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OHIO
Medicare Bulletin
A service of CGS
Ohio General Release
NOVEMBER 2012
HOT TOPIC
MM8021 - Healthcare Provider Taxonomy Codes (HPTC) Update, October 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
SE1221 - Phase 2 of Ordering/Referring Requirement . . . . 76
INSIDE THIS ISSUE
3rd Quarter Update Part B Not Otherwise Classified Drug Fee Schedule
2012 Payment Allowance Limits for Medicare Part B Not Otherwise Classified
(NOC) Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4th Quarter Update Part B Not Otherwise Classified Drug Fee Schedule
2012 Payment Allowance Limits for Medicare Part B Not Otherwise Classified
(NOC) Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
INSERT TOPICS
CR 8059 - Implementation of the Award for the Jurisdiction 5 Part A and Part B
Medicare Administrative Contractor (J5 A/B MAC) Reprocurment Including a
New Workload Number for the Remaining WPS Legacy Workload . . . . . . 19
General Part B
Erythropoiesis Stimulating Agents (ESA) L31867 . . . . . . . . . . . . . . . . . . 30
Local Carrier Payment Allowance Limits for Medicare Part B Drugs . . . . . .30
Local Payment Allowance Limits for Medicare Part B Drugs . . . . . . . . . . .34
REACHING OUT TO THE MEDICARE COMMUNITY
WWW.CGSMEDICARE.COM
MM7791 - Contractor and Common Working File (CWF) Additional Instructions
Related to Change Request (CR) 7633 - Screening and Behavioral Counseling
Interventions in Primary Care to Reduce Alcohol Misuse . . . . . . . . . . . . . 37
MM7806 - Extracorporeal Photopheresis (ICD-10) . . . . . . . . . . . . . . . . 39
PA RT
B
KY • OH
MM7818 - International Classification of Diseases, 10th Edition (ICD)-10 Conversion from (ICD-9) and Related Code Infrastructure of the Medicare Shared
Systems as They Relate to CMS National Coverage Determinations (NCDs)
(CR 1 of 3) (ICD-10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
MM7881 - Expiration of 2012 Therapy Cap Revisions and User-Controlled
Mechanism to Identify Legislative Effective Dates . . . . . . . . . . . . . . . . . . 44
MM7883 - 2013 Annual Update for the Health Professional Shortage Area
(HPSA) Bonus Payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
MM7890 - Ordering and Certifying Documentation - Maintenance Requirements
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
MM7897 - National Coverage Determination (NCD) for Transcatheter Aortic
Valve Replacement (TAVR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
MM8021 - Healthcare Provider Taxonomy Codes (HPTC) Update, October
2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
MM8032 - October 2012 Update of the Ambulatory Surgical Center Payment
System (ASC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
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.
MM8036 - Manual Medical Review of Therapy Services . . . . . . . . . . . . 54
OHIO
Medicare Bulletin
REACHING OUT TO THE
MEDICARE COMMUNITY
WWW.CGSMEDICARE.COM
A service of CGS
Ohio General Release
NOVEMBER 2012
MM8037 - 2013 Annual Update of Healthcare Common Procedure Coding
System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing
(CB) Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
MM8045 - Claim Status Category and Claim Status Codes Update . . . . . . 58
MM8047 - Influenza Vaccine Payment Allowances - Annual Update for 20122013 Season . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
MM8049 - Annual Clotting Factor Furnishing Fee Update 2013 . . . . . . . . . 61
MM8054 - New Waived Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
PA RT B
KY • OH
MOHs Micrographic Surgery L31877 . . . . . . . . . . . . . . . . . . . . . . . . . 65
OVA1 or ROMA for Ovarian Cancer Screening . . . . . . . . . . . . . . . . . . 66
Rescinded: MM7819 - Coding Changes to Ultrasound Diagnostic Procedures
for Transesophageal Doppler Monitoring . . . . . . . . . . . . . . . . . . . . . . . . 66
Results of Kentucky Progressive Corrective Action (PCA) for New Patient Office
Visit Code 99205© . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
REVISED: MM8017 - October Update to the Calendar Year (CY) 2012 Medicare
Physician Fee Schedule Database (MPFSDB) . . . . . . . . . . . . . . . . . . 67
Revised: SE1011 - Edits on the Ordering/Referring Providers in Medicare Part
B, DME and Part A HHA Claims (Change Requests 6417, 6421, 6696, and
6856) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68
Revised: SE1201 - Important Reminder for Providers and Suppliers Who Provide
Services and Items Ordered or Referred by Other Providers and Suppliers
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
SE1221 - Phase 2 of Ordering/Referring Requirement . . . . . . . . . . . . . 76
SE1234 - Important Information Concerning the Medicare Crossover Process
and State Medicaid Agency Requirements for National Drug Codes (NDCs)
Associated with Physician-Administered Part B Drugs . . . . . . . . . . . . . . . 80
SE1236 - Documenting Medical Necessity for Major Joint Replacement (Hip
and knee) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
SE1238 - Claim Modifier Did Not Prevent Medicare from Paying Millions in
Unallowable Claims for Selected Durable Medical Equipment . . . . . . . . . 84
SE1239 - Updated ICD-10 Implementation Information . . . . . . . . . . . . . . 89
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.
SE1240 - Partial Code Freeze Prior to ICD-10 Implementation . . . . . . . . . 94
Skin Substitute- Apligraf Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Small Provider and Medicare Update Workshops: Free! . . . . . . . . . . . . . 96
3rd Quarter Update Part B Not Otherwise Classified Drug Fee Schedule
2012 Payment Allowance Limits for Medicare Part B Not Otherwise
Classified (NOC) Drugs
Effective July 1, 2012 through September 30, 2012
Revised: 09/20/2012
Name of Drug and EXACT Dosage Given MUST be in Block 19 (paper), as an Attachement, or
Narrative Field (EMC)
NOTE 1: Payment allowance limits subject to the ASP methodology are based on 1Q11 ASP data.
NOTE 2: Providers should contact their local Medicare contractor processing the claim for the most
appropriate unlisted/unclassified HCPCS code to use in reporting these drugs to Medicare.
NOTE 3: The absence or presence of a HCPCS code and the payment allowance limits in this table
does not indicate Medicare coverage of the drug. Similarly, the inclusion of a payment allowance limit
within a specific column does not indicate Medicare coverage of the drug in that specific category.
These determinations shall be made by the local Medicare contractor processing the claim.
Note 4: ** - Carrier Priced
Changes In Bold
DRUG NAME
DOSAGE
Abatacept (Orencia) The subcutaneous form of
abatacept is considered self-administered
Actemra (see Tocilizumab)
Adcetris (see Brentuximab Vedotin)
Alfentanil Hydrochloride (Alfenta)
Alglucosidase Alfa (Myozyme)
Allopurinol Sodium (Aloprim) ICD-9’s 274.9
or 790.6 plus the ICD-9 for the neoplasm.
Need name of chemotherapy agent causing
the elevation of uric acid and a statement as
to why patient can not tolerate oral form of
the drug.
Afinitor (see Everolimus)
Aflibercept (see EYLEA)
Amidate (see Etomidate)
Amino Acid
Amino Acid
Aminocaproic Acid
Antihemophilic Factor (Recomb) Plasma/
Albumin-Free (Xyntha)
Arformoterol Tartrate (Brovana)
Arginine Hydrochloride (R-Gene 10)
Arzerra (see Ofatumumab)
** Ascorbic Acid (Vitamin C) Non-covered by
Carrier
** Atenolol (Tenormin) ICD-9’s = 401.0 - 429.9
Atropine Sulfate / Edrophonium Chloride
Avastin (See Bevacizumab)
Aztreonam (Azactam)
** Bacitracin (Bacim)
Belimumab (Benlysta) Covered ICD-9: 710.0
500 mcg/5 ml
Current
PAR
Current
NON-PAR
$1.626
$1.545
$336.086
$319.282
2 mg vial
$1,961.000
$1,862.950
500 ml
1000 ml
250 mg
$21.110
$35.190
$0.058
$20.055
$33.431
$0.055
300 ml
$11.225
$10.664
0.5 mg / ml
10 mg
$0.800
$1.651
$0.760
$1.568
500 mg
50,000 U
$13.934
$10.170
$13.237
$9.662
10 mg
500 mg/SDV
1 IU
15 mcg
10 mg
Notes
increase
Code for 2012:
J0221
decrease
Added December
2011
increase
Code for 2011:
J7185
Code for 2011:
J7605
decreased
Code for 2012:
J0490
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 3 -
November 2012
Beltatacept (Nulojix) Covered indications: V420
and 075 or 996.52
Bendamustine Hydrochloride (Treanda)
Covered indications: 204.10 - lymphoid
leukemia, chronic, without mention of remission
or 204.11 - lymphoid leukemia, chronic, in
remission
Benlysta (see Belimumab)
Berinert (see C1 Esterase Inhibitor)
Bevacizumab (Avastin) CPT 67028 must be
on claim or in history; allow if billed with J3490
or J3590 and the ICD-9 requirements from one
of the following codes: 115.02, 115.12, 115.92,
362.01 - 362.07 (any), 362.16, 362.35 - 362.37
(any), 362.42, 362.52 or 362.83.
Brentuximab Vedotin (Adcetris) Covered
indications 200.60-200.68 or 201.00-201.98
Bretylium Tosylate (Bretylol)
Brevibloc (see Esmolol Hydrochloride)
Brovana (see Arformoterol Tartrate)
Bumetanide (Bumex)
Bupivacaine Hcl, 0.25%, 2 ml (Considered Part
of Procedure)
Bupivacaine Hcl, 0.50%, 2 ml (Considered Part
of Procedure)
Bupivacaine, Sterile, 0.25%/10ml
(Sensorcaine, Sterile) Allowed when billed
with 51700, 51720, 62310, 62311, 62318,
62319, 62368, 64400 - 64484, 64505 - 64530,
77003, 95990, or 96530. When billed with
other procedures, considered part of
procedure performed.
Bupivacaine, Sterile, 0.50%/10ml (Sensorcaine,
Sterile) Allowed when billed with 51700, 51720,
62310, 62311, 62318, 62319, 62368, 64400 64484, 64505 - 64530, 77003, 95990, or 96530.
When billed with other procedures, considered
part of procedure performed.
Bupivacaine, Sterile, 0.75%/10ml
(Sensorcaine, Sterile) Allowed when billed
with 51700, 51720, 62310, 62311, 62318,
62319, 62368, 64400 - 64484, 64505 - 64530,
77003, 95990, or 96530. When billed with
other procedures, considered part of
procedure performed.
C1 Esterase Inhibitor (Berinert) - For the
treatment of acute abdominal or facial attacks of
hereditary angioedema in adult and adolescent
patients (277.6)
Cabazitaxel (Jevtana®)
Calciferol (see Ergocalciferol D2)
Calcium Chloride
Canakinumab (Ilaris) - For Cryopyrin-associated
periodic syndromes
Capsaicin 8% Patch (Qutenza) - Must be
administered under provider supervision.
Cardizem IV (see Diltiazem Hydrochloride)
Carfilzomib (Kyprolis) covered ICD-9 203.00 or
203.02
250 mg.
$978.380
$929.461
Code for 2011:
J9033
1 mg
Updated ICD-9
Coverage Effective:
01/01/2011
New Unit Price Per
Carrier Medical
Director Effective:
05/01/2011
effective 7/1/2012
new dosage and
unit price
N/A
$60.000
$57.000
1mg
$95.400
$90.630
5 mg
$0.175
$0.166
0.25 mg
$0.129
$0.123
decrease
0.25% - 1 ml
$0.058
$0.055
decrease
0.50% - 1 ml
$0.058
$0.055
decrease
0.75% - 1 ml
$0.058
$0.055
decrease
Code for 2011:
J0597
10 units
1 mg
100 mg / ml
Code for 2012:
J9043
$0.169
1 mg
10 sq cm
60 mg
$1,669.606
$0.161
decrease
Code for 2011:
J0638
Code for 2011:
J7335
Added September
2012
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 www.cgsmedicare.com.
November 2012
- page 4 -
Medicare Bulletin – GR 2012-11
** Cefamanadole Nafate (Mandol)
** Cefoperazone Sodium (Cefobid)
Cefotetan Disodium (Cefotan)
Certolizumab Pegol (Cimzia)
Chirocaine (see Levobupivacaine
Hydrochloride)
Cimetidine Hcl. (Tagamet)
Cimzia (see Certolizumab Pegol)
Clavulanate Potassium / Ticarcillin Disodium
Clevidipine Butyrate
Clindamycin Phosphate (Cleocin)
Clorpactin WCS-90 (see Oxychlorosene
Sodium)
Collagenase Clostridium Histolyticum (Xiaflex)
Covered for Contracture of palmar fascia
(Dupuytren’s concracture) ICD-9 728.6.
Copper Sulfate
Cosyntropin IV
Cystografin (see Diatrizoate Meglumine)
Dantrolene Sodium
Degarelix (Firmagon)
Depacon (see Valproate Sodium)
Denileukin Difitox (Ontak) (For 300 mcg, use
code J9160)
Denosumab (Prolia ™ or Xgeva) If Prolia ™,
covered ICD-9 = 733.01; if Xgeva, covered ICD9 = 198.5.
Dexamethasone Intravitreal Implant (Ozurdex)
If billed under J3490 or J3590, with CPT code
67028 & 1 of the following ICD-9 combinations:
1) 362.83 plus 362.35 or 362.36; or
2) 362.30
Dextrose 2.5%
Dextrose 5%
Dextrose 10%
Dextrose 50%
** Dextrose / Nitroglycerin 5%-20 mg/ 100
ml/250 ml
** Dextrose 5% / Sodium Chloride
Diatrizoate Meglumine (Cystografin)
Diltiazem Hydrochloride (Cardizem IV)
Diprivan (see Propofol)
Doripenem (Doribax)
Doxapram Hydrochloride (Dopram)
Doxycycline Hyclate
Ecallantide (Kalbitor) Covered Indications 277.6 (accute attack of hereditary angioedema)
Eculizumab (Soliris)
Edecrin Sodium (see Ethacrynate Sodium)
Edrophonium Chloride (Tensilon) (Allow for
ICD9 - 358.0)
Elaprase (see Idursulfase)
1 gm
1 gm
1 gm
$8.610
$16.380
$11.376
$8.180
$15.561
$10.807
Code for 2011:
J0718
1 mg
150 mg
$1.064
$1.011
0.1 - 3 gm
1 mg
150 mg
$10.933
$2.964
$1.488
$10.386
$2.816
$1.414
Code for 2011:
J0775
0.1 mg
0.4 mg
$0.116
$0.110
$78.800
$74.860
0.25 mg
20 mg
increase
Code for 2011:
J0833
Code for 2011:
J9155
1 mg
150 mcg
increase
decrease
decrease
$595.430
$565.659
1 mg
Code for 2012:
J0897
0.1 mg
Code for 2011:
J7312
2.50%
5%
500 ml
50 ml
20 mg/100
ml/250 ml
1000 ml
10 ml
5 mg
$7.680
$7.860
$10.000
$0.101
$7.296
$7.467
$9.500
$0.096
$6.320
$6.004
$11.220
$2.10
$0.156
$10.659
$2.00
$0.148
10 mg
20 mg
100 mg
$2.212
$10.990
$2.101
$10.441
$2.420
$2.299
1 mg
10 mg
10 mg
Effective 05/01/2011
decrease
Code for 2011:
J1267
increase
decrease
Code for 2011:
J1290
Code for 2011:
J1300
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 5 -
November 2012
Emend for Injection (see Fosaprepitant
Dimeglumine)
Enalaprilat (Vasotec IV)
Eovist (see Gadoxetate Disodium)
Ergocalciferol D2 (Calciferol) ICD-9’s = 579.8 or
579.9 Allowed when administered in physician’s
office
Eribulin Mesylate (Halaven) - Covered ICD-9’s =
174.0 - 174.9
Esmolol Hydrochloride (Brevibloc) Covered
ICD-9 = 427.89 (Dosage change from 100 mg
to 10 mg.)
Esomeprazole Sodium (Nexium IV) Covered
ICD-9’s = 530.10 - 530.19 or 530.81 when
administered in the physician’s office.
Estradiol
** Estradiol Pellets
Ethacrynate Sodium (Edecrin Sodium)
** Ethiodized Oil (Ethiodol)
Etomidate (Amidate)
Everolimus (Afinitor / Zortress) - Non-Covered;
Oral drug considered as self-administered.
EYLEA (see Aflibercept)
Famotidine (Pepcid)
Ferumoxytol (Feraheme)
1.25 mg
$1.640
$1.558
500,000 IU/ 1ml
$29.840
$28.348
Code for 2012
J9179
0.1 mg
10 mg
$0.722
$0.686
decrease
20 MG
$3.938
$3.741
increase
1 gram
Per Pellet
50 mg
1 ml
2 mg
$13.300
Invoice
$19.040
$8.060
$0.584
$12.635
Invoice
$18.088
$7.657
$0.555
10 mg
$0.373
$0.354
1 mg
Fibrinogen Concentrate Human (RiaSTAP)
Firazyr (see Icantibant)
Firmagon (see Degarelix)
Flagyl IV (see Metronidazole In Nacl.)
Floxin IV (see Ofloxacin)
Fludarabine phosphate, oral - Not Covered by
Part B
Flumazenil (Mazicon, Romazicon)
Flumazenil (Mazicon, Romazicon)
Folic Acid
Folotyn (see Pralatrexate)
Fosaprepitant Dimeglumine (Emend) Allowed
when billed on the same day as chemotherapy.
Fospropofol Disodium injection (Lusedra)
Gadoxetate Disodium (Eovist)
Gammaked injection
Gammaplex (see Human Immune Globulin
Intravenous)
Glycopyrrolate (Robinul)
Graftjacket Gel
Halaven (see Eribulin Mesylate)
** Heparin Sodium
Hetastarch Sodium Cl., 6 gm/500 ml
Hexaminolevulinate Hydrochloride - Covered for
ICD-9’s 188.0 through 188.9
Hizentra (see Immune Globulin Subcutaneous)
decrease
10 mg
0.1 mg
0.5 mg
5 mg
$0.841
$42.830
$1.729
$0.799
$40.689
$1.643
$0.201
increase
$0.191
1 ml
500 mg
$37.484
$35.610
0.2 mg
$0.317
$0.301
$0.032
$23.040
$0.030
$21.888
$623.280
$592.116
1 cc
100 units
6 gm
100 mg, per
study dose
Code for 2011:
J8562
increase
Code for 2011:
J1453
1 mg
35 mg
increase
Code for 2012:
J8561
Added December
2011
decrease
Codes for 2011:
Q0138 (non-esrd) &
Q0139 (esrd)
Code for 2011:
J1680
Code for 2011:
A9581
Added October
2011
decrease
Code for 2011:
Q4113
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 www.cgsmedicare.com.
November 2012
- page 6 -
Medicare Bulletin – GR 2012-11
Human Immune Globulin Intravenous
(Gammaplex)
Hydroxocobalamin - Covered when billed with
J9305.
Hylan G-F 20 (Synvisc-One)
Icantibant (Firazyr) - Usually considered selfadministered
Idursulfase (Elaprase)
Code for 2012:
J1557
IV
1000 mcg/ml
$1.212
$1.151
Effective 06/01/2011
48 mg
Code for 2011:
J7325
1 mg
Code for 2011:
J1743
100 mg
Code for 2011:
J0597
Ilaris (see Canakinumab)
Immune Globulin Subcutaneous (Hizentra)
** Inamrinone Lactate
IncobotulinumtoxinA (Xeomin) - Covered for the
treatment of Genetic torsion dystonia (333.6)
and Blepharospasm (333.81)
INTEGRA™ Bilayer Matrix Wound Dressing Covered Indications = 757.39, 941.20-941.21,
941.24-941.31, 941.34-941.41, 941.44-941.51,
941.54-941.59, 942.20-942.59, 943.20-943.59,
944.20-944.58, 945.20-945.59, 946.2-946.5,
948.00-948.99
Invega® Sustenna® (see Paliperidone
Palmitate injection)
Ipilimumab (Yervoy) - Covered for unresectable
or metastatic melanoma.
Isoproterenol Hydrochloride (Isuprel)
Isoptin IV (see Verapamil Hydrochloride)
Istodax (see Romidepsin)
Isuprel (see Isoproterenol Hydrochloride)
Ixabepilone (Ixempra) Covered for metastatic
or locally advanced breast cancer (ICD-9 codes
174.0 - 175.9)
Jevtana® (see Cabazitaxel)
Kalbitor (see Ecallantide)
Kenalog (see Triamcinolone Acetonide)
Keppra intraveneous (see Levetiracetam)
Ketamine Hydrochloride (Ketalar) Allowed when
billed on same day as 20550-20610, 62289,
62298, 62368, 95990, or 96530.
Kyprolis (see Carfilzomib)
Krystexxa (see Pegloticase)
Labetalol Hydrochloride (Trandate,
Normodyne) Covered if given IV in the office
for control of BP in severe hypertension.
Patient is normally switched to oral for
maintainance doses.
5 mg
$4.050
$3.848
New Code for 2012:
J0588
1 Unit
1 sq cm
$19.391
$18.421
Code for 2012:
J9228
1mg
0.2 mg
$2.250
$2.138
Code for 2011:
J9207
1 mg
10 mg
increase
$0.067
$0.064
Added September
2012
5 mg
Lanreotide (Somatuline Depot)
1 mg
Levetiracetam (Keppra intraveneous)
** Levobupivacaine Hydrochloride (Chirocaine)
Allowed separately when billed on same day
as 51700, 51720, 62310, 62311, 62318, 62319,
62368, 64400 - 64484, 64505-64530, 76003,
95990, or 96530. Not payable separately when
billed with any other procedures
** Levophed Bitartrate (see Norepinephrine
Bitartrate)
10 mg
2.5 mg/ml
$0.248
$0.236
decrease
Code for 2011:
J1930
Code for 2011:
J1953
$0.310
$0.295
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 7 -
November 2012
** Levothyroxine Sodium (Synthroid) Need
statemnt on claim as to why patient can’t take
oral form of drug.
Lexiscan (see Regadenoson)
Lidocaine - Allowed separately when billed on
same day as 51700, 51720, 62310, 62311,
62318, 62319, 62368, 64400 - 64484, 64505
- 64530, 77033, 95990, or 96530. Not payable
when billed with any other procedure.
Lopressor (see Metoprolol Tartrate)
Lucentis (see Ranibizumab)
Lusedra (see Fospropofol Disodium injection)
Mandol (see Cefamanadole Nafate)
Marqibo (see Vincristine sulfate Liposome)
Mazicon (see Flumazenil)
Methylnaltrexone Bromide (Relistor) Noncovered by carrier.
Metoprolol Tartrate (Lopressor) Covered
when given IV with Dobutamine J1250
during Dobutamine Stress Test.
Metronidazole Hcl. (Flagyl IV) IV in the office.
Covered for ICD-9’s= 001.0-009.3, 040.0041.9, 481-482.9, 567.0-567.9, 599.0-599.9,
615.0-615.9.
Miconazole (Monistat IV) 10 mg
Minocycline Hydrochloride (Non-covered oral
drug)
Monistat IV (see Miconazole)
Morrhuate Sodium
Myozyme (see Alglucoside Alfa)
Nafcillin Sodium (Nallpen) (Dosage Change
from 500 mg to 1 gm)
Nalmefene Hydrochloride (Revex)
Netilmicin Sulfate (Netromycin), 150 mg
Nexium IV (see Esomeprazole Sodium)
Nitroglycerin IV – Allowed in emergency
situations.
Nodolo & Tusal (see Sodium Thiosalicylate)
** Norepinephrine Bitartrate (Levophed
Bitartrate) Allow in emergency situations.
Norcuron (see Vecuronium Bromide)
Normal Saline (Sterile Water)
Normodyne (see Labetalol Hydrochloride)
Nplate™ (see Romiplostim)
Nulojix (see Beltatacept)
Ofatumumab (Arzerra) Covered indications 204.10 or 204.12
Ofloxacin (Floxin IV), 20 mg
Olanzapine long-acting intramuscular injection
Covered indications = 295.00 - 295.95 or 296.40
- 296.66 when administered in the physicians
office.
Olanzapine short-acting intramuscular
injection (Zyprexa IM) Covered indications
= 295.01 - 295.84 when administered in the
physicians office.
Ontak (see Denileukin Difitox)
Optison
0.5 mg
$62.010
$58.910
1 ml
$0.143
$0.136
Added September
2012
1 mg
$0.160
$0.152
increase
500 mg
$1.056
$1.003
increase
Invoice
Invoice
Code for 2012:
J2265
50 mg
$2.105
$2.000
1 gm
$8.058
$7.655
10 mcg
$0.276
Invoice
$0.262
Invoice
5 mg
$0.337
$0.320
1 mg
$2.161
$2.053
50 ml
$1.430
$1.359
decrease
Code for 2011:
J9302
10 mg
Invoice
Invoice
Code for 2011:
J2358
1 mg
0.5 mg
increase
$1.703
$1.618
Invoice
Invoice
decrease
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 www.cgsmedicare.com.
November 2012
- page 8 -
Medicare Bulletin – GR 2012-11
Orencia (see Abatacept)
** Oxychlorosene Sodium (Clorpactin WCS-90)
Ozurdex (see Dexamethasone Intravitreal
Implant)
Paliperidone Palmitate injection (Invega®
Sustenna®) Covered indications: 295.00295.95, 296.40-296.46, 296.50-296.56, or
296.60-296.66
Panitumumab (Vectibix) Covered
indications-153.0-154.8
Pantoprazole Sodium, IV (Protonix IV) Need
statement as to why patient is not able to take
oral form.
** Peginterferon Alfa-2A/Isopropyl Alchol
(Pegasys®) Covered indication 070.54 when
administered in the office.
Peginterferon Alfa-2B (PEG-Intron) 50 mcg
Covered indication 070.54 when administered in
the office.
** Peginterferon Alfa-2B, 80mcg
** Peginterferon Alfa-2B, 120mcg
** Peginterferon Alfa-2B, 150mcg
Pegloticase (Krystexxa) When billed with J3490
or J3590, covered for chronic gout, ICD-9’s
274.00 through 274.03
** Pegvisomant for Injection (Somavert)
Considered Usually Self-Administered
Pepcid (see Famotidine)
Perjeta (see Pertuzumab)
Pertuzumab (Perjeta) Covered ICD-9 174.0 175.9 in combination with Trastuzumab J9355
and Docetaxel J9171
Potassium Acetate
Potassium Phosphate
Pralatrexate (Folotyn) - Covered indications:
202.70 - 202.78
Prednisolone Acetate
Procaine Hydrochloride
Procaine Hydrochloride
Prolia ™ (see Denosumab)
Propofol (Diprivan)
Protonix IV (see Pantoprazole Sodium)
Provenge (see Sipuleucel-T)
Qutenza (see Capsaicin 8% Patch)
** R-Gene 10 (see Arginine Hcl.)
Ranibizumab Injection (Lucentis)
Regadenoson (Lexiscan)
Relistor (see Methylnaltrexone Bromide)
Revex (see Nalmefene Hydrochloride)
Rexolate & Arthrolate (see Sodium
Thiosalicylate)
RiaSTAP (see Fibrinogen Concentrate Human)
Rifampin
Robinul (see Glycopyrrolate)
Romazicon (see Flumazenil)
1 gm
$1.850
$1.758
1 mg
Code for 2011:
J2426
10 mg
Code for 2011:
J9303
40 mg
$4.511
$4.285
180mcg/ml
$480.273
$456.259
50 mcg
$320.610
$304.580
80 mcg
120 mcg
150 mcg
$336.600
$353.460
$371.120
$319.770
$335.787
$352.564
Code for 2012:
J2507
1mg
Added September
2012
1mg/ml
$9.704
$9.219
2 meq
3 mmol
$0.027
$0.043
$0.026
$0.041
Code for 2011:
J9307
Code for 2010:
J2650
1 mg
1 ml
1%
2%
$2.360
$3.400
$2.242
$3.230
10 mg
$0.103
$0.098
decrease
Code for 2011:
J2778
Code for 2011:
J2785
1 mcg
0.1 mg
600 mg
Added September
2012
$31.692
$30.107
decrease
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 9 -
November 2012
Romidepsin (Istodax) Covered indications:
202.70 - 202.78
Romiplostim (Nplate™)
Sarracenia Purpura Non-covered by Carrier
Secretin (SecreFlo) Used in secretin stimulation
testing
Sensorcaine, Sterile (see Bupivicaine, Sterile)
Sipuleucel-T (Provenge) ICD-9 = 185
Sodium Acetate
** Sodium Bicarbonate, PF (NACH03)
Sodium Bicarbonate, 8.4% (NACH03)
Sodium Chloride, Hypertonic
** Sodium Tetradecyl Sulfate (Sotradecol)
** Sodium Thiosalicylate (Rexolate & Arthrolate,
Nodolo & Tusal)
Sodium Thiosulfate
Soliris (see Eculizumab)
Somatuline Depot (see Lanreotide)
** Somavert (see Pegvisomant for Injection)
Stelara (see Ustekinumab)
Sterile Saline / Water
** Sterile Saline / Water, 1000 ml
** Sufentanil Citrate (Sufenta) Separate
payment allowed when billed with 62310,
62311, 62318, 62319, 76005, 95990, or 96530.
If billed with any other procedures, it will be
considered part of the procedure and separate
payment will not be allowed.
Sulfamethoxazole/Trimethoprim (SMZTMP) Documentation as to why the patient
needs to be on IV infusion instead of oral
medication, must be in block 19 or as
an attachment for paper claims or in the
notepad for EMC claims.
SurgiMend
Synthroid (see Levothyroxine Sodium)
Synvisc-One (see Hylan G-F 20)
Tagamet (see Cimetidine Hydrochloride)
Telavancin Injection (VIBATIV™)
Temsirolimus (Torisel) Covered indication is for
the treatment of advanced renal cell carcinoma
(189.0 Malignant neoplasm of kidney, except
pelvis).
Tenormin (see Atenolol)
Tensilon (see Edrophonium Chloride)
Testosterone
** Testosterone Pellets (Testopel)
Tetanus Toxoid (use codes 90702, 90703, or
90718)
Tetracycline
Tocilizumab (Actemra) Covered Indications:
714.0, 714.1 or 714.2.
Torisel (see Temsirolimus)
Trandate (see Labetalol Hydrochloride)
Treanda (see Bendamustine Hydrochloride)
Code for 2011:
J9315
Code for 2011:
J2796
1 mg
10 mcg
Code for 2011:
J2850
1 mcg
Per infusion
(minimum 50
million cells)
2 meq
7.5%/50 ml
50 ml
250 cc
New Code for 2012:
Q2043
$0.037
$2.730
$0.122
$0.683
Invoice
$0.035
$2.594
$0.116
$0.649
Invoice
50 mg
$0.970
$0.922
100 mg
$0.155
$0.147
5 cc
$0.052
$0.049
1000 ml
50mcg/ml
$5.640
$9.810
$5.358
$9.320
400 - 80 mg
$0.221
$0.210
decrease
0.5 sq cm
$11.874
$11.280
increase
decrease
10 mg
Code for 2011:
J3095
1 mg
Code for 2011:
J9330
37.5 mg
Per Pellet
1 mg
$0.110
Invoice
$0.105
Invoice
Invoice
Invoice
Code for 2011:
J3262
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 www.cgsmedicare.com.
November 2012
- page 10 -
Medicare Bulletin – GR 2012-11
Treprostinil inhalation (Tyvaso) - If administered
in-office, considered part of service performed.
If administered at-home, not covered by Part B.
Triamcinolone Acetonide, Preservative Free
Triamcinolone Acetonide (Kenalog)
Truxton (see Prednisolone Acetate)
Tyvaso (see Treprostinil inhalation)
Ustekinumab (Stelara) - For the treatment of
adults (18+) with moderate to severe plaque
psoriasis who are candidates for phototherapy
or systemic therapy (696.1)
Vaccinia IVIG (see Human Immune Globulin
Intravenous)
Valproate Sodium (Depacon) IV, Covered
ICD9’s = 345.00 - 345.91, Allowed when
administered IV, in the physician’s office.
(Dosage change from 500 mg to 100 mg)
Vasopressin
Vasotec IV (see Enalaprilat)
Vectibix (see Panitumumab)
Vecuronium Bromide (Norcuron)
Velaglucerase alfa for injection (VPRIV™)
Verapamil Hydrochloride (Isoptin IV)
VIBATIV™ (see Telavancin Injection)
Vincristine Sulfate Liposome (Marquibo)
covered ICD-9: 204.00-204.02
** Vitamin B Complex (Follow B-12 guidelines)
** Vitamin C (see Ascorbic Acid) Non-covered
by Carrier
Vivaglobin (see Immune Globulin
Subcutaneous)
VPRIV™ (see Velaglucerase alfa for injection)
Wilate (Human coagulation factor VIII (FVIII)
and von Willebrand factor (VWF) powder and
solvent for solution for injection) Covered ICD9: 286.4
Xeomin (see IncobotulinumtoxinA)
Xgeva (see Denosumab)
Xiaflex (see Collagenase Clostridum
Histolyticum)
Xyntha (see Antihemophilic Factor (Recomb)
Plasma/Albumin-Free)
Yervoy (see Ipilimumab)
Zaltrap (see Ziv-Aflibercept)
Ziv-Aflibercept (Zaltrap) covered ICD-9 153.0 153.7 or 154.0 - 154.2
Zortress (see Everolimus)
Zyprexa IM (see Olanzapine)
HOCM <= 149 MG/ML
HOCM 200 - 249 MG/ML
HOCM 250 - 299 MG/ML
HOCM 300 - 349 MG/ML
HOCM 350 - 399 MG/ML
HOCM >= 400 MG/ML
Code for 2011:
J7686
1.74 mg
Code for 2011:
J3300
Code for 2011:
J3301
1 mg
10 mg
Code for 2011:
J3357
1 mg
100 mg
$0.558
$0.530
20 units
$2.251
$2.138
increase
1 mg
$0.535
$0.508
decrease
Code for 2011:
J3385
2.5 mg
$3.167
$3.009
2.25 mg.
Invoice
Up to 3 ml
$0.930
100 units
Added September
2012
$0.884
New Code for 2012:
J7183
1 IU VWF:RCO
100 mg.
1 ml
1 ml
1 ml
1 ml
1 ml
1 ml
Added September
2012
Added September
2012
$1,611.200
$0.041
$0.093
$0.100
$0.104
$0.107
$0.191
$0.039
$0.088
$0.095
$0.099
$0.102
$0.181
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 11 -
November 2012
4th Quarter Update Part B Not Otherwise Classified Drug Fee Schedule
2012 Payment Allowance Limits for Medicare Part B Not Otherwise
Classified (NOC) Drugs
Effective October 1, 2012 through December 31, 2012
Revised: 09/20/2012
Name of Drug and EXACT Dosage Given MUST be in Block 19 (paper), as an Attachement, or
Narrative Field (EMC)
NOTE 1: Payment allowance limits subject to the ASP methodology are based on 2Q12 ASP data.
NOTE 2: Providers should contact their local Medicare contractor processing the claim for the most
appropriate unlisted/unclassified HCPCS code to use in reporting these drugs to Medicare.
NOTE 3: The absence or presence of a HCPCS code and the payment allowance limits in this table
does not indicate Medicare coverage of the drug. Similarly, the inclusion of a payment allowance limit
within a specific column does not indicate Medicare coverage of the drug in that specific category. These
determinations shall be made by the local Medicare contractor processing the claim.
Note 4: ** - Carrier Priced
Changes In Bold
DRUG NAME
DOSAGE
Current
PAR
Current
NON-PAR
Notes
Abatacept (Orencia) The subcutaneous form of
abatacept is considered self-administered
Actemra (see Tocilizumab)
Adcetris (see Brentuximab Vedotin)
Alfentanil Hydrochloride (Alfenta)
Alglucosidase Alfa (Myozyme)
500 mcg/5 ml
10 mg
$1.809
$1.719
500 mg/SDV
$328.177
$311.768
Increase
Code for 2012:
J0221
Decrease
2 mg vial
$1,961.000
$1,862.950
500 ml
1000 ml
250 mg
300 ml
$21.110
$35.190
$0.049
$11.225
$20.055
$33.431
$0.047
$10.664
0.5 mg / ml
10 mg
$0.800
$1.651
$0.760
$1.568
500 mg
50,000 U
10 mg
$13.997
$10.170
$13.297
$9.662
250 mg.
$978.380
Allopurinol Sodium (Aloprim) ICD-9’s 274.9 or 790.6
plus the ICD-9 for the neoplasm. Need name of
chemotherapy agent causing the elevation of uric acid
and a statement as to why patient can not tolerate
oral form of the drug.
Afinitor (see Everolimus)
Aflibercept (see EYLEA)
Amidate (see Etomidate)
Amino Acid
Amino Acid
Aminocaproic Acid
Arginine Hydrochloride (R-Gene 10)
Arzerra (see Ofatumumab)
** Ascorbic Acid (Vitamin C) Non-covered by Carrier
** Atenolol (Tenormin) ICD-9’s = 401.0 - 429.9
Atropine Sulfate / Edrophonium Chloride
Avastin (See Bevacizumab)
Aztreonam (Azactam)
** Bacitracin (Bacim)
Belimumab (Benlysta) Covered ICD-9: 710.0
Beltatacept (Nulojix) Covered indications: V420 and
075 or 996.52
Benlysta (see Belimumab)
Berinert (see C1 Esterase Inhibitor)
Decrease
Increase
Code for 2012:
J0490
$929.461
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November 2012
- page 12 -
Medicare Bulletin – GR 2012-11
Bevacizumab (Avastin) CPT 67028 must be on claim
or in history; allow if billed with J3490 or J3590 and
the ICD-9 requirements from one of the following
codes: 115.02, 115.12, 115.92, 362.01 - 362.07
(any), 362.16, 362.35 - 362.37 (any), 362.42, 362.52
or 362.83.
N/A
$60.000
$57.000
Brentuximab Vedotin (Adcetris) Covered indications
200.60-200.68 or 201.00-201.98
1mg
$95.400
$90.630
Bretylium Tosylate (Bretylol)
Brevibloc (see Esmolol Hydrochloride)
Brovana (see Arformoterol Tartrate)
Bumetanide (Bumex)
Bupivacaine Hcl, 0.25%, 2 ml (Considered Part of
Procedure)
Bupivacaine Hcl, 0.50%, 2 ml (Considered Part of
Procedure)
Bupivacaine, Sterile, 0.25%/10ml (Sensorcaine,
Sterile) Allowed when billed with 51700, 51720,
62310, 62311, 62318, 62319, 62368, 64400 - 64484,
64505 - 64530, 77003, 95990, or 96530. When billed
with other procedures, considered part of procedure
performed.
Bupivacaine, Sterile, 0.50%/10ml (Sensorcaine,
Sterile) Allowed when billed with 51700, 51720,
62310, 62311, 62318, 62319, 62368, 64400 - 64484,
64505 - 64530, 77003, 95990, or 96530. When billed
with other procedures, considered part of procedure
performed.
Bupivacaine, Sterile, 0.75%/10ml (Sensorcaine,
Sterile) Allowed when billed with 51700, 51720,
62310, 62311, 62318, 62319, 62368, 64400 - 64484,
64505 - 64530, 77003, 95990, or 96530. When billed
with other procedures, considered part of procedure
performed.
Cabazitaxel (Jevtana®)
5 mg
$0.175
$0.166
0.25 mg
$0.182
$0.173
Increase
0.25% - 1 ml
$0.091
$0.086
Increase
0.50% - 1 ml
$0.091
$0.086
Increase
0.75% - 1 ml
$0.091
$0.086
Increase
Calciferol (see Ergocalciferol D2)
Calcium Chloride
Cardizem IV (see Diltiazem Hydrochloride)
Carfilzomib (Kyprolis) covered ICD-9 203.00 or
203.02
** Cefamanadole Nafate (Mandol)
** Cefoperazone Sodium (Cefobid)
Cefotetan Disodium (Cefotan)
Chirocaine (see Levobupivacaine Hydrochloride)
Cimetidine Hcl. (Tagamet)
Cimzia (see Certolizumab Pegol)
Clavulanate Potassium / Ticarcillin Disodium
Clevidipine Butyrate
Clindamycin Phosphate (Cleocin)
Clorpactin WCS-90 (see Oxychlorosene Sodium)
Copper Sulfate
Cystografin (see Diatrizoate Meglumine)
Dantrolene Sodium
Depacon (see Valproate Sodium)
Denileukin Difitox (Ontak) (For 300 mcg, use code
J9160)
1 mg
Updated ICD9 Coverage
Effective: 01
/01/2011
New Unit Price
Per Carrier
Medical Director
Effective:
05/01/2011
Code for 2012:
J9043
$0.151
Decrease
100 mg / ml
$0.159
60 mg
$1,669.606
1 gm
1 gm
1 gm
$8.610
$16.380
$11.376
$8.180
$15.561
$10.807
150 mg
$1.064
$1.011
0.1 - 3 gm
1 mg
150 mg
$11.704
$2.958
$2.009
$11.119
$2.810
$1.909
Increase
Decrease
Increase
0.4 mg
$0.111
$0.105
Decrease
20 mg
$78.800
$74.860
150 mcg
$595.430
$565.659
Added September
2012
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Medicare Bulletin – GR 2012-11
- page 13 -
November 2012
Denosumab (Prolia ™ or Xgeva) If Prolia ™, covered
ICD-9 = 733.01; if Xgeva, covered ICD-9 = 198.5.
Dextrose 2.5%
Dextrose 5%
Dextrose 10%
Dextrose 50%
** Dextrose / Nitroglycerin 5%-20 mg/ 100 ml/250 ml
1 mg
** Dextrose 5% / Sodium Chloride
Diatrizoate Meglumine (Cystografin)
Diltiazem Hydrochloride (Cardizem IV)
Diprivan (see Propofol)
Doxapram Hydrochloride (Dopram)
Doxycycline Hyclate
Edecrin Sodium (see Ethacrynate Sodium)
Edrophonium Chloride (Tensilon) (Allow for ICD9 358.0)
Elaprase (see Idursulfase)
Emend for Injection (see Fosaprepitant Dimeglumine)
Enalaprilat (Vasotec IV)
Eovist (see Gadoxetate Disodium)
Ergocalciferol D2 (Calciferol) ICD-9’s = 579.8 or 579.9
Allowed when administered in physician’s office
Eribulin Mesylate (Halaven) - Covered ICD-9’s =
174.0 - 174.9
Esmolol Hydrochloride (Brevibloc) Covered ICD-9 =
427.89 (Dosage change from 100 mg to 10 mg.)
Esomeprazole Sodium (Nexium IV) Covered ICD-9’s
= 530.10 - 530.19 or 530.81 when administered in the
physician’s office.
Estradiol
** Estradiol Pellets
Ethacrynate Sodium (Edecrin Sodium)
** Ethiodized Oil (Ethiodol)
Etomidate (Amidate)
Everolimus (Afinitor / Zortress) - Non-Covered; Oral
drug considered as self-administered.
EYLEA (see Aflibercept)
Famotidine (Pepcid)
Firazyr (see Icantibant)
Firmagon (see Degarelix)
Flagyl IV (see Metronidazole In Nacl.)
Floxin IV (see Ofloxacin)
Flumazenil (Mazicon, Romazicon)
Flumazenil (Mazicon, Romazicon)
Folic Acid
Folotyn (see Pralatrexate)
Fospropofol Disodium injection (Lusedra)
Gammaked injection
Gammaplex (see Human Immune Globulin
Intravenous)
Glycopyrrolate (Robinul)
Halaven (see Eribulin Mesylate)
** Heparin Sodium
Hetastarch Sodium Cl., 6 gm/500 ml
Code for 2012:
J0897
2.50%
5%
500 ml
50 ml
20 mg/100
ml/250 ml
1000 ml
10 ml
5 mg
$7.680
$7.860
$10.000
$0.101
$6.320
$7.296
$7.467
$9.500
$0.096
$6.004
$11.220
$2.10
$0.167
$10.659
$2.00
$0.159
Increase
20 mg
100 mg
$1.695
$10.885
$1.610
$10.341
Decrease
Decrease
10 mg
$2.420
$2.299
1.25 mg
$1.142
$1.085
500,000 IU/
1ml
0.1 mg
$29.840
$28.348
10 mg
$0.778
$0.739
Code for 2012:
J9179
Increase
20 MG
$1.904
$1.809
Decrease
1 gram
Per Pellet
50 mg
1 ml
2 mg
$13.300
Invoice
$19.040
$8.060
$0.699
$12.635
Invoice
$18.088
$7.657
$0.664
10 mg
$0.446
$0.424
Increase
0.1 mg
0.5 mg
5 mg
$2.005
$42.830
$2.179
$1.905
$40.689
$2.070
Increase
35 mg
500 mg
$1.048
$37.484
$0.996
$35.610
Increase
0.2 mg
$0.614
$0.583
Increase
100 units
6 gm
$0.032
$23.040
$0.030
$21.888
Decrease
Increase
Code for 2012:
J8561
Increase
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November 2012
- page 14 -
Medicare Bulletin – GR 2012-11
Hexaminolevulinate Hydrochloride - Covered for ICD9’s 188.0 through 188.9
Hizentra (see Immune Globulin Subcutaneous)
Human Immune Globulin Intravenous (Gammaplex)
100 mg, per
study dose
$660.677
$627.643
IV
Hydroxocobalamin - Covered when billed with J9305.
Icantibant (Firazyr) - Usually considered selfadministered
Ilaris (see Canakinumab)
** Inamrinone Lactate
IncobotulinumtoxinA (Xeomin) - Covered for the
treatment of Genetic torsion dystonia (333.6) and
Blepharospasm (333.81)
INTEGRA™ Bilayer Matrix Wound Dressing Covered Indications = 757.39, 941.20-941.21,
941.24-941.31, 941.34-941.41, 941.44-941.51,
941.54-941.59, 942.20-942.59, 943.20-943.59,
944.20-944.58, 945.20-945.59, 946.2-946.5, 948.00948.99
Invega® Sustenna® (see Paliperidone Palmitate
injection)
Ipilimumab (Yervoy) - Covered for unresectable or
metastatic melanoma.
Isoproterenol Hydrochloride (Isuprel)
Isoptin IV (see Verapamil Hydrochloride)
Istodax (see Romidepsin)
Isuprel (see Isoproterenol Hydrochloride)
Jevtana® (see Cabazitaxel)
Kalbitor (see Ecallantide)
Kenalog (see Triamcinolone Acetonide)
Keppra intraveneous (see Levetiracetam)
Ketamine Hydrochloride (Ketalar) Allowed when billed
on same day as 20550-20610, 62289, 62298, 62368,
95990, or 96530.
Kyprolis (see Carfilzomib)
Krystexxa (see Pegloticase)
Labetalol Hydrochloride (Trandate, Normodyne)
Covered if given IV in the office for control of BP in
severe hypertension. Patient is normally switched to
oral for maintainance doses.
** Levobupivacaine Hydrochloride (Chirocaine)
Allowed separately when billed on same day as
51700, 51720, 62310, 62311, 62318, 62319, 62368,
64400 - 64484, 64505-64530, 76003, 95990, or
96530. Not payable separately when billed with any
other procedures
** Levophed Bitartrate (see Norepinephrine Bitartrate)
** Levothyroxine Sodium (Synthroid) Need statemnt
on claim as to why patient can’t take oral form of
drug.
Lexiscan (see Regadenoson)
Lidocaine - Allowed separately when billed on same
day as 51700, 51720, 62310, 62311, 62318, 62319,
62368, 64400 - 64484, 64505 - 64530, 77033, 95990,
or 96530. Not payable when billed with any other
procedure.
Lopressor (see Metoprolol Tartrate)
Lucentis (see Ranibizumab)
Lusedra (see Fospropofol Disodium injection)
Increase
Code for 2012:
J1557
1000 mcg/ml
$1.212
$1.151
5 mg
1 Unit
$4.050
$3.848
1 sq cm
$24.147
New Code for
2012: J0588
$22.940
1mg
Increase
Code for 2012:
J9228
0.2 mg
$2.250
$2.138
10 mg
$0.067
$0.064
Added September
2012
5 mg
$0.240
$0.228
2.5 mg/ml
$0.310
$0.295
0.5 mg
$62.010
$58.910
1 ml
$0.143
$0.136
Decrease
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Medicare Bulletin – GR 2012-11
- page 15 -
November 2012
Mandol (see Cefamanadole Nafate)
Marqibo (see Vincristine sulfate Liposome)
Mazicon (see Flumazenil)
Methylnaltrexone Bromide (Relistor) Non-covered by
carrier.
Metoprolol Tartrate (Lopressor) Covered when given
IV with Dobutamine J1250 during Dobutamine Stress
Test.
Metronidazole Hcl. (Flagyl IV) IV in the office.
Covered for ICD-9’s= 001.0-009.3, 040.0-041.9, 481482.9, 567.0-567.9, 599.0-599.9, 615.0-615.9.
Miconazole (Monistat IV) 10 mg
Minocycline Hydrochloride (Non-covered oral drug)
Monistat IV (see Miconazole)
Morrhuate Sodium
Myozyme (see Alglucoside Alfa)
Nafcillin Sodium (Nallpen) (Dosage Change from 500
mg to 1 gm)
Nalmefene Hydrochloride (Revex)
Netilmicin Sulfate (Netromycin), 150 mg
Nexium IV (see Esomeprazole Sodium)
Nitroglycerin IV – Allowed in emergency situations.
Nodolo & Tusal (see Sodium Thiosalicylate)
** Norepinephrine Bitartrate (Levophed Bitartrate)
Allow in emergency situations.
Norcuron (see Vecuronium Bromide)
Normal Saline (Sterile Water)
Normodyne (see Labetalol Hydrochloride)
Nplate™ (see Romiplostim)
Nulojix (see Beltatacept)
Ofloxacin (Floxin IV), 20 mg
Olanzapine short-acting intramuscular injection
(Zyprexa IM) Covered indications = 295.01 - 295.84
when administered in the physicians office.
Ontak (see Denileukin Difitox)
Optison
Orencia (see Abatacept)
** Oxychlorosene Sodium (Clorpactin WCS-90)
Ozurdex (see Dexamethasone Intravitreal Implant)
Pantoprazole Sodium, IV (Protonix IV) Need
statement as to why patient is not able to take oral
form.
** Peginterferon Alfa-2A/Isopropyl Alchol (Pegasys®)
Covered indication 070.54 when administered in the
office.
Peginterferon Alfa-2B (PEG-Intron) 50 mcg Covered
indication 070.54 when administered in the office.
** Peginterferon Alfa-2B, 80mcg
** Peginterferon Alfa-2B, 120mcg
** Peginterferon Alfa-2B, 150mcg
Pegloticase (Krystexxa) When billed with J3490 or
J3590, covered for chronic gout, ICD-9’s 274.00
through 274.03
** Pegvisomant for Injection (Somavert) Considered
Usually Self-Administered
Pepcid (see Famotidine)
Added September
2012
1 mg
$0.163
$0.155
Increase
500 mg
$1.069
$1.016
Increase
Invoice
Invoice
Code for 2012:
J2265
50 mg
$2.105
$2.000
1 gm
$8.058
$7.655
10 mcg
$0.276
Invoice
$0.262
Invoice
5 mg
$0.345
$0.328
1 mg
$2.161
$2.053
50 ml
$1.430
$1.359
0.5 mg
Invoice
$1.705
Invoice
$1.620
Invoice
Invoice
1 gm
$1.850
$1.758
40 mg
$4.511
$4.285
180mcg/ml
$480.273
$456.259
50 mcg
$320.610
$304.580
80 mcg
120 mcg
150 mcg
1mg
$336.600
$353.460
$371.120
$319.770
$335.787
$352.564
Increase
Increase
Code for 2012:
J2507
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November 2012
- page 16 -
Medicare Bulletin – GR 2012-11
Perjeta (see Pertuzumab)
Pertuzumab (Perjeta) Covered ICD-9 174.0 175.9 in combination with Trastuzumab J9355 and
Docetaxel J9171
Potassium Acetate
Potassium Phosphate
Procaine Hydrochloride
Procaine Hydrochloride
Prolia ™ (see Denosumab)
Propofol (Diprivan)
Protonix IV (see Pantoprazole Sodium)
Provenge (see Sipuleucel-T)
Qutenza (see Capsaicin 8% Patch)
** R-Gene 10 (see Arginine Hcl.)
Relistor (see Methylnaltrexone Bromide)
Revex (see Nalmefene Hydrochloride)
Rexolate & Arthrolate (see Sodium Thiosalicylate)
RiaSTAP (see Fibrinogen Concentrate Human)
Rifampin
Robinul (see Glycopyrrolate)
Romazicon (see Flumazenil)
Sarracenia Purpura Non-covered by Carrier
Sensorcaine, Sterile (see Bupivicaine, Sterile)
Sipuleucel-T (Provenge) ICD-9 = 185
Sodium Acetate
** Sodium Bicarbonate, PF (NACH03)
Sodium Bicarbonate, 8.4% (NACH03)
Sodium Chloride, Hypertonic
** Sodium Tetradecyl Sulfate (Sotradecol)
** Sodium Thiosalicylate (Rexolate & Arthrolate,
Nodolo & Tusal)
Sodium Thiosulfate
Soliris (see Eculizumab)
Somatuline Depot (see Lanreotide)
** Somavert (see Pegvisomant for Injection)
Stelara (see Ustekinumab)
Sterile Saline / Water
** Sterile Saline / Water, 1000 ml
** Sufentanil Citrate (Sufenta) Separate payment
allowed when billed with 62310, 62311, 62318,
62319, 76005, 95990, or 96530. If billed with any
other procedures, it will be considered part of the
procedure and separate payment will not be allowed.
Sulfamethoxazole/Trimethoprim (SMZ-TMP)
Documentation as to why the patient needs to be
on IV infusion instead of oral medication, must be in
block 19 or as an attachment for paper claims or in
the notepad for EMC claims.
SurgiMend
Synthroid (see Levothyroxine Sodium)
Synvisc-One (see Hylan G-F 20)
Tagamet (see Cimetidine Hydrochloride)
Tenormin (see Atenolol)
Tensilon (see Edrophonium Chloride)
1mg/ml
$9.704
$9.219
2 meq
3 mmol
1%
2%
$0.027
$0.043
$2.360
$3.400
$0.026
$0.041
$2.242
$3.230
10 mg
$0.103
$0.098
600 mg
$32.776
$31.137
Per infusion
(minimum 50
million cells)
2 meq
7.5%/50 ml
50 ml
250 cc
Added September
2012
Added September
2012
Increase
New Code for
2012: Q2043
Decrease
50 mg
$0.031
$2.730
$0.122
$0.708
Invoice
$0.970
$0.029
$2.594
$0.116
$0.673
Invoice
$0.922
100 mg
$0.155
$0.147
5 cc
$0.052
$0.049
1000 ml
50mcg/ml
$5.640
$9.810
$5.358
$9.320
400 - 80 mg
$0.276
$0.262
Increase
0.5 sq cm
$12.026
$11.425
Increase
Increase
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Medicare Bulletin – GR 2012-11
- page 17 -
November 2012
Testosterone
** Testosterone Pellets (Testopel)
Tetanus Toxoid (use codes 90702, 90703, or 90718)
Tetracycline
Torisel (see Temsirolimus)
Trandate (see Labetalol Hydrochloride)
Treanda (see Bendamustine Hydrochloride)
Truxton (see Prednisolone Acetate)
Tyvaso (see Treprostinil inhalation)
Vaccinia IVIG (see Human Immune Globulin
Intravenous)
Valproate Sodium (Depacon) IV, Covered ICD9’s =
345.00 - 345.91, Allowed when administered IV, in the
physician’s office. (Dosage change from 500 mg to
100 mg)
Vasopressin
Vasotec IV (see Enalaprilat)
Vectibix (see Panitumumab)
Vecuronium Bromide (Norcuron)
Verapamil Hydrochloride (Isoptin IV)
VIBATIV™ (see Telavancin Injection)
Vincristine Sulfate Liposome (Marquibo) covered ICD9: 204.00-204.02
** Vitamin B Complex (Follow B-12 guidelines)
** Vitamin C (see Ascorbic Acid) Non-covered by
Carrier
Vivaglobin (see Immune Globulin Subcutaneous)
VPRIV™ (see Velaglucerase alfa for injection)
Wilate (Human coagulation factor VIII (FVIII) and
von Willebrand factor (VWF) powder and solvent for
solution for injection) Covered ICD-9: 286.4
Xeomin (see IncobotulinumtoxinA)
Xgeva (see Denosumab)
Xiaflex (see Collagenase Clostridum Histolyticum)
Xyntha (see Antihemophilic Factor (Recomb) Plasma/
Albumin-Free)
Yervoy (see Ipilimumab)
Zaltrap (see Ziv-Aflibercept)
Ziv-Aflibercept (Zaltrap) covered ICD-9 153.0 - 153.7
or 154.0 - 154.2
Zortress (see Everolimus)
Zyprexa IM (see Olanzapine)
HOCM <= 149 MG/ML
HOCM 200 - 249 MG/ML
HOCM 250 - 299 MG/ML
HOCM 300 - 349 MG/ML
HOCM 350 - 399 MG/ML
HOCM >= 400 MG/ML
37.5 mg
Per Pellet
$0.110
Invoice
$0.105
Invoice
Invoice
Invoice
100 mg
$0.558
$0.530
20 units
$2.310
$2.195
Increase
1 mg
2.5 mg
$0.499
$3.167
$0.474
$3.009
Decrease
2.25 mg.
Invoice
Up to 3 ml
$0.930
Added September
2012
$0.884
1 IU
VWF:RCO
New Code for
2012: J7183
100 mg.
$1,611.200
1 ml
1 ml
1 ml
1 ml
1 ml
1 ml
$0.041
$0.093
$0.100
$0.104
$0.107
$0.191
Added September
2012
Added September
2012
$0.039
$0.088
$0.095
$0.099
$0.102
$0.181
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November 2012
- page 18 -
Medicare Bulletin – GR 2012-11
CR 8059 - Implementation of the Award for the Jurisdiction 5 Part A and
Part B Medicare Administrative Contractor (J5 A/B MAC) Reprocurment
Including a New Workload Number for the Remaining WPS Legacy
Workload
Pub 100-20 One-Time Notification
Transmittal 1119
Department of Health & Human Services (DHHS)
Centers for Medicare & Medicaid Services (CMS)
Date: September 14, 2012
Change Request 8059
SUBJECT: Implementation of the Award for the Jurisdiction 5 Part A and Part B Medicare
Administrative Contractor (J5 A/B MAC) Reprocurment Including a New Workload Number for the
Remaining WPS Legacy Workload
I. SUMMARY OF CHANGES:
The Centers for Medicare &Medicaid Services (CMS) is required to compete the A/B MAC workloads at
least once every 5 years. It recently did so for the Jurisdiction 5 A/B MAC workload as well as the Title
18 legacy workload being processed by Wisconsin Physicians Service (WPS) under its Medicare Title 18
contract. CMS awarded this workload to WPS, the incumbent contractor for all of these workloads.
CMS has determined that it will not need to change the current Jurisdiction 5 workload numbers when
this new contract is implemented. CMS will need to change the workload numbers for the Part A WPS
legacy workload. This change is being made because CMS needs to identify each MAC workload using
a standardized numbering system.
EFFECTIVE DATE: October 22, 2012
IMPLEMENTATION DATE: October 22, 2012
Disclaimer for manual changes only: The revision date and transmittal number apply only to
red italicized material. Any other material was previously published and remains unchanged.
However, if this revision contains a table of contents, you will receive the new/revised
information only, and not the entire table of contents.
II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated) R=REVISED, N=NEW,
D=DELETED-Only One Per Row.
R/N/D
N/A
CHAPTER / SECTION / SUBSECTION / TITLE
III. FUNDING:
For Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs) and/or Carriers:
Funding or implementation activities will be provided to contractors through the regular budget process
For Medicare Administrative Contractors (MACs):
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as
defined in your contract. CMS does not construe this as a change to the MAC statement of Work. The
contractor is not obliged to incur costs in excess of the amounts allotted in your contract unless and
until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as
described above, to be outside the current scope of work, the contractor shall withhold performance on
the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request
formal directions regarding continued performance requirements.
IV. ATTACHMENTS:
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Medicare Bulletin – GR 2012-11
- page 19 -
November 2012
One-Time Notification
*Unless otherwise specified, the effective date is the date of service.
Attachment - One-Time Notification
Pub. 100-20
Transmittal: 1119
Date: September 14, 2012
Change Request: 8059
SUBJECT: Implementation of the Award for the Jurisdiction 5 Part A and Part B Medicare
Administrative Contractor (J5 A/B MAC) Reprocurment Including a New Workload Number for the
Remaining WPS Legacy Workload
EFFECTIVE DATE: October 22, 2012
IMPLEMENTATION DATE: October 22, 2012
I.
GENERAL INFORMATION
A. Background: The Centers for Medicare and Medicaid Services (CMS) is required to compete
each A/B MAC workload at least once every 5 years. It recently did so for the J5 A/B MAC workload as
well as the Title 18 legacy workload being processed by Wisconsin Physicians Service (WPS) under
its Medicare Title 18 contract. CMS awarded this workload to WPS, the incumbent contractor for all of
these workloads.
WPS address is:
Wisconsin Physicians Service
1751 West Broadway
Madison, WI 53713
CMS has determined that it will not need to change the current J5 A/B MAC workload numbers when the
new contract is implemented. However, the reprocurement also included an existing Title 18 workload
whose contractor workload number will need to be changed. This change is being made because CMS
needs to identify each MAC workload using a standardized numbering system.
The workload number shall be changed and the WPS Legacy Title 18 workload shall be transitioned to
the J5 A/B MAC as indicated below.
Workload Description WPS Legacy
MAC Workload Number 05901
Effective Date 10/22/2012
Current Contractor Workload No. 52280
The following applications or business owners shall continue to accept the current J5 A/B MAC workload
number as well as the new J5 A/B workload number once the above cited workload is transitioned to the
J5 A/B MAC.
• CMS Analysis, Reporting and Tracking System (CMS ARTS),
• Contractor Administrative, Budget and Cost Reporting System (CAFM),
• Comprehensive Error Rate Testing System (CERT),
• Contractor Management Information System (CMIS),
• CMS Baltimore Data Center
• Coordination of Benefits Agreement program (COBA),
• Coordination of Benefits Contractor (COBC),
• Contractor Reporting of Operational Workload Data System (CROWD),
• Common Working File (CWF),
• CWF Part B Eligibility and Security Maintenance (CWF ELGE)
• Customer Service Assessment and Management System (CSAMS),
• Debt Collection System (DCS),
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November 2012
- page 20 -
Medicare Bulletin – GR 2012-11
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
B.
II.
Electronic Correspondence Referral System (ECRS)
Electronic Health Records Incentive Program (EHR),
Enterprise Data Centers (EDCs)
Expert Claims Processing System (ECPS),
Fiscal Intermediary Shared System (FISS),
Health Care Information System (HCIS),
Healthcare Integrated General Ledger Accounting System (HIGLAS),
Health Insurance Master Record (HIMR),
Intern and Resident Information System (IRIS),
Local Coverage Determination Database (LCD),
Medicare Secondary Payer Recovery Contractor (MSPRC),
Multi-Carrier System (MCS),
National Data Warehouse (NDW),
National Level Repository (NLR),
National Part B Pricing Files,
National Provider Identifier Crosswalk (NPI),
Next Generation Desktop (NGD),
Part B Analytics Reporting System (PBAR),
Physician/Supplier Overpayment report (PSOR),
Production Performance Monitoring System (PULSE),
Provider Enrollment, Chain, and Ownership System (PECOS),
Provider Customer Service Program Contractor Information Database (PCID),
Provider Inquiry Evaluation System (PIES),
Program Integrity Management Reporting System (PIMR),
Program Safeguard Contractor (PSC),
Provider Overpayment Reporting System (PORS),
Provider Statistical and Reimbursement System (PS and R),
Quality Improvement Evaluation System (QIES),
Recovery Auditors (RA),
Recover Management and Accounting System (REMAS),
Renal Management Information System (REMIS),
System Tracking for Audit and Reimbursement (STAR),
Zip Code File, and
Zoned Program Integrity Contractors (ZPICs).
Policy: N/A
BUSINESS REQUIREMENTS TABLE
Use “Shall” to denote a mandatory requirement.
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Medicare Bulletin – GR 2012-11
- page 21 -
November 2012
Number
Requirements
Responsibility
A/B
D F C R
MA C M E I A R H
RI HI
ER
MA
P P
C
ar art
t
B
A
SharedSystem
Maintainers
F
I
S
S
M
C
S
V
M
S
Other
C
W
F
8059.1
The Jurisdiction 5 A/B MAC workloads shall
continue to be processed under their current MAC
workload numbers of 05101 (Part A Iowa), 05201
(Part A Kansas), 05301 (Part A Missouri) 05401
(Part A Nebraska), 05102 (Part B Iowa), 05202
(Part B Kansas), 05302 (Part B Missouri), and
05402 (Part B Nebraska) when its new contract
becomes effective.
J5 A/B
MAC; Hewlett
Packard (HP)
EDC
8059.1.1
The Part A IA, KS, MO and NE customer
information control system (CICS) region shall
continue to use FISS rollup number 05001 for
claims processing.
J5 A/B
MAC; Hewlett
Packard (HP)
EDC
8059.1.2
All shared systems, applications and business
owners listed in the background section of this CR
shall continue to accept the J5 A/B MAC workload
numbers as per 8059.1 and shall accept the new
MAC workload number of 05901 as per 8059.2.
All shared
systems,
application s,
and business
owners
listed in the
background
section of this
CR
8059.1.3
Following the expiration of its current contract,
the J5 A/B MAC shall track and charge all costs
related to that contract to the appropriate Contract
Line Item Number (CLIN) as instructed by CMS.
J5 A/B
MAC
8059.1.3.1 Once its new contract reflecting the J5 A/B MAC
reprocurement becomes effective, the J5 A/B MAC
shall track and charge all costs related to that contract
to the appropriate CLIN as instructed by CMS.
J5 A/B
MAC
8059.2
The workload number for the Part A WPS
Legacy workload (workload number 52280) shall
be changed to MAC workload number 05901
in accordance with the effective date in the
background section of this Change Request (CR).
8059.2.1
The J5 A/B MAC shall provide project
management, testing, and any other services
necessary to achieve the transition of the Title
18 Part A workload currently processed under
contractor workload number 52280 to MAC workload
number 05901. This shall include (but not be limited
to) working with the FISS maintainer, the HP EDC,
and all other entities as applicable to ensure the
success of the MAC workload number transition.
October 2012
- page 22 -
X
J5 A/B
MAC, HP
EDC
J5 A/B
MAC
Medicare Bulletin – GR 2012-10
Number
Requirements
Responsibility
A/B
D F C R
MA C M E I A R H
RI HI
ER
MA
P P
C
ar art
t
B
A
Other
SharedSystem
Maintainers
F
I
S
S
M
C
S
V
M
S
C
W
F
8059.2.2
The HP EDC and the HP FISS maintainer shall
provide all of the support necessary to successfully
transition the Part A workload currently processed
under contractor workload number 52280 to MAC
workload number 05901, including (but not limited
to) production support, testing, and coordination.
X
8059.2.3
FISS shall supply the software needed to
change the legacy workload numbers to the new
MAC workload numbers in accordance with 8059.2
X
8059.2.4
The HP EDC, the J5 A/B MAC, CWF, FISS,
and the Medicare applications or entities listed in
the background section of this CR shall perform
the modifications needed to accommodate the new
MAC workload number of 05901 (WPS Legacy)
as of the effective date listed in the background
section.
X
X
J5 A/B
MAC, HP
EDC, all
Medicare
application
s or entities
listed in
background
section
8059.2.4.1
The J5 A/B MAC, FISS, CWF, PECOS, and all
entities listed in this CR shall associate all
providers whose claims are currently processed
under contractor workload number 52280 with
MAC workload number 05901 (WPS Legacy) as of
the effective date of that workloads MAC transition.
X
X
J5 A/B
MAC,
PECOS
8059.2.5
The J5 A/B MAC shall utilize the existing Part
A WPS Legacy production and user acceptance
testing (UAT) CICS region to accomplish the
transition of the WPS Legacy to the J5 A/B MAC.
X
J5 A/B
MAC, WPS,
HP EDC
8059.2.5.1
WPS, the legacy contractor for the Part A WPS
Legacy workload shall work with the J5 A/B
MAC, FISS, the HP EDC, and all other entities as
necessary to ensure the success of the transition
of the WPS Legacy workload to the J5 A/B MAC
environment.
X
WPS, J5
A/B MAC,
HP EDC
X
WPS, J5
A/B MAC,
HP EDC
8059.2.5.1.1 WPS shall turn over to the J5 A/B MAC control
of its Part A WPS Legacy UAT region no later
than three weeks prior to the transition date of
that workload as per the Background section of
this CR. The Part A WPS Legacy UAT region shall
be utilized by the J5 A/B MAC, FISS and the HP
EDC to facilitate the transition of the Part A WPS
Legacy workload to MAC workload number 05901.
8059.2.5.1.2 WPS shall provide the J5 A/B MAC with the
information and documentation it needs to process
claims utilizing the current WPS Legacy CICS region.
Medicare Bulletin – GR 2012-10
- page 23 -
HP EDC
WPS, J5
A/B MAC
October 2012
Number
Requirements
Responsibility
A/B
D F C R
MA C M E I A R H
RI HI
ER
MA
P P
C
ar art
t
B
A
SharedSystem
Maintainers
F
I
S
S
M
C
S
V
M
S
Other
C
W
F
8059.3
CWF shall read the contractor workload
number in history for the informational unsolicited
response (IUR) and the CWF reports processes.
X
8059.3.1
Where a providers claims are currently being
processed under contractor workload number
52280, CWF shall direct any associated IURs and
reports to MAC workload number 05901.
X
8059.4
WPS shall be prepared to provide information
about which providers are assigned to legacy
workload number 52280 to any of the contractors,
maintainers, shared systems, applications, or CMS
business owners listed in this CR. If any such entity
requires this information, it should contact the CMS.
The CMS contact information is listed in this CR
following the business requirements (BRs).
WPS
8059.4.1
At least 2 weeks prior to the MAC transition of
each workload, the J5 A/B MAC shall request
CMS to drop out of service area (OSA) processing
during the transition period for the transitioning
workload. The J5 A/B MAC shall use the language
in 8059.4.1.1. The request shall be sent to
J5 A/B
MAC, CWF
Host
8059.4.1.1
The following language shall be used by the J5 A/B
MAC to request the dropping of OSA processing as per
8059.4.1.
X
J5 A/B
MAC
“ This OSA drop request is associated with CR 8059.
The J5 A/B MAC requests that CMS authorizes the
dropping of OSA transactions for the WPS Legacy
workload (Contractor Workload No. 52280) which is
being transitioned to the J5 A/B MAC. The OSA drop
date should be Oct. 15, 2012.
Cutover weekend for this workload is October 20 and
21, 2012 and the first shared system batch cycle is
scheduled for Oct. 22, 2012, which should be the OSA
restart date.
The last cycle at the outgoing contractor is scheduled
to be sent to the CWF Host on (insert month, day and
year). This last file received should be returned to the
outgoing contractor.
The first cycle at the new contractor is scheduled to be
sent to the CWF Host on Oct. 22, 2012. The first file
received should be returned to the new contractor.”
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 www.cgsmedicare.com.
November 2012
- page 24 -
Medicare Bulletin – GR 2012-11
Number
Requirements
Responsibility
A/B
D F C R
MA C M E I A R H
RI HI
ER
MA
P P
C
ar art
t
B
A
SharedSystem
Maintainers
F
I
S
S
M
C
S
V
M
S
Other
C
W
F
8059.5
FISS, CWF, PECOS, the J5 A/B MAC, the HP
EDC, and the CMS shared systems, applications
or business owners listed in Background section of
this CR shall be able to implement the new MAC
workload number by the effective date listed in this
CR for that workload for the purpose of ongoing
production. In the event the transition needs to
be delayed, these applications shall be able to
accommodate the delay within five business days
of receiving notification from CMS.
X
X
8059.6
CWF and FISS shall make system changes (if
any are required) so that any claims or
adjustments associated with contractor workload
number 52280 can continue to be processed
(when appropriate) following the effective date of
the WPS Legacy MAC implementation.
X
X
8059.7
Where practical, CWF, FISS, and all of the
CMS shared systems, applications or business
owners listed in Background section of the CR
shall be able to implement the new WPS Legacy
MAC workload number at least 3 weeks prior to
the effective date of that workload transition as
listed in the Background section of this CR for the
purpose of testing with the Medicare contractor.
X
X
8059.8
CMS ARTS shall be modified (as necessary) to
reflect the new MAC workload number.
CMS
ARTS
8059.9
CAFM shall be modified (as necessary) to
reflect the new MAC workload number.
CAFM
8059.14
CSAMS shall be modified (as necessary) to
reflect the new MAC workload number.
CSAMS
8059.15
The CMS Debt Collection System (DCS) shall
be modified (as necessary) to reflect the new
MAC workload number.
The J5 A/B MAC shall manually adjust the DCS to
reflect those providers whose contractor workload
number has been changed. If this change was not
made, any updates (collection or recall) would be
sent to the original contractor workload number.
ECRS shall be modified (as necessary) to reflect
the new MAC workload number.
DCS
8059.15.1
8059.16
J5 A/B MAC,
HP EDC, all
CMS shared
systems,
application s
or business
owners
listed in the
Background
section of
this CR.
All of the
CMS shared
systems,
application s
or business
owners listed
in Backgroun
d section of
the CR
J5 A/B
MAC
ECRS
8059.17
The NDW shall be modified (as necessary) to
reflect the new MAC workload number.
NDW
8059.18
The NGD shall be modified (as necessary) to
reflect the new MAC workload number.
NGD
8059.19
The NPI Crosswalk shall be modified to accept
the new MAC workload number.
NPI
Crosswalk
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Medicare Bulletin – GR 2012-11
- page 25 -
November 2012
Number
Requirements
Responsibility
A/B
D F C R
MA C M E I A R H
RI HI
ER
MA
P P
C
ar art
t
B
A
SharedSystem
Maintainers
F
I
S
S
M
C
S
V
M
S
Other
C
W
F
8059.19.1
WPS, the J5 A/B MAC, and the HP EDC shall
work together to contact the CMS Baltimore Data
Center (Donald Dimitriou) to set up file transfer protocols
(where necessary) in accordance with the CMS
Enterprise File Transfer (EFT) Infrastructure standard so
that crosswalk files can be received by the HP EDC and
the J5 A/B MAC for the new MAC workload number.
When this file transfer process is in place, the contractor
currently processing the workload covered by this CR
shall send in a complete master provider file containing
the new MAC workload number to the NPI crosswalk.
The NPI crosswalk shall send back a file with the NPI
to legacy crosswalk. Then daily files shall be sent
and returned. The contractor using the new number
shall also set up file transfers to send files correctly as
described in JSM-06545. (Refer to CR 5040, 5041)
WPS, J5
A/B MAC,
HP EDC,
BDC, NPI
Crosswalk
8059.20
PIMR shall be modified (as necessary) to
reflect the new MAC workload number.
PIMR
8059.21
PSOR shall be modified (as necessary) to
reflect the new MAC workload number.
PULSE shall be modified (as necessary) to
reflect the new MAC workload number.
PSOR
8059.22
PULSE
8059.23
REMAS shall be modified (as necessary) to
reflect the new MAC workload number.
REMAS
8059.24
REMIS shall be modified (as necessary) to
reflect the new MAC workload number.
REMIS
8059.25
The PSCs and ZPICs shall make any necessary
modifications to reflect the new MAC workload
number.
STAR shall be modified (as necessary) to
reflect the new MAC workload number.
PSCs,
ZPICs
8059.26
8059.27
8059.28
8059.29
8059.29.1
8059.29.2
HCIS shall be modified (as necessary) to reflect
the new MAC workload number.
PBAR shall be modified (as necessary) to
reflect the new MAC workload number.
The J5 A/B MAC shall make any changes
necessary to ensure its non-base jobs, applications
and reports support the new MAC workload number.
The J5 A/B MAC shall modify any electronic claims
billing or other software it provides to suppliers,
providers or submitters to reflect the MAC
workload number.
The J5 A/B MAC shall also modify its Medicare
website and electronic portal to reflect the new
MAC workload number.
The J5 A/B MAC shall obtain approval from the CMS
Non-Base Workgroup for any non- base applications
it wants to run at the HP EDC as well as for any data
files it wants to request from the EDC.
STAR
HCIS
PBAR
J5 A/B
MAC
J5 A/B
MAC
J5 A/B
MAC
Number
Requirements
Responsibility
A/B
D F C R
MA C M E I A R H
RI HI
ER
MA
P P
C
ar art
t
B
A
8059.30
The national Part B pricing files shall be updated to X
reflect the new MAC workload number. Contractors
shall utilize the updated file whenever it is received.
8059.31
PECOS shall create a nightly extract file for
MAC workload number 05901. The HP EDC shall
arrange to pick up this file after the CMS PECOS
business owner (Meena Patel) grants the HP EDC
access to the file.
Any user at the J5 A/B MAC who wants access to
the new MAC workload number shall submit an
application as per the instructions in the on line
Help (FAQ) section of PECOS as soon as possible
following the issuance of this CR. The application
shall be sent to Alisha Banks ([email protected].
gov) and Meena.Patel ([email protected]).
The user must do this in order to have access to the
enrollments under these MAC number.
8059.31.1
8059.31.2
PECOS shall be modified to reflect the new
MAC workload number. The PECOS team shall
make all internal code changes to the PECOS
Administrative Interface (AI) and the PECOS
Provider Interface (PI) in order to accommodate
the new MAC workload number of 05901.
X
X X
SharedSystem
Maintainers
F
I
S
S
M
C
S
V
M
S
Other
C
W
F
National
Part B
Pricing Files
PECOS,
HP EDC
J5 A/B MAC
PECOS
PECOS shall delete all reference to the old
contractor IDs. PECOS shall remove all users from
the old contractor IDs. PECOS shall delete the old
nightly export file names and access rights.
8059.31.2.1 PECOS shall move all providers currently associated
with workload number 52280 to MAC workload
number 05901 as of the effective date of that
transition as per the background section of this CR.
8059.31.2.1.1 The J5 A/B MAC shall be responsible for manually
correcting any enrollment record that fails to move
systematically to the new contractor number
due to a PECOS audit issue. This may require
revalidation of the provider.
PECOS
J5 A/B
MAC
The J5 A/B MAC shall be responsible for manually
correcting any enrollment that fails to process
due to a PECOS audit issue after completion of
the move to the new contractor number. This may
require revalidation of the provider.
8059.32
QIES shall be modified (as necessary) to reflect
the new MAC workload number.
QIES
8059.33
PORS shall be modified (as necessary) to reflect
the new MAC workload number.
PORS
8059.34
The PS and R shall be modified (as necessary) to
reflect the new MAC workload number.
PS and R
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Medicare Bulletin – GR 2012-11
- page 27 -
November 2012
Number
Requirements
Responsibility
A/B
D F C R
MA C M E I A R H
RI HI
ER
MA
P P
C
ar art
t
B
A
SharedSystem
Maintainers
F
I
S
S
M
C
S
V
M
S
Other
C
W
F
8059.34.1
The J5 A/B MAC shall transition the legacy PS
and R data to reflect the new workload number
following the MAC transition.
J5 A/B
MAC
8059.35
IRIS shall be modified (as necessary) to reflect the
new MAC workload number.
IRIS
8059.36
The CWF ELGE module shall be modified (as
necessary) to reflect the new MAC workload number.
CWF
ELGE
8059.37
The CMS Baltimore Data Center shall modify its
records to reflect the new MAC workload number.
CMS
Baltimore
Data Center
8059.38
ECPS shall be modified (as necessary) to
reflect the new MAC workload number.
FISS shall work with the CWF and the HP
EDC to ensure history files can be cross- referred
to the new MAC workload number dating back at
least 27 months.
8059.39
X
X
CWF, HP
EDC
8059.40
The Local Coverage Determination (LCD)
Database shall be updated to reflect the new MAC
workload number.
LCD
8059.40.1
The J5 A/B MAC shall advise the CMS LCD
database CMS business owner of the policies it
will be using to adjudicate claims once the legacy
workloads have been transitioned to the MAC. The
LCD database CMS business owner shall use this
information to populate its database.
J5 A/B MAC,
LCD
Database
8059.41
The J5 A/B MAC shall apply the LCDs of the
legacy contractor as applicable to claims for
services rendered by the transitioning providers
with a date of service prior to the effective date of
that workloads transition to the MAC.
J5 A/B
MAC
8059.42
HIGLAS shall rename the existing 52280 HIGLAS
Organization as of the date of the transition of that
workload to the J5 A/B MAC.
HIGLAS
8059.42.1
WPS, the J5 A/B MAC and the HP EDC shall
assist HIGLAS as necesary to support the rename
of the 52280 workload as per 8059.43.
8059.43
The EHR program shall make whatever
modifications are necessary to support the new
MAC workload number.
WPS, J5
A/B MAC,
HP EDC,
HIGLAS
EHR
8059.44
The HIMR system shall be modified (if
necessary) to ensure the J5 MAC will be able to
access it.
The MSPRC shall make any changes necessary
to accommodate the new MAC workload number.
8059.45
HIMR
MSPRC
8059.46
The NLR shall make whatever modifications are
necessary to support the new MAC workload
number.
NLR
8059.47
PIES shall make any changes necessary to
accommodate the new MAC workload number.
PIES
November 2012
- page 28 -
Medicare Bulletin – GR 2012-11
Number
Requirements
Responsibility
Other
SharedSystem
Maintainers
A/B
D F C R
MA C M E I A R H
RI HI
ER
MA
P P
C
ar art
t
B
A
F
I
S
S
M
C
S
V
M
S
C
W
F
8059.48
The Recovery Auditors (RA) interfacing with the
J5 A/B MAC shall make whatever modifications
are necessary to support the new MAC workload
number
RA
8059.48.1
The RAs shall use the appropriate MAC
workload number when submitting adjustment
requests to the J5 A/B MAC.
RA
The HIGLAS Organization number does
not need to be synchronized with the MAC
workload number. The RAs shall take that into
account when submitting adjustment request
to the J5 A/B MAC.
The PCID shall make whatever modifications
are necessary to support the new MAC workload
number.
The Zip Code file shall be updated to reflect the
new MAC workload number. Contractors shall
utilize the updated zip code file whenever it is
received.
8059.49
8059.50
III.
X
X X
Zip Code
File
PROVIDER EDUCATION TABLE
Number
8059.51
IV.
PCID
Requirement
Responsibility
FI C
A/B MAC D
A
M
R
E
R
I
M
P P
E
A
a a
R
C
r
r
t
t
A
B
X
CR as Provider Education: Contractors shall
post this entire instruction, or a direct link to
this instruction, on their Web sites and include
information about it in a listserv message within
1 week of the release of this instruction. In
addition, the entire instruction must be included
in the contractor’s next regularly scheduled
bulletin. Contractors are free to supplement it
with localized information that would benefit their
provider community in billing and administering the
Medicare program correctly.
X
X
R
H
H
I
Other
X
SUPPORTING INFORMATION
Section A: Recommendations and supporting information associated with listed requirements: N/A
Use “Should” to denote a recommendation.
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Medicare Bulletin – GR 2012-11
- page 29 -
November 2012
X-Ref Requirement Number
Recommendations or other supporting information:
Section B: All other recommendations and supporting information: N/A V. CONTACTS
Pre-Implementation Contact(s): Amber Trujillo, [email protected], Scott Levine, 347-5010837 or [email protected]
Post-Implementation Contact(s): Contact your Contracting Officer’s Representative (COR) or
Contractor Manager, as applicable.
VI. FUNDING
Section A: For Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs), and/
or Carriers:
Funding or implementation activities will be provided to contractors through the regular budget process
Section B: For Medicare Administrative Contractors (MACs):
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as
defined in your contract. CMS do not construe this as a change to the MAC Statement of Work. The
contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and
until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as
described above, to be outside the current scope of work, the contractor shall withhold performance on
the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request
formal directions regarding continued performance requirements.
Erythropoiesis Stimulating Agents (ESA) L31867
The Erythropoiesis Stimulating Agent (ESA) LCD L31867 has been updated to include new FDA
approved drug Omantys ®, HCPCS code Q2047, effective March 27, 2012. This is covered when billed
with both of the following ICD-9 –CM 285.21 and 585.6.
Local Carrier Payment Allowance Limits for Medicare Part B Drugs
Effective July 1, 2012 through September 30, 2012
Note 1: The complete ASP Payment Allowance Limits list can be accessed at the following link:
http://www.cms.gov/McrPartBDrugAvgSalesPrice/01a18_2011ASPFiles.asp#TopOfPage
Note 2: Payment allowance limits subject to the ASP methodology are based on 1Q11 ASP data.
Note 3: The absence or presence of a HCPCS code and the payment allowance limits in this table
does not indicate Medicare coverage of the drug.
Similarly, the inclusion of a payment allowance limit within a specific column does not indicate Medicare
coverage of the drug in that specific category. These determinations shall be made by the local Medicare
contractor processing the claim.
Note 4: ** - Carrier-priced HCPCS Code
Short Description
HCPCS Code
Dosage
Payment
Limit
Notes
90396**
90396**
varicella-zoster immune globulin
varicella-zoster immune globulin
125 U /1.25 ML
625 U / 6.25 ML
Invoice
Invoice
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November 2012
- page 30 -
Medicare Bulletin – GR 2012-11
A9505
Flu vaccine, derived from cell cultures,
subunit
Thallium TI201
Per Carrier Medical Director
not covered by Part B.
Invoice
J0135**
J0200**
J0270**
J0275**
J0364**
J0380**
J0390**
J0395**
Adalimumab, 20 MG
Alatrofloxacin mesylate
Alprostadil, 1.25 MCG
Alprostadil Urethral Suppository
Apomorphine / Hydrochloride
metaraminol bitartrate, inj
Chloroquine injection
Arbutamine HCl injection
Considered self-administered.
100 MG
Invoice
Considered self-administered.
Considered self-administered.
Considered self-administered.
10 MG
Invoice
250 MG
Invoice
1 MG
Invoice
J0520**
Bethanechol chloride inject
Oral drug considered part of
procedure in physician’s office.
J0620**
J0630**
J0715**
J1060**
J1324**
J1438**
J1590**
J1595**
J1675**
J1680**
J1700**
J1710**
J1725**
J1830**
J1890**
J1960**
J1990**
J2170**
J2278KD**
J2320**
J2354**
J2513**
J2650**
J2670**
J2940**
J2941**
J3030**
J3110**
J3140**
J3150**
J3265**
J3280**
J7130**
J7191**
J7500**
J7502**
J7506**
J7507**
J7509**
J7510**
Calcium glycerophosphate/Calcium lactate
Calcitonin Salmon
Ceftizoxime sodium / 500 MG
Testosterone cypionate 1 ML
Enfuvirtide
Etanercept
Gatifloxacin injection
Injection glatiramer acetate
Histrelin Acetate
fibrinogen concentrate human
Hydrocortisone acetate inj
Hydrocortisone sodium ph inj
Hydroxyprogesterone Caporate
Interferon beta-1b / .25 MG
Cephalothin sodium injection
Levorphanol tartrate
Chlordiazepoxide injection
Mecasermin
Ziconotide injection
Nandrolone decanoate 50 MG
Octreotide Acetate
Pentastarch 10% solution
Prednisolone acetate
Tolazoline hcl injection
Somatrem injection
Somatropin injection
Sumatriptan Succinate
Teriparatide injection
Testosterone suspension
Testosterone propionate
Injection torsemide 10 mg/ml
Thiethylperazine maleate, inj
Hypertonic saline solution
Factor viii (porcine)
Azathioprine oral 50 mg
Cyclosporine oral 100 mg
Prednisone oral
Tacrolimus oral per 1 MG
Methylprednisolone oral
Prednisolone oral per 5 mg
10 ML
Invoice
Considered self-administered.
500 MG
Invoice
1 ML
Invoice
Considered self-administered.
Considered self-administered.
Considered self-administered.
Considered self-administered.
Considered self-administered.
100 MG
$
103.550
25 MG
$
0.360
50 MG
Invoice
1 MG
Invoice
Not covered by carrier.
1G
Invoice
2 MG
$
3.765
100 MG
Invoice
Considered self-administered.
1 MCG
Invoice
50 MG
$
4.452
Considered self-administered.
10%
Invoice
1 ML
$
0.342
25 MG
Invoice
Considered self-administered.
Considered self-administered.
Considered self-administered.
Considered self-administered.
50 MG
$
0.420
100 MG
$
0.798
10 MG
$
4.000
10 MG
Invoice
20 CC
Invoice
1 IU
Invoice
Should be billed to DMAC
Should be billed to DMAC
Should be billed to DMAC
Should be billed to DMAC
Should be billed to DMAC
Should be billed to DMAC
90661**
added March
2012
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Medicare Bulletin – GR 2012-11
- page 31 -
November 2012
J7515**
J7517**
J7518**
J7520**
Cyclosporine oral 25 mg
Mycophenolate mofetil oral
Mycophenolic acid
Sirolimus, oral
J7604**
Acetylcystein
J7605**
Arformoterol non-comp unit
J7606**
Formoterol fumarate, inh
J7608**
Acetylcystein non-comp unit
J7611**
Albuterol non-comp con
J7612**
Levalbuterol non-comp con
J7613**
Albuterol non-comp unit
J7614**
Levalbuterol non-comp unit
J7620**
Albuterol ipratrop non-comp
J7622**
Beclomethasone inhalation sol
J7624**
Betamethasone inhalation sol
J7626**
Budesonide non-comp unit
J7628**
Bitolterol mes inhal sol con
J7629**
Bitolterol mes inh sol u d
J7631**
Cromolyn sodium non-comp unit
J7633**
Budesonide concentrated sol
J7639**
Dornase alfa non-comp unit
J7641**
Flunisolide, inhalation sol
J7644**
Ipratropium bromide non-comp
J7648**
Isoetharine hcl inh sol con
J7649**
Isoetharine hcl inh sol u d
J7658**
Isoproterenol hcl inh sol con
J7659**
Isoproterenol hcl inh sol ud
J7668**
Metaproterenol inh sol con
J7669**
Metaproterenol non-comp unit
J7674**
Methacholine chloride, neb
J7680**
Terbutaline so4 inh sol con
J7681**
Terbutaline so4 inh sol u d
J7682**
Tobramycin non-comp unit
J7683**
Triamcinolone inh sol con
J7684**
Triamcinolone inh sol u d
J7686**
Treprostinil non-comp unit
J8501**
J8510**
J8520**
J8521**
J8530**
J8540**
Oral aprepitant
Oral busulfan
Capecitabine, oral 150 mg
Capecitabine, oral 500 mg
Cyclophosphamide oral 25 MG
Oral dexamethasone
Should be billed to DMAC
Should be billed to DMAC
Should be billed to DMAC
Should be billed to DMAC
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Considered part of procedure
in physician’s office.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
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 www.cgsmedicare.com.
November 2012
- page 32 -
Medicare Bulletin – GR 2012-11
J8560**
J8562**
J8600**
J8610**
J8700**
J8705**
J9165**
J9213**
J9215**
J9218**
J9270**
J9600**
Q0163**
Q0164**
Q0165**
Q0166**
Q0167**
Q0168**
Q0169**
Q0170**
Q0174**
Q0179**
Q0180**
Q4074**
Etoposide oral 50 MG
Oral fludarabine phosphate
Melphalan oral 2 MG
Methotrexate oral 2.5 MG
Temozolomide
Topotecan oral
Diethylstilbestrol diphosphate injection
Interferon alfa-2a inj
Interferon, alfa-n3
Leuprolide Acetate
Plicamycin (mithramycin) inj
Porfimer Sodium injection
Diphenhydramine HCI 50 mg
Prochlorperazine maleate 5 mg
Prochlorperazine maleate 10 mg
Granisetron hcl 1 mg oral
Dronabinol 2.5 mg oral
Dronabinol 5 mg oral
Promethazine HCI 12.5 mg oral
Promethazine HCI 25 mg oral
Thiethylperazine maleate, 10mg
Ondansetron hcl 9 mg oral
Dolasetron mesylate oral
Unspecified oral dosage form, FDA
approved presription anti-emetic
Radiesse injection
Sculptra injection
Agriflu
Not Otherwise Classified flu vacc, 3 yrs &
>, im
Iloprost non-comp unit dose
Q4118**
Q4119**
Q4122**
Q4124**
Q4125**
Q4126**
Q4127**
Q4128**
Q4129**
Q4130**
Q9955**
Matristem Micromatrix
Matristem Micromatrix
Dermacell
Oasis Ultra Tri-Layer Wound Matrix
Arthroflex
Memoderm
Talymed
Flex HD or Allopatch HD
Unite Biomatrix
Strattice TM
Inj perflexane lip micros, ml
Q0181**
Q2026**
Q2027**
Q2034**
Q2039**
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
250 MG
Invoice
3 MIL UNITS
Invoice
250,000 IU
$
23.834
Considered self-administered.
2.5 MG
Invoice
75 MG
$ 3,004.740
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
0.1 ML
0.1 ML
.05 ML
Invoice
Invoice
Invoice
0.5 ML
$
12.375
Considered part of procedure
in physician’s office.
1 MG
$
2.433
1 SQ CM
$
2.470
1 SQ CM
Invoice
1 SQ CM
$
11.400
1 SQ CM
Invoice
1 SQ CM
Invoice
1 SQ CM
Invoice
1 SQ CM
Invoice
1 SQ CM
Invoice
1 SQ CM
Invoice
1 ML
Invoice
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 33 -
November 2012
Local Payment Allowance Limits for Medicare Part B Drugs
Effective October 1, 2012 through December 31, 2012
Note 1: The complete ASP Payment Allowance Limits list can be accessed at the following link:
http://www.cms.gov/McrPartBDrugAvgSalesPrice/01a18_2011ASPFiles.asp#TopOfPage
Note 2: Payment allowance limits subject to the ASP methodology are based on 2Q12 ASP data.
Note 3: The absence or presence of a HCPCS code and the payment allowance limits in this table
does not indicate Medicare coverage of the drug.
Similarly, the inclusion of a payment allowance limit within a specific column does not indicate Medicare
coverage of the drug in that specific category. These determinations shall be made by the local Medicare
contractor processing the claim.
Note 4: ** - Carrier-priced
HCPCS
Code
90396**
90396**
Short Description
HCPCS Code Dosage
J0135**
J0200**
J0270**
J0275**
J0364**
J0380**
J0390**
J0395**
varicella-zoster immune globulin
varicella-zoster immune globulin
Flu vaccine, derived from cell cultures,
subunit
Adalimumab, 20 MG
Alatrofloxacin mesylate
Alprostadil, 1.25 MCG
Alprostadil Urethral Suppository
Apomorphine / Hydrochloride
metaraminol bitartrate, inj
Chloroquine injection
Arbutamine HCl injection
125 U / 1.25 ML
Invoice
625 U / 6.25 ML
Invoice
Per Carrier Medical Director not covered
by Part B.
Considered self-administered.
100 MG
Invoice
Considered self-administered.
Considered self-administered.
Considered self-administered.
10 MG
Invoice
250 MG
Invoice
1 MG
Invoice
J0520**
Bethanechol chloride inject
Oral drug considered part of procedure in
physician’s office.
J0620**
J0630**
J0715**
J1060**
J1324**
J1438**
J1590**
J1595**
J1675**
J1680**
J1700**
J1710**
J1725**
J1830**
J1890**
J1960**
J1990**
J2170**
J2265**
J2278KD**
J2320**
J2354**
Calcium glycerophosphate/Calcium lactate
Calcitonin Salmon
Ceftizoxime sodium / 500 MG
Testosterone cypionate 1 ML
Enfuvirtide
Etanercept
Gatifloxacin injection
Injection glatiramer acetate
Histrelin Acetate
fibrinogen concentrate human
Hydrocortisone acetate inj
Hydrocortisone sodium ph inj
Hydroxyprogesterone Caporate
Interferon beta-1b / .25 MG
Cephalothin sodium injection
Levorphanol tartrate
Chlordiazepoxide injection
Mecasermin
Minocycline Hydrochloride
Ziconotide injection
Nandrolone decanoate 50 MG
Octreotide Acetate
10 ML
Invoice
Considered self-administered.
500 MG
Invoice
1 ML
Invoice
Considered self-administered.
Considered self-administered.
Considered self-administered.
Considered self-administered.
Considered self-administered.
100 MG
$
103.550
25 MG
$
0.360
50 MG
Invoice
1 MG
Invoice
Not covered by carrier.
1G
Invoice
2 MG
$
3.765
100 MG
Invoice
Considered self-administered.
Considered self-administered.
1 MCG
Invoice
50 MG
$
4.452
Considered self-administered.
90661**
Payment Limit
Notes
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 www.cgsmedicare.com.
November 2012
- page 34 -
Medicare Bulletin – GR 2012-11
J2513**
J2650**
J2670**
J2940**
J2941**
J3030**
J3110**
J3140**
J3150**
J3265**
J3280**
J7130**
J7180**
J7191**
J7500**
J7502**
J7506**
J7507**
J7509**
J7510**
J7515**
J7517**
J7518**
J7520**
Pentastarch 10% solution
Prednisolone acetate
Tolazoline hcl injection
Somatrem injection
Somatropin injection
Sumatriptan Succinate
Teriparatide injection
Testosterone suspension
Testosterone propionate
Injection torsemide 10 mg/ml
Thiethylperazine maleate, inj
Hypertonic saline solution
Factor XIII
Factor viii (porcine)
Azathioprine oral 50 mg
Cyclosporine oral 100 mg
Prednisone oral
Tacrolimus oral per 1 MG
Methylprednisolone oral
Prednisolone oral per 5 mg
Cyclosporine oral 25 mg
Mycophenolate mofetil oral
Mycophenolic acid
Sirolimus, oral
J7604**
Acetylcystein
J7605**
Arformoterol non-comp unit
J7606**
Formoterol fumarate, inh
J7608**
Acetylcystein non-comp unit
J7611**
Albuterol non-comp con
J7612**
Levalbuterol non-comp con
J7613**
Albuterol non-comp unit
J7614**
Levalbuterol non-comp unit
J7620**
Albuterol ipratrop non-comp
J7622**
Beclomethasone inhalation sol
J7624**
Betamethasone inhalation sol
J7626**
Budesonide non-comp unit
J7628**
Bitolterol mes inhal sol con
J7629**
Bitolterol mes inh sol u d
J7631**
Cromolyn sodium non-comp unit
J7633**
Budesonide concentrated sol
10%
Invoice
1 ML
$
25 MG
Invoice
Considered self-administered.
Considered self-administered.
Considered self-administered.
Considered self-administered.
50 MG
$
100 MG
$
10 MG
$
10 MG
Invoice
20 CC
Invoice
1 I.U.
Invoice
1 IU
Invoice
Should be billed to DMAC
Should be billed to DMAC
Should be billed to DMAC
Should be billed to DMAC
Should be billed to DMAC
Should be billed to DMAC
Should be billed to DMAC
Should be billed to DMAC
Should be billed to DMAC
Should be billed to DMAC
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
0.342
0.420
0.798
4.000
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 35 -
November 2012
J7639**
Dornase alfa non-comp unit
J7641**
Flunisolide, inhalation sol
J7644**
Ipratropium bromide non-comp
J7648**
Isoetharine hcl inh sol con
J7649**
Isoetharine hcl inh sol u d
J7658**
Isoproterenol hcl inh sol con
J7659**
Isoproterenol hcl inh sol ud
J7665**
Mannitol inh sol
J7668**
Metaproterenol inh sol con
J7669**
Metaproterenol non-comp unit
J7674**
Methacholine chloride, neb
J7680**
Terbutaline so4 inh sol con
J7681**
Terbutaline so4 inh sol u d
J7682**
Tobramycin non-comp unit
J7683**
Triamcinolone inh sol con
J7684**
Triamcinolone inh sol u d
J7686**
Treprostinil non-comp unit
J8501**
J8510**
J8520**
J8521**
J8530**
J8540**
J8560**
J8561**
J8562**
J8600**
J8610**
J8700**
J8705**
J9165**
J9213**
J9215**
J9218**
J9270**
J9600**
Q0163**
Q0164**
Q0165**
Q0166**
Oral aprepitant
Oral busulfan
Capecitabine, oral 150 mg
Capecitabine, oral 500 mg
Cyclophosphamide oral 25 MG
Oral dexamethasone
Etoposide oral 50 MG
Everolimus, 0.25 MG
Oral fludarabine phosphate
Melphalan oral 2 MG
Methotrexate oral 2.5 MG
Temozolomide
Topotecan oral
Diethylstilbestrol diphosphate injection
Interferon alfa-2a inj
Interferon, alfa-n3
Leuprolide Acetate
Plicamycin (mithramycin) inj
Porfimer Sodium injection
Diphenhydramine HCI 50 mg
Prochlorperazine maleate 5 mg
Prochlorperazine maleate 10 mg
Granisetron hcl 1 mg oral
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Considered part of procedure in
physician’s office.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
250 MG
Invoice
3 MIL UNITS
Invoice
250,000 IU
$
23.834
Considered self-administered.
2.5 MG
Invoice
75 MG
$ 3,004.740
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
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 www.cgsmedicare.com.
November 2012
- page 36 -
Medicare Bulletin – GR 2012-11
Q0167**
Q0168**
Q0169**
Q0170**
Q0174**
Q0179**
Q0180**
Q4074**
Dronabinol 2.5 mg oral
Dronabinol 5 mg oral
Promethazine HCI 12.5 mg oral
Promethazine HCI 25 mg oral
Thiethylperazine maleate, 10mg
Ondansetron hcl 9 mg oral
Dolasetron mesylate oral
Unspecified oral dosage form, FDA
approved presription anti-emetic
Radiesse injection
Sculptra injection
Agriflu
Not Otherwise Classified flu vacc, 3 yrs &
>, im
Iloprost non-comp unit dose
Q4118**
Q4119**
Q4122**
Q4123**
Q4124**
Q4125**
Q4126**
Q4127**
Q4128**
Q4129**
Q4130**
Q9955**
Matristem Micromatrix
Matristem Micromatrix
Dermacell
Alloskin RT
Oasis Ultra Tri-Layer Wound Matrix
Arthroflex
Memoderm
Talymed
Flex HD or Allopatch HD
Unite Biomatrix
Strattice TM
Inj perflexane lip micros, ml
Q0181**
Q2026**
Q2027**
Q2034**
Q2039**
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
Should be billed to DMAC.
0.1 ML
0.1 ML
0.05 ML
Invoice
Invoice
Invoice
0.5 ML
$
12.375
Considered part of procedure in
physician’s office.
1 MG
$
2.433
1 SQ CM
$
2.470
1 SQ CM
Invoice
1 SQ CM
$
13.372
1 SQ CM
$
11.400
1 SQ CM
Invoice
1 SQ CM
Invoice
1 SQ CM
Invoice
1 SQ CM
Invoice
1 SQ CM
Invoice
1 SQ CM
Invoice
1 ML
Invoice
MM7791 - Contractor and Common Working File (CWF) Additional
Instructions Related to Change Request (CR) 7633 - Screening and
Behavioral Counseling Interventions in Primary Care to Reduce Alcohol
Misuse
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – Medicare is denying an increasing number of claims, because providers are not
identifying the correct primary payer prior to claims submission. Medicare would like to remind providers,
physicians, and suppliers that they have the responsibility to bill correctly and to ensure claims are
submitted to the appropriate primary payer. Please refer to the “Medicare Secondary Payer (MSP)
Manual,” Chapter 3, and MLN Matters® Article SE1217 for additional guidance.
Note: This article was revised on September 17, 2012, to reflect a revised CR7791 issued on
September 13. The CR transmittal number, release date, and the Web address for accessing the
CR have been changed. All other information is the same.
Provider Types Affected
This MLN Matters® Article is intended for physicians, providers and suppliers submitting claims to Fiscal
Intermediaries (FI), carriers and A/B Medicare Administrative Contractors (A/B MAC) for screening and
behavioral counseling services provided to Medicare beneficiaries.
What You Need to Know
If a claim is submitted by a provider for G0443 (Brief face-to-face behavioral counseling for alcohol
misuse, 15 minutes) when there are no claims for G0442 (Annual alcohol misuse screening, 15 minutes)
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 37 -
November 2012
in Medicare’s claims history within a prior 12 month period, CR 7791 requires contractors to
deny these claims. Be sure to inform your staff of these changes.
Background
Pursuant to section 1861(ddd) of the Social Security Act, the Centers for Medicare & Medicaid
Services (CMS) may add coverage of “additional preventive services” through the National Coverage
Determination (NCD) process if all of the following criteria are met. They must be: (1) reasonable and
necessary for the prevention or early detection of illness or disability, (2) recommended with a grade of A
or B by the United States Preventive Services Task Force (USPSTF), and, (3) appropriate for individuals
entitled to benefits under Part A or enrolled under Part B of the Medicare Program. CMS reviewed the
USPSTF’s “B” recommendation and supporting evidence for “Screening and Behavioral Counseling
Interventions in Primary Care to Reduce Alcohol Misuse” preventive services and determined that all
three criteria were met.
According to the USPSTF (2004), alcohol misuse includes risky/hazardous and harmful drinking which
place individuals at risk for future problems; and in the general adult population, risky or hazardous
drinking is defined as >7 drinks per week or >3 drinks per occasion for women, and >14 drinks per week
or >4 drinks per occasion for men. Harmful drinking describes those persons currently experiencing
physical, social or psychological harm from alcohol use, but who do not meet criteria for dependence.
In the Medicare population, Saitz (2005) defined risky use as >7 standard drinks per week or >3
drinks per occasion for women and persons >65 years of age, and >14 standard drinks per week or
>4 drinks per occasion for men ≤65 years of age. Importantly, Saitz included the caveat that such
thresholds do not apply to pregnant women for whom the healthiest choice is generally abstinence.
The 2005 “Clinician’s Guide” from the National Institutes of Health National Institute on Alcohol
Abuse and Alcoholism also stated that clinicians recommend lower limits or abstinence for patients
taking medication that interacts with alcohol, or who engage in activities that require attention, skill, or
coordination (e.g., driving), or who have a medical condition exacerbated by alcohol (e.g., gastritis).
CR 7791 adds further instructions for contractors if a claim is submitted by a provider for G0443 (Brief
face-to-face behavioral counseling for alcohol misuse, 15 minutes) when there are no claims for G0442
(Annual alcohol misuse screening, 15 minutes) in claims history within a prior 12 month period. It
requires contractors to deny such claims with the following specific messages:
• Claim Adjustment Reason Code (CARC) B15 – This service/procedure requires that a qualifying
service/procedure be received and covered. The qualifying other service/procedure has not been
received/adjudicated. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110
Service Payment Information REF), if present.
• Remittance Advice Remark Code (RARC) M16 – Alert: Please see our web site, mailings, or
bulletins for more details concerning this policy/procedure/decision.
• Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is
received with a modifier indicating a signed Advanced Beneficiary Notice (ABN) is on file.
• Group code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is
received without a modifier indicating no signed ABN is on file.
Also, remember that Medicare will only pay for up to four G0443 services within a 12 month period.
Claims for G0443 that exceed that four session limit in a 12 month period will be rejected. In addition,
Medicare will continue to reject incoming claims when G0442 (PROF) and G0443 (PROF) are billed on
the same day on types of bills 71X, 77X, and 85X with revenue codes 096X, 097X, and 098X.
Additional Information
The official instruction, CR 7791, issued to your FI, carrier, and A/B MAC regarding this change, may be
viewed at http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2544CP.
pdf on the CMS website.
The MLN Matters® Article MM7663, entitled, “Screening and Behavioral Counseling Interventions
in Primary Care to Reduce Alcohol Misuse,” may be viewed at http://www.cms.gov/Outreach-andEducation/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7633.pdf on the CMS
website.
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 www.cgsmedicare.com.
November 2012
- page 38 -
Medicare Bulletin – GR 2012-11
If you have any questions, please contact your FI, carrier, or A/B MAC at their toll-free number, which
may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring- Programs/
provider-compliance-interactive-map/index.html on the CMS website.
MM7806 - Extracorporeal Photopheresis (ICD-10)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – In response to shortage of liposomal doxorubicin (Doxil), the Food and Drug Administration
is permitting the temporary importation of Lipodox, a brand of liposomal doxorubicin hydrochloride.
Visit http://www.FDA.gov/NewsEvents/Newsroom/PressAnnouncements/ucm292658.htm for additional
information. The Centers for Medicare & Medicaid Services (CMS) Healthcare Common Procedure
Coding System (HCPCS) Quarterly Update includes two new codes (Q2048 and Q2049) for liposomal
doxorubicin that will become effective Sunday, July 1, 2012. The code descriptors are worded in a manner
that distinguishes Lipodox and Doxil. As of Sunday, July 1, 2012, HCPCS code J9001 will not be used for
Medicare billing. CMS will release a Change Request (CR) with additional instructions in the near future.
Note: This article was revised on September 25, 2012, to reflect the revised CR7806 issued
on September 24, 2012. The CR release date, transmittal number, and the Web address for
accessing CR7806 were revised. All other information is the same.
Provider Types Affected
This MLN Matters® Article is intended for physicians and other providers who bill Medicare Carriers,
Fiscal Intermediaries (FIs), or Medicare Administrative Contractors (A/B MACs) for providing
extracorporeal photopheresis procedures for the treatment of Bronchiolitis Obliterans Syndrome
(BOS) following lung allograft transplantation.
Provider Action Needed
Effective for claims with dates of service on and after April 30, 2012, Medicare will cover extracorporeal
photopheresis for the treatment of Bronchiolitis Obliterans Syndrome (BOS) following lung allograft
transplantation, but only when provided under an approved clinical research study that meets specific
requirements to assess the effect of extracorporeal photopheresis for the treatment of BOS following
lung allograft transplantation. You should make sure that your billing staffs are aware of the expanded
coverage provided in this NCD.
Background
Extracorporeal photopheresis is a second-line treatment for a variety of oncological and autoimmune
disorders that is performed in the hospital inpatient, hospital outpatient, and Critical Access Hospital
(CAH) settings. In the procedure, some of a patient’s removed white blood cells are exposed first to the
drug 8-methoxypsoralen (8-MOP) and then to ultraviolet A (UVA) light. After UVA light exposure, the
treated white blood cells are re-infused into the patient, stimulating their immune system in a series of
cascading reactions. This activation of the immune system then impacts the illness being treated.
Currently, Medicare covers extracorporeal photopheresis for the following indications:
• Palliative treatment of skin manifestations of CTCL that has not responded to other therapy;
• Patients with acute cardiac allograft rejection whose disease is refractory to standard
immunosuppressive drug treatment; and
• Patients with chronic graft versus host disease whose disease is refractory to standard
immunosuppressive drug treatment.
On August 4, 2011, the Centers for Medicare & Medicaid Services (CMS) accepted a formal request
for a reconsideration to add coverage for extracorporeal photopheresis treatment for patients who have
received lung allografts and then developed progressive Bronchiolitis Obliterans Syndrome (BOS)
refractory to immunosuppressive drug treatment.
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Medicare Bulletin – GR 2012-11
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November 2012
As a result of the reconsideration, effective for claims with dates of service on and after April 30, 2012,
Medicare will begin to cover extracorporeal photopheresis for the treatment of BOS following lung
allograft transplantation; but only when provided under a clinical research study that meets specific
requirements to assess its effect in the treatment of BOS following lung allograft transplantation.
NCD Clinical Research Study Requirements
This is a National Coverage Determination (NCD). In keeping with this NCD, any clinical research study
that includes Medicare coverage of extracorporeal photopheresis for the treatment of BOS following
lung allograft transplantation must be approved by meeting the requirements listed below. Additionally,
consistent with section 1142 of the Social Security Act, AHRQ supports clinical research studies that
CMS determines meet these standards and address the research questions.
An approved clinical research study:
1. Must address one or more aspects of the following question:
Prospectively, do Medicare beneficiaries who have received lung allografts, developed BOS refractory to
standard immunosuppressive therapy, and received extracorporeal photopheresis, experience improved
patient-centered health outcomes as indicated by:
a. Improved Forced Expiratory Volume in One Second (FEV1);
b. Improved survival after transplant; and/or
c. Improved quality of life?
2. Must adhere to the following standards of scientific integrity and relevance to the Medicare
population:
a. Its principal purpose is to test whether extracorporeal photopheresis potentially improves the
participants’ health outcomes;
b. It is well supported by available scientific and medical information or it is intended to clarify or
establish the health outcomes of interventions already in common clinical use;
c. It does not unjustifiably duplicate existing studies;
d. Its design is appropriate to answer the research question being asked in the study;
e. It is sponsored by an organization or individual capable of successfully executing the proposed
study;
f. It is in compliance with all applicable Federal regulations concerning the protection of human
subjects found at 45 Code of Federal Regulations CFR Part 46. If a study is regulated by the
Food and Drug Administration (FDA), it must also be in compliance with
a. 21 CFR parts 50 and 56;
g. All of its aspects are conducted according to appropriate standards of scientific integrity (see
http://www.icmje.org);
h. It has a written protocol that clearly addresses, or incorporates by reference, the standards listed
here as Medicare requirements for Coverage with Evidence Development (CED) coverage;
i. It is not designed to exclusively test toxicity or disease pathophysiology in healthy individuals.
Trials of all medical technologies measuring therapeutic outcomes as one of the objectives meet
this standard only if the disease or condition being studied is life threatening as defined in 21
CFR Section 312.81(a) and the patient has no other viable treatment options;
j. It is registered on the ClinicalTrials.gov website (http://clinicaltrials.gov) by the principal
sponsor/investigator prior to the enrollment of the first study subject;
k. Its protocol specifies the method and timing of public release of all prespecified outcomes to be
measured including release of outcomes if outcomes are negative or study is terminated early.
The results must be made public within 24 months of the end of data collection. If a report is
planned to be published in a peer reviewed journal, then that initial release may be an abstract
that meets the requirements of the International Committee of Medical Journal Editors (http://
www.icmje.org).
l. It explicitly discusses subpopulations affected by the treatment under investigation, particularly
traditionally underrepresented groups in clinical studies, how the inclusion and exclusion
criteria effect enrollment of these populations, and a plan for the retention and reporting of said
populations on the trial. If the inclusion and exclusion criteria are expected to have a negative
effect on the recruitment or retention of underrepresented populations, the protocol must discuss
why these criteria are necessary
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November 2012
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Medicare Bulletin – GR 2012-11
m. Its study protocol explicitly discusses how the results are or are not expected to be generalizable
to the Medicare population to infer whether Medicare patients may benefit from the intervention.
Separate discussions in the protocol may be necessary for populations eligible for Medicare due
to age, disability or Medicaid eligibility.
Note: Any clinical study in which there is coverage of extracorporeal photopheresis for this indication
under this NCD must be approved by April 30, 2014 (two years from the effective date of this NCD). If
there are no approved clinical studies by this date, this NCD will expire and coverage of extracorporeal
photopheresis for BOS will revert to the coverage policy in effect prior to the issuance of its Final
Decision Memorandum (DM) on April 30, 2012.
Billing Requirements
Effective for claims with dates of service on and after April 30, 2012, your carrier, FI, or A/B MAC will
accept and pay for hospital outpatient and physician claims containing Healthcare Common Procedure
Coding System (HCPCS) procedure code 36522 along with one of the International Classification of
Diseases (ICD-9-CM or ICD-10) diagnosis codes displayed in the following table.
ICD 9 CM ICD 9 CM Description
ICD-10
ICD-10 Description
491.20
Obstructive chronic bronchitis without
exacerbation
J44.9
Chronic obstructive pulmonary
disease, unspecified
491.21
Obstructive chronic bronchitis with
(acute) exacerbation
J44.1
Chronic obstructive pulmonary
disease with (acute) exacerbation
491.9
Unspecified chronic bronchitis
J42
Unspecified chronic bronchitis
496
Chronic airway obstruction, not
elsewhere classified
J44.9
Chronic obstructive pulmonary
disease, unspecified
996.84
Complications of transplanted lung
T86.810
Lung transplant rejection
996.84
Complications of transplanted lung
T86.811
Lung transplant failure
996.84
Complications of transplanted lung
T86.812
Lung transplant infection (not
recommended for ECP coverage)
996.84
Complications of transplanted lung
T86.818
Other complications of lung
transplant
996.84
Complications of transplanted lung
T86.819
Unspecified complication of lung
transplant
V70.7
Examination of participant in clinical
trial
Z00.6
Encounter for examination for normal
comparison and control in clinical
research program (needed for CED)
Please note that your claims will only be paid when they also contain all of the following:
• Diagnosis code V70.7 (as secondary diagnosis) (ICD-10 Z00.6);
• Condition code 30 (institutional claims only);
• Clinical trial modifier Q0 (Investigational clinical service provided in a clinical research study
that is in an approved research study); and
• Value Code D4 with an 8-digit clinical trial number (optional)(FIs only).
Additionally, should your Medicare contractor return your claims as unprocessable because they are
missing: 1) Diagnosis code V70.7 (as secondary diagnosis), 2) Condition code 30 (Institutional claims
only), 3) Clinical trial modifier Q0 (Institutional claims only), and 4) Value Code D4 with an 8-digit clinical
trial number (optional) (FIs only); they will use the following messages:
• CARC 4 – The procedure code is inconsistent with the modifier used or a required modifier is
missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service
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Medicare Bulletin – GR 2012-11
- page 41 -
November 2012
•
•
Payment Information REF), if present.
RARC MA 130 – 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.
RARC M16 – Alert: Please see our web site, mailings, or bulletins for more details
concerning this policy/procedure/decision.
Please keep in mind that your contractor will not retroactively adjust claims from April 30, 2012,
processed prior to implementation of CR7806. However, they may adjust claims that you bring to their
attention.
Additional Information
The official instruction, CR7806, was issued in two transmittals. The first updates to the “Medicare
National Coverage Determinations Manual” are available at http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R143NCD.pdf on the CMS website. The second updates
the “Medicare Claims Processing Manual” and it is at http://www.cms.gov/Regulations- and-Guidance/
Guidance/Transmittals/Downloads/R2551CP.pdf on the CMS website.
If you have any questions, please contact your carrier, FI, or A/B 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.
MM7818 - International Classification of Diseases, 10th Edition (ICD)10 Conversion from (ICD-9) and Related Code Infrastructure of the
Medicare Shared Systems as They Relate to CMS National Coverage
Determinations (NCDs) (CR 1 of 3) (ICD-10)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash –
NEW products from the Medicare Learning Network® (MLN)
• “Cardiovascular Disease Services,” Booklet, ICN 907784, Downloadable
• “Screening Pap Tests,” Booklet, ICN 907791, Downloadable
Provider Types Affected
This MLN Matters® Article for Change Request (CR) 7818 is intended for physicians, other providers,
and suppliers who submit claims to Medicare contractors (carriers and A/B Medicare Administrative
Contractors (A/B MACs)) for services provided to Medicare beneficiaries.
Provider Action Needed
This article is based on Change Request (CR) 7818 which creates and updates National Coverage
Determination (NCD) hard-coded Medicare shared system edits that contain ICD-9 diagnosis codes
with comparable ICD-10 diagnosis codes. The requirements described in CR7818 reflect the operational
changes that are necessary to implement the conversion of the Medicare shared system diagnosis codes
specific to numerous Medicare NCDs, which are identified in an attachment to CR7818. In order to be
prepared to meet the timeline to implement the new ICD-10 diagnosis codes on October 1, 2014, the
Medicare shared systems will begin implementation of the necessary changes to the NCDs in the January
2013 systems release. No DME MAC edits are included in this CR but will be addressed in subsequent
CRs. All remaining changes to the Medicare shared systems, as they relate to Medicare NCDs, will be
made in subsequent releases. See the Background and Additional Information Sections of this article for
further details regarding these changes and be sure that you are ready for ICD-10 implementation.
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November 2012
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Medicare Bulletin – GR 2012-11
Background
On October 1, 2014, all Medicare claims submissions will convert from the International Classification
of Diseases, 9th Edition (ICD-9) to the 10th Edition (ICD-10). The transition will require business and
systems changes throughout the health care industry. All covered entities, as defined by the Health
Insurance Portability and Accountability Act (HIPAA), must adhere to the conversion.
In accordance with HIPAA, the Secretary of the Department of Health and Human Services adopts standard
medical data code sets for use in standard transactions adopted under this law. According to the ICD-10 Final
Rule, published in the Federal Register of January 16, 2009 (see http://www.gpo.gov/fdsys/pkg/FR-2009-01-16/
pdf/E9-743.pdf on the Internet), the Secretary adopts the ICD-10-CM and ICD-10-PCS code sets for use in
appropriate HIPAA standard transactions. Entities covered under HIPAA (which include Medicare and its providers
submitting claims electronically) are bound by these requirements and must comply. Medicare will also require
submitters of paper claims to use ICD-10 codes on their claims according to the same compliance date.
The purpose of CR7818 is to both create and update NCD hard-coded Medicare shared system edits
that contain ICD-9 diagnosis codes with comparable ICD-10 diagnosis codes, plus all associated editing
such as procedure codes, HCPCS/CPT codes, denial messages, frequency edits, Place of Service
(POS)/Type of Bill (TOB)/provider specialty editing, etc. The requirements described in CR7818 reflect
the operational changes that are necessary to implement the conversion of the Medicare shared system
diagnosis codes specific to the Medicare NCDs listed as an attachment to CR7818.
Note: This exercise is in no way intended to expand, restrict, or alter existing Medicare national coverage.
Also, it is not intended to minimize the authority granted to Medicare Administrative Contractors (MACs) in
their discretionary implementation of NCDs or Local Coverage Determinations (LCDs). However, where
hard-coded edits were not initially implemented due to time and/or resource constraints, doing so at this
time will better serve the intent and integrity of national coverage and the Medicare Program overall.
Additional Information
The official instruction, CR7818 issued to your carrier or A/B MAC regarding this change may be viewed
at http://www.cms.hhs.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R1122OTN.
pdf on the CMS website.
If you have any questions, please contact your carrier or A/B MAC at their toll-free number, which may
be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring- Programs/providercompliance-interactive-map/index.html on the CMS website.
News Flash - Influenza Season is Around the Corner - As your patients age, their immune systems may
weaken. This weakening can make seniors more susceptible to complications from seasonal influenza
(flu). Now is the perfect time to remind your patients that seasonal influenza vaccination is the best defense
against the flu. Medicare provides coverage for one flu vaccine and its administration per influenza season
for seniors and other Medicare beneficiaries with no co-pay or deductible. Talk with your Medicare patients
about their risk for getting the flu and start protecting your patients as soon as your 2012-2013 seasonal flu
vaccine arrives. And, don’t forget to immunize yourself and your staff. Know what to do about the flu.
Remember – Influenza vaccine plus its administration is a covered Part B benefit. Influenza vaccine is
NOT a Part D covered drug. CMS will provide information and a link to the 2012-2013 Influenza Vaccine
prices when they are available.
For more information on coverage and billing of the flu vaccine and its administration, please visit
the CMS Medicare Learning Network® Preventive Services Educational Products and CMS
Immunizations web pages. And, while some providers may offer the flu vaccine, others can help their
patients locate a vaccine provider within their local community. HealthMap Vaccine Finder is a free,
online service where users can search for locations offering flu vaccines.
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 43 -
November 2012
MM7881 - Expiration of 2012 Therapy Cap Revisions and User-Controlled
Mechanism to Identify Legislative Effective Dates
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – Are you billing correctly for ordered/referred services? Will you be impacted when the
Centers for Medicare & Medicaid Services (CMS) turns on the edits for these services? See the revised
MLN Matters® articles SE1221, SE1011, and MLN fact sheets “Medicare Enrollment Guidelines for
Ordering/Referring Providers” and “The Basics of Medicare Enrollment for Physicians Who Infrequently
Receive Medicare Reimbursement” to learn what you need to do.
Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers who submit
claims to Medicare contractors (carriers, Fiscal Intermediaries (FIs), A/B Medicare Administrative
Contractors (A/B MACs), and/or Regional Home Health Intermediaries (RHHIs)) for therapy services
provided to Medicare beneficiaries.
Provider Action Needed
This article is informational in nature and is based on Change Request (CR) 7881 which implements the statutory
expiration date of certain provisions affecting claims for therapy services, to which the therapy caps apply.
Provisions relating to therapy caps are among a number of legislative changes that may be extended
from year to year or for portions of a year. These changes may currently require a non-recurring CR to
change hard coded edits in Medicare systems. Frequently, these CRs cannot be implemented quickly
enough to meet the changing effective dates. Therefore, CR7881 creates a mechanism that MACs can
use to extend the effective dates of certain policies in urgent situations.
See the Background and Additional Information Sections of this article for further details regarding these changes.
Background
The Middle Class Tax Relief and Job Creation Act of 2012 (MCTRJCA, Section 3005; see http://
www.gpo.gov/fdsys/pkg/PLAW-112publ96/pdf/PLAW-112publ96.pdf on the Internet) extended the
therapy caps exceptions process through December 31, 2012, and made several changes affecting
the processing of claims for therapy services. Previously, therapy services furnished in an outpatient
hospital setting had been exempt from the application of the therapy caps.
However, MCTRJCA required Original Medicare to apply the therapy caps temporarily to the therapy
services furnished in an outpatient hospital on/after October 1, 2012, and on/before December 31, 2012.
Although claims processing requirements associated with the cap are only applicable to hospitals on/
after October 1, 2012, claims paid for hospital outpatient therapy services since January 1, 2012, are
included in calculating the cap beginning October 1, 2012.
MCTRJCA also required a manual review process for those exceptions where the beneficiary therapy
services for the year reach a threshold of $3,700. The separate thresholds triggering manual medical
reviews build upon the separate therapy caps - one for Physical Therapy (PT) and Speech-Language
Pathology (SLP) services combined and one for Occupational Therapy (OT) services. The count of
services to which these thresholds apply began on January 1, 2012.
Unless Congressional action is taken, all of these provisions expire for dates of service after December
31, 2012. Provisions relating to the therapy caps are among a number of legislative changes that may
be extended from year to year, or for portions of a year.
Medicare systems currently lack the flexibility to apply policies to claims based on frequently changing
effective dates. These changes may currently require a non-recurring Change Request (CR) to change
hard coded edits in Medicare systems, and often, these CRs cannot be implemented quickly enough to
meet the changing effective dates.
This newsletter should be shared with all health care practitioners and managerial members of the provider/supplier staff.
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November 2012
- page 44 -
Medicare Bulletin – GR 2012-11
Therefore, CR7881 creates a mechanism that MACs can use to extend the effective dates of certain
policies based in urgent situations. This mechanism will be first used to set the expiration dates of the
MCTRJCA (Section 3005) therapy provisions.
Additional Information
The official instruction, CR7881 issued to your carriers, FIs, A/B MACs, and RHHIs regarding this
change may be viewed at http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/
Downloads/R2537CP.pdf on the CMS website.
If you have any questions, please contact your carriers, FIs, A/B MACs, and RHHIs at their toll-free
number, which may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/MonitoringPrograms/provider-compliance-interactive-map/index.html on the CMS website.
MM7883 - 2013 Annual Update for the Health Professional Shortage Area
(HPSA) Bonus Payments
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash –
NEW product from the Medicare Learning Network® (MLN)
• “Safeguarding Your Medical Identity,” Web-based Training (WBT) Course Continuing education
credits are available to learners who successfully complete this course. See course description for more
information. To access the WBT, go to Web-Based Training, and click on ‘Web-Based Training Courses’
under ‘Related Links’ at the bottom of the web page.
Provider Types Affected
This MLN Matters® Article is intended for physicians, hospitals, and other providers who bill Medicare
contractors (Fiscal Intermediaries (FIs), carriers, or Medicare Administrative Contractors (A/B MACs)) for
services provided to Medicare beneficiaries in Health Professional Shortage Areas (HPSAs).
Provider Action Needed
Change Request (CR) 7883, from which this article is taken, alerts you that the annual HPSA bonus
payment file for 2013 will be made available by the Centers for Medicare & Medicaid Services (CMS) to
your Medicare contractor and will be used for HPSA bonus payments on applicable claims with dates of
service on or after January 1, 2013, through December 31, 2013. These files will be posted tothe internet
on or about December 1, 2012. You should review http://www.cms.gov/Medicare/Medicare-Fee-forService-Payment/HPSAPSAPhysicianBonuses/index.html on the CMS website each year to determine
whether you need to add the AQ modifier to their claim in order to receive the bonus payment, or to see
if the ZIP code area in which you rendered services will automatically receive the HPSA bonus payment.
Note that Medicare contractors will continue to accept the AQ modifier for partially designated HPSA
claims. Please be sure that your staffs are aware of this update.
Background
The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) (Section 413(b))
mandated an annual update to the automated HPSA bonus payment file. CMS creates a new automated
HPSA bonus payment file and provides it to your Medicare contractors each year. Contractors use
this file for the automated bonus payment for claims with dates of service on or after January 1, 2013,
through December 31, 2013. Contractors will continue to accept the AQ modifier for partially designated
HPSA claims.
Additional Information
The official instruction, CR 7883, issued to your FI, carrier, or A/B MAC regarding this change, may be
viewed at http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2526CP.
pdf on the CMS website.
This newsletter should be shared with all health care practitioners and managerial members of the provider/supplier staff.
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Medicare Bulletin – GR 2012-11
- page 45 -
November 2012
You will find annual HPSA files (as they become available) and other important HPSA information at
http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/HPSAPSAPhysicianBonuses/index.
html on the CMS website.
If you have any questions, please contact your FI, carrier or A/B MAC at their toll-free number, which
may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring- Programs/
provider-compliance-interactive-map/index.html on the CMS website.
MM7890 - Ordering and Certifying Documentation - Maintenance
Requirements
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – Looking for the latest new and revised MLN Matters® articles? Subscribe to the MLN
Matters® electronic mailing list! For more information about MLN Matters® and how to register for
this service, go to http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/
MLNProducts/downloads/What_Is_MLNMatters.pdf and start receiving updates immediately!
Provider Types Affected
This MLN Matters® Article is intended for physicians, non-physician practitioners, Durable Medical
Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) suppliers and Home Health Agencies
(HHAs) submitting claims to Medicare contractors (Fiscal Intermediaries (FIs), Regional Home Health
Intermediaries (RHHIs), carriers, and A/B Medicare Administrative Contractors (MACs)) for services to
Medicare beneficiaries.
Provider Action Needed
STOP – Impact to You
This article, based on Change Request (CR) 7890, informs you of instructions to Medicare contractors
regarding the implementation of ordering and certifying documentation and maintenance requirements
found in 42 Code of Federal Regulations (CFR) 424.516(f).
CAUTION – What You Need to Know
A provider or supplier that furnishes covered ordered items of DMEPOS, clinical laboratory, imaging
services, or covered ordered/certified home health services is required to:
• Maintain documentation for 7 years from the date of service, and
• Provide access to that documentation upon the request of the Centers for Medicare & Medicaid
Services (CMS) or a Medicare contractor.
A physician who orders/certifies home health services and a physician or, when permitted, other eligible
professional, who orders items of DMEPOS or clinical laboratory or imaging services is required to:
• Maintain the documentation for 7 years from the date of service, and
• Provide access to that documentation upon the request of CMS or a Medicare contractor.
If the provider, supplier, physician or eligible professional (as applicable) fails to maintain this
documentation or to furnish this documentation upon request, the contractor may revoke the party’s
Medicare billing privileges under 42 CFR 424.535(a)(10).
GO – What You Need to Do
Review the description of documentation to be maintained in the Background section below. Make sure
that your billing staffs are aware of these requirements for documentation.
Background
Under 42 CFR 424.516(f)(1), a provider or supplier that furnishes covered ordered items of DMEPOS,
clinical laboratory, imaging services, or covered ordered/certified home health services is required to
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November 2012
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Medicare Bulletin – GR 2012-11
(1) maintain documentation (see next paragraph) for 7 years from the date of service, and (2) provide
access to that documentation upon the request of CMS or a Medicare contractor.
The documentation to be maintained includes written and electronic documents (including the National
Provider Identifier (NPI) of the physician who ordered/certified the home health services and the NPI of
the physician or, when permitted, other eligible professional who ordered items of DMEPOS or clinical
laboratory or imaging services) relating to written orders and certifications and requests for payments for
items of DMEPOS and clinical laboratory, imaging, and home health services.
In addition, under 424.516(f)(2), a physician who orders/certifies home health services and the physician
or, when permitted, other eligible professional, who orders items of DMEPOS or clinical laboratory or
imaging services is required to maintain the documentation described in the previous paragraph for
7 years from the date of service and to provide access to that documentation pursuant to a CMS or
Medicare contractor request.
If the provider, supplier, physician, or eligible professional (as applicable) fails to maintain this
documentation or to furnish this documentation upon request, the contractor may revoke the party’s
Medicare billing privileges under 42 CFR 424.535(a)(10).
The CMS policy states that, absent a CMS directive to the contrary, the Medicare contractor will
request the documentation described above if it has reason to believe that the provider, supplier,
physician or eligible professional (hereinafter collectively referred to as “provider”) is not maintaining the
documentation in accordance with Section 424.516(f)(1) or (2).
Examples of when a request might be appropriate include, but are not limited to, the following:
• The contractor has detected an unusually high number of denied claims involving the provider, or the
Fraud Prevention System has otherwise generated an alert with respect to the provider.
• The provider has been the subject of a recent Zone Program Integrity Contractor referral.
• The provider maintains an elevated surety bond amount.
If a provider fails to respond to a letter request for documentation within 30 days of the Medicare
contractor’s request, the contractor may revoke the provider’s Medicare billing privileges and impose a
1-year re-enrollment bar.
Additional Information
The official instruction, CR7890 issued to your carrier, FI, or A/B MAC regarding this change may be
viewed http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R431PI.pdf
on the CMS website.
If you have any questions, please contact your carrier, FI, or A/B 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.
MM7897 - National Coverage Determination (NCD) for Transcatheter
Aortic Valve Replacement (TAVR)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – Looking for the latest new and revised MLN Matters® articles? Subscribe to the MLN
Matters® electronic mailing list! For more information about MLN Matters® and how to register for
this service, go to http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/
MLNProducts/downloads/What_Is_MLNMatters.pdf and start receiving updates immediately!
Note: This article was revised on September 25, 2012, to reflect the revised CR7897 issued on
September 24. In this article, the CR release date, transmittal numbers, and the Web addresses
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Medicare Bulletin – GR 2012-11
- page 47 -
November 2012
for accessing the transmittals have been changed. All other information remains the same.
Provider Types Affected
This MLN Matters® Article is intended for physicians and hospitals who provide Transcatheter Aortic
Valve Replacement (TAVR) services to Medicare beneficiaries.
Provider Action Needed
STOP – Impact to You
Effective for claims with dates of service on and after May 1, 2012, Medicare Carriers, Fiscal
Intermediaries (FIs), and Medicare Administrative Contractors (A/B MACs) will reimburse for
Transcatheter Aortic Valve Replacement (TAVR) under Coverage with Evidence Development (CED).
CAUTION – What You Need to Know
Change Request (CR) 7897, from which this article is taken, announces that on May 1, 2012, the
Centers for Medicare and Medicaid Services (CMS) issued a National Coverage Determination (NCD)
covering TAVR under CED and CR7897 details requirements that must be met when claims are
submitted to Medicare for these services.
GO – What You Need to Do
You should make sure that your billing staffs are aware of this decision and its requirements which are
summarized in the Background section below.
Background
Transcatheter Aortic Valve Replacement (TAVR - also known as TAVI or Transcatheter Aortic Valve
Implantation) is a new technology for use in treating certain patients with aortic stenosis. A bioprosthetic
valve is inserted percutaneously using a catheter and implanted in the orifice of the native aortic valve.
CR7879, from which this article is taken announces that on May 1, 2012, the Centers for Medicare
& Medicaid Services (CMS) issued a National Coverage Determination (NCD) covering TAVR under
Coverage with Evidence Development (CED) and only when specific requirements are met.
CED Coverage Conditions with Registry Participation
CMS covers TAVR for the treatment of symptomatic aortic valve stenosis under CED with the following
conditions:
1. It is furnished according to a Food and Drug Administration (FDA)-approved indication and when all
of the following conditions are met:
a. It is furnished with a complete aortic valve and implantation system that has received FDA
Premarket Approval (PMA) for that system’s FDA approved indication;
b. Two cardiac surgeons have independently examined the patient face-to-face and evaluated
the patient’s suitability for open Aortic Valve Replacement (AVR) surgery; and both surgeons
have documented the rationale for their clinical judgment, and this rationale is available to the
heart team;
c. The patient (preoperatively and postoperatively) is under the care of a heart team: a
cohesive, multi-disciplinary, team of medical professionals that embodies collaboration and
dedication across medical specialties to offer optimal patient-centered care;
d. It is furnished in a hospital with the appropriate infrastructure that includes (but is not limited
to):
o On-site heart valve surgery program;
o Cardiac catheterization lab or hybrid operating room/catheterization lab equipped
with a fixed radiographic imaging system with flat-panel fluoroscopy, offering quality
imaging;• Non-invasive imaging such as echocardiography, vascular ultrasound,
Computed Tomography (CT) and Magnetic Resonance (MR);
o Sufficient space, in a sterile environment, to accommodate necessary equipment for
cases with and without complications;
o Post-procedure intensive care facility with personnel experienced in managing
patients who have undergone open-heart valve procedures; and
o Appropriate volume requirements per the applicable qualifications (specifically, for
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November 2012
- page 48 -
Medicare Bulletin – GR 2012-11
hospitals without TAVR experience and for those with experience performing the
procedure), which follow.
2. Required qualifications for the hospitals and heart teams performing the procedure.
Hospitals without TAVR experience must have the following qualifications to begin a TAVR
program:
a. ≥ 50 total AVRs in the previous year prior to TAVR, including ≥ 10 high-risk patients;
b. ≥ Two physicians with cardiac surgery privileges; and
c. ≥ 1000 catheterizations per year, including ≥ 400 Percutaneous Coronary Interventions
(PCIs) per year.
Heart Teams without TAVR experience must include the following to begin a TAVR
program:
a. A cardiovascular surgeon with: 1) ≥ 100 career AVRs including 10 high-risk patients; or, 2) ≥
25 AVRs in one year; or, 3) ≥ 50 AVRs in 2 years; and which include at least 20 AVRs in the
last year prior to TAVR initiation; and,
b. An interventional cardiologist with: 1) Professional experience with 100 structural heart
disease procedures lifetime; or, 2) 30 left-sided structural procedures per year of which 60%
should be Balloon Aortic Valvuloplasty (BAV). Atrial septal defect and patent foramen ovale
closure are not considered left-sided procedures; as well as
c. Additional members of the heart team such as echocardiographers, imaging specialists,
heart failure specialists, cardiac anesthesiologists, intensivists, nurses, and social workers;
and,
d. Device-specific training as required by the manufacturer.
Hospital programs with TAVR experience must have the following qualifications:
a. Maintain ≥ 2 physicians with cardiac surgery privileges;
b. Perform ≥ 20 AVRs per year or ≥ 40 AVRs every 2 years; and
c. Perform ≥ 1000 catheterizations per year, including ≥ 400 Percutaneous Coronary
Interventions (PCIs) per year.
Heart teams with TAVR experience must have the following qualifications:
a. Include a cardiovascular surgeon and an interventional cardiologist whose combined
experience maintains: 1) ≥ 20 TAVR procedures in the prior year, or 2) ≥ 40 TAVR
procedures in the prior 2 years;
b. Include additional members of the heart team such as echocardiographers, imaging
specialists, heart failure specialists, cardiac anesthesiologists, intensivists, nurses, and social
workers; and
c. The interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the intraoperative technical aspects of TAVR.
In addition, the heart team and hospital must be participating in a prospective, national, audited registry.
The complete list of requirements for a qualifying registry can be found in the NCD, which is available at
http://www.cms.hhs.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R147NCD.pdf
on the CMS website. To date, CMS has approved one registry, the Transcatheter Valve Therapy Registry
operated by the Society of Thoracic Surgeons and the American College of Cardiology.
CED Coverage Conditions with Clinical Studies
For indications that are not approved by the FDA, CMS covers TAVR under CED when patients are
enrolled in qualifying clinical studies. The clinical study requirements are available in the NCD, which
is available at http://www.cms.hhs.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/
R147NCD.pdf on the CMS website. Approved studies are listed at http://www.cms.gov/Medicare/
Coverage/Coverage-with-EvidenceDevelopment/Transcatheter-Aortic-Valve-Replacement-TAVR-.html on the CMS website.
Note: TAVR is not covered for patients in whom existing co-morbidities would preclude the expected
benefit from correction of the aortic stenosis.
Coding Requirements -Professional Claims
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Medicare Bulletin – GR 2012-11
- page 49 -
November 2012
For TAVR services furnished on or after May 1, 2012, you should bill with the appropriate temporary
level III Current Procedural Terminology (CPT) code:
• 0256T: Implantation of catheter-delivered prosthetic aortic heart valve; endovascular approach;
• 0257T: Implantation of catheter-delivered prosthetic aortic heart valve; open thoracic approach (eg,
transapical, transventricular);
• 0258T: Transthoracic cardiac exposure (i.e. sternotomy, thoracotomy, subxiphoid) for catheterdelivered aortic valve replacement; without cardiopulmonary bypass; and
• 0259T: Transthoracic cardiac exposure (i.e. sternotomy, thoracotomy, subxiphoid) for catheterdelivered aortic valve replacement; with cardiopulmonary bypass.
Beginning January 1, 2013, CMS anticipates permanent CPT level 1 codes will replace the above 4 codes
for processing TAVR claims, and will issue instructions for the permanent CPT level 1 codes in a future CR.
You should be aware that, on or after May 1, 2012, your carrier or A/B MAC will only reimburse your
professional claims for TAVR services (for CPT codes 0256T, 0257T, 0258T, and 0259T) when used with
Place of Service (POS) code 21 (Inpatient Hospital). They will deny all other POS codes. Should they
deny your claim because of an incorrect POS, they will use the following messages:
This article was prepared as a service to the public and is not intended to grant rights or impose
obligations. This article may contain references or links to statutes, regulations, or other policy materials.
The information provided is only intended to be a general summary. It is not intended to take the place
of either the written law or regulations. We encourage readers to review the specific statutes, regulations
and other interpretive materials for a full and accurate statement of their contents. CPT only copyright
2011 American Medical Association.
• Claim Adjustment Reason Code (CARC) 58: “Treatment was deemed by the payer to have been
rendered in an inappropriate or invalid place of service. Note: Refer to the 835
• Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present;”
• Remittance advice remark code (RARC) N428: “Not covered when performed in this place of
service;” and
• Group Code: Contractual Obligation (CO).
Similarly, Medicare will only pay claim lines with these TAVR CPT codes when billed with modifier 62
(two surgeons/co-surgeons). They will return all others as unprocessable. Should they return such
claims, they will use:
• CARC 4: “The procedure code is inconsistent with the modifier used or a required modifier is
missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service
Payment Information REF), if present;”
• RARC N29: “Missing documentation/orders/notes/summary/report/chart;” and
• Group Code: Contractual Obligation (CO).
Medicare will only pay claim lines for these codes in a clinical trial when billed with modifier Q0 (zero).
For TAVR services, use of modifier Q0 signifies CED participation (qualified registry or qualified clinical
study).They will return such claims billed without modifier Q0 as unprocessable using:
• CARC 4: “The procedure code is inconsistent with the modifier used or a required modifier is
missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service
Payment Information REF), if present; ”
• RACR N29: “Missing documentation/orders/notes/summary/report/chart,” and
• Group Code: Contractual Obligation (CO).
Medicare will only pay claims for these codes in a clinical trial when billed with International
Classification of Diseases, Ninth Revision Clinical Modification (ICD-9-CM) secondary diagnosis code
V70.7 (routine general medical examination at a health care facility) (ICD-10 = Z00.6 -- encounter for
examination for normal comparison and control in clinical research program). For TAVR services, use of
V70.7 signifies CED participation (qualified registry or qualified clinical study).They will return claim lines
billed without secondary diagnosis code V70.7 as unprocessable, using:
• CARC 16: “Claim/service lacks information which is needed for adjudication. At least one Remark
Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or
Remittance Advice Remark Code that is not an ALERT);”
• RARC N29: “Missing documentation/orders/notes/summary/report/chart;” and
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November 2012
- page 50 -
Medicare Bulletin – GR 2012-11
•
Group Code Contractual Obligation (CO).
Coding Requirements - Inpatient Hospital Claims
Hospitals should bill for TAVR services on an 11X Type of Bill (TOB), effective for discharges on or
after May 1, 2012. Your FI or A/B MAC will reimburse such claims containing ICD-9 procedure codes
35.05 (Endovascular replacement of aortic valve) or 35.06 (Transapical replacement of aortic valve)
only when billed with secondary diagnosis code V70.7 (Examination of participant in clinical trial) and
condition code 30 (qualifying clinical trial). For TAVR services, use of the latter two codes signifies CED
participation (qualified registry or qualified clinical study).
Claims from hospitals without those latter two codes will be rejected using:
• CARC: 50: “These are non-covered services because this is not deemed a “medical necessity” by
the payer;”
• 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 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
• Group Code: Contractual Obligation (CO).
The following are the ICD-10 procedure codes applicable for TAVR:
TAVR ICD-9 Procedure Codes
TAVR ICD-10 Procedure Codes
35.05
02RF37Z
02RF38Z
02RF3JZ
02RF3KZ
02RF37H
02RF38H
02RF3JH
02RF3KH
35.06
Additional Information
CR7897 was issued to your Medicare contractor in two transmittals. The first transmittal modifies the
“Medicare National Coverage Determinations Manual” and it is available at http://www.cms.hhs.gov/
Regulations-and- Guidance/Guidance/Transmittals/Downloads/R147NCD.pdf on the CMS website.
The second transmittal updates the “Medicare Claims Processing Manual” and it is available at http://
www.cms.hhs.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2552CP.pdf on the
CMS website.
If you have any questions, please contact your carrier, FI, or A/B 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.
MM8021 - Healthcare Provider Taxonomy Codes (HPTC) Update, October
2012
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – When billing Medicare, Home Health Agencies (HHAs) must use the individual National
Provider Identifier (NPI) of the physician who orders/refers services, not the NPI of the physician’s group
practice. If an HHA asks for your NPI, be sure to provide your individual NPI. Don’t know your individual
NPI? You may verify your NPI on the NPI Registry on the CMS website.
Provider Types Affected
This MLN Matters® Article is intended for providers submitting claims to Medicare contractors (carriers
This newsletter should be shared with all health care practitioners and managerial members of the provider/supplier staff.
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Medicare Bulletin – GR 2012-11
- page 51 -
November 2012
and Part B Medicare Administrative Contractors (B MACs)) for services to Medicare beneficiaries.
What You Need to Know
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 set is available for view or for download from the Washington
Publishing Company (WPC) Web site at http://www.wpc-edi.com/codes on the Internet.
CR 8021 implements the NUCC HPTC code set that is effective on October 1, 2012. The changes for
October consist of the addition of two new HPTCs, both under the Individual Section, for Dental Provider
types:
• 125J00000X Dental Therapist Classification; and
• 125K00000X Advanced Practice Dental Therapist Classification.
There are no other changes to the October 2012 code set.
Medicare does not use HPTCs to adjudicate its claims. It would not expect to see these codes on a
Medicare claim. However, currently, it validates any HPTC that a provider happens to supply against the
NUCC HPTC code set.
Additional Information
The official instruction, CR 8021 issued to your carrier or B MAC regarding this change may be viewed
at http://www.cms.hhs.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2534CP.pdf
on the CMS website.
If you have any questions, please contact your carrier or B MAC at their toll-free number, which may
be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring- Programs/providercompliance-interactive-map/index.html on the CMS website.
MM8032 - October 2012 Update of the Ambulatory Surgical Center
Payment System (ASC)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – The Medicare Learning Network® (MLN) Product Ordering System was recently
upgraded to add new enhancements. You can now view an image of the product and access its
downloadable version, if available, before placing your order. To access a new or revised product
available for order in hard copy format, go to MLN Products and click on “MLN Product Ordering Page”
under “Related Links” at the bottom of the web page.
Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims
to Medicare contractors (carriers and A/B Medicare Administrative Contractors (MACs)) for services to
Medicare beneficiaries.
Provider Action Needed
This article is based on Change Request (CR) 8032 which informs Medicare contractors about the
changes to and billing instructions for various payment policies implemented in the October 2012
Ambulatory Surgical Center (ASC) update. CR8032 applies to Chapter 14, Section 10 of the “Medicare
Claims Processing Manual.” Make sure that your billing staffs are aware of these changes.
Background
The key changes in CR8032 are as follows:
Drugs and Biologicals with Payments Based on Average Sales Price (ASP) Effective October 1, 2012
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November 2012
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Medicare Bulletin – GR 2012-11
Payment for separately payable drugs and biologicals based on the ASPs are updated on a quarterly
basis as later quarter ASP submissions become available. In cases where adjustments to payment
rates are necessary based on the most recent ASP submissions, the Centers for Medicare & Medicaid
Services (CMS) incorporates changes to the payment rates in the October 2012 release of the ASC
DRUG file. The updated payment rates, effective October 1, 2012, will be included in the October
2012 update of the ASC Payment system Addendum BB, which will be posted at http://www.cms.gov/
Medicare/Medicare-Feefor-Service-Payment/ASCPayment/11_Addenda_Updates.html CMS website.
New HCPCS Codes for Drugs and Biologicals Separately Payable under the ASC Payment System
Effective October 1, 2012.
Two drugs and biologicals have been granted ASC payment status effective October 1, 2012. These
items, along with their descriptors and payment indicators, are identified in Table 1.
Table 1 – New Separately Payable Drugs and Biologicals Effective October 1, 2012
HCPCS Code
Long Descriptor
Short Descriptor
ASC PI
C9292
Injection, pertuzumab, 10 mg
Injection, pertuzumab
K2
C9293
Injection, , glucarpidase, 10 units
Injection, , glucarpidase
K2
Updated Payment Rates for Certain Drugs and Biologicals HCPCS Codes Effective July 1, 2012
through September 30, 2012
The payment rates for three HCPCS codes were incorrect in the July 2012 ASC Drug File. The corrected
payment rates are listed in Table 2 and have been included in the revised July 2012 ASC Drug File,
effective for services furnished on July 1, 2012, through implementation of the October 2012 update.
Suppliers who have received an incorrect payment for dates of service from July 1, 2012, through
September 30, 2012, may request contractor adjustment of the previously processed claims.
Table 2 – Updated Payment Rates for Certain Drugs and Biologicals HCPCS Codes Effective July 1,
2012, through September 30, 2012
HCPCS Code Short Descriptor
ASC PI
Corrected Payment Rate
C9368
Grafix core
K2
$160.66
C9369
Grafix prime
K2
$51.84
Q2045
Human fibrinogen conc inj
K2
$0.89
Additional Information
The official instruction, CR8032 issued to your carrier and A/B MAC regarding this change may be
viewed at http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/
R2525CP.pdf on the CMS website.
If you have any questions, please contact your carrier or A/B MAC at their toll-free number, which may
be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring- Programs/providercompliance-interactive-map/index.html on the CMS website.
To review MM7854, the July 2012 Update to the ASC Payment System, you may go to https://www.
cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/
MM7854.pdf on the CMS website.
To review the Ambulatory Surgical Center Fee Schedule Fact Sheet you may go to https://www.
cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/
AmbSurgCtrFeepymtfctsht508-09.pdf on the CMS website.
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Medicare Bulletin – GR 2012-11
- page 53 -
November 2012
MM8036 - Manual Medical Review of Therapy Services
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – Want to stay connected about the latest new and revised Medicare Learning Network®
(MLN) products and services? Subscribe to the MLN Educational Products electronic mailing list! For
more information about the MLN and how to register for this service, visit http://www.cms.gov/Outreachand-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads//MLNProducts_listserv.pdf
and start receiving updates immediately!
Note: This article was revised on September 28, 2012, to reflect the revised CR8036 issued on
September 25. In the article, the CR release date, transmittal number, and the Web address for
accessing the CR were revised. All other information remains the same.
Provider Types Affected
This MLN Matters® Article is intended for occupational therapists, speech language therapists, physical
therapists, physicians, other practitioners, in certain provider settings submitting claims to Medicare
contractors (Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs), carriers, and A/B
Medicare Administrative Contractors (MACs)) for therapy services to Medicare beneficiaries.
Provider Action Needed
STOP – Impact to You
All requests for therapy services above $3,700 provided by speech language therapists, physical therapists,
occupational therapists, and physicians must be approved in advance. This includes services in these
settings: Part B Skilled Nursing Facilities (SNFs), Comprehensive Outpatient Rehabilitation Facilities (CORFs),
rehabilitation agencies (Outpatient Rehabilitation Facilities (ORFs), private practices, home health agencies
(TOB 34X), and hospital outpatient departments.
CAUTION – What You Need to Know
You must send a request for approval to the MAC or legacy contractor, i.e., FI, RHHI, or carrier, in
advance of providing service. There are no automatic exceptions. Your MAC or legacy contractor will
provide a fax number and mailing address where requests for pre-claim review can be submitted.
GO – What You Need to Do
Please read the Background and the Additional Information sections for details. Make sure that your
billing staffs are aware of these changes.
Background
The Balanced Budget Act of 1997 enacted financial limitations on outpatient physical therapy,
occupational therapy, and speech-language pathology services in all settings except outpatient hospital.
Exceptions to the limits were enacted by the Deficit Reduction Act, and have been extended by
legislation several times.
Section 3005 of the Middle Class Tax Relief and Job Creation Act of 2012 (MCTRJCA) extended the
therapy caps exceptions process through December 31, 2012, and made several changes affecting the
processing of claims for therapy services. Suppliers and providers will continue to use the KX modifier
to request an exception to the therapy cap on claims that are over the 2012 cap amounts -- $1,880 for
occupational therapy services and $1,880 for the combined services for physical therapy and speechlanguage pathology. Use of the KX modifier indicates that the services are reasonable and necessary
and that there is documentation of medical necessity in the patient’s medical record.
MCTRJCA also established a requirement for manual medical review of claims over $3,700. In midSeptember 2012, CMS will mail a letter to beneficiaries who have received therapy services in Calendar
Year (CY) 2012 over $1,700. The CMS letter will inform them of the $1,880 therapy cap, the exceptions
process and that, if services over the cap do not qualify for the exception as medically necessary, that
they will be responsible for the charges.
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November 2012
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Medicare Bulletin – GR 2012-11
Request for Approval and Review Process
You must send a request for approval to the MAC or legacy contractor in advance of providing service.
The MAC or legacy contractor will provide a mailing address and may provide a fax number where
requests for pre-claim review can be submitted. Pre-claim reviews will not be reviewed any sooner than
15 days before the start of each Phase for providers within that phase.
The request must contain the following information:
• Beneficiary Last Name;
• Beneficiary First Name;
• Beneficiary Middle Initial;
• Beneficiary Medicare Claim Number (HICN);
• Beneficiary Date of Birth;
• Beneficiary Address and Telephone Number;
• Name of Provider Certifying Plan of Care;
• Address of Provider Certifying Plan of Care;
• Telephone and Fax Number of Provider Certifying Plan of Care;
• Provider Number (National Provider Identifier (NPI)) of Physician/NPP Certifying Plan of Care;
• Name of Performing Provider;
• Address of Performing Provider;
• Performing Provider Number (NPI);
• Telephone and Fax Number of Performing Provider;
• Number of treatment days requested;
• Expected date range of services; and
• Date of Submission.
A cover/transmittal sheet containing the following information and documentation must be sent:
• Cover sheet;
• Justification;
• Evaluation or reevaluation(s) for Plan(s) of Care;
• Certification(s) of the plan(s) of care, where available;
• Objectives and measurable goals and any other documentation requirements of the Local Coverage
Determinations (LCDs);
• Progress reports;
• Treatment notes;
• Any orders, if applicable, for the additional therapy services; and
• Any additional information requested by the Medicare contractor. You may request preapproval of up
to 20 treatment days of services.
The contractor will make a decision and inform (by telephone, fax, or letter (if by letter, the letter must
be postmarked by the 10th day)) the provider and beneficiary within 10 business days of receipt of all
requested documentation. If the contractor cannot make a decision with 10 days, the therapy will be
considered approved. The letter will indicate that the approval was made because of time constraints
and not on the information provided to the contractor.
The contractors will use the coverage and payment policy requirements contained in the “Medicare
Benefit Policy Manual,” Chapter 15, Section 220 (available at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/bp102c15.pdf) and any applicable local coverage decision
policies when making decisions as to whether a service will be preapproved.
If the decision is non-affirmative, the letter communicating the decision will be detailed. If the request
was non-approved, you may submit additional requests and provide additional information for
consideration.
Contractors shall develop a methodology to identify preapproval requests that have been submitted for
pre-approval and match them to submitted claims for specific periods of time. Contractor shall inform the
provider of the tracking mechanism being used for preapproval requests (either approved or denied) and
instructions on how to submit the claim. Contractors shall use the tracking mechanism to identify that the
claims were preapproved or non-approved.
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Medicare Bulletin – GR 2012-11
- page 55 -
November 2012
Pre-authorization itself is not a guarantee of payment. Retrospective reviews of claims receiving preapproval may still be performed. Any claims submitted without the pre-approval notice from providers in
the respective Phase will be subject to pre-payment review. If you or the beneficiary wishes to appeal a
decision, you may provide the service.The MAC or legacy contractor will, upon receipt of the claim, deny
the claim. Then you or the beneficiary may file an appeal.
CMS will notify beneficiaries when they reach the $1,700 level by September 1, 2012 by letter.
Phased Implementation
Implementation will occur in three phases. The requirement for pre-approval of all therapy services shall
apply to specifically identified providers on the effective date determined by CMS for the phase. CMS
will publish the list of providers (by NPI number only) and the Phase to which they are assigned. If CMS
publishes a list and a provider is not on the list, then that provider shall be deemed to be in Phase III.
Contractors will post the list of NPI numbers CMS provides on their websites.
CMS will publish a list of providers and the respective phases in which they are placed. In addition, CMS
shall send a mailing to every provider subject to the therapy manual medical review threshold notifying
them of the respective phase they have been placed into. CMS is implementing this process in phases in
order to ensure a smooth transition to the new process. Effective dates for the phases are:
• Phase I: October 1, 2012 – December 31, 2012
• Phase II: November 1, 2012 – December 31, 2012
• Phase III: December 1, 2012 – December 31, 2012
Claims suspended because of the cap will be automatically approved unless the provider is being
reviewed in Phase I, Phase II, or Phase III.
Contractors will notify providers by posting on their website when they have stopped doing the reviews.
Out of Sequence Claim s – Post Pay Review Not Required
Medicare has a 12 months claims filing limitation. Therefore, claims may be received and processed in
a sequence different than that of the services provided. When this occurs, a contractor is not required to
conduct post payment review on claims that would have been subjected to the $3,700 manual medical
review threshold had the claims been received and processed in the order provided.
For example, a beneficiary was in a SNF and exhausted their SNF benefit days under Part A. The
beneficiary continued to receive therapy services under Part B totaling $3,600 (all dates of service before
10/1/2012). The beneficiary was then discharged from the SNF and received therapy services from an
independently practicing PT totaling $1,800. The independent PT billed in November 2012 for services
provided after 10/1/2012. The MAC received the claims and processed them. After these claims were
processed the MAC received the SNF Part B claims totaling $3,600 and processed them. Had these
claims been received in advance of the independent PT services, the independent PT would have been
required to have the services approved in advance. In circumstances such as this example, the contractor
is not required to perform post payment review on the $1,800 provided by the independent therapist.
Additional Information
The official instruction, CR8036, issued to your carrier, FI, or A/B MAC regarding this change may be
viewed at http://www.cms.hhs.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/
R1124OTN.pdf on the CMS website.
If you have any questions, please contact your carrier, FI, or A/B 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.
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 www.cgsmedicare.com.
November 2012
- page 56 -
Medicare Bulletin – GR 2012-11
MM8037 - 2013 Annual Update of Healthcare Common Procedure Coding
System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated
Billing (CB) Update
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash –
REVISED products from the Medicare Learning Network® (MLN)
• “The Basics of Internet-based Provider Enrollment, Chain and Ownership System (PECOS) for
Provider and Supplier Organizations,” Fact Sheet, ICN 903767, Downloadable only
2013 Annual Update of Healthcare Common Procedure Coding System (HCPCS)
Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update
Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to
Medicare contractors (carriers, Durable Medical Equipment Medicare Administrative Contractors (DME
MACs), Fiscal Intermediaries (FIs), and/or A/B Medicare Administrative Contractors (A/B MACs)) for
services provided to Medicare beneficiaries who are in a Part A covered Skilled Nursing Facility (SNF) stay.
Provider Action Needed
STOP – Impact to You
If you provide services to Medicare beneficiaries in a Part A covered SNF stay, information in CR8037
could impact your payments.
CAUTION – What You Need to Know
This article is based on Change Request (CR) 8037 which provides the 2013 annual update of Healthcare
Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility Consolidated Billing (SNF
CB) and how the updates affect edits in Medicare claims processing systems.
By the first week in December 2012:
• Physicians and other providers/suppliers who bill carriers, DME MACs, or A/B MACs are advised
that new code files (entitled 2013 Carrier/A/B MAC Update) will be posted at http://www.cms.
gov/Medicare/Billing/SNFConsolidatedBilling/index.html on the Centers for Medicare & Medicaid
Services (CMS) website; and
• Providers who bill Fiscal Intermediaries or A/B MACs are advised that new Excel and PDF
files (entitled 2013 FI/A/B MAC Update) will be posted to http://www.cms.gov/Medicare/Billing/
SNFConsolidatedBilling/index.html on the CMS website.
GO – What You Need to Do
It is important and necessary for you to read the “General Explanation of the Major Categories” PDF
file located at the bottom of each year’s FI/A/B MAC update in order to understand the Major Categories,
including additional exclusions not driven by HCPCS codes.
Background
Medicare’s claims processing systems currently have edits in place for claims received for beneficiaries
in a Part A covered SNF stay, as well as for beneficiaries in a non-covered stay. Changes to HCPCS
codes and Medicare Physician Fee Schedule designations are used to revise these edits to allow
carriers, A/B MACs, DME MACs, and FIs to make appropriate payments in accordance with policy for
Skilled Nursing Facility Consolidated Billing (SNF CB) contained in the “Medicare Claims Processing
Manual,” Chapter 6 (SNF Inpatient Part A Billing and SNF Consolidated Billing), Section 110.4.1 (Annual
Update Process) for carriers and A/B MACs, and Section 20.6 (SNF CB Annual Update Process for
Fiscal Intermediaries) for FI and A/B MACs. You can find this manual at http://www.cms.gov/Regulationsand- Guidance/Guidance/Manuals/downloads/clm104c06.pdf on the CMS website.
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 57 -
November 2012
Please note that these edits only allow services that are excluded from CB to be separately paid by
Medicare contractors.
Additional Information
The official instruction, CR8037 issued to your carrier, FI, A/B MAC, or DME MAC regarding this change
may be viewed http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/
R2542CP.pdf on the CMS website.
If you have any questions, please contact your carrier, FI, A/B MAC, or DME MAC at their toll-free
number, which may be found at http://www.cms.gov/Research-Statistics-Data-and- Systems/MonitoringPrograms/provider-compliance-interactive-map/index.html on the CMS website.
MM8045 - Claim Status Category and Claim Status Codes Update
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – The Medicare Learning Network® (MLN) Product Ordering System was recently
upgraded to add new enhancements. You can now view an image of the product and access its
downloadable version, if available, before placing your order. To access a new or revised product
available for order in hard copy format, go to MLN Products and click on “MLN Product Ordering Page”
under “Related Links” at the bottom of the web page.
Provider Types Affected
This MLN Matters® Article is intended for all physicians, providers, and suppliers submitting claims
to Medicare contractors (Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs),
carriers, A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment (DME)
MACs) for Medicare beneficiaries are affected.
Provider Action Needed
This article, based on Change request (CR) 8045, explains that Claim Status and Claim Status Category
Codes for use by Medicare contractors with the Health Care Claim Status Request and Response ASC
X12N 276/277, Health Care Claim Acknowledgement ASC X12N 277 are updated three times per year
at the national Code Maintenance Committee meetings.
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/ or http://www.wpc-edi.com/reference/codelists/healthcare/claimstatus-codes/ on the Internet. Make sure that your billing staffs are aware of these updates.
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. All code changes approved during the June 2012 committee
meeting will be posted on the Internet on or about July 1, 2012.
Additional Information
The official instruction, CR8045, issued to your Medicare contractor regarding this change, may be
viewed at http://www.cms.hhs.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/
R2547CP.pdf on the CMS website.
If you have any questions, please contact your FI, carrier, RHHI, A/B MAC, or DME MAC at their toll- free
number, which may be found at http://www.cms.gov/Research-Statistics-Data-and- Systems/MonitoringPrograms/provider-compliance-interactive-map/index.html on the CMS website.
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 www.cgsmedicare.com.
November 2012
- page 58 -
Medicare Bulletin – GR 2012-11
News Flash - Influenza Season is Around the Corner - As your patients age, their immune systems may
weaken. This weakening can make seniors more susceptible to complications from seasonal influenza
(flu). Now is the perfect time to remind your patients that seasonal influenza vaccination is the best defense
against the flu. Medicare provides coverage for one flu vaccine and its administration per influenza season
for seniors and other Medicare beneficiaries with no co-pay or deductible. Talk with your Medicare patients
about their risk for getting the flu and start protecting your patients as soon as your 2012-2013 seasonal flu
vaccine arrives. Also, don’t forget to immunize yourself and your staff. Know what to do about the flu.
Remember – Influenza vaccine plus its administration is a covered Part B benefit. Influenza vaccine is
NOT a Part D covered drug. CMS will provide information and a link to the 2012-2013 Influenza Vaccine
prices when they are available.
For more information on coverage and billing of the flu vaccine and its administration, please visit
the CMS Medicare Learning Network® Preventive Services Educational Products and CMS
Immunizations web pages. While some providers may offer the flu vaccine, others can help their
patients locate a vaccine provider within their local community. HealthMap Vaccine Finder is a free,
online service where users can search for locations offering flu vaccines.
MM8047 - Influenza Vaccine Payment Allowances - Annual Update for
2012-2013 Season
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash –
NEW product from the Medicare Learning Network® (MLN)
“Communicating With Your Medicare Patients”, Fact Sheet, ICN 908063, Downloadable
Note: This article was revised on October 4, 2012, to reflect a revised Change Request (CR) 8047 that
was released on October 3, 2012. The revised CR changed the implementation date to “No later than
December 28, 2012.” The Transmittal Number, CR date and the web link to the CR was also changed.
All other information remains unchanged.
Provider Types Affected
This MLN Matters® Article is intended for physicians and providers submitting claims to Medicare
contractors (carriers, Fiscal Intermediaries (FIs), and Part A/B Medicare Administrative Contractors (A/B
MACs)) for influenza vaccines provided to Medicare beneficiaries.
Provider Action Needed
The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 8047 in order to update
payment allowances, effective August 1, 2012, for seasonal influenza virus vaccines when payment is based on
95 percent of the Average Wholesale Price (AWP). Be sure your billing staffs are aware of this update.
Background
CR8047 provides payment allowances for the following seasonal influenza virus vaccine codes when
payment is based on 95 percent of the AWP (except for when payment is based on reasonable cost
where the vaccine is furnished in a hospital outpatient department, a Rural Health Clinic, or a Federally
Qualified Health Center):
• Current Procedural Terminology (CPT) codes 90654, 90655, 90656, 90657, 90660, and 90662; and
• Healthcare Common Procedure Coding System (HCPCS) codes Q2034, Q2035, Q2036, Q2037,
and Q2038.
Effective for dates of service on or after August 1, 2012, the Medicare Part B payment allowance for:
• CPT 90655 is $16.456
• CPT 90656 is $12.398
• CPT 90657 is $6.023
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 59 -
November 2012
•
•
•
•
HCPCS Q2035 (Afluria®) is $11.543
HCPCS Q2036 (Flulaval®) is $9.833
HCPCS Q2037 (Fluvirin®) is $14.051
HCPCS Q2038 (Fluzone®) is $12.046
Note: The Medicare Part B payment allowance for HCPCS Q2034 (Agriflu®) and HCPCS Q2039 (Flu
Vaccine Adult - Not Otherwise Classified) will be determined by the local claims processing contractor.
Payment for the following may be made if the local claims processing contractor determines its use is
medically reasonable and necessary for the beneficiary:
• CPT 90654 (Flu vaccine, Intradermal, Preservative free (Fluzone ID®));
• CPT 90660 (FluMist®, a nasal influenza vaccine); or
• CPT 90662 (Fluzone High-Dose®).
Effective for dates of service on or after August 1, 2012, when payment is based on 95 percent of the
AWP, the Medicare Part B payment allowance for:
• CPT 90654 is $18.981
• CPT 90660 is $23.456
• CPT 90662 is $30.923
The payment allowances for pneumococcal vaccines are based on 95 percent of the AWP and are
updated on a quarterly basis via the Quarterly Average Sales Price (ASP) Drug Pricing Files.
Note: Annual Part B deductible and coinsurance amounts do not apply. All physicians, non-physician
practitioners and suppliers who administer the influenza virus vaccination and the pneumococcal
vaccination must take assignment on the claim for the vaccine.
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.
Additional Information
The official instruction, CR8047, issued to your Medicare contractor (carrier, (FI), and A/B MAC)
regarding this change, may be viewed at http://www.cms.hhs.gov/Regulations-and- Guidance/Guidance/
Transmittals/Downloads/R2562CP.pdf on the CMS website.
If you have any questions, please contact your carrier, (FI), or A/B 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.
News Flash - Vaccination is the Best Protection Against the Flu – Each office visit is an opportunity
to check your patients’ seasonal influenza (flu) and pneumonia immunization status and to start protecting
your patients as soon as your 2012–2013 seasonal flu vaccine arrives. Ninety percent of flu-related deaths
and more than half of flu-related hospitalizations occur in people age 65 and older. Seniors also have
an increased risk of getting pneumonia, a complication of the flu. Remind your patients that seasonal flu
vaccinations and a pneumococcal vaccination are recommended for optimal protection.
Medicare provides coverage for one seasonal influenza virus vaccine per influenza season for all
Medicare beneficiaries. Medicare generally provides coverage of pneumococcal vaccination and
its administration once in a lifetime for all Medicare beneficiaries. Medicare may provide coverage
of additional pneumococcal vaccinations based on risk or uncertainty of beneficiary pneumococcal
vaccination status. Medicare provides coverage for these vaccines and their administration with no copay or deductible. Also, don’t forget to immunize yourself and your staff. Know what to do about the flu.
Remember – Influenza vaccine plus its administration is a covered Part B benefit. Influenza vaccine is
NOT a Part D covered drug. CMS will provide information and a link to the 2012-2013 Influenza Vaccine
prices when they are available. For more information on coverage and billing of the flu vaccine and its
administration, please visit the CMS Medicare Learning Network® Preventive Services Educational
Products and CMS Immunizations web pages. While some providers may offer the flu vaccine,
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 www.cgsmedicare.com.
November 2012
- page 60 -
Medicare Bulletin – GR 2012-11
others can help their patients locate a vaccine provider within their local community. HealthMap Vaccine
Finder is a free, online service where users can search for locations offering flu vaccines.
MM8049 - Annual Clotting Factor Furnishing Fee Update 2013
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – The ICD-10-related implementation date is now October 1, 2014, as announced in final
rule CMS-0040-F issued on August 24, 2012. This final rule is available at http://www.cms.gov/Medicare/
Coding/ICD10/Statute_Regulations.html on the Centers for Medicare & Medicaid Services (CMS) website.
The switch to the new code set will affect every aspect of how your organization provides care, but with
adequate planning and preparation, you can ensure a smooth transition for your practice. Keep Up to Date
on ICD-10. Please visit the ICD-10 website for the latest news and resources to help you prepare.
Provider Types Affected
This MLN Matters® Article is intended for physicians and other providers billing Medicare Carriers, Fiscal
Intermediaries (FIs), Part A/B Medicare Administrative Contractors (MACs), or Regional Home Health
Intermediaries (RHHIs) for services related to the administration of clotting factors to Medicare beneficiaries.
Provider Action Needed
This article is based on Change Request (CR) 8049 and announces that for Calendar Year 2013, the
clotting factor furnishing fee of $0.188 per unit is included in the published payment limit for clotting factors.
For dates of service in 2013, the clotting factor furnishing fee of $0.188 per unit is added to the payment
when no payment limit for the clotting factor is included in the Average Sales Price (ASP) or Not Otherwise
Classified (NOC) drug pricing files. Please be sure your billing staffs are aware of this fee update.
Background
Section 1842(o)(5)(C) of the Social Security Act (added by the Medicare Modernization Act Section 303(e)(1))
requires, beginning January 1, 2005, that a clotting factor furnishing fee be paid separately if you furnish clotting
factor; unless the costs associated with furnishing the clotting factor are paid through another payment system.
The Centers for Medicare & Medicaid Services (CMS) includes the clotting factor furnishing fee in the published
national payment limits for clotting factor billing codes. When the national payment limit for a clotting factor is not
included on the ASP Medicare Part B Drug Pricing File, or the NOC Pricing File; your carrier, FI, RHHI, or A/B
MAC must make payment for the clotting factor as well as make payment for the furnishing fee.
The clotting factor furnishing fees applicable for dates of service in each Calendar Year (CY) are listed below:
Clotting Factor Furnishing Fee
CY 2005
$0.140 per unit
CY 2006
$0.146 per unit
CY 2007
$0.152 per unit
CY 2008
$0.158 per unit
CY 2009
$0.164 per unit
CY 2010
$0.170 per unit
CY 2011
$0.176 per unit
CY 2012
$0.181 per unit
CY2013
$0.188 per unit
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 61 -
November 2012
Additional Information
The official instruction, CR 8049 issued to your Medicare Carrier, FI, RHHI, or A/B MAC regarding
this change may be viewed http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/
Downloads/R2554CP.pdf on the CMS website.
If you have any questions, please contact your carrier, FI, RHHI, or A/B MAC at their toll-free number,
which may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/MonitoringPrograms/provider-compliance-interactive-map/index.html on the CMS website.
News Flash - As your patients age, their immune systems may weaken. This weakening can make
seniors more susceptible to complications from seasonal influenza (flu). Now is the perfect time to
remind your patients that seasonal influenza vaccination is the best defense against the flu. Medicare
provides coverage for one flu vaccine and its administration per influenza season for seniors and other
Medicare beneficiaries with no co-pay or deductible. Talk with your Medicare patients about their risk for
getting the flu and start protecting your patients as soon as your 2012-2013 seasonal flu vaccine arrives.
Also, don’t forget to immunize yourself and your staff. Know what to do about the flu.
Remember – The influenza vaccine plus its administration is a covered Part B benefit. The influenza
vaccine is NOT a Part D covered drug. CMS will provide information and a link to the 2012-2013
Influenza Vaccine prices when they are available.
For more information on coverage and billing of the flu vaccine and its administration, please visit
the CMS Medicare Learning Network® Preventive Services Educational Products and CMS
Immunizations web pages. While some providers may offer the flu vaccine, others can help their
patients locate a vaccine provider within their local community. HealthMap Vaccine Finder is a free,
online service where users can search for locations offering flu vaccines.
MM8054 - New Waived Tests
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – On August 24, Health and Human Services (HHS) Secretary Kathleen Sebelius announced
a final rule that will save time and money for physicians and other health care providers by establishing a
unique Health Plan Identifier (HPID). The rule is one of a series of changes required by the Affordable Care
Act to cut red tape in the health care system and will save up to $6 billion over ten years. Currently, when
a health care provider bills a health plan, that plan may use a wide range of different identifiers that do not
have a standard format. As a result, health care providers run into a number of time-consuming problems,
such as misrouting of transactions, rejection of transactions due to insurance identification errors, and
difficulty determining patient eligibility. The change announced on August 24 will greatly simplify these
processes. For more information, see the Fact Sheet related to this final rule.
Provider Types Affected
This MLN Matters® Article is intended for clinical diagnostic laboratories submitting claims to Medicare
contractors (carriers and A/B Medicare Administrative Contractors (A/B MACs)) for services to
Medicare beneficiaries.
Provider Action Needed
STOP – Impact to You
This article is based on Change Request (CR) 8054 which informs Medicare contractors that there are
36 newly added waived tests. In addition, the new CPT code, 86803QW, was assigned for the hepatitis C
antibody test performed using the OraQuick HCV Rapid Antibody Test and OraQuick Visual Reference Panel.
CAUTION – What You Need to Know
CLIA requires that for each test it performs, a laboratory facility must be appropriately certified. The
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 www.cgsmedicare.com.
November 2012
- page 62 -
Medicare Bulletin – GR 2012-11
CPT codes that the Centers for Medicare & Medicaid Services (CMS) considers to be laboratory tests
under CLIA (and thus requiring certification) change each year. CR 8054, from which this article is taken,
informs carriers and MACs about the latest new CPT codes that are subject to CLIA edits.
GO – What You Need to Do
Make sure that your billing staffs are aware of these changes. See the Background and Additional
Information Sections of this article for further details regarding these changes.
Background
The Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations require a facility to
be appropriately certified for each test performed. To ensure that Medicare & Medicaid only pay for
laboratory tests categorized as waived complexity under CLIA in facilities with a CLIA certificate of
waiver, laboratory claims are currently edited at the CLIA certificate level. If you do not have a valid,
current Clinical Laboratory Improvement Amendments of 1998 (CLIA) certificate and submit a claim to
your Medicare Carrier or A/B MAC for a Current Procedural Terminology (CPT) code that is considered
to be a laboratory test requiring a CLIA certificate, your Medicare payment may be impacted.
Listed below are the latest tests approved by the Food and Drug Administration (FDA) as waived tests
under CLIA. The CPT codes for the following new tests must have the modifier QW to be recognized as
a waived test. (However, the tests mentioned on the first page of the list attached to CR8054 (i.e., CPT
codes 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651) do not require a QW
modifier to be recognized as a waived test.)
CPT Code
Effective Date
Description
86803QW
November 29, 2011
OraQuick HCV Rapid Antibody Test and OraQuick Visual
Reference Panel
87809QW
April 24, 2012
AdenoPlus (human eye fluid)
81003QW
May 8, 2012
McKesson 120 Urine Analyzer
81003QW
May 11, 2012
Acon Laboratories, Inc. Foresight U120 Urine Analyzer
86294QW
May 15, 2012
LifeSign Status BTA
82055QW
May 25, 2012
Alere Toxicology Services, iScreen Saliva Alcohol Test Strip
82055QW
May 25, 2012
American Screening Corporation, Reveal
Saliva Alcohol Test Strip
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug
Test Cassette
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug
Test Cassette Amp/Amphetamine
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug
Test Secobarbital Cassette
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug
Test Oxazepam Cassette
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug
Test Strip
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 63 -
November 2012
CPT Code
Effective Date
Description
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug
Test Strip Amp/Amphetamine
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug
Test Secobarbital Strip
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug
Test Oxazepam Strip
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug
Test (COC/Cocaine){Cup format}
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug
Test (MET/Methamphetamine){Cup format}
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug Test (MDMA/
Methylenedioxymethamphetamine) {C up format}
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug Test (MOP/Morphine)
{Cup format}
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug Test (MTD/Methadone)
{Cup format}
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug Test Morphine (2000)
{Cup format}
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug Test (PCP/
Phencyclidine){Cup format}
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug Test Notriptyline
{Cup format}
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug Test (COC/Cocaine)
{Dip card format}
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug Test (MET/
Methamphetamine){Dip card format}
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug Test (MDMA/
Methylenedioxymethamphetamine){D ip card format}
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug Test (MOP/Morphine)
{Dip card format}
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug Test (MTD/Methadone)
{Dip card format}
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug Test Morphine (2000)
{Dip card format}
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug Test (PCP/
Phencyclidine){Dip card format}
G0434QW
May 29, 2012
BTNX Inc Rapid Response X-Press Drug Test Notriptyline
{Dip card format}
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 www.cgsmedicare.com.
November 2012
- page 64 -
Medicare Bulletin – GR 2012-11
83036QW
May 30, 2012
Bayer AICNow+ Professional Use
87880QW
June 7, 2012
Mooremedical Strep A Rapid Test - Dipstick
G0434QW
July 13, 2012
Ultimate Analysis Cup UA Cups
86701QW
July 20, 2012
bioLytical INSTI HIV-1 Antibody Test {Fingerstick Whole Blood}
G0433QW
July 20, 2012
OraSure Technologies OraQuick In-Home HIV Test {Oral Fluid}
The new CPT code, 86803QW, has been assigned for the hepatitis C antibody test performed using the
OraQuick HCV Rapid Antibody Test and OraQuick Visual Reference Panel.
Additional Information
The official instruction, CR 8054 issued to your carrier and A/B MAC regarding this change may be
viewed at http://www.cms.hhs.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/
R2553CP.pdf on the CMS website.
If you have any questions, please contact your carrier or A/B MAC at their toll-free number, which may
be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring- Programs/providercompliance-interactive-map/index.html on the CMS website.
News Flash - Influenza Season is Around the Corner - As your patients age, their immune systems may
weaken. This weakening can make seniors more susceptible to complications from seasonal influenza
(flu). Now is the perfect time to remind your patients that seasonal influenza vaccination is the best defense
against the flu. Medicare provides coverage for one flu vaccine and its administration per influenza season
for seniors and other Medicare beneficiaries with no co-pay or deductible. Talk with your Medicare patients
about their risk for getting the flu and start protecting your patients as soon as your 2012-2013 seasonal flu
vaccine arrives. Also, don’t forget to immunize yourself and your staff. Know what to do about the flu.
Remember – The influenza vaccine plus its administration is a covered Part B benefit. The influenza
vaccine is NOT a Part D covered drug. CMS will provide information and a link to the 2012-2013
Influenza Vaccine prices when they are available.
For more information on coverage and billing of the flu vaccine and its administration, please visit
the CMS Medicare Learning Network® Preventive Services Educational Products and CMS
Immunizations web pages. While some providers may offer the flu vaccine, others can help their
patients locate a vaccine provider within their local community. HealthMap Vaccine Finder is a free,
online service where users can search for locations offering flu vaccines.
MOHs Micrographic Surgery L31877
CGS updated the MOHs LCD L31877 to correct the first asterisk section under the ICD-9 codes
that support medical necessity for diagnosis 173.50-173.52, 173.59, 173.60-173.62, 173.69, 73.70173.72, and 173.79 should only be used when the surgery is done on the trunk, arms, or legs for one
of the indications listed under “Basal cell carcinomas, squamous cell carcinomas, or basal squamous
carcinomas that have one or more of the following features” or “Squamous cell carcinoma exhibiting any
of the following”. This change is effective July 1, 2012.
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 65 -
November 2012
OVA1 or ROMA for Ovarian Cancer Screening
OVA1 has been FDA cleared for use in women who meet the following criteria:
• Over 18 years of age
• Have an ovarian adnexal mass
• Have surgery planned
• Have not yet been referred to a gynecologic oncologist; and
• Have not had cancer in the past five years
OVA1 is not intended to be a screening test or to determine whether a patient should proceed to surgery.
It can, however, be used as a tool by the patient’s primary physician to decide if the referral for treatment
of a mass should go to a gynecologist or a gyn-oncologist.
OVA1 will not be approved in conjunction with other screening testing for ovarian cancer, including the
following CPT codes:
• 86304: CA- 125
• 80418, 80426, 83001: Follicle Stimulating Hormone (FSH)
• 80418, 80426, 83002: Luteinizing Hormone (LH)
Submit CPT code 84999 for OVA 1 and ROMA testing for ovarian cancer. CGS will review the supporting
documentation for individual claims to determine if the medical need is established.
Rescinded: MM7819 - Coding Changes to Ultrasound Diagnostic
Procedures for Transesophageal Doppler Monitoring
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – Over the last year, the Centers for Medicare & Medicaid Services (CMS) has listened to your
feedback about the Medicare online enrollment system, Provider Enrollment, Chain, and Ownership System
(PECOS). As a result, we’ve made upgrades in order to reduce data entry time and increase access to
information. Providers and staff using internet-based PECOS will now be able to digitally sign and certify your
application and to see more information such as whether a request for revalidation has been sent to you by
your Medicare contractor. You will be able to switch from Topic View to Fast Track View to review all of your
enrollment information in a single screen. Overall, the system will be easier for you to use. Learn more about
PECOS at http://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/MedicareProviderSupEnroll/
InternetbasedPECOS.html and be on the look-out for more enhancements in the coming months!
Note: This article was rescinded because the related CR7819 was rescinded.
Results of Kentucky Progressive Corrective Action (PCA) for New
Patient Office Visit Code 99205©
Focus on Code 99205© - Office or other outpatient visit for the evaluation and management of a
new patient, which requires these 3 key components:
• A comprehensive history;
• A comprehensive examination;
• Medical decision making of high complexity
Provider specific probes were conducted for code 99205. The findings consist of the following:
• The components of code 99205 were not met. Services were down coded to the lower level
codes 99202, 99203 and 99204
• Records submitted did not support the services billed
• No records were submitted
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Newsletters issued after January 1997 are available at no cost from our website at www.cgsmedicare.com.
November 2012
- page 66 -
Medicare Bulletin – GR 2012-11
Based on the claims reviewed, 20 claims were allowed, 236 were reduced and 24 claims were denied.
The overall average overpayment was over 50%.
Please take a moment to review the following references and take advantage of our E&M checklists that
are provided to help you optimize your coding, billing and documentation process.
CGS website: http://www.cgsmedicare.com/kyb/coverage/mr/index.html
CGS Checklist: http://www.cgsmedicare.com/kyb/coverage/mr/Checklists.html
CMS website - http://www.cms.gov/
Documentation Guidelines for Evaluation and Management Services
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/
EMDOC.html
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/
downloads//eval_mgmt_serv_guide-ICN006764.pdf
Medicare Claims Processing Manual
http://www.cms.gov/manuals/downloads/clm104c12.pdf
• Chapter 12 of the Claims Processing Manual includes guidelines for many topics that involve
evaluation and management services. Please peruse the entire table of contents and chapter.
E/M Coding: Volume of Documentation versus Medical Necessity
http://www.cgsmedicare.com/kyb/coverage/mr/articles/em_volume.html
Medical Necessity for Evaluation and Management Services
http://www.cgsmedicare.com/kyb/claims/cert/articles/045.html
REVISED: MM8017 - October Update to the Calendar Year (CY) 2012
Medicare Physician Fee Schedule Database (MPFSDB)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – The 2013 ICD-10-PCS files have been posted on the 2013 ICD-10 PCS and GEMs web
page. This includes the 2013 Index and Tabular files, guidelines, code titles, addendum to reference
manual, and slides. The 2013 ICD-10-PCS files contain information on the new procedure coding
system, ICD-10-PCS, that is being developed as a replacement for ICD-9-CM, Volume 3. The 2013
General Equivalent Mappings (GEMs), Reimbursement Mappings, and Reference Manual will be posted
at a later date.
Note: This article was revised on October 1, 2012, to reflect a revised Change Request (CR). The CR
changes include additional instructions clarifying the effective date for HCPCS code 43775, which is
June 27, 2012. The CR number, transmittal number and link to the CR are also changed. All other
information is unchanged.
Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers who submit claims
to Medicare contractors (carriers, Fiscal Intermediaries (FIs), A/B Medicare Administrative Contractors
(A/B MACs), and/or Regional Home Health Intermediaries (RHHIs)) for services that are paid under the
Medicare Physician Fee Schedule (MPFS).
Provider Action Needed
This article is based on CR 8017 which informs Medicare contractors that, in order to reflect appropriate
payment policy in line with the Calendar Year (CY) 2012 Medicare Physician Fee Schedule (MPFS) Final
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 67 -
November 2012
Rule, the MPFS Data Base (MPFSDB) has been updated effective October 1, 2012, and new payment
files have been created. CR8017 instructs Medicare contractors to retrieve and implement the revised
payment files when they are notified that these files are available for retrieval. Contractors will also
give providers 30 days notice before implementing the changes identified in CR8017. Changes will be
retroactive to January 1, 2012, unless otherwise stated in CR8017.
CR8017 also points out that the Office of Clinical Standards and Quality (OCSQ-CMS) has updated their
National Coverage Determination (NCD) concerning Healthcare Common Procedure Coding System
(HCPCS) code 43775 (Lap sleeve gastrectomy). This HCPCS code was previously a Non- covered
Service (N), and CR8017 now instructs that it will be Carrier Priced (C).
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 U.S. Secretary of Health and Human Services (HHS) to establish
ancillary policies necessary to implement relative values for the services of physicians. In order to reflect
appropriate payment policy in line with the Calendar Year (CY) 2012 Medicare Physician Fee Schedule
(MPFS) Final Rule, the MPFS Data Base (MPFSDB) has been updated effective October 1, 2012.
On December 23, 2011, the Temporary Payroll Tax Cut Continuation Act of 2011 (TPTCCA; see
http://www.gpo.gov/fdsys/pkg/PLAW-112publ78/pdf/PLAW-112publ78.pdf on the Internet) became
law and suspended the automatic negative update that would have taken effect with current law.
The TPTCCA temporarily allowed for a zero percent update to the MPFS from January 1, 2012, until
February 29, 2012. On February 22, 2012, the TPTCCA was signed into law and extended the zero
percent update to the end of the calendar year, to December 31, 2012.
The Centers for Medicare & Medicaid Services (CMS) updated these payment files in July through
CR7844. You can review the MLN Matters® article, MM7844, which corresponds to CR7844 at https://
www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/
Downloads/MM7844.pdf on the CMS website.
CR8017 constitutes the October amendment to those payment files, and unless otherwise stated in
CR8017, changes will be retroactive to January 1, 2012.
Additional Information
The official instruction, CR8017 issued to your carrier, FI, A/B MAC, or RHHI regarding this change
may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/
R2559CP.pdf on the CMS website.
If you have any questions, please contact your Medicare contractor at their toll-free number, which may
be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring- Programs/providercompliance-interactive-map/index.html on the CMS website
Revised: SE1011 - Edits on the Ordering/Referring Providers in Medicare
Part B, DME and Part A HHA Claims (Change Requests 6417, 6421, 6696,
and 6856)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – Did you know that Medicare provider enrollment application forms can be completed on your
computer? This means that you can fill out the information required by typing into the open fields while the form
is displayed on your computer monitor. Filling out the forms this way before printing, signing, and mailing means
more easily-readable information – which means fewer mistakes, questions, and delays when your application is
processed. Be sure to make a copy of the signed form for your records before mailing. You can find the Medicare
provider enrollment application forms at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/
MedicareProviderSupEnroll/index.html on the Centers for Medicare & Medicaid Services (CMS) website.
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 www.cgsmedicare.com.
November 2012
- page 68 -
Medicare Bulletin – GR 2012-11
Note: This MLN Matters® Article was revised on September 17, 2012, to change the reference to
Certified Clinical Nurse Specialist on page 3 to say Clinical Nurse Specialist. Also, we have added a
reference to MLN Matters® Article SE1221 in the Additional Information section of the article. All other
information remains the same.
Provider Types Affected
This Special Edition MLN Matters® Article is intended for physicians, non-physician practitioners
(including interns, residents, fellows, and also those who are employed by the Department of
Veterans Affairs (DVA) or the Public Health Service (PHS)) who order or refer items or services for
Medicare beneficiaries, Part B providers and suppliers who submit claims to carriers, Part B Medicare
Administrative Contractors (MACs), Part A Regional Home Health Intermediaries, Fiscal Intermediaries
who still have a Home Health Agency (HHA) workload and DME MACs for items or services that they
furnished as the result of an order or a referral should be aware of this information.
Provider Action Needed
If you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment
record, you need to submit an enrollment application to Medicare.. You can do this using Internet-based
PECOS or by completing the paper enrollment application (CMS-855O). Review the background and
additional information below and make sure that your billing staffs are aware of these updates.
What Providers Need to Know
Phase 1: Beginning October 5, 2009, if the billed Part B service requires an ordering/referring provider
and the ordering/referring provider is not reported on the claim, the claim will not be paid. If the ordering/
referring provider is reported on the claim, but does not have a current enrollment record in PECOS or
is not of a specialty that is eligible to order and refer, the claim will be paid and the billing provider will
receive an informational message in the remittance indicating that the claim failed the ordering/referring
provider edits.
Phase 2: CMS has not announced a date when the edits for Phase 2 will become active. CMS
will give the provider community at least 60 days notice prior to turning on these edits. During
Phase 2, Medicare will deny Part B, DME and Part A HHA claims that fail the ordering/referring
provider edits. Physicians and others who are eligible to order and refer items or services need to
establish their Medicare enrollment record and must be of a specialty that is eligible to order and refer.
Enrollment applications must be processed in accordance with existing Medicare instructions. It is
possible that it could take 45-60 days, sometimes longer, for Medicare enrollment contractors to process
enrollment applications. All enrollment applications, including those submitted over the web, require
verification of the information reported. Sometimes, Medicare enrollment contractors may request
additional information in order to process the enrollment application.
Waiting too late to begin this process could mean that your enrollment application will not be able to be
processed prior to the implementation date of Phase 2 of the ordering/referring provider edits.
Background
The Centers for Medicare & Medicaid Services (CMS) has implemented edits on ordering and
referring providers when they are required to be identified in Part B, DME and Part A HHA claims from
Medicare providers or suppliers who furnished items or services as a result of orders or referrals. Below
are examples of some of these types of claims:
• Claims from laboratories for ordered tests;
• Claims from imaging centers for ordered imaging procedures; and
• Claims from suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS)
for ordered DMEPOS.
• Only physicians and certain types of non-physician practitioners are eligible to order or refer items or
services for Medicare beneficiaries. They are as follows:
• Physician (doctor of medicine or osteopathy, doctor of dental medicine, doctor of dental surgery,
doctor of podiatric medicine, doctor of optometry),
• Physician Assistant,
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 69 -
November 2012
•
•
•
•
•
•
Clinical Nurse Specialist,
Nurse Practitioner,
Clinical Psychologist,
Interns, Residents, and Fellows,
Certified Nurse Midwife, and
Clinical Social Worker.
Questions and Answers Relating to the Edits
1. What will the edits do?
The edits will determine if the Ordering/Referring Provider (when required to be identified in Part B,
DME, and Part A HHA claims) (1) has a current Medicare enrollment record and it contains a valid
National Provider Identifier (NPI) (the name and NPI must match), and (2) is of a provider type that is
eligible to order or refer for Medicare beneficiaries (see list above).
2. Why did Medicare implement these edits?
These edits help protect Medicare beneficiaries and the integrity of the Medicare program.
3. How and when will these edits be implemented?
These edits are being implemented in two phases:
• Phase 1: Beginning October 5, 2009, if the billed Part B service requires an ordering/referring
provider and the ordering/referring provider is not reported on the claim, the claim is not paid. If the
ordering/referring provider is reported on the claim, but does not have a current Medicare enrollment
record or is not of a specialty that is eligible to order and refer, the claim was paid, but the billing
provider received an informational message1 in the Medicare Remittance Advice2 indicating that the
claim failed the ordering/referring provider edits.
1 The informational messages vary depending on the claims processing system.
2 DMEPOS suppliers who submit paper claims will not receive an informational message on the Remittance Advice.
The informational message will indicate that the identification of the ordering/referring provider is
missing, incomplete, or invalid, or that the ordering/referring provider is not eligible to order or refer. The
informational message on an adjustment claim that does not pass the edits will indicate that the claim/
service lacks information that is needed for adjudication. The informational messages are identified below:
For Part B providers and suppliers who submit claims to carriers:
N264
Missing/incomplete/invalid ordering physician provider name
N265
Missing/incomplete/invalid ordering physician primary identifier
For adjusted claims CARC code 45 along with RARC codes N264 and N265 will be used. DME suppliers
who submit claims to carriers (applicable to 5010 edits):
N544
Alert: Although this was paid, you have billed with a referring/ordering provider that
does not match our system record. Unless, corrected, this will not be paid in the future
For Part A HHA providers who order and refer, the claims system shall initially process the claim and add
the following remark message:
N272
Missing/incomplete/invalid other payer attending provider identifier
For adjusted claims the CARC code 16 and/or the RARC code N272 shall be used.
Note: if the billed service requires an ordering/referring provider and the ordering/referring
provider is not on the claim, the claim will not be paid.
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 www.cgsmedicare.com.
November 2012
- page 70 -
Medicare Bulletin – GR 2012-11
•
Phase 2 CMS has not announced a date when the edits for Phase 2 will become active.
CMS will give the provider community at least 60 days notice prior to turning on these edits.
In Phase 2, if the Ordering/Referring Provider does not pass the edits, the claim will be denied. This
means that the billing provider will not be paid for the items or services that were furnished based on
the order or referral. The denial edits are identified below:
Below are the denial edits for Part B providers and suppliers who submit claims to carriers including DME:
254D
Referring/Ordering Provider Not Allowed To Refer
255D
Referring/Ordering Provider Mismatch
289D
Referring/Ordering Provider NPI Required
CARC code 16 and/or the RARC code N264 and N265 shall be used for denied or adjusted claims.
Below are the denial edits for Part A HHA providers who submit claims:
37236 –
•
This reason
code will
assign
•
when:
•
The statement “From” date on the claim is on or after the date the phase 2 edits are
turned on.
37237 •
This reason
code will
assign
•
when:
•
The statement “From” date on the claim is on or after the date the phase 2 edits are
turned on.
•
The type of bill is ‘32’ or ‘33’
Covered charges or provider reimbursement is greater than zero but the attending
physician NPI on the claim is not present in the eligible attending physician file from
PECOS or the attending physician NPI on the claim is present in the eligible attending
physician files from PECOS but the name does not match the NPI record in the
eligible attending physician files from EPCOS or the specialty code is not a valid
eligible code
The type of bill is ‘32’ or ‘33’
The type of bill frequency code is ‘7’ or ‘F-P’
Covered charges or provider reimbursement is greater than zero but the attending
physician NPI on the claim is not present in the eligible attending physician file
from PECOS or the attending physician NPI on the claims is present in the eligible
attending physician files from PECOS but the name does not match the NPI record in
the eligible attending physician files from PECOS or the specialty code is not a valid
eligible code
CMS has taken actions to reduce the number of informational messages.
In December 2009, CMS added the NPIs to more than 200,000 PECOS enrollment records of
physicians and non-physician practitioners who are eligible to order and refer but who had not updated
their PECOS enrollment records with their NPIs.3
On January 28, 2010, CMS made available to the public, via the Downloads section of the “Ordering
Referring Report” page on the Medicare provider/supplier enrollment website, a file containing the NPIs
and the names of physicians and non-physician practitioners who have current enrollment records in
PECOS and are of a type/specialty that is eligible to order and refer. The file, called the
3 NPIs were added only when the matching criteria verified the NPI.
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 71 -
November 2012
Ordering Referring Report, lists, in alphabetical order based on last name, the NPI and the name (last
name, first name) of the physician or non-physician practitioner. To keep the available information up to
date, CMS will replace the Report on a bi-weekly basis. At any given time, only one Report (the most
current) will be available for downloading. To learn more about the Report, and to download it, go to
http://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/MedicareProviderSupEnroll/index.
html; click on “Ordering Referring Report” (on the left). Information about the Report will be displayed.
Effect of Edits on Providers
A. I order and refer. How will I know if I need to take any sort of action with respect to these two
edits?
In order for the claim from the billing provider (the provider who furnished the item or service) to be
paid by Medicare for furnishing the item or service that you ordered or referred, you—the Ordering/
Referring Provider—need to ensure that:
1. You have a current Medicare enrollment record.
• If you are not sure you are enrolled in Medicare, you may: (1) check the Ordering Referring
Report mentioned above, and if you are on that report, you have a current enrollment record in
Medicare and it contains your NPI; (2) contact your designated Medicare enrollment contractor
and ask if you have an enrollment record in Medicare and it contains the NPI; or (3) use Internetbased PECOS to look for your Medicare enrollment record (if no record is displayed, you do not
have an enrollment record in Medicare). If you choose (3), please read the information on the
Medicare provider/supplier enrollment web page about Internet-based PECOS before you begin.
•
If you do not have an enrollment record in Medicare:
• You need to submit an enrollment application to Medicare in one of two ways:
a. Use Internet-based PECOS to submit your enrollment application over the Internet to your
designated Medicare enrollment contractor. You will have to either e-sign the certification
statement or mail a printed, signed, and dated Certification Statement and any required
supporting paper documentation, to your designated Medicare enrollment contractor. The
designated enrollment contractor cannot begin working on your application until it has received
the signed and dated Certification Statement. If you will be using Internet-based PECOS,
please visit the Medicare provider/supplier enrollment web page to learn more about the
web-based system before you attempt to use it. Go to http://www.cms.gov/Medicare/ProviderEnrollment-and- Certification/MedicareProviderSupEnroll/index.html, click on “Internet-based
PECOS” on the left-hand side, and read the information that has been posted there. Download
and read the documents in the Downloads Section on that page that relate to physicians and
non-physician practitioners. A link to Internet-based PECOS is included on that web page.
b. Submit an electronic application through the use of internet-based PECOS or
obtain a paper enrollment application, fill it out, sign and date it, and mail it, along
with any required supporting paper documentation, to your designated Medicare
enrollment contractor. If you order or refer items or services for Medicare beneficiaries
and you do not have a Medicare enrollment record, you need to submit an enrollment
application to Medicare. You can do this using Internet-based PECOS or by completing
the paper enrollment application (CMS-855O). Enrollment applications are available via
internet-based PECOS or .pdf for downloading from the CMS forms page (http://www.
cms.gov/Medicare/CMS-Forms/CMS-Forms/index.html).
NOTE about physicians/non-physician practitioners who have opted-out of Medicare but who
order and refer: Physicians and non-physician practitioners who have opted out of Medicare may order
items or services for Medicare beneficiaries. Their opt-out information must be current (an affidavit must
be completed every 2 years, and the NPI is required on the affidavit).
2. You are of a type/specialty that can order or refer items or services for Medicare beneficiaries.
When you enrolled in Medicare, you indicated your Medicare specialty. Any physician specialty
(Chiropractors are excluded) and only the non-physician practitioner specialties listed above in this
article are eligible to order or refer in the Medicare program.
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 www.cgsmedicare.com.
November 2012
- page 72 -
Medicare Bulletin – GR 2012-11
B. I bill Medicare for items and services that were ordered or referred. How can I be sure that my
claims for these items and services will pass the Ordering/Referring Provider edits?
As the Billing Provider, you need to ensure that your Medicare claims for items or services that you
furnished based on orders or referrals will pass the edits on the Ordering/Referring Provider so that you
will not receive informational messages in Phase 1 and so that your claims will be paid in Phase 2.
You need to use due diligence to ensure that the physicians and non-physician practitioners from whom you
accept orders and referrals have current Medicare enrollment records (i.e., they have Medicare enrollment
records that contain their NPIs) and are of a type/specialty that is eligible to order or refer in the Medicare
program. If you are not sure that the physician or non-physician practitioner who is ordering or referring items or
services meets those criteria, it is recommended that you check the Ordering Referring Report described earlier
in this article. Ensure you are correctly spelling the Ordering/Referring Provider’s name. If you furnished items or
services from an order or referral from someone on the Ordering Referring Report, your claim should pass the
Ordering/Referring Provider edits. Keep in mind that this Ordering Referring Report will be replaced bi-weekly
to ensure it is current. It is possible, therefore, that you may receive an order or a referral from a physician or
non-physician practitioner who is not listed in the Ordering Referring Report but who may be listed on the next
Report. You may appeal a claim that did not initially pass the Ordering/Referring provider edits.
Make sure your claims are properly completed. Do not use “nicknames” on the claim, as their use
could cause the claim to fail the edits. Do not enter a credential (e.g., “Dr.”) in a name field. On paper
claims (CMS-1500), in item 17, you should enter the Ordering/Referring Provider’s first name first, and
last name second (e.g., John Smith). Ensure that the name and the NPI you enter for the Ordering/
Referring Provider belong to a physician or non-physician practitioner and not to an organization, such
as a group practice that employs the physician or non-physician practitioner who generated the order or
referral. Make sure that the qualifier in the electronic claim (X12N 837P 4010A1) 2310A NM102 loop is a
1 (person). Organizations (qualifier 2) cannot order and refer. If there are additional questions about the
informational messages, Billing Providers should contact their local carrier, A/B MAC, or DME MAC.
Billing Providers should be aware that claims that are denied because they failed the Ordering/Referring
Provider would expose the Medicare beneficiary to liability. Therefore, an Advance Beneficiary Notice
is not appropriate.
Additional Guidance
1. A note on terminology: Part B claims use the term “ordering/referring provider” to denote the
person who ordered, referred or certified an item or service reported in that claim. The final rule uses
technically correct terms: 1) a provider “orders” non physician items or services for the beneficiary, such
as DMEPOS, clinical laboratory services, or imaging services and 2) a provider “certifies” home health
services to a beneficiary. The terms “ordered” “referred” and “certified” are often used interchangeably
within the health care industry. Since it would be cumbersome to be technically correct, CMS will
continue to use the term “ordered/referred” in materials directed to a broad provider audience.
2. Orders or referrals by interns or residents. The IFC mandated that all interns and residents who
order and refer specify the name and NPI of a teaching physician (i.e., the name and NPI of the teaching
physician would have been required on the claim for service(s)). The final rule states that State-licensed
residents may enroll to order and/or refer and may be listed on claims. Claims for covered items and
services from un-licensed interns and residents must still specify the name and NPI of the teaching
physician. However, if States provide provisional licenses or otherwise permit
residents to order and refer services, CMS will allow interns and residents to enroll to order and refer,
consistent with State law.
3. Orders or referrals by physicians and non-physician practitioners who are of a type/specialty
that is eligible to order and refer who work for the Department of Veterans Affairs (DVA), the
Public Health Service (PHS), or the Department of Defense(DoD)/Tricare. These physicians and
non-physician practitioners will need to enroll in Medicare in order to continue to order or refer items
or services for Medicare beneficiaries. They may do so by filling out the paper CMS-855O or they may
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 73 -
November 2012
use Internet-based PECOS. They will not be submitting claims to Medicare for services they furnish to
Medicare beneficiaries.
4. Orders or referrals by dentists. Most dental services are not covered by Medicare; therefore, most
dentists do not enroll in Medicare. Dentists are a specialty that is eligible to order and refer items or
services for Medicare beneficiaries (e.g., to send specimens to a laboratory for testing). To do so, they
must be enrolled in Medicare. They may enroll by filling out the paper CMS-855O or they may
use Internet-based PECOS. They will not be submitting claims to Medicare for services they furnish to
Medicare beneficiaries.
Additional Information
You may want to review MLN Matters® Article SE1201 (http://www.cms.gov/Outreach-and- Education/
Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1201.pdf) and SE1221 (http://www.
cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/
SE1221.pdf) for important reminders on the requirements for Ordering and Referring Physicians.
If you have questions, please contact your Medicare Carrier, Part A/B MAC, or DME MAC, at their
toll- free numbers, 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.
Revised: SE1201 - Important Reminder for Providers and Suppliers Who
Provide Services and Items Ordered or Referred by Other Providers and
Suppliers
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – On November 17, 2011, the Centers for Medicare & Medicaid Services’ Office of EHealth Standards and Services (OESS) announced that it would not initiate enforcement with respect to
any Health Insurance Portability and Accountability Act (HIPAA) covered entity that is not in compliance
on January 1, 2012, with the ASC X12 Version 5010 (Version 5010), National Council for Prescription
Drug Programs (NCPDP) Telecom D.0 (NCPDP D.0) and NCPDP Medicaid Subrogation 3.0 (NCPDP
3.0) standards until March 31, 2012. Notwithstanding OESS’ discretionary application of its enforcement
authority, the compliance date for use of these new standards remains January 1, 2012. (Small health
plans have until January 1, 2013, to comply with NCPDP 3.0.)
Note: This article was revised on September 19, 2012, to add a statement at the top of page
3 regarding Optometrists. The article also now contains a reference to MLN Matters® Article
SE1221 and all Web addresses have been updated. All other information remains the same.
Provider Types Affected
This MLN Matters® Special Edition Article is intended for providers and suppliers (including residents,
fellows, and also those who are employed by the Department of Veterans Affairs (DVA) or the Public
Health Service (PHS)) who order or refer items or services for Medicare beneficiaries.
Provider Action Needed
STOP – Impact to You
Medicare will only pay for items or services for Medicare beneficiaries that have been ordered by a
physician or eligible professional who is enrolled in Medicare and their individual National Provider
Identifier (NPI) has been provided on the claim. The ordering provider or supplier (physician or eligible
professional) must also be enrolled with a specialty type that is eligible (per Medicare statute and
regulation) to order and refer those particular items or services.
CAUTION – What You Need to Know
Make sure you follow Medicare directives when providing services ordered for the services
outlined below.
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 www.cgsmedicare.com.
November 2012
- page 74 -
Medicare Bulletin – GR 2012-11
GO – What You Need to Do
You should ensure that any items or services submitted on Medicare claims are referred or ordered by
Medicare-enrolled providers of a specialty type authorized to order or refer the same. You must also
place the ordering or referring provider or supplier’s NPI on the claim you submit to Medicare for the
service or item you provide.
Background
CMS emphasizes that generally Medicare will only reimburse for specific items or services when those
items or services are ordered or referred by providers or suppliers authorized by Medicare statute and
regulation to do so. Claims that a billing provider or supplier submits in which the ordering/referring
provider or supplier is not authorized by statute and regulation will be denied as a non-covered service.
The denial will be based on the fact that neither statute nor regulation allows coverage of certain
services when ordered or referred by the identified supplier or provider specialty.
CMS would like to highlight the following limitations:
• Chiropractors are not eligible to order or refer supplies or services for Medicare beneficiaries. All
services ordered or referred by a chiropractor will be denied.
• Home Health Agency (HHA) services may only be ordered or referred by a Doctor of Medicine
(M.D.), Doctor of Osteopathy (D.O.) or Doctor of Podiatric Medicine (DPM). Claims for HHA services
ordered by any other practitioner specialty will be denied.
• Portable X-Ray services may only be ordered by a Doctor of Medicine or Doctor of Osteopathy.
Portable X-Ray services ordered by any other practitioners will be denied.
• Optometrists may only order and refer laboratory and X-Ray services.
MLN Matters® Special Edition Articles SE1011 and SE1221 provide further details about edits on the
ordering/referring provider information on claims. SE1011 is available at http://www.cms.gov/Outreachand-Education/Medicare-Learning- Network-MLN/MLNMattersArticles/downloads/SE1011.pdf and
SE1212 is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning- Network-MLN/
MLNMattersArticles/Downloads/SE1221.pdf on the CMS website.
Additional Information
For more information about the Medicare enrollment process, visit http://www.cms.gov/Medicare/
Provider-Enrollment-and- Certification/MedicareProviderSupEnroll/index.html or contact the
designated Medicare contractor for your State. Medicare provider enrollment contact information for
each State can be found at http://www.cms.gov/Medicare/Provider- Enrollment-and- Certification/
MedicareProviderSupEnroll/downloads/Contact_list.pdf on the CMS website.
The Medicare Learning Network® (MLN) fact sheet titled, “Medicare Enrollment Guidelines for Ordering/
Referring Provider,” is available at http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork- MLN/MLNProducts/downloads/MedEnroll_OrderReferProv_factSheet_ICN906223.pdf on the
CMS website.
MLN Matters® Article MM7097, “Eligible Physicians and Non-Physician Practitioners Who Need to
Enroll in the Medicare Program for the Sole Purpose of Ordering and Referring Items and Services for
Medicare Beneficiaries,“ is available at http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork- MLN/MLNMattersArticles/Downloads/MM7097.pdf on the CMS website.
MLN Matters® Article 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),” is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/
MLNMattersArticles/Downloads/MM6417.pdf on the CMS website.
MLN Matters® Article 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),” is available at http://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM6421.pdf on the CMS website;
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 75 -
November 2012
MLN Matters® Article MM6129, “New Requirement for Ordering/Referring Information on Ambulatory
Surgical Center (ASC) Claims for Diagnostic Services,” is available at http://www.cms.gov/Outreachand-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM6129.pdf on the
CMS website.
SE1221 - Phase 2 of Ordering/Referring Requirement
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – In response to shortage of liposomal doxorubicin (Doxil), the Food and Drug Administration
is permitting the temporary importation of Lipodox, a brand of liposomal doxorubicin hydrochloride.
Visit http://www.FDA.gov/NewsEvents/Newsroom/PressAnnouncements/ucm292658.htm for additional
information. The Centers for Medicare & Medicaid Services (CMS) Healthcare Common Procedure
Coding System (HCPCS) Quarterly Update includes two new codes (Q2048 and Q2049) for liposomal
doxorubicin that will become effective Sunday, July 1, 2012. The code descriptors are worded in a manner
that distinguishes Lipodox and Doxil. As of Sunday, July 1, 2012, HCPCS code J9001 will not be used for
Medicare billing. CMS will release a Change Request (CR) with additional instructions in the near future.
Note: This article was revised on September 17, 2012, to remove the word “Certified” from in
front of Clinical Nurse Specialist on Page 3. All other information remains the same.
Provider Types Affected
This MLN Matters® Special Edition Article is intended for:
• Physicians and non-physician practitioners (including interns, residents, fellows, and those who are
employed by the Department of Veterans Affairs (DVA) or the Public Health Service (PHS)) who
order or refer items or services for Medicare beneficiaries,
• Part B providers (including Portable X-Ray services) and suppliers of Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies (DMEPOS) who submit claims to carriers, Part A/B Medicare
Administrative Contractors (MACs), and DME MACs for items or services that they furnished as the
result of an order or a referral, and
• Part A Home Health Agency (HHA) services who submit claims to RHHIs, Fiscal Intermediaries (who
still maintain an HHA workload), and Part A/B MACs.
Provider Action Needed
STOP – Impact to You
CMS will soon begin denying Part B, DME, and Part A HHA claims that fail the Ordering/Referring
Provider edits. These edits ensure that physicians and others who are eligible to order and refer items
or services have established their Medicare enrollment records and are of a specialty that is eligible
to order and refer. CMS will provide 60 day advanced notice prior to turning on the Ordering/Referring
edits. CMS does not have a date at this time.
CAUTION – What You Need to Know
CMS shall authorize A/B MACs and DME MACs to begin editing Medicare claims with Phase 2 Ordering/
Referring edits. This means that the Billing Provider will not be paid for the items or services that were
furnished based on the order or referral from a provider who does not have a Medicare enrollment record.
GO – What You Need to Do
If you order or refer items or services for Medicare beneficiaries and you do not have a Medicare
enrollment record, you need to submit an enrollment application to Medicare. You can do this using
Internet-based PECOS or by completing the paper enrollment application (CMS-855O).
Background
The Social Security Act (the Act) requires that all physicians and non-physician practitioners be uniquely
identified for all claims for services that are ordered or referred. Effective January 1, 1992, a physician
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 www.cgsmedicare.com.
November 2012
- page 76 -
Medicare Bulletin – GR 2012-11
or supplier that bills Medicare for a service or item must show the name and unique identifier of the
attending physician on the claim if that service or item was the result of an order or referral. Effective
May 23, 2008, the unique identifier was determined to be the National Provider Identifier (NPI).
CMS began expanding the claims editing to meet the Act’s requirements for ordering and referring
providers as follows:
•
Phase 1: Beginning October 5, 2009, if the billed Part B service requires an ordering/referring
provider and the ordering/referring provider is not reported on the claim, the claim is not paid. If the
ordering/referring provider is reported on the claim, but does not havea current Medicare enrollment
record or is not of a specialty that is eligible to order and refer, the claim was paid, but the billing
provider received an informational message in the remittance advice indicating that the claim failed
the ordering/referring provider edits.
Only physicians and certain types of non-physician practitioners are eligible to order or refer items or
services for Medicare beneficiaries. They are as follows:
o Physician (doctor of medicine or osteopathy, doctor of dental medicine, doctor of dental surgery,
doctor of podiatric medicine, doctor of optometry),
o Physician Assistant,
o Clinical Nurse Specialist,
o Nurse Practitioner,
o Clinical Psychologist,
o Interns, Residents, and Fellows
o Certified Nurse Midwife, and
o Clinical Social Worker.
The informational message will indicate that the identification of the Ordering/Referring provider is
missing, incomplete, or invalid, or that the Ordering/Referring Provider is not eligible to order or refer. The
informational message on an adjustment claim that does not pass the edits will indicate that the claim/
service lacks information that is needed for adjudication. The informational messages are identified below:
For Part B providers and suppliers who submit claims to carriers:
N264
Missing/incomplete/invalid ordering physician provider name
N265
Missing/incomplete/invalid ordering physician primary identifier
For adjusted claims CARC code 45 along with RARC codes N264 and N265 will be used.
DME suppliers who submit claims to carriers (applicable to 5010 edits):
N544
Alert: Although this was paid, you have billed with a referring/ordering provider that
does not match our system record. Unless, corrected, this will not be paid in the future
For Part A HHA providers who order and refer, the claims system shall initially process the claim and add
the following remark message:
N272
Missing/incomplete/invalid other payer attending provider identifier
For adjusted claims the CARC code 16 and/or the RARC code N272 shall be used.
Note: if the billed service requires an ordering/referring provider and the ordering/referring
provider is not on the claim, the claim will not be paid.
Phase 2: CMS has not announced a date when the edits for Phase 2 will become active. CMS
will give the provider community at least 60 days notice prior to turning on these edits. During Phase
2, Medicare will deny Part B, DME and Part A HHA claims that fail the ordering/referring provider
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 77 -
November 2012
edits. Physicians and others who are eligible to order and refer items or services need to be enrolled
in Medicare and must be of a specialty that is eligible to order and refer. If the billed service requires
an ordering/referring provider and the ordering/referring provider is not on the claim, the claim will not
be paid. If the ordering/referring provider is on the claim, but is not enrolled in Medicare, the claim will
not be paid. In addition, if the ordering/referring provider is on the claim, but is not of a specialty that is
eligible to order and refer, the claim will not be paid. Below are the denial edits for Part B providers and
suppliers who submit claims to carriers including DME:
254D
Referring/Ordering Provider Not Allowed To Refer
255D
Referring/Ordering Provider Mismatch
289D
Referring/Ordering Provider NPI Required
CARC code 16 and/or the RARC code N264 and N265 shall be used for denied or adjusted
claims. Below are the denial edits for Part A HHA providers who submit claims:
37236 –
•
This reason
code will
assign
•
when:
•
The statement “From” date on the claim is on or after the date the phase 2 edits are
turned on.
37237 •
This reason
code will
assign
•
when:
•
The statement “From” date on the claim is on or after the date the phase 2 edits are
turned on.
•
The type of bill is ‘32’ or ‘33’
Covered charges or provider reimbursement is greater than zero but the attending
physician NPI on the claim is not present in the eligible attending physician file from
PECOS or the attending physician NPI on the claim is present in the eligible attending
physician files from PECOS but the name does not match the NPI record in the
eligible attending physician files from EPCOS or the specialty code is not a valid
eligible code
The type of bill is ‘32’ or ‘33’
The type of bill frequency code is ‘7’ or ‘F-P’
Covered charges or provider reimbursement is greater than zero but the attending
physician NPI on the claim is not present in the eligible attending physician file
from PECOS or the attending physician NPI on the claims is present in the eligible
attending physician files from PECOS but the name does not match the NPI record in
the eligible attending physician files from PECOS or the specialty code is not a valid
eligible code
CMS published the final rule, CMS-6010-F, RIN 0938-AQ01, “Medicare and Medicaid Programs;
Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation
Requirements; and Changes in Provider Agreements,” on April 24, 2012, permitting Phase 2 edits to be
implemented.
CMS will announce the date via an updated article when it shall authorize Part A/B and DME MACs and
Part A RHHIs to implement Phase 2 edits.
Additional Information
A note on terminology: Part B claims use the term “ordering/referring provider” to denote the person who
ordered, referred or certified an item or service reported in that claim. CMS has used this term on its
website and in educational products. The final rule uses technically correct terms: 1) a provider “orders”
non physician items or services for the beneficiary, such as DMEPOS, clinical laboratory services, or
imaging services and 2) a provider “certifies” home health services for a beneficiary. The terms “ordered”
“referred” and “certified” are often used interchangeably within the health care industry. Since it would be
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 www.cgsmedicare.com.
November 2012
- page 78 -
Medicare Bulletin – GR 2012-11
cumbersome to be technically correct, CMS will continue to use the term “ordered/referred” in materials
directed to a broad provider audience.
For more information about the Medicare enrollment process, visit http://www.cms.gov/Medicare/
Provider-Enrollment-and- Certification/MedicareProviderSupEnroll/index.html, or contact the
designated Medicare contractor for your State. Medicare provider enrollment contact information
for each State can be found at http://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/
MedicareProviderSupEnroll/downloads/Contact_list.pdf on the CMS website.
The Medicare Learning Network® fact sheet, “Medicare Enrollment Guidelines for Ordering/Referring
Providers” provides information about the requirements for eligible ordering/referring providers and
is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/
MLNProducts/downloads/MedEnroll_OrderReferProv_FactSheet_ICN906223.pdf on the CMS website.
You may find the following articles helpful in understanding this matter:
•
MLN Matters® Article MM6417, “Expansion of the Current Scope of Editing for Ordering/Referring
Providers for Claims Processed by Medicare Carriers and Part B MedicareAdministrative
Contractors (MACs),” is available at http://www.cms.gov/Outreach-and- Education/MedicareLearning-Network- MLN/MLNMattersArticles/downloads/MM6417.pdf on the CMS website.
•
MLN Matters® Article 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),” is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM6421.pdf on the CMS website.
•
MLN Matters® Article MM6856, “Expansion of the Current Scope of Editing for Attending Physician
Providers for free-standing and provider-based Home Health Agency (HHA) claims processed
by Medicare Regional Home Health Intermediaries (RHHIs)”, is available at http://www.cms.gov/
Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/
MM6856.pdf on the CMS website.
•
MLN Matters® Article MM7097, “Eligible Physicians and Non-Physician Practitioners Who Need to
Enroll in the Medicare Program for the Sole Purpose of Ordering and Referring Items and Services
for Medicare Beneficiaries,“ is available at http://www.cms.gov/Outreach-and- Education/MedicareLearning-Network- MLN/MLNMattersArticles/downloads/MM7097.pdf on the CMS website.
•
MLN Matters® Article MM6129, “New Requirement for Ordering/Referring Information on Ambulatory
Surgical Center (ASC) Claims for Diagnostic Services,” is available at http://www.cms.gov/Outreachand-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/MM6129.pdf on
the CMS website.
•
MLN Matters® Special Edition Article SE1011, “Edits on the Ordering/Referring Providers in
Medicare Part B Claims (Change Requests 6417, 6421, and 6696),” is available at http://www.cms.
gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/
SE1011.pdf on the CMS website.
•
MLN Matters® Article Special Edition Article SE1201 “Important Reminder for Providers and
Suppliers Who Provide Services and Items Ordered or Referred by Other Providers and Suppliers”
is available at http://www.cms.gov/Outreach-and-Education/Medicare- Learning-Network-MLN/
MLNMattersArticles/downloads/SE1201.pdf on the CMS website.
•
MLN Matters® Special Edition Article SE1208, “855-O Medicare Enrollment Application Ordering and
Referring Physicians or Other Eligible Professionals,” is available at https://www.cms.gov/Outreachand-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/SE1208.pdf on the
CMS website.
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 79 -
November 2012
•
If you have any questions, please contact your carrier, Part A/B MAC, RHHI, Fiscal Intermediary, or DME
MAC at their toll-free number, which may be found at http://www.cms.gov/Research- Statistics-Data-andSystems/Monitoring-Programs/provider-compliance-interactive- map/index.html on the CMS website.
SE1234 - Important Information Concerning the Medicare Crossover
Process and State Medicaid Agency Requirements for National Drug
Codes (NDCs) Associated with Physician-Administered Part B Drugs
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – On August 24, HHS Secretary Kathleen Sebelius announced a final rule that will save
time and money for physicians and other health care providers by establishing a unique health plan
identifier (HPID). The rule is one of a series of changes required by the Affordable Care Act to cut red
tape in the health care system and will save up to $6 billion over ten years. Currently, when a health
care provider bills a health plan, that plan may use a wide range of different identifiers that do not have
a standard format. As a result, health care providers run into a number of time-consuming problems,
such as misrouting of transactions, rejection of transactions due to insurance identification errors, and
difficulty determining patient eligibility. The change announced on August 24 will greatly simplify these
processes. For more information, see the Fact Sheet related to this final rule.
Provider Types Affected
This MLN Matters® Special Edition (SE) Article is intended for physicians, hospitals, clinics, other
providers, their billing vendors or clearinghouses that regularly include line-item billing for physicianadministered drugs as part of the claims that they send to Medicare contractors (carriers, Fiscal
Intermediaries (FIs), or Medicare Administrative Contractors (MACs)).
Provider Action Needed
In this article, the Centers for Medicare & Medicaid Services (CMS) outlines guidance to help reduce the
amount of claims being denied and/or not accepted by State Medicaid Agencies in conjunction with the
national Coordination of Benefits Agreement (COBA) Medicare claims crossover process.
CMS is providing this guidance in an effort to improve the effectiveness of the Medicare claims crossover process.
Background
Currently, many payers use both the 11 digit National Drug Code (NDC), reported in the 5-4-2
format, and the associated Healthcare Common Procedure Coding System (HCPCS) code for claims
adjudication that include billing for physician-administered drugs. In accordance with the Deficit
Reduction Act (DRA) of 2005 and its subsequent implementing regulation, as found in 42 Code of
Federal Regulations (CFR) 447 Section 520, State Medicaid Agencies must include information on
individual NDCs directly related to physician-administered drugs when sending their billing to drug
manufacturers to claim drug rebates under the Title XIX program. Such information is normally available
to State Medicaid Agencies through the national COBA Medicare Claims Crossover Process, by which
Medicare automatically transfers fully-adjudicated Medicare claims to Title XIX Medicaid agencies for
their supplemental, or tertiary, payment consideration.
Through ongoing discussions with Title XIX Medicaid agencies, CMS has determined that physician
offices, outpatient hospital departments, and outpatient clinics do not always include a one-to-one reporting
of an NDC for each Part B drug HCPCS (e.g., J3140) code reported on incoming Medicare claims. This
trend was found mostly on multi-line claims. Consequently, the Medicaid agencies are either denying the
COBA Medicare crossover claims that report Part B drug HCPCS codes without corresponding NDCs, or
developing the required information with physicians and outpatient hospital and clinic providers.
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 www.cgsmedicare.com.
November 2012
- page 80 -
Medicare Bulletin – GR 2012-11
Key Points
Billing of NDCs on Health Insurance Portability and Accountability Act (HIPAA) 837 Institutional
Claims Sent to Medicare
When physician billing offices and hospital outpatient departments and outpatient clinic billing offices
determine that their patients are: 1) dually entitled to Medicare and Medicaid, and 2) have received
physician-administered drugs as part of a medical encounter, they should bill the physician-administered
drug(s) on the resulting claims to Medicare as follows:
• For each line level reporting of a Part B physician-administered drug, continue to report the
associated HCPCS (e.g., J3140) in 2400 SV202-2, with SV202-1=HC; and
• For each Part B drug HCPCS reported in 2400 SV202-2, complete the required associated
• 2410 LIN and CPT04 segments as follows:
• Include the NDC in 2410 LIN03, with LIN02=N4;
• Include the quantity/unit count in 2410 CPT04; and
• Input the needed information in 2410 CPT05 and CPT05-1.
Billing NDCs on Incoming CMS-1500 or UB04 Hard Copy Claims to Medicare
• Most physicians and providers may realize that Medicare transforms incoming CMS-1500 or UB04
hard copy claims into their electronic equivalent HIPAA 837 professional and institutional formats
as part of the Medicare claims crossover process. CMS previously issued guidance to physicians
and providers about the reporting of NDCs and associated information (i.e., qualifier for NDC and
qualifier for quantity/units, as well as reporting of quantity/unit count, including fractional units)
on hard copy CMS-1500 and UB04 claim formats during 2008. These directions, which remain
unchanged, may be reviewed in:
• MLN Matters® Article MM5930, “Medicare Shared Systems Modifications Necessary to Capture
and Crossover Medicaid Drug Rebate Data Submitted on Form UB 04 Paper Claims and Direct
Data Entry (DDE) Claims,” is available at http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network- MLN/MLNMattersArticles/downloads/MM5950.pdf; and
• MLN Matters® Article MM5835, “Medicare Shared Systems Modifications Necessary to Accept and
Crossover to Medicaid National Drug Codes (NDC) and Corresponding Quantities Submitted on
CMS-1500 Paper Claims,” is available at http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network- MLN/MLNMattersArticles/downloads/MM5835.pdf on the CMS website.
Billing of NDCs via Direct Data Entry (DDE) Claims Screen
• Outpatient hospital departments and outpatient clinics that bill via DDE and are experiencing nonacceptance and/or denial of Medicare crossover claims by State Medicaid Agencies due to missing
NDCs should contact their designated MAC or FI for assistance.
Additional Information
If you have any questions, please contact your carrier, FI, or MAC at their toll-free number, which may
be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring- Programs/providercompliance-interactive-map/index.html on the CMS website.
SE1236-Documenting Medical Necessity for Major Joint Replacement
(Hip and knee)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – On August 24, HHS Secretary Kathleen Sebelius announced a final rule that will save
time and money for physicians and other health care providers by establishing a unique health plan
identifier (HPID). The rule is one of a series of changes required by the Affordable Care Act to cut red
tape in the health care system and will save up to $6 billion over ten years. Currently, when a healthcare
provider bills a health plan, that plan may use a wide range of different identifiers that do not have a
standard format. As a result, health care providers run into a number of time-consuming problems,
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 81 -
November 2012
such as misrouting of transactions, rejection of transactions due to insurance identification errors, and
difficulty determining patient eligibility. The change announced on August 24 will greatly simplify these
processes. For more information, see the Fact Sheet related to this final rule.
This MLN Matters® Special Edition (SE) is intended for physicians who perform major joint replacement
(hip and knee) surgery on Medicare beneficiaries. This article may also be of interest to hospitals,
multispecialty clinics, and accountable care organizations.
What You Need to Know
The Centers for Medicare & Medicaid Services (CMS) is publishing this article as an educational guide
to improve compliance with documentation requirements for major joint replacement surgery. The article
presents suggestions for documenting medical necessity to avoid denial of Medicare Fee-For- Service
(FFS) claims. The use of this guide is not mandatory and does not guarantee payment.
Background
In 2010, the President announced the goals for cutting the Medicare FFS improper payment rate by
half and reducing overall payment errors by $50 billion. Medicare has initiated a number of auditing
projects with the intention of reaching those goals. Multiple auditing entities including the Recovery
Audit Contractors, Comprehensive Error Rate Testing (CERT) Contractors, and Medicare Administrative
Contractors (MACs) have demonstrated very high paid claim error rates among both hospital and
professional claims associated with major joint replacement surgery.
Key Points
Document Medical Necessity to Avoid Denial of Claims
CMS recognizes that joint replacement surgery is reserved for patients whose symptoms have not
responded to other treatments. To avoid denial of claims for major joint replacement surgery, the medical
records should contain enough detailed information to support the determination that major joint
replacement surgery was reasonable and necessary for the patient. Progress notes consisting of only
conclusive statements should be avoided.
Consequently, the medical record must specifically document a complete description of the patients’
historical and clinical findings. Examples of such information may include:
History:
• Description of the pain (onset, duration, character, aggravating, and relieving factors);
• Limitation of Activities of Daily Living (ADLs) – specify;
• Safety issues (e.g. falls);
• Contraindications to non-surgical treatments;
• Listing and description of failed non-surgical treatments such as:
· Trial of medications (e.g. NSAIDs);
· Weight loss;
· Physical therapy;
· Intra-articular injections;
· Braces, orthotics or assistive devices.
Physical Examination:
• Deformity;
• Range of motion;
• Crepitus;
• Effusions;
• Tenderness;
• Gait description (with/without mobility aides).
Investigations:
• Results of applicable investigations (e.g. plain radiographs).
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November 2012
- page 82 -
Medicare Bulletin – GR 2012-11
Clinical Judgment:
• Reasons for deviating from a stepped-care approach.
Examples of Medical Documentation
The following examples show portions of a medical record that either support or do not support the
medical necessity of the joint replacement. Please note these examples do not describe all of necessary
documentation required for a joint replacement surgery or all the clinical situations that require major
joint surgery. These examples are solely for educational purposes.
Example of Documentation Demonstrating Medical Necessity for Joint Replacement Surgery
A. The hospital record for the preoperative joint replacement surgical patient includes:
History:
•
•
•
•
Present illness from onset until the present;
Current symptoms and functional limitations;
Outcomes of nonsurgical treatments, such as;
·
Medications e.g., Anti-inflammatory medication, Analgesics;
·
Intra-articular injections;
·
Physical Therapy and/or home exercise plans;
·
Assistive devices e.g., cane, walker, braces (specify type of brace), orthotics;
Comorbidities.
Physical Examination:
• Joint examination with detailed objective findings.
Investigations:
• Preoperative imaging studies.
The hospital record for the joint replacement surgical patient includes documentation of specific
conditions. For example:
• Osteoarthritis (mild, moderate, severe);
• Inflammatory arthritis (e.g., rheumatoid arthritis, psoriatic arthritis);
• Failure of previous osteotomy;
• Malignancy of distal femur, proximal tibia, knee joint, soft tissues;
• Failure of previous unicompartmental knee replacement;
• Avascular necrosis of knee;
• Malignancy of the pelvis or proximal femur or soft tissues of the hip;
• Avascular necrosis of the femoral head;
• Fractures (e.g., distal femur, femoral neck, acetabulum);
• Nonunion, malunion, or failure of previous hip fracture surgery; and
• Osteonecrosis.
B. The hospital record for the postoperative joint replacement surgical patient includes:
• Operative report for the procedure, including observed pathology;
• Daily progress notes for inpatients; and
• Discharge plan and discharge orders.
Example of a medical record that may result in a DENIED claim
Mrs. Smith is a female, age 70, with chronic right knee pain. She states she is unable to walk without
pain and pain meds do not work. Therefore, she needs a total right knee replacement.
Example of a medical record with more detail and support of medical necessity
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Medicare Bulletin – GR 2012-11
- page 83 -
November 2012
History:
Mrs. Smith is a 70-year-old female who is suffering from end-stage Osteoarthritis (OA) of her right knee, worsening
gradually over the past 10 years. Treatment has included NSAIDs which have not effectively relieved her pain/
inflammation and which have recently begun to cause her gastric distress. She has also participated in an exercise
program/physical therapy for the past 3 months without functional improvement. Sometimes the pain keeps her
awake at night. She is using a cane and is no longer able to climb the five steps to her front door. Personal safety
is compromised as she had falls x 3 in attempting the stairs to her home entrance. Her knee pain and stiffness limit
her ability to perform ADLs. She cannot walk from her bedroom to her kitchen without stopping to rest.
Physical Examination:
Vital Signs: 140/90, Heart rate 78, RR 18.
Physical exam: Bilateral varus knee deformity consistent with severe osteoarthritis. Right knee extension
reduced to minus 15 degrees and flexion to less than 100 degrees. Unable to rise from chair unassisted.
Full motion of the right hip, no calf tenderness or ankle edema. Antalgic gait noted.
Investigations:
X-ray (7/2/11): right knee shows joint space narrowing along with marginal osteophytes.
Impression:
Total Knee Arthroplasty (TKA) indicated.
Plan/Orders:
Discussed risks and benefits of total joint replacement with patient. Patient understands both. Admit to
inpatient care for right TKA. Forward a copy of this note to include in patients chart along with a copy of
the patient’s x-ray reports.
Additional Information
If you have any questions, please contact your carrier, Fiscal Intermediary, or MAC at their toll-free
number, which may be found at http://www.cms.gov/Research-Statistics-Data-and- Systems/MonitoringPrograms/provider-compliance-interactive-map/index.html on the CMS website.
For additional information and educational materials related to provider compliance, visit http://www.cms.
gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/ProviderCompliance.html
on the CMS website.
SE1238 - Claim Modifier Did Not Prevent Medicare from Paying Millions
in Unallowable Claims for Selected Durable Medical Equipment
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – Registration is now open to all suppliers interested in participating in the Round 1 Recompete
of the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive
Bidding Program. In order to submit a bid for the Round 1 Recompete, you must first register in the
Individuals Authorized Access to the CMS Computer Services (IACS) online application. Once you have
registered in IACS, you will receive a user ID and password to access the online DMEPOS Bidding System
(DBidS).You must register even if you registered during a previous round of competition (Round 1 Rebid,
Round 2, or the national mail-order competition). Only suppliers who have a user ID and password will be
able to access DBidS; suppliers that do not register will not be able to bid. Registration for the recompete will
close on Friday, October 19, 2012 at 9pm prevailing Eastern Time. To register, go to the Competitive Bidding
Implementation Contractor (CBIC) website, http://www.dmecompetitivebid.com click on Round 1 Recompete,
and then click on “REGISTRATION IS OPEN” above the Registration clock. If you have any questions about
the registration process, please contact the CBIC Customer Service Center at877-577-5331 between 9am
and 9pm prevailing Eastern Time, Monday through Friday.
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November 2012
- page 84 -
Medicare Bulletin – GR 2012-11
Provider Types Affected
This MLN Matters® Special Edition (SE) Article is intended for providers and suppliers who submit
claims to Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for services
provided to Medicare beneficiaries.
What You Need to Know
This article highlights the April 2012 report from the Office of the Inspector General (OIG) titled
“Claim Modifier Did Not Prevent Medicare from Paying Millions in Unallowable Claims for Selected
Durable Medical Equipment.” The article also focuses on the Medicare policy regarding the required
documentation suppliers must have on file.
The objective of this OIG study was to determine whether the KX modifier was effective in ensuring that
DMEPOS suppliers who submitted Medicare claims had the required supporting documentation on file.
The study included individual reviews of the four contractors that processed the DMEPOS claims for
Jurisdictions A through D with ndates of service in 2007.
The OIG report focused on the following four categories of DMEPOS claims containing the KX modifier
for Calendar Year (CY) 2007:
1. therapeutic shoes for diabetics,
2. continuous positive airway pressure systems,
3. respiratory assist devices, and
4. pressure reducing support surfaces (groups 1 and 2).
Background
Medicare providers and suppliers have a vital role in helping the Centers for Medicare & Medicaid
Services (CMS) effectively manage Medicare resources. CMS acknowledges the daily challenges
providers and suppliers face in serving Medicare beneficiaries and the complex process involved in
obtaining and receiving the required documentation.
For certain DMEPOS, suppliers must use the KX modifier. The KX modifier indicates that the claim
meets Medicare coverage criteria and the supplier has the required documentation on file. While
suppliers must have a written physician’s order and proof of delivery for all DMEPOS, suppliers must
have additional documentation on file for items requiring the KX modifier. For example, therapeutic
shoes also require that a certifying physician’s statement be on file before the supplier bills Medicare.
OIG Findings
The report found that in CY 2007:
1. 60% of the sampled 400 claims, suppliers did not have the required documentation on file;
2. 37% of the claims were missing the physician orders;
3. 21% were missing proof of delivery;
4. 25% were missing use or complaint use follow-up statements; and
5. 2% were missing sleep studies.
The Key Points section below reviews Medicare policy for coverage of therapeutic shoes for diabetics,
continuous positive airway pressure systems, respiratory assist devices, and pressure reducing support
surfaces (groups 1 and 2). Each DMEPOS has similar requirements that will be listed first. For additional
document requirements, each DMEPOS will be listed thereafter.
Key Points
CMS reminds physicians that in order for these items to be reimbursed for their patients, the DME
supplier must collect medical documentation. This includes copies of the initial evaluation and any other
reports needed to comply with coverage criteria specific to:
1. therapeutic shoes for diabetics;
2. continuous positive airway pressure systems;
3. respiratory assist devices; and
4. pressure reducing support surfaces (groups 1 and 2).
Cooperation and coordination between physicians and suppliers is necessary to meet Medicare
coverage documentation requirements and deliver effective and efficient healthcare to beneficiaries.
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Medicare Bulletin – GR 2012-11
- page 85 -
November 2012
The Local Coverage Determinations (LCDs) for all four DME MACs require suppliers to have the same
documentation on file for the categories of DMEPOS and dates of service included in this OIG audit.
Additional coverage and payment rules for therapeutic shoes for diabetics, continuous positive airway
pressure systems, respiratory assist devices, and pressure reducing support surfaces (groups 1 and
2) may be found in the LCDs for the applicable DME MAC. See the Additional Information section
below to find websites for all four contractors.
The complete medical policy is posted on individual DME MAC websites, or in the CMS Medicare
Coverage Database. The database is available at http://www.cms.gov/medicare-coverage- database/
overview-and-quick-search.aspx on the CMS website. Each category of DMEPOS in this study requires
the following documentation:
1) Valid written order that contains:
• Beneficiary’s name;
• Treating physician’s signature;
• Date the treating physician signed the order, and
• Start date of the order.
2) Proof of delivery.
Additional documentation requirements for each category of DMEPOS are also listed as follows:
Therapeutic Shoes
1) Signed statement from the certifying physician (must be MD or DO) who is treating the patient’s
systemic diabetes condition;
• Patient has diabetes mellitus; and
• Patient has one of the following:
a. Previous amputation of the other foot, or part of either foot; or
b. History of previous foot ulceration of either foot; or
c. History of pre-ulcerative calluses of either foot; or
d. Peripheral neuropathy with evidence of callus formation of either foot; or
e. Foot deformity of either foot; or
f. Poor circulation in either foot.
Certify that the above two indications are met and that he/she is treating the patient under a
comprehensive plan of care for his/her diabetes; and the patient needs diabetic shoes.
2) Documentation of an in-person evaluation of the patient by the certifying physician who is managing
the patient’s systemic diabetes condition within 6 months specifying:
a. The patient has diabetes mellitus;
b. Has one of the conditions 2a-2f listed in Policy Article A37076;
c. Is being treated under a comprehensive plan of care for his/her diabetes, and
d. Requires diabetic shoes.
3) Documentation of an in-person evaluation of the patient by the supplier prior to selection of
the items billed that included:
a. An examination of the patient’s feet with a description of the abnormalities that will need
to be accommodated by the shoes/inserts/modifications.
b. For all shoes, taking measurements of the patient’s feet.
c. For custom molded shoes and inserts, taking impressions, making casts, or obtaining
CAD-CAM images of the patient’s feet that will be used in creating positive models of the feet.
4) Medical records supporting that the patient has diabetes mellitus and at least one of the conditions
noted above.
5) Documentation of an in-person visit with the patient by the supplier at the time of delivery must be
conducted with the patient wearing the shoes and inserts and must document that the shoes/inserts/
modifications fit properly.
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November 2012
- page 86 -
Medicare Bulletin – GR 2012-11
Note: Please refer to the basic coverage criteria specified in the Therapeutic Shoes LCD for your DME
MAC for further guidance.
Continuous Positive Airway Pressure Systems
1) Documentation of a verbal order (if item is dispensed based on a verbal order) that contains:
a. Description of the item;
b. Name of the beneficiary;
c. Name of the physician, and
d. Start date of the order.
2) Valid written order that contains:
a. Beneficiary’s name
b. Treating physician’s signature
c. Date the treating physician signed the order
d. Start date of the order-if the start date differs from the signature date.
e. Order for PAP with pressure setting.
3) Beneficiary Authorization.
4) Proof of Delivery.
5) Face-to-Face clinical evaluation by the physician prior to the sleep test to assess the patient for
obstructive sleep apnea (OSA) containing the following elements:
a. Sleep history and symptoms which may be caused by OSA;
b. Epworth Sleepiness Scale (a standardized patient questionnaire which helps to assess the
likelihood of sleep apnea) or other validated sleep inventory, and
c. Pertinent physical examination – e.g., body mass index, neck circumference, upper airway
exam, and cardiopulmonary exam.
6) Medicare-covered sleep test that meets either of the following criteria:
a. Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) greater than or equal to15
events per hour with a minimum of 30 events; OR
b. AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with a
minimum of 10 events and documentation of:
i. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia, OR
ii. ii. Hypertension, ischemic heart disease, or history of stroke.
7) Documentation that the patient and/or caregiver received instruction from the supplier of the Positive
Airway Pressure (PAP) device and accessories in the proper use and care of the equipment.
8) To continue coverage for the PAP device (Continuous Positive Airway Pressure (CPAP) or
Respiratory Assist Device (RAD)) beyond an initial 3-month trial period, there must be:
a. A face-to-face visit with the physician during the second or third month of the trial that documents
an improvement of the beneficiary’s symptoms; and
b. A data report from the PAP device which documents use of the PAP device for at least 4 hours
per night on 70% of nights for a 30 consecutive day period during the trial.
9) For beneficiaries who received a PAP device prior to Fee-For-Service (FFS) Medicare enrollment
and are now enrolled in Medicare and are seeking a new PAP device and/or accessories, both of the
following coverage requirements must be met:
a. Sleep test – There must be documentation that the beneficiary had a sleep test, prior to FFS
Medicare enrollment, that meets the FFS Medicare AHI/RDI coverage criteria in effect at the time
that the beneficiary seeks a replacement PAP device and/or accessories, and,
b. Clinical Evaluation – Following enrollment in FFS Medicare, the beneficiary must have a face-toface evaluation by their treating physician who documents in the beneficiary’s medical record that:
i.
The beneficiary has a diagnosis of obstructive sleep apnea; and,
ii.
The beneficiary continues to use the PAP device.
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Medicare Bulletin – GR 2012-11
- page 87 -
November 2012
Note: Please refer to the basic coverage criteria specified in the PAP LCD by your DME MAC
contractor for further guidance.
Respiratory Assist Devices
1) Documentation of a verbal order (if item is dispensed based on a verbal order) that contains:
a. Description of the item;
b. Name of the beneficiary;
c. Name of the physician, and d. Start date of the order.
2) Valid written order that contains:
a. Beneficiary’s name
b. Item to be dispensed
c. Pressure setting with or without backup rate
d. Treating physician’s signature
e. Date the treating physician signed the order
f. Start date of the order if the start date differs from the signature date.
3) Beneficiary Authorization.
4) Proof of Delivery.
5) Medical records documenting:
a. Symptoms characteristic of sleep-associated hypoventilation.
b. Patient has one of the following disorders and meets all coverage criteria for that disorder:
i. Restrictive Thoracic Disorder, or
ii. Severe COPD, or
iii. Central Sleep or Complex Sleep Apnea, or
iv. Hypoventilation Syndrome.
Note: Please refer to the basic coverage criteria specified in the RAD LCD by your DME MAC
contractor for further guidance.
Pressure Reducing Support Surfaces (groups 1 and 2).
1) Valid written order that contains:
a. Beneficiary’s name
b. Treating physician’s signature
c. Date the treating physician signed the order
d. Start date of the order if the start date differs from the signature date.
e. Clear, detailed description of the type of support surface the physician is ordering.
2) Beneficiary Authorization.
3) Signed statement from the treating physician indicating what, if any, payment criteria the patient
meets.
4) Medical records supporting patient meets the basic coverage criteria specified in the Pressure
Reducing Support Surfaces- Group 1 and 2 LCD.
Note: Please refer to the basic coverage criteria specified in the Pressure Reducing Support
Surfaces- Group 1 and 2 LCDs by your DME MAC contractor for further guidance.
Additional Information
For questions about documentation requirements, please contact your DME MAC at their toll-free
number, which may be found at http://www.cms.gov/Research-Statistics-Data-and- Systems/MonitoringPrograms/provider-compliance-interactive-map/index.html on the CMS website.
The OIG report titled “Claim Modifier Did Not Prevent Medicare from Paying Millions in Unallowable
Claims for Selected Durable Medical Equipment” is available at http://oig.hhs.gov/oas/reports/
region4/41004004.pdf on the OIG website.
The Medicare Learning Network® (MLN) fact sheet titled “Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS)Quality Standards,” is available at http://www.cms.gov/Outreach-andThis newsletter should be shared with all health care practitioners and managerial members of the provider/supplier staff.
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November 2012
- page 88 -
Medicare Bulletin – GR 2012-11
Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/DMEPOS_Qual_Stand_Booklet_
ICN905709.pdf on the CMS website.
The DME MAC websites are available as follows:
• Cigna Government Services
• National Government Services
• National Heritage Insurance Company (NHIC)
• Noridian Administrative Services
News Flash - Influenza Season is Around the Corner - As your patients age, their immune systems
may weaken. This weakening can make seniors more susceptible to complications from seasonal
influenza (flu). Now is the perfect time to remind your patients that seasonal influenza vaccination is
the best defense against the flu. Medicare provides coverage for one flu vaccine and its administration
per influenza season for seniors and other Medicare beneficiaries with no co-pay or deductible. Talk
with your Medicare patients about their risk for getting the flu and start protecting your patients as soon
as your 2012-2013 seasonal flu vaccine arrives. Also, don’t forget to immunize yourself and your staff.
Know what to do about the flu.
Remember – The influenza vaccine plus its administration is a covered Part B benefit. The influenza
vaccine is NOT a Part D covered drug. CMS will provide information and a link to the 2012-2013
Influenza Vaccine prices when they are available.
For more information on coverage and billing of the flu vaccine and its administration, please visit the
CMS Medicare Learning Network® Preventive Services Educational Products and CMS Immunizations web pages. While some providers may offer the flu vaccine, others can help their patients locate
a vaccine provider within their local community. HealthMap Vaccine Finder is a free, online service
where users can search for locations offering flu vaccines.
SE1239 - Updated ICD-10 Implementation Information
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash –The Centers for Medicare & Medicaid Services has posted an updated Medicare FFS
Version 5010 835 Health Care Claim Payment/Advice Companion Guide to the Medicare FFS
Companion Guides web page.
Provider Types Affected
This MLN Matters® Article is intended for all physicians, providers, suppliers, and other covered entities
who submit claims to Medicare contractors for services provided to Medicare beneficiaries in any health
care setting.
What You Need to Know
This MLN Matters® special edition article replaces article SE1019 and provides updated information
about the implementation of the International Classification of Diseases, 10th Edition, Clinical
Modification and Procedure Coding System (ICD-10-CM/ICD-10-PCS) code sets to help you better
understand (and prepare for) the United States health care industry’s change from ICD-9-CM to ICD10 for medical diagnosis and inpatient hospital procedure coding.
The ICD-10-related implementation date is now October 1, 2014, as announced in final rule CMS0040-F issued on August 24, 2012. This final rule is available at http://www.cms.gov/Medicare/Coding/
ICD10/Statute_Regulations.html on the Centers for Medicare & Medicaid Services (CMS) website.
Thus, on October 1, 2014, medical coding in U.S. health care settings will change from ICD-9-CM to
ICD-10. The transition will require business and systems changes throughout the health care industry.
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Medicare Bulletin – GR 2012-11
- page 89 -
November 2012
Everyone who is covered by the Health Insurance Portability and Accountability Act (HIPAA) must make
the transition, not just those who submit Medicare or Medicaid claims. The compliance dates are firm
and not subject to change. If you are not ready, your claims will not be paid. Preparing now can help you
avoid potential reimbursement issues.
Background
ICD-1 0 Implementation Com pliance Date
On October 1, 2014, CMS will implement the ICD-10-CM (diagnoses) and ICD-10-PCS (inpatient
procedures), replacing the ICD-9-CM diagnosis and procedure code sets.
• ICD-10-CM diagnoses codes will be used by all providers in every health care setting.
• ICD-10-PCS procedure codes will be used only for hospital claims for inpatient hospital
procedures.
• The compliance dates are firm and not subject to change.
o There will be no delays.
o There will be no grace period for implementation.
Important, please be aware:
• ICD-9-CM codes will not be accepted for services provided on or after October 1, 2014.
• ICD-10 codes will not be accepted for services prior to October 1, 2014.
You must begin using the ICD-10-CM codes to report diagnoses from all ambulatory and physician
services on claims with dates of service on or after October 1, 2014, and for all diagnoses on claims for
inpatient settings with dates of discharge that occur on or after October 1, 2014.
Additionally, you must begin using the ICD-10-PCS (procedure codes) for all hospital claims for inpatient
procedures on claims with dates of discharge that occur on or after October 1, 2014.
Note: Only ICD-10-CM, not ICD-10-PCS, will affect physicians. ICD-10-PCS will only be
implemented for facility inpatient reporting of procedures – it will not be used for physician
reporting. There will be no impact on Current Procedural Terminology (CPT) and Healthcare
Common Procedure Coding System (HCPCS) codes. You should continue to use these codes
for physician, outpatient, and ambulatory services. Physician claims for services provided to
inpatient patients will continue to report CPT and HCPCS codes.
What are the Differences Betw een the ICD-10-CM/ICD-1 0-P CS and ICD-9-CM Code Sets?
The differences between the ICD-10 code sets and the ICD-9 code sets are primarily in the overall number
of codes, their organization and structure, code composition, and level of detail. There are approximately
70,000 ICD-10-CM codes compared to approximately 14,000 ICD-9-CM diagnosis codes, and
approximately 70,000 ICD-10-PCS codes compared to approximately 4,000 ICD-9-CM procedure codes.
In addition, ICD-10 codes are longer and use more alpha characters, which enable them to provide
greater clinical detail and specificity in describing diagnoses and procedures. Also, terminology and
disease classification have been updated to be consistent with current clinical practice.
Finally, system changes are also required to accommodate the ICD-10 codes.
What are Benefits of the ICD-1 0 Codin g System ?
The new, up-to-date classification system will provide much better data needed to:
• Measure the quality, safety, and efficacy of care
• Reduce the need for attachments to explain the patient’s condition
• Design payment systems and process claims for reimbursement
• Conduct research, epidemiological studies, and clinical trials
• Set health policy
• Support operational and strategic planning
• Design health care delivery systems
• Monitor resource utilization
• Improve clinical, financial, and administrative performance
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November 2012
- page 90 -
Medicare Bulletin – GR 2012-11
•
•
Prevent and detect health care fraud and abuse
Track public health and risks
ICD-10-CM Code Use an d Structure
The ICD-10-CM (diagnoses) codes are to be used by all providers in all health care settings. Each ICD10-CM code is 3 to 7 characters, the first being an alpha character (all letters except U are used), the
second character is numeric, and characters 3-7 are either alpha or numeric (alpha characters are not
case sensitive), with a decimal after the third character. Examples of ICD-10-CM codes follow:
• A78 – Q fever
• A69.21 – Meningitis due to Lyme disease
• O9A.311 – Physical abuse complicating pregnancy, first trimester
• S52.131A – Displaced fracture of neck of right radius, initial encounter for closed fracture
Additionally, the ICD-10-CM coding system has the following new features:
1) Laterality (left, right, bilateral) For example:
• C50.511 – Malignant neoplasm of lower-outer quadrant of right female breast
• H16.013 – Central corneal ulcer, bilateral
• L89.022 – Pressure ulcer of left elbow, stage II
2) Combination codes for certain conditions and common associated symptoms and manifestations
For example:
• K57.21 – Diverticulitis of large intestine with perforation and abscess with bleeding
• E11.341 – Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with
macular edema
• I25.110 – Atherosclerotic heart disease of native coronary artery with unstable angina
pectoris
3) Combination codes for poisonings and their associated external cause
For example:
• T42.3x2S – Poisoning by barbiturates, intentional self-harm, sequela
4) Obstetric codes identify trimester instead of episode of care
For example:
• O26.02 – Excessive weight gain in pregnancy, second trimester
5) Character “x” is used as a 5th character placeholder in certain 6 character codes to allow for
future expansion and to fill in other empty characters (e.g., character 5 and/or 6) when a code
that is less than 6 characters in length requires a 7th character
For example:
• T46.1x5A – Adverse effect of calcium-channel blockers, initial encounter
• T15.02xD – Foreign body in cornea, left eye, subsequent encounter
6) Two types of Excludes notes
Excludes 1 – Indicates that the code excluded should never be used with the code where the note is
located (do not report both codes).
For example:
• Q03 – Congenital hydrocephalus (Excludes1: Acquired hydrocephalus (G91.-) Excludes 2
– Indicates that the condition excluded is not part of the condition represented by the code
but a patient may have both conditions at the same time, in which case both codes may be
assigned together (both codes can be reported to capture both conditions).
• L27.2 – Dermatitis due to ingested food (Excludes 2: Dermatitis due to food in contact with
skin (L23.6, L24.6, L25.4)
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Medicare Bulletin – GR 2012-11
- page 91 -
November 2012
7) Inclusion of clinical concepts that do not exist in ICD-9-CM (e.g., underdosing, blood type, blood
alcohol level)
For example:
• T45.526D – Underdosing of antithrombotic drugs, subsequent encounter
• Z67.40 – Type O blood, Rh positive
• Y90.6 – Blood alcohol level of 120–199 mg/100 ml
8) A number of codes have been significantly expanded (e.g., injuries, diabetes, substance abuse,
postoperative complications)
For example:
• E10.610 – Type 1 diabetes mellitus with diabetic neuropathic arthropathy
• F10.182 – Alcohol abuse with alcohol-induced sleep disorder
• T82.02xA – Displacement of heart valve prosthesis, initial encounter
9) Codes for postoperative complications have been expanded and a distinction made between
intraoperative complications and postprocedural disorders
For example:
• D78.01 – Intraoperative hemorrhage and hematoma of spleen complicating a procedure on
the spleen
• D78.21 – Postprocedural hemorrhage and hematoma of spleen following a procedure on the
spleen
Finally, there are additional changes in ICD-10-CM, to include:
• Injuries are grouped by anatomical site rather than by type of injury
• Category restructuring and code reorganization have occurred in a number of ICD-10-CM
chapters, resulting in the classification of certain diseases and disorders that are different
from ICD-9-CM
• Certain diseases have been reclassified to different chapters or sections in order to reflect
current medical knowledge
• New code definitions (e.g., definition of acute myocardial infarction is now 4 weeks rather
than 8 weeks)
• The codes corresponding to ICD-9-CM V codes (Factors Influencing Health Status and
Contact with Health Services) and E codes (External Causes of Injury and Poisoning)
are incorporated into the main classification rather than separated into supplementary
classifications as they were in ICD-9-CM.
To learn more about the ICD-10-CM coding structure you may review “Basic Introduction to ICD-10- CM”
audio or written transcripts from the March 23, 2010 provider outreach conference call, which is available
at http://www.cms.gov/Medicare/Coding/ICD10/index.html on the CMS website.
ICD -1 0-PCS Code Use and Structure
The ICD-10-PCS codes are for use only on hospital claims for inpatient procedures. ICD-10-PCS codes
are not to be used on any type of physician claims for physician services provided to hospitalized
patients. These codes differ from the ICD-9-CM procedure codes in that they have 7 characters that
can be either alpha (non-case sensitive) or numeric. The numbers 0 - 9 are used (letters O and I are not
used to avoid confusion with numbers 0 and 1), and they do not contain decimals. For example:
• 0FB03ZX - Excision of liver, percutaneous approach, diagnostic
• 0DQ10ZZ - Repair, upper esophagus, open approach
Help with Converting Codes
The General Equivalence Mappings (GEMs) are a tool that can be used to convert data from ICD-9- CM
to ICD-10-CM/PCS and vice versa. Mapping from ICD-10-CM/PCS codes back to ICD-9-CM codes is
referred to as backward mapping. Mapping from ICD-9-CM codes to ICD-10-CM/PCS codes is referred
to as forward mapping. The GEMs are a comprehensive translation dictionary that can be used to
accurately and effectively translate any ICD-9-CM-based data, including data for:
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Newsletters issued after January 1997 are available at no cost from our website at www.cgsmedicare.com.
November 2012
- page 92 -
Medicare Bulletin – GR 2012-11
•
•
•
•
Tracking quality
Recording morbidity/mortality
Calculating reimbursement
Converting any ICD-9-CM-based application to ICD-10-CM/PCS
The GEMs can be used by anyone who wants to convert coded data, including:
• All payers
• All providers
• Medical researchers
• Informatics professionals
• Coding professionals—to convert large data sets
• Software vendors—to use within their own products;
• Organizations—to make mappings that suit their internal purposes or that are based on their
own historical data
• Others who use coded data
The GEMs are not a substitute for learning how to use the ICD-10 codes. More information about GEMs
and their use can be found on the CMS website at http://www.cms.gov/Medicare/Coding/ICD10/index.html
(select from the left side of the web page ICD-10-CM or ICD-10-PCS to find the most recent GEMs).
Additional information about GEMs was provided on the following CMS sponsored conference call - May
19, 2009, “ICD-10 Implementation and General Equivalence Mappings” (http://www.cms.gov/Medicare/
Coding/ICD10/index.html on the CMS website).
What to do Now in Preparation for ICD-10 Implementation ?
If you have not already done so, here are the steps you need to consider to implement ICD-10:
• Learn about the structure, organization, and unique features of ICD-10-CM - all provider
types.
• Learn about the structure, organization, and unique features of ICD-10-PCS - inpatient
hospital claims.
• Learn about system impact and 5010.
• Use assessment tools to identify areas of strength/weakness in medical terminology and
medical record documentation.
• Review and refresh knowledge of medical terminology as needed based on the assessment
results.
• Provide additional training to refresh or expand knowledge in the biomedical sciences
• (anatomy, physiology, pathophysiology, pharmacology, and medical terminology).
• Plan to provide intensive coder training approximately 6 -9 months prior to implementation.
• Allocating 16 hours of ICD-10-CM training will likely be adequate for most coders, and very
proficient ICD-9-CM coders may not need that much.
Additional Information
To find additional information about ICD-10, visit http://www.cms.gov/Medicare/Coding/ICD10/index.
html on the CMS website. In addition, CMS makes the following resources available to assist in your
transition to ICD-10:
• Medicare Fee-for-Service Provider Resources Web Page -This site links Medicare feefor- service (FFS) providers to information and educational resources that are useful for all
providers to implement and transition to ICD-10 medical coding in a 5010 environment. As
educational materials become available specifically for Medicare FFS providers, they will be
posted to this web page. Bookmark http://www.cms.gov/Medicare/Coding/ICD10/index.html
and check back regularly for access to ICD-10 implementation information of importance to
you. Note: Use the links on the left side of the web page to navigate to ICD-10 and 5010
information applicable to your specific interest.
• CMS Sponsored National Provider Conference Calls - During the ICD-10 implementation
period, CMS will periodically host national provider conference calls focused on various
topics related to the implementation of ICD-10. Calls will include a question and answer
session that will allow participants to ask questions of CMS subject matter experts. These
conference calls are offered free of charge and require advance registration. Continuing
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 93 -
November 2012
•
•
•
education credits may be awarded for participation in CMS national provider conference
calls. For more information, including announcements and registration information for
upcoming calls, presentation materials and written and audio transcripts of previous calls,
please visit http://www.cms.gov/Medicare/Coding/ICD10/index.html on the CMS website.
Frequently Asked Questions (FAQs) - To access FAQs related to ICD-10, please visit the
CMS ICD-10 web page at http://www.cms.gov/Medicare/Coding/ICD10/index.html, select the
Medicare Fee-for-Service Provider Resources link from the menu on the left side of the
page, scroll down the page to the “Related Links Inside CMS” section and select “ICD-10
FAQs”. Please check the ICD-10 FAQ section regularly for newly posted or updated ICD-10
FAQs.
See MLN Matters® Special Edition Article, SE1240, at http://www.cms.gov/Outreach- andEducation/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/SE1240.pdf
for a discussion of a partial freeze on ICD-10 code set prior to implementation.
The following organizations offer providers and others ICD-10 resources:
• Workgroup for Electronic Data Interchange (WEDI) http://www.wedi.org; and
• Health Information and Management Systems Society (HIMSS) http://www.himss.org/
icd10 on the Internet.
SE1240 - Partial Code Freeze Prior to ICD-10 Implementation
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – On August 24, Health and Human Services (HHS) Secretary Kathleen Sebelius
announced a final rule that will save time and money for physicians and other health care providers
by establishing a unique Health Plan Identifier (HPID). The rule is one of a series of changes required
by the Affordable Care Act to cut red tape in the health care system and will save up to $6 billion over
ten years. Currently, when a health care provider bills a health plan, that plan may use a wide range
of different identifiers that do not have a standard format. As a result, health care providers run into a
number of time-consuming problems, such as misrouting of transactions, rejection of transactions due
to insurance identification errors, and difficulty determining patient eligibility. The change announced on
August 24 will greatly simplify these processes. For more information, see the Fact Sheet related to this
final rule.
Provider Types Affected
This MLN Matters® Special Edition Article affects all Medicare Fee-For-Service (FFS) physicians,
providers, suppliers, and other entities who submit claims to Medicare contractors for services provided
to Medicare beneficiaries in any health setting.
What You Need to Know
At a meeting on September 14, 2011, the ICD-9-CM Coordination & Maintenance (C&M) Committee
implemented a partial freeze of the ICD-9-CM and ICD-10 (ICD-10-CM and ICD-10-PCS) codes prior
to the implementation of ICD-10 which would end one year after the implementation of ICD-10. The
implementation of ICD-10 was delayed from October 1, 2013 to October 1, 2014 by final rule CMS0040-F issued on August 24, 2012. This final rule is available at http://www.cms.gov/Medicare/Coding/
ICD10/Statute_Regulations.html on the Centers for Medicare & Medicaid Services (CMS) website.
There was considerable support for this partial freeze. The partial freeze will be implemented as follows:
• The last regular, annual updates to both ICD-9-CM and ICD-10 code sets were made on
October 1, 2011.
• On October 1, 2012 and October 1, 2013 there will be only limited code updates to both the
ICD-9-CM and ICD-10 code sets to capture new technologies and diseases as required by
section 503(a) of Pub. L. 108-173.
• On October 1, 2014, there will be only limited code updates to ICD-10 code sets to capture
new technologies and diagnoses as required by section 503(a) of Pub. L. 108-173. There will
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Newsletters issued after January 1997 are available at no cost from our website at www.cgsmedicare.com.
November 2012
- page 94 -
Medicare Bulletin – GR 2012-11
•
be no updates to ICD-9-CM, as it will no longer be used for reporting.
On October 1, 2015, regular updates to ICD-10 will begin.
The ICD-9-CM Coordination and Maintenance Committee will continue to meet twice a year during
the partial freeze. At these meetings, the public will be asked to comment on whether or not requests
for new diagnosis or procedure codes should be created based on the criteria of the need to capture
a new technology or disease. Any code requests that do not meet the criteria will be evaluated for
implementation within ICD-10 on and after October 1, 2015 once the partial freeze has ended.
The code freeze was initially discussed at the September 15, 2010, meeting of the committee.
To view the transcript of that meeting, go to: http://www.cms.gov/Medicare/Coding/
ICD9ProviderDiagnosticCodes/index.html on the CMS website. From there, select the September 1516, 2010, meeting documents and transcripts from the Downloads section, and then from the ZIP files,
select the ‘091510_Morning_Transcript’ file. This section appears on page 4 of the 78-page document.
To view the Summary Report of the meeting, go to: http://www.cms.gov/Medicare/Coding/
ICD9ProviderDiagnosticCodes/index.html on the CMS website. From there, select the September 15-16,
2010, meeting documents and transcripts from the Downloads section, and then from the ZIP files, select
the ‘091510_ICD9_Meeting_Summary_report.pdf’ file. Information on the Code Freeze begins on page 5.
Additional Information
CMS has developed a variety of educational resources to help Medicare FFS providers understand and
prepare for the transition to ICD-10. General information about ICD-10 is available at http://www.cms.
gov/Medicare/Coding/ICD10/index.html on the CMS website.
In addition, the following CMS resources are available to assist in your transition to ICD-10:
• Medicare Fee-for-Service Provider Resources Web Page -This site links Medicare FeeFor-Service (FFS) providers to information and educational resources that are useful for all
providers to implement and transition to ICD-10 medical coding in a 5010 environment. As
educational materials become available specifically for Medicare FFS providers, they will be
posted to this web page. Bookmark http://www.cms.gov/Medicare/Coding/ICD10/index.html
and check back regularly for access to ICD-10 implementation information of importance to
you. Note: Use the links on the left side of the web page to navigate to ICD-10 and 5010
information applicable to your specific interest.
• CMS Sponsored National Provider Conference Calls - During the ICD-10 implementation
period, CMS will periodically host national provider conference calls focused on various
topics related to the implementation of ICD-10. Calls will include a question and answer
session that will allow participants to ask questions of CMS subject matter experts. These
conference calls are offered free of charge and require advance registration. Continuing
education credits may be awarded for participation in CMS national provider conference
calls. For more information, including announcements and registration information for
upcoming calls, presentation materials and written and audio transcripts of previous calls,
please visit http://www.cms.gov/Medicare/Coding/ICD10/index.html on the CMS website.
• See MLN Matters® Special Edition Article, SE1239, at http://www.cms.gov/Outreach- andEducation/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/SE1239.pdf for
an overview of what is needed to implement ICD-10.
• Frequently Asked Questions (FAQs) - To access FAQs related to ICD-10, please visit the
CMS ICD-10 web page at http://www.cms.gov/Medicare/Coding/ICD10/index.html, select
the Medicare Fee-for-Service Provider Resources link from the menu on the left side of
the page, scroll down the page to the “Related Links Inside CMS” section and select “ICD10 FAQs”. Please check the ICD-10 FAQ section regularly for newly posted or updated
ICD-10 FAQs.
The following organizations offer providers and others ICD-10 resources:
• Workgroup for Electronic Data Interchange (WEDI) http://www.wedi.org; and
• Health Information and Management Systems Society (HIMSS)
http://www.himss.org/icd10 on the Internet.
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 95 -
November 2012
Skin Substitute - Apligraf Update
CGS has updated the Apligraf article A50691 to allow a maximum of five applications within no more
than twelve weeks for any ulcer, effective October 1, 2012. This article is attached to the Biologic
Products for Wound Treatment and Surgical Interventions LCD L31853.
Small Provider and Medicare Update Workshops: Free!
Small Provider Workshops:
CGS is pleased to offer a series of upcoming Small Provider Workshops. A “small provider” is defined
as a practice with ten or fewer full-time equivalent (FTE) employees. These workshops are tailored
to address issues that directly affect this provider population. We will be adding additional dates and
locations over the coming months, so continue to monitor our ListServ for additional opportunities as
they become available. Although these workshops are primarily designed for staff at small provider
offices and practices, all providers and staff members are welcome to attend. These workshops will
feature the following topics:
•
•
•
•
•
•
•
Self-Service Technology Options
Electronic vs. Paper Billing
Medicare Incentive Programs
Preventive Services
Top Claim Denials, and Denial Resolution Resources
Offsets, Overpayments, and Claim Adjustments
Provider Enrollment Revalidation
Scheduled dates for CGS Small Provider Workshops:
Date
Thursday, October 18,
2012
Wednesday, October
24, 2012
Thursday, October 25,
2012
Tuesday, October 30,
2012
Location
City Willoughby Hills
Community Center
35400 Chardon Road
Willoughby Hills, OH 44094
NOTE: Limit = 50
Mercer County District Public
Library
303 North Main Street
Celina, OH 45822
NOTE: Limit =25
Cuyahoga Falls Library
2015 Third Street
Cuyahoga Falls, Ohio 44221
NOTE: Limit =30
Mansfield/Richland County
Public Library
Main Branch
43 West Third Street
Mansfield, OH 44902
NOTE: Limit =40
Times
Registration: 9:30 a.m. ET
Workshop: 10:00 a.m. – 12 p.m.
ET
NOTE: Registration end date =
10/15/12
Registration: 10 a.m. ET
Workshop: 10:30 a.m. – 12 p.m.
ET
NOTE: Registration end date =
10/22/12
Registration: 9:30 a.m. ET
Workshop: 10:00 a.m. – 12 p.m.
ET
NOTE: Registration end date =
10/22/12
Registration: 10:30 a.m. ET
Workshop: 11 a.m. -12:30 p.m. ET
NOTE: Registration end date =
10/26/12
Cost
Free
FREE
Free
FREE
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 www.cgsmedicare.com.
November 2012
- page 96 -
Medicare Bulletin – GR 2012-11
Date
Friday, November 2,
2012
Friday, December 7,
2012
Location
Guernsey County District
Public Library
Crossroads Branch
63500 Byesville Rd.
Cambridge, OH 43725
NOTE: Limit =40
Upper Sandusky Community
Library
301 N. Sandusky Ave.
Upper Sandusky, OH 43351
NOTE: Limit =50
Times
Registration: 10 a.m. ET
Workshop: 10:30 a.m. -12 p.m. ET
NOTE: Registration end date =
10/30/12
Cost
FREE
Registration: 10 a.m. ET
Workshop: 10:30 a.m. -12 p.m. ET
NOTE: Registration end date =
12/04/12
Free
Medicare Update Workshops:
CGS is also hosting Medicare Update workshops to provide you with information on the latest changes to the
Medicare program. We will be adding additional dates and locations over the coming months, so continue
to monitor our ListServ for additional opportunities as they become available. Medicare Update Workshops
will be held on the same dates and in the same locations as Small Provider Workshops. You are welcome to
attend both, although we recommend that you choose either the Small Provider Workshop or the Medicare
Update Workshop that is the best fit for you. These workshops will feature the following topics:
•
•
•
•
•
•
2013 Medicare Physician Fee Schedule Proposed Rule
Part B Outpatient Therapy Cap and Manual Review
Electronic Submission of Medical Documentation (esMD)
Medicare Claim Review Programs
Top “problem areas” and tips to help
myCGS
Scheduled Dates for the CGS Medicare Updates Workshops:
Date
Thursday,
October 18,
2012
Location
City Willoughby Hills Community
Center, 35400 Chardon Road,
Willoughby Hills, OH 44094
NOTE: Limit =50
Wednesday,
October 24,
2012
Mercer County District Public
Library
303 North Main Street
Celina, OH 45822
NOTE: Limit =25
Cuyahoga Falls Library
2015 Third Street
Cuyahoga Falls, Ohio 44221
NOTE: Limit =30
Thursday,
October 25,
2012
Times
Registration: 1:30 p.m. ET
Workshop: 2:00 p.m. – 4:00 p.m.
ET
NOTE: Registration end date =
10/15/12
Registration: 1 p.m. ET
Workshop: 1:30 a.m. – 3:30 p.m.
ET
NOTE: Registration end date =
10/22/12
Registration: 1:30 p.m. ET
Workshop: 2:00 p.m. – 4:00 p.m.
ET
NOTE: Registration end date =
10/22/12
Cost
Free
FREE
Free
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 97 -
November 2012
Date
Tuesday,
October 30,
2012
Friday,
November 2,
2012
Friday,
December 7,
2012
Location
Mansfield/Richland County Public
Library
Main Branch
43 West Third Street
Mansfield, OH 44902
NOTE: Limit =40
Guernsey County District Public
Library
Crossroads Branch
63500 Byesville Rd.
Cambridge, OH 43725
NOTE: Limit =40
Upper Sandusky Community
Library
301 N. Sandusky Ave.
Upper Sandusky, OH 43351
NOTE: Limit =50
Times
Registration: 1:30 p.m. ET
Workshop: 2 p.m. - 4 p.m. ET
NOTE: Registration end date =
10/26/12
Cost
FREE
Registration: 1:30 p.m. ET
Workshop: 2 p.m. - 4 p.m. ET
NOTE: Registration end date =
10/30/12
FREE
Registration: 1:30 p.m. ET
Workshop: 2 p.m. - 4 p.m. ET
NOTE: Registration end date =
12/04/12
Free
Can’t attend one of these workshops? CGS will be offering more of these workshops over the coming
months. Stay tuned to our ListServ and Calendar of Events for additional educational opportunities.
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 www.cgsmedicare.com.
November 2012
- page 98 -
Medicare Bulletin – GR 2012-11
Join the
CGS ListServ
By joining the CGS electronic mailing list, you
can get immediate updates on Medicare information, including:
• Medicare publications
• Important updates
• Workshops
• Medical Review information
To join the ListServ follow this link:
https://www.cgsmedicare.com/medicare_
dynamic/ls/001.asp
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 www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
- page 99 -
November 2012
Overpayment Refunds
Personal provider checks sent to us for any reason should be sent to the following address (if
you are submitting a refund due to Medicare Secondary Payer, include “MSP” on the envelope
or correspondence):
Kentucky and Ohio Providers
CGS – J15 Part B Kentucky and Ohio
PO Box 957065
St. Louis, MO 63195-7065
Personal provider checks should never be sent to our Nashville operations as this will create
processing delays. For example, in situations where you have received a letter of notification
regarding a Medicare overpayment, these delays can result in payment offset and/or interest
accrual.
Checks issued by CGS that need to be returned to us should be sent to the following address:
Kentucky and Ohio Providers
CGS – J15 Part B Kentucky and Ohio
PO Box 957065
St. Louis, MO 63195-7065
Medicare Bulletin
. . . a service of CGS
Two Vantage Way
Nashville, TN 37228
The CGS website (www.cgsmedicare.com) provides formal notification for all notices developed
and distributed by CGS, including the Part B Medicare Bulletin. Providers/suppliers are
obligated and responsible for remaining updated on current Medicare issues and legislation as
it is posted to the website.
Please note that for LCDs listed on the website, the start of the notice period may be different
than the date it is posted to the website. Please abide by the notice period dates on the
document, not the posting date.
A quarterly CD-ROM, which includes the Medicare Bulletin and other additional resources,
is mailed to the same location as Medicare checks. Provider groups will receive one copy of
the CD-ROM. Each individual provider in that group will not receive their own copy for his/her
individual provider identification number (PIN).
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 www.cgsmedicare.com.
November 2012
- page 100 -
Medicare Bulletin – GR 2012-11
OHIO
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 Web site at www.cgsmedicare.com.
Medicare Bulletin – GR 2012-11
OH Insert, page 101
NOVEMBER 2012