligently to resolve enrollment backlogs and other system issues and will provide ample advanced notice to the provider and beneficiary communities before we begin any automatic nonpayment actions.
09 December 2010
02 December 2010
- MM7210 – Quarterly Update to Correct Coding Initiative (CCI) Edits, Version 17.0, effective January 1, 2011
- MM7220 – Ventricular Assist Devices (VADs) as Destination Therapy
- MM7087 – National Modifier and Condition Code to Identify Items or Services Related to the 2010 Oil Spill in the Gulf of Mexico
- MM7234 – New HCPCS Q-codes for 2010-2011 Seasonal Influenza Vaccines
- MM7049 – Expansion of Medicare Telehealth Services for Calendar Year (CY) 2011
- MM7065 – Fractional Mileage Amounts Submitted on Ambulance Claims
- MM7225 – Reasonable Charge Update for 2011 for Splints, Casts, and Certain Intraocular Lenses
- MM7209 – New Physician Specialty Codes for Cardiac Electrophysiology and Sports Medicine
- Rescinded Feb. 17, 2011: MM7061 – Edit to Deny Payment to Physicians and Other Suppliers for the Technical Component (TC) of Pathology Services Furnished on Same Date as Inpatient and Outpatient Services and Implements New Messages
- MM7224 – Update to Medicare Deductible, Coinsurance and Premium Rates for 2011
- Revised: MM7120 – Influenza Vaccine Payment Allowances - Annual Update for 2010-2011 Season
- MM6991 – Calendar Year (CY) 2011 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment
- MM7003 – End Stage Renal Disease (ESRD) Home Dialysis Monthly Capitation Payment (MCP)
- MM7068 – Instructions for PLB code reporting on Remittance Advice, a Crosswalk between the HIGLAS PLB codes and ASC X12 Transaction 835 PLB codes, and RAC Recoupment Reporting on Remittance Advice for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) claims
- Revised: SE1011 – Edits on the Ordering/Referring Providers in Medicare Part B Claims (Change Requests 6417, 6421, and 6696)
- Revised: MM6953 – Dermal Injections for Treatment of Facial Lipodystrophy Syndrome (LDS)
- Revised: SE1031 – 2010 - 2011 Seasonal Influenza (Flu) Resources for Health Care Professionals
01 December 2010
- Delay in Claim Editing for Ordering/Referring Providers
(JSM/TDL 11051)
The Centers for Medicare & Medicaid Services (CMS) previously announced that, beginning January 3, 2011, if certain Part B billed items and services require an ordering/referring provider and the ordering/referring provider is not on the claim, is not of a profession that is permitted to order/refer, or does not have an enrollment record in the Medicare Provider Enrollment, Chain and Ownership System (PECOS), the claim will not be paid. The automated edits will not be turned on effective January 3, 2011. We are working diligently to resolve enrollment backlogs and other system issues and will provide ample advanced notice to the provider and beneficiary communities before we begin any automatic nonpayment actions.
November
30 November 2010
- Delay in Claim Editing for Ordering/Referring Providers
(JSM/TDL 11051)
The Centers for Medicare & Medicaid Services (CMS) previously announced that, beginning January 3, 2011, if certain Part B billed items and services require an ordering/referring provider and the ordering/referring provider is not on the claim, is not of a profession that is permitted to order/refer, or does not have an enrollment record in the Medicare Provider Enrollment, Chain and Ownership System (PECOS), the claim will not be paid. The automated edits will not be turned on effective January 3, 2011. We are working diligently to resolve enrollment backlogs and other system issues and will provide ample advanced notice to the provider and beneficiary communities before we begin any automatic nonpayment actions.
23 November 2010
18 November 2010
11 November 2010
09 November 2010
- The Medicare Physician Fee Schedules, the Anesthesia Conversion Factors, and the Calendar Year (CY) 2011 Participation Enrollment form have been posted to the NHIC, Corp. web site. The annual participation enrollment program for CY 2011 begins on November 12th and runs through December 31st. Please “Click Here” to view details. (CR 7157)
04 November 2010
October
29 October 2010
- The Medicare Physician Fee Schedule for 2011 will be published on the NHIC, Corp. Web site after the CY 2011 physician fee schedule regulation is put on display. You will find the new schedules at http://www.medicarenhic.com/ne_prov/fee_sched.shtml once they are available. NHIC, Corp. will announce this on our Web site and via our Listservs as soon as they are posted. (IOM – Chapter 1, section 30.3.12.1)
28 October 2010
21 October 2010
14 October 2010
September
30 September 2010
27 September 2010
23 September 2010
16 September 2010
02 September 2010
August
26 August 2010
19 August 2010
12 August 2010
5 August 2010
July
29 July 2010
22 July 2010
15 July 2010
08 July 2010
01 July 2010
June
24 June 2010
17 June 2010
14 June 2010
- The 2010 Medicare Physician Fee Schedule
CMS Message 201006-15
The Continuing Extension Act of 2010, enacted on April 15, 2010, extended the zero percent (0%) update to the 2010 Medicare Physician Fee Schedule (MPFS) through May 31, 2010. At this time, Congress is debating the elimination of the negative update that took effect June 1, 2010. The Centers for Medicare & Medicaid Services (CMS) is hopeful that Congressional action will be taken within the next several days to avert the negative update.
To avoid disruption in the delivery of health care services to beneficiaries and payment of claims for physicians, non-physician practitioners, and other providers paid under the MPFS, CMS had instructed its contractors on May 27th to hold claims for services paid under the MPFS for the first 10 business days of June (i.e., through June 14, 2010). This hold only affects MPFS claims with dates of service of June 1, 2010, and later.
Given the possibility of Congressional action in the very near future, CMS is now directing its contractors to continue holding June 1 and later claims through Thursday, June 17, lifting the hold on Friday, June 18.
This action will facilitate accurate claims processing at the outset and minimize the need for claims reprocessing if Congressional action changes the negative update. It also should minimize the provider and beneficiary burdens and costs associated with reprocessing claims.
We understand that the delayed processing of Medicare claims may present cash flow problems for some Medicare providers. However, we expect that the delay, if any, beyond the normal processing period will be only a few days. Be on the alert for more information regarding the 2010 Medicare Physician Fee Schedule Update.
10 June 2010
3 June 2010
May
27 May 2010
- MM6823 – Pulmonary Rehabilitation (PR) Services
- Revised: MM6786 – Screening for the Human Immunodeficiency Virus (HIV) Infection
- Updated Banking Transition
CMS Message 201005-31
The CMS recently awarded new banking contracts to U.S. Bank and JP Morgan Chase. Medicare providers do not have to take any action. However, providers should be aware that the Medicare payments may be made by a different bank than in the past because of these new banking contractors.
The following Medicare claims processing contractors will remain with JP Morgan Chase: Cahaba Government Benefit Administrators, Pinnacle Business Solutions, First Coast Service Options, Palmetto GBA (except for A/B MAC Jurisdiction 1) and Wisconsin Physician Service. Providers that bill to these contractors will not experience any change.
The following Medicare claims processing contractors will transition to JP Morgan Chase on August 2, 2010: Palmetto A/B MAC Jurisdiction 1 and Trailblazer.
The following contractors will transition to U.S. Bank on August 2, 2010, Noridian Administrative Services, CIGNA Government Services, Highmark Medicare Services, National Government Services, and NHIC.
- MM6809 – Quarterly Healthcare Common Procedure Coding System (HCPCS) Code Changes – July 2010 Update
- MM6972 – Extension for the Two Percent and Three Percent Add-On for the Ground Ambulance, Air Ambulance in Rural Areas and "Super Rural" Add-0n through December 31, 2010
- MM6850 – Cardiac Rehabilitation and Intensive Cardiac Rehabilitation
- Revised: MM6973 – Revised Payment Files for the 2010 Medicare Physician Fee Schedule Database (MPFSDB) and Retroactive Provisions under the Patient Protection and Affordable Care Act (Pub. L. 111-148) (the Affordable Care Act)
- MM6930 – Quarterly Update to Correct Coding Initiative (CCI) Edits, Version 16.2, effective July 1, 2010
20 May 2010
- MM6973 – Revised Payment Files for the 2010 Medicare Physician Fee Schedule Database (MPFSDB) and Retroactive Provisions under the Patient Protection and Affordable Care Act (Pub. L. 111-148) (the Affordable Care Act)
- MM6945 – July Quarterly Update for 2010 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
- Important Message Regarding Medicare's Implementation of the Patient Protection and Affordable Care Act and Health Care and Education Reconciliation Act of 2010
CMS Message 201005-24
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act. One week later, on March 30, the President also signed into law the Health Care and Education Reconciliation Act of 2010. These two new laws have a significant impact on the Medicare program and many of the provisions have effective dates prior to this point in time. Over the past several weeks, the Centers for Medicare & Medicaid Services (CMS) has begun implementing various provisions of the new laws, including those with past effective dates. In addition to implementing these legislative changes, the Medicare Physician Fee Schedule is being updated to include certain corrections, retroactive to January 1, 2010, as prescribed in recently published notices in the Federal Register.
Once Medicare contractors have the new payment files in place, per the above, all claims going forward will be processed at the revised rates. However, we continue to work on the best way to address the many claims that are paid at the rates that were in place before the current corrections and updates are made. Please be on the alert for further information about how CMS will address past claims. Until then, providers should NOT resubmit previously-processed claims affected by the payment changes, as it is likely that these resubmissions may be denied as duplicate claims.
- Additional Intern and Resident Information System Codes
JSM/TDL 10278
This message is to make you aware of recent updates to the Intern and Resident Information System (IRIS) software programs (IRISV3 and IRISEDV3) used by teaching hospitals and the provider community for collecting and reporting information on resident training in hospital and nonhospital settings:
Four new IRIS residency type codes were added to the IRIS Residency Code Table. In addition, two new IRIS medical school codes were added to the IRIS Medical School Code Table. Providers may start using these codes in the IRISV3 program for cost reporting periods ending on or after December 31, 2009. You may download these programs by going to http://www.cms.gov/IRIS.
- SE1016 – Re-Assignment of Certain Providers to Jurisdiction 1 and Jurisdiction 4 Medicare Administrative Contractors (MACs)
- MM6949 - Ambulance Services - Updating the Medicare Benefit Policy Manual Chapter 10, Section 10.5 to Include Ambulance Transports with Joint Responses
- MM6954 - Clinical Review Judgment
- MM6786 – Screening for the Human Immunodeficiency Virus (HIV) Infection
- MM6914 – Addition of Repair Codes to the List of Healthcare Common Procedure Coding System (HCPCS) Codes Payable Under the Instructions Provided in Change Requests (CRs) 6573 and 5917
13 May 2010
06 May 2010
April
29 April 2010
22 April 2010
15 April 2010
8 April 2010
- SE1011 – Edits on the Ordering/Referring Providers in Medicare Part B Claims (Change Requests 6417, 6421, and 6696)
- MM6696 – Ordering/Referring Providers Who Are Not Enrolled in Medicare
- Revised: MM6417 – Expansion of the Current Scope of Editing for Ordering/Referring Providers for claims processed by Medicare Carriers and Part B Medicare Administrative Contractors (MACs)
- 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)
- Extension of Ambulance Add-Ons for Ambulance Services
(JSM/TDL 10217) (CMS Message 201004-10)
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA). PPACA Sections 3105 and 10311 impact certain ambulance payment provisions. It should be noted that PPACA Section 3105 establishes the implementation date as April 1, 2010. PPACA Section 10311 revises Section 3105 and changes the implementation date retroactive to January 1, 2010.
The PPACA extends increases in the ambulance fee schedule amounts for covered ground ambulance transports which originated in rural areas by 3 percent and for covered ground ambulance transports which originated in urban areas by 2 percent retroactive to January 1, 2010, through December 31, 2010. The new law similarly extends the provision for air ambulance services provided in any area that was designated as a rural area for purposes of making payments under the ambulance fee schedule for services furnished on December 31, 2006. Finally, the PPACA extends retroactive to January 1, 2010, and through December 31, 2010, Section 414 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 which established the super rural bonus.
The Centers for Medicare & Medicaid Services is working to expeditiously implement these three ambulance provisions of the PPACA. Be on the alert for more information about these ambulance provisions and their impact on your past and future claims. Further, be on the alert for more information pertaining to the Patient Protection and Affordable Care Act.
6 April 2010
- Banking Transition
(JSM/TDL 10162)
The CMS recently awarded new banking contracts to U.S. Bank and JP Morgan Chase. Medicare providers do not have to take any action. However, providers should be aware that the Medicare payments may be made by a different bank than in the past because of these new banking contractors.
The following Medicare claims processing contractors will remain with JP Morgan Chase: Cahaba Government Benefit Administrators, Pinnacle Business Solutions, First Coast Service Options, Palmetto GBA (except for A/B MAC Jurisdiction 1) and Wisconsin Physician Service. Providers that bill to these contractors will not experience any change.
The following Medicare claims processing contractors will transition to JP Morgan Chase on June 1, 2010: Palmetto A/B MAC Jurisdiction 1 and Trailblazer.
The following contractors will transition to U.S. Bank on June 1, 2010, CIGNA Government Services, Highmark Medicare Services, National Government Services, NHIC and Noridian Administrative Services.
1 April 2010
- MM6852 – Clinical Laboratory Fee Schedule (CLFS) - Special Instructions for Specific Test Codes (CPT Code 80100, CPT Code 80101, CPT Code 80101QW, G0430, G0430QW, and G0431QW)
- MM6864 – Clinical Laboratory Fee Schedule (CLFS) - Medicare Travel Allowance Fees for Collection of Specimens
- MM6807 – Change in Provider Enrollment Timeliness Standards for Certain Paper Applications
- Revised: MM6775 – Outpatient Intravenous Insulin Treatment (Therapy)
- Revised: MM6005 – Comprehensive Outpatient Rehabilitation Facility Manual
- Revised: MM6683 – Validating the Billing of End Stage Renal Disease (ESRD) 50/50 Rule Modifier
- MM6867: Update to List of ICD-9-CM Diagnosis Codes Not Requiring the Q0 Healthcare Common Procedure Coding System (HCPCS) Modifier for Automatic Implantable Cardiac Defibrillator (ICD) Services Provided in a Clinical Study
- MM6861 - Positron Emission Tomography (PET) (NaF-18) to Identify Bone Metastasis of Cancer
- MM6859 - Claim Status Category Code and Claim Status Code Update
- The Patient Protection and Affordable Care Act (PPACA)
(JSM10207) (Message 201003-54)
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA). The Centers for Medicare & Medicaid Services (CMS) is working hard to expeditiously implement the new law. The law's Medicare fee-for-service provisions have varying effective dates and our first priority is to address provisions with the earliest effective dates. CMS is committed to assuring Medicare providers are well informed as early as possible. For that reason, CMS is urging you to be on the alert for notices and instructions from CMS and from your Medicare fiscal intermediary, carrier, or Medicare Administrative Contractor, on forthcoming policy and operational changes as we implement the PPACA.
- Timely Filing Requirements for Medicare Fee-For-Service Claims
(JSM/TDL-10214) (Message 201004-02)
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), which amended the time period for filing Medicare fee-for-service (FFS) claims as one of many provisions aimed at curbing fraud, waste, and abuse in the Medicare program.
The time period for filing Medicare FFS claims is specified in Sections 1814(a), 1835(a)(1), and 1842(b)(3) of the Social Security Act and in the Code of Federal Regulations (CFR), 42 CFR Section 424.44. Section 6404 of the PPACA amended the timely filing requirements to reduce the maximum time period for submission of all Medicare FFS claims to one calendar year after the date of service.
Under the new law, claims for services furnished on or after January 1, 2010, must be filed within one calendar year after the date of service. In addition, Section 6404 mandates that claims for services furnished before January 1, 2010, must be filed no later than December 31, 2010. The following rules apply to claims with dates of service prior to January 1, 2010. Claims with dates of service before October 1, 2009, must follow the pre-PPACA timely filing rules. Claims with dates of service October 1, 2009, through December 31, 2009, must be submitted by December 31, 2010.
Section 6404 of the PPACA also permits the Secretary to make certain exceptions to the one-year filing deadline. At this time, no exceptions have been established. However, proposals for exceptions will be specified in future proposed rulemaking.
Please be on the alert for more information pertaining to the Patient Protection and Affordable Care Act.
March
29 March 2010
- Holding of April Claims for Services Paid Under the 2010 Medicare Physician Fee Schedule
(CMS Message 201003-46)
Information Regarding the Holding of April Claims for Services Paid Under the
2010 Medicare Physician Fee Schedule (3-26-2010)
The Centers for Medicare & Medicaid Services (CMS) is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the Medicare Physician Fee Schedule (MPFS). As you are aware, the Temporary Extension Act of 2010, enacted on March 2, 2010, extended the zero percent (0%) update to the 2010 MPFS through March 31, 2010.
CMS believes Congress is working to avert the negative update that will take effect April 1. Consequently, CMS has instructed its contractors to hold claims containing services paid under the MPFS (including anesthesia services) for the first 10 business days of April. This hold will only affect claims with dates of service April 1, 2010, and forward. In addition, the hold should have minimum impact on provider cash flow because, under the current law, clean electronic claims are not paid any sooner than 14 calendar days (29 for paper claims) after the date of receipt.
Be on the alert for more information about the 2010 Medicare Physician Fee Schedule Update.
25 March 2010
- Reissued: Change Request 6712 - (CR6712) Medically Unlikely Edits.
This CR provides updates and clarifications to MUE requirements established in 2006. For more information, the Centers for Medicare & Medicaid Services has issued the following transmittal at: http://www.cms.hhs.gov/transmittals/downloads/R617OTN.pdf
- Healthcare Provider Taxonomy Codes (HPTC) Update April 2010
The HPTC set is maintained by the National Uniform Claim Committee (NUCC) for standardized classification of health care providers. The NUCC updates the code set twice a year with changes effective April 1 and October 1. The HPTC list is posted to the NUCC Web site at www.nucc.org/taxonomy. The PDF download of the codes is available from the NUCC site at www.nucc.org/index.php?option=com_content&task=view&id=91&Itemid=53.
The changes to the code set include the addition of a new code and addition of definitions to existing codes. When reviewing the Health Care Provider Taxonomy code set online, revisions made since the last release can be identified by the color code; new items are green, modified items are orange, and inactive items are red.
Reference: CMS CR6840 www.cms.hhs.gov/transmittals/downloads/R1896CP.pdf
18 March 2010
11 March 2010
February
25 February 2010
- Revised: Revision of Definition of Compendia as Authoritative Source for Use in the Determination of a Medically-Accepted Indication of Drugs/Biologicals Used Off-label in Anti-Cancer Chemotherapeutic Regimens (CR6806)
- Reporting Inpatient Hospital Evaluation and Management (E/M) Services that Could be Described by Current Procedural Terminology (CPT) Consultation Codes
(JSM/TDL-10152)
This message is to clarify proper reporting in Calendar Year (CY) 2010 of initial E/M services provided by physicians (and other qualified nonphysicians when permitted) in the inpatient hospital setting that could be described by CPT Consultation Codes (99251-99255) that are no longer recognized for payment under the Medicare Physician Fee Schedule (MPFS). The Centers for Medicare & Medicaid Services (CMS) previously instructed physicians and other providers to use other applicable CPT E/M Codes to report the services that could be described by CPT Consultation Codes. The CMS also provided that, in the inpatient hospital setting, physicians (and qualified nonphysicians) who perform an initial E/M service may bill the initial hospital care CPT Codes (99221 – 99223). Since that instruction, CMS has received inquiries specifically as relates to reporting initial hospital care services for which the minimum key component work and/or medical necessity requirements for CPT Codes 99221–99233 are not documented. For instance, one element of inpatient consultation CPT Codes 99251 and 99252, respectively, require “a problem focused history” and “an expanded problem focused history.” In contrast, initial hospital care CPT Code 99221 requires “a detailed or comprehensive history.”
First, CMS reminds providers that CPT Code 99221 may be reported for an E/M service if the requirements for billing that code, which are greater than CPT Consultation Codes 99251 and 99252, are met by the service furnished to the patient. The CMS has alerted Medicare Administrative Contractor Audit Staffs as well as Medicare Recovery Audit Contractors of its expectation that physicians may bill more E/M Codes for initial hospital care, in place of billing inpatient CPT Consultation Codes. The CMS has also alerted contractors to expect a different proportion of various initial hospital care CPT Codes under the new policy. The CMS expects its contractors to consider that these may be appropriate changes when making decisions about whether to pursue medical review and other types of claims review.
Second, CMS notes that subsequent hospital care CPT Codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history” and could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT Consultation Code 99251 or 99252. The CMS has instructed contractors to not find fault with providers who report a subsequent hospital care CPT Code, in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay
Finally, only in the case when an E/M service that could be described by CPT Code 99251 or 99252 is furnished and there is no other specific E/M code payable by Medicare that describes that service shall CPT Code 99499 (Unlisted evaluation and management service) be reported. Reporting 99499 requires submission of medical records and contractor manual medical review of the service prior to payment, and CMS expects reporting under these circumstances to be unusual.
While CMS expects that the CPT Code reported accurately reflects the service provided, CMS has instructed contractors to not find fault with providers who report a subsequent hospital care CPT Code, in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code for an initial hospital E/M service.”
“Reporting Hospice Services Provided by Physicians Under Part A that Could be Described by Current Procedural Terminology (CPT) Consultation Codes
When hospices bill Part A for the services of physicians, they must use CPT Codes that are paid under the Medicare Physician Fee Schedule (MPFS). Since the CPT Consultation Codes are no longer recognized for payment under the MPFS, hospices shall follow the same guidelines for reporting E/M services as physicians billing Part B. Hospices shall use the most appropriate E/M Codes to bill for E/M services furnished by physicians that could be described by CPT Consultation Codes.”
- Revised Clinical Laboratory Fee Schedule and ZIP Code File to Include New Kansas Payment Locality Structure (CR6787)
- Questions and Answers on Reporting Physician Consultation Services (SE1010)
- Revised: Revisions to Consultation Services Payment Policy (CR6740)
18 February 2010
- Rescinded: Compliance Standards for Consignment Closets and Stock and Bill Arrangements (CR6528)
- Revised: Dialysis Adequacy, Infection and Vascular Access Reporting (CR6782)
- Instructions on How to Process Negative Claim Adjustment Reason Code (CARC) Adjustment Amounts when Certain CARCs Appear on Medicare Secondary Payer Claims (CR6736)
- Quarterly Update to Correct Coding Initiative (CCI) Edits, Version 16.1, effective April 1, 2010 (CR6819)
- Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits (CR6812)
- Implementation of a New Skilled Nursing Facility (SNF) Consolidated Billing (CB) Edit for Facility Services Billed by Ambulatory Surgical Centers (ASCs) (CR6702)
- Maintenance and Servicing Payments for Certain Oxygen Equipment after July 1, 2010 (CR6792)
- New Waived Tests (CR6800)
- Interim Instructions for Processing Claims and Recouping Overpayments for Claims Submitted Under the Guidelines Established in Change Request 5917 (CR6762)
- Rescinded– Place of Service (POS) and Date of Service (DOS) Instructions for Interpretation of Diagnostic Tests (CR6375)
- Medicare Claims Crossover to Supplemental Payer Problem
(JSM10139) (Message 201002-25)
The Centers for Medicare & Medicaid Services (CMS) has identified a problem where claims were not automatically crossing over to supplemental payers even though the provider remittance advice indicated otherwise. This problem began January 5, 2010. Part A institutional claims and Part B professional claims, with the exception of supplier claims processed by Durable Medical Equipment Medicare Administrative Contractors (DME MACs), were impacted by this problem. Claims processed by DME MACs were not impacted.
Part A Institutional Claims
No action is required by Part A institutional providers. As of February 2, 2010, CMS successfully implemented a systems fix to ensure that all Part A institutional claims are now crossing over to supplemental payers as indicated on the remittance advice received by providers. As part of the fix, CMS’ Medicare contractors were able to identify claims processed between January 5 and February 1, 2010, where the provider remittance advice indicated that the affected claims were crossed over to various supplemental payers but were not. On February 2, 2010, the affected Medicare contractors began to send the affected claims to the Coordination of Benefits Contractor (COBC) to be crossed over to supplemental payers. This effort is now largely completed. Please allow until March 1, 2010, for supplemental payers to receive and process these claims before attempting to balance bill them for any remaining balances after Medicare.
Part B Professional Claims
Action is required on behalf of Part B professional providers where a remittance advice with an issue date between January 5, 2010, and February 12, 2010, has two or more service lines for a beneficiary where both of the following apply:
· One service line is 100 percent reimbursable (i.e., the approved amount and amount to be paid are equal,) AND
· One service line where part of or the entire Medicare approved amount is applied to the Part B deductible and/or carries co-insurance amounts.
CMS is not able to forward these beneficiary claims to supplemental payers even though the remittance advice may indicate otherwise. Providers will need to identify these claims by reviewing their remittance advice with an issue date between January 5, 2010, and February 12, 2010, that contain the criteria noted above. Once identified, providers will need to take action to balance bill the beneficiary’s supplemental payer. As of February 12, 2010, this system problem was fixed and all claims are crossing over to supplemental payers as indicated on the provider remittance advice.
The CMS has already notified supplemental payers of these issues. We regret any inconvenience you may experience related to this Medicare claim supplemental payer crossover problem.
- Medicare Non-Covered Claims with Professional Component Claims Process Issue
(JSM10144)
The Centers for Medicare & Medicaid Services (CMS) has identified a Medicare claims processing issue where non-covered claims submitted with a professional component are incorrectly receiving Reason Code 31387 preventing the claims from finalizing. Non-covered claims containing professional component receiving Reason Code 31387 are being held and will be released on or about September 6, 2010, once this claims processing system issue is fixed. We apologize for any inconvenience you may experience related to this issue.”
- Medicare Mammography Services Claims Process Issue
(JSM10143)
The Centers for Medicare & Medicaid Services (CMS) has identified a Medicare claims processing issue where adjustments submitted against original bills containing mammography services are incorrectly receiving Reason Code 36440 preventing the claims from finalizing. Adjustments performed on claims containing mammography services receiving Reason Code 36440 are being held and will be released on approximately September 6, 2010, once this claims processing system issue is fixed. We apologize for any inconvenience you may experience related to this issue.”
11 February 2010
4 February 2010
1 February 2010
January
28 January 2010
25 January 2010
- Expiration of Increased Medicare Payments for Ground Ambulance Services and Air Ambulance Payment Improvements Provisions (JSM10125)
Section 146(a) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) provided for an increase in the ambulance fee schedule amounts for covered ground ambulance transport. For transports that originated in urban areas, the increase was two (2) percent. For transports that originated in rural areas, the increase was three (3) percent. The increases were applicable only for claims with dates of service July 1, 2008, through December 31, 2009.
Further, Section 146(b)(1) of MIPPA amended the designation of rural areas for air ambulance services. The statute specified that any area that was designated as a rural area as of December 31, 2006, for purposes of making payments under the ambulance fee schedule for air ambulance services should continue to be treated as a rural area for purposes of making air ambulance service payments under the ambulance fee schedule. This statute was also applicable only for claims with dates of service July 1, 2008, through December 31, 2009.
As such, as of January 1, 2010, for ground and air ambulance claims received with dates of service on this date and beyond, Medicare will no longer be paying ground and air ambulance service providers based on these two expired provisions.
21 January 2010
19 January 2010
- Change Request 6712 - (CR6712) Medically Unlikely Edits
This CR provides updates and clarifications to MUE requirements established in 2006. For more information, the Centers for Medicare & Medicaid Services has issued the following transmittal at http://www.cms.hhs.gov/transmittals/downloads/R617OTN.pdf.
14 January 2010
7 January 2010
December
30 December 2009
28 December 2009
- Expiration of Moratorium that Allowed Independent Laboratories to Bill for the Technical Component of Physician Pathology Services Furnished to Hospital Patients and Expiration of Therapy Cap Exceptions
(JSM/TDL-10110)
1. Expiration of Moratorium that Allowed Independent Laboratories to Bill for the TC of Physician Pathology Services Furnished to Hospital Patients
The Centers for Medicare & Medicaid Services (CMS) continues to work with Congress on significant legislation which affects the Medicare program. We believe this and other provisions may be extended as part of this legislation. We encourage you to monitor Congressional activity and stay apprised of the status of potential legislation. In the meantime, if such legislation is enacted, CMS will notify Medicare fee-for-service claims processing contractors to again process claims for those affected services. Providers may choose to hold their claims in the event legislation about this issue is enacted. However, current law mandates the following change:
In the final physician fee schedule regulation published in the Federal Register on November 2, 1999, CMS stated that it would implement a policy to pay only the hospital for the technical component (TC) of physician pathology services furnished to hospital patients. At the request of the industry, to allow independent laboratories and hospitals sufficient time to negotiate arrangements, the implementation of this rule was administratively delayed. Subsequent legislation formalized a moratorium on the implementation of the rule.
The most recent extension of the moratorium was established by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). Section 136 of the MIPPA expires on December 31, 2009, thus ending the moratorium. Therefore, independent laboratories may no longer bill Medicare for the TC of physician pathology services furnished to patients of a hospital, regardless of the beneficiary's hospitalization status (inpatient or outpatient) on the date that the service was performed. This prohibition is effective for claims with dates of service on and after January 1, 2010.
We will continue to be in communication with you should there be further information regarding payment of claims impacted by the above guidance. In addition, be on the alert for more information about this and other legislative provisions which may affect you.”
2. Expiration of Therapy Cap Exceptions Process
The Centers for Medicare & Medicaid Services (CMS) continues to work with Congress on significant legislation which affects the Medicare program. We believe this and other provisions may be extended as part of this legislation. We encourage you to monitor Congressional activity and stay apprised of the status of potential legislation. In the meantime, if such legislation is enacted, CMS will notify Medicare fee-for-service claims processing contractors to again process claims for those affected services. Providers may choose to hold their claims in the event legislation about this issue is enacted. However, current law mandates the following change:
The exceptions to outpatient therapy caps expire on December 31, 2009. Outpatient therapy service providers should not submit claims with the KX modifier for services furnished on or after January 1, 2010. The therapy caps are determined on a calendar year basis, so all patients will begin a new cap year on January 1, 2010. For physical therapy and speech language pathology services combined, the limit on incurred expenses is $1,860. For occupational therapy services, the limit is $1,860. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached.
Note that patients who have reached their limit(s) on outpatient therapy services, other than those who reside in a Medicare-certified part of a skilled nursing facility, may obtain medically necessary therapy services that exceed the caps if the services are furnished and billed by the outpatient department of a hospital. In other settings, outpatient therapy services in excess of the caps are not covered, and the therapy provider may charge the beneficiary for those services. We will continue to be in communication with you should there be further information regarding payment of claims impacted by the above guidance. In addition, be on the alert for more information about this and other legislative provisions which may affect you.
23 December 2009
17 December 2009
10 December 2009
3 December 2009
November
24 November 2009
20 November 2009
- JSM/TDL-10054 -The 2010 Medicare Physician Fee Schedule (MPFS) Update/Disclosures have been posted.
NOTE: These files reflect technical corrections to the relative value units, including for CPT codes G0341, 29870, 36481, 37183, 47382, 50200, 55873, 92610, 99221, 99222, 99223, 99304, 99305 and 99306, and to the CY 2010 conversion factor contained in the CY 2010 Medicare physician fee schedule final rule. (See http://www.federalregister.gov/OFRUpload/OFRData/2009-26502_PI.pdf).
The conversion factor for CY 2010 is $28.3895 instead of $28.4061 as previously indicated in the final rule. A correction notice will be published in the Federal Register regarding these corrections.
CMS is extending the 2010 Annual Participation Enrollment Program. The participation enrollment period will now end
January 31, 2010, instead of December 31, 2009.
19 November 2009
- Therapy Cap Values for Calendar Year (CY) 2010 (CR6660)
- Update to Medicare Deductible, Coinsurance, and Premium Rates for 2010 (CR6690)
- Ambulance Services (CR6707)
- Claim Status Category Code and Claim Status Code Update (CR6723)
- January 2010 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files (CR6708)
- Outpatient Mental Health Treatment Limitation (CR6686)
- 2010 Annual Participation Enrollment Program Extension (SE0929)
- Calendar Year (CY) 2010 Fee Schedule Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) (CR6720)
- Healthcare Common Procedure Coding System (HCPCS) Code Q2024 for Small Dose Bevacizumab (Avastin®)
JSM/TDL-10049
Effective immediately, the Centers for Medicare & Medicaid Services (CMS) no longer recognizes Healthcare Common Procedure Coding System (HCPCS) Code Q2024 Bevacizumab (Avastin®) for payment of nonoutpatient hospital claims. Practitioners shall return to their previous reporting practice for small intraocular doses of Bevacizumab (Avastin®) furnished prior to October 1, 2009. HCPCS Code Q2024 will be deleted as of January 1, 2010, and, therefore, it will be removed from the Average Sales Price (ASP) pricing file effective with the January 2010 Release.
12 November 2009
- Mental Health Medically Unlikely Edit (MUE)
JSM/TDL-10038
The Centers for Medicare & Medicaid Services (CMS) has identified an incorrect Medically Unlikely Edit (MUE) of 3 units for hospital outpatient services described by Current Procedural Terminology (CPT) Code 90853 (Group psychotherapy (other than of a multiple-family group)). The proper MUE for this code is 5 units. This will be retroactively corrected in the January 1, 2010 Release. Your FI/MAC will hold hospital outpatient claims (Type of Bill (TOB) 13X) with 4 or 5 units of CPT Code 90853 on one line with dates of service on or after October 1, 2009.
However, when providing 4 or 5 units of the service described by CPT Code 90853 between October 1, 2009, and January 1, 2010, you may choose to bill 3 units of CPT Code 90853 on one line, and 1 or 2 units of CPT Code 90853 on another line with Modifier -59 in order to receive payment for these services prior to the implementation of the corrected MUE on January 1, 2010. This is a time-limited instruction and applies only to services described by CPT Code 90853 provided between October 1, 2009, and January 1, 2010. In all other cases, the use of Modifier -59 is reserved only for services provided in distinct clinical circumstances. It is improper to use Modifier -59 to circumvent MUEs unless specifically instructed by your FI/MAC to do so.
- Instructions for Processing Claims Containing Anti-Markup Services but with Partial Information Completed in Item 20 of the CMS-1500 Claim Form (CR6670)
- Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2010 (CR 6717)
- Ensuring the Denial of Claims for Ambulance Services Rendered to Beneficiaries in Part A Skilled Nursing Facility Stays (CR6700)
9 November 2009
- The 2010 Medicare Physician Fee Schedule (MPFS) amounts are currently unavailable until further notice, but will be posted as soon as they become available. Please check this web site periodically for any updates. (JSMTDL 10046)
5 November 2009
October
29 October 2009
22 October 2009
15 October 2009
8 October 2009
1 October 2009
September
24 September 2009
17 September 2009
10 September 2009
3 September 2009
August
27 August 2009
20 August 2009
13 August 2009
- The Use of the CR Modifier and DR Condition Code on Disaster/Emergency-Related Claims (CR6451)
- Revised: Appropriate Use of Modifier 50 and Add-On Codes for Facet Joint Injections Services (CR6518)
- Marketing the Upcoming Health Insurance Portability and Accountability Act Version 5010 Conference Call to Billing Software Vendors and Clearinghouses
JSM/TDL-09385
The Centers for Medicare & Medicaid Services (CMS) will present the second in a series of National Education Training Conference Calls focused on Medicare’s Fee-for-Service (FFS) implementation of Health Insurance Portability and Accountability Act (HIPAA) Version 5010. The training presentation, geared to clearinghouses and billing software vendors, will cover Medicare FFS error handling transactions (TA1, 999, and 277CA), planned use of each transaction and applicable rules and exceptions for the Medicare FFS program. A Question & Answer (Q&A) session will follow the presentation that will give participants an opportunity to ask questions of CMS’ subject matter experts.
Due to the nature of the content, only clearinghouse and billing software vendor staff are encouraged to participate in this important CMS training conference call.
You must register for this call in advance, in order to receive the call-in information.
Please note if your organization is planning to participate in this training call as a group, only one person needs to register to receive the call-in information. This registration is solely to reserve a telephone line, NOT to allow participation.
Date: August 26, 2009
Conference Title: Version 5010: Medicare FFS Error Handling Transactions
Time: 2:00 – 3:30 p.m. ET
Registration will close at 2:00 p.m. ET on August 25, 2009, or when available space has been filled. No exceptions will be made, so please be sure to register prior to this time.
1. To register for the call, participants need to go to http://www2.eventsvc.com/palmettogba/082609.
2. Fill in all required data.
3. Verify your time zone is displayed correctly the drop down box.
4. Click "Register".
5. You will be taken to the “Thank you for registering” page and will receive a confirmation e-mail shortly thereafter. Note: Please print and save this page, in the event that your server blocks the confirmation emails. If you do not receive the confirmation e-mail, please check your spam/junk mail filter as it may have been directed there.
6. A few days prior to the call (not before August 24th), check the Educational Resources page on CMS’ 5010 Web page at http://www.cms.hhs.gov/Versions5010andD0/40_Educational_Resources.asp to obtain a copy of the presentation that will be used during the call.
6 August 2009
July
30 July 2009
23 July 2009
16 July 2009
9 July 2009
2 July 2009
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