Download December 2003 Medicare Report

Medicare Report
A Quarterly Newsletter for Medicare Healthcare Professionals
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Icons will be used in the table of contents of the Medicare
Report to identify articles that may be of interest to a
particular type of provider. Articles of a general interest
will have no associated icon. A Key, listing those icons used,
will be included in each edition.
We have exercised due diligence in identifying articles that
pertain to particular types of practices. We strongly
encourage you to review the entire table of contents to
identify other articles and information that may also pertain
to your specific practice.
These are the icons that appear in this edition of the Medicare
Report.
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Description
Ambulance
Anesthesia/CRNA
December 1, 2003
www.hgsa.com
In This Issue
Carrier Medical Director Column . 3
News .............................................. 5
Educational Calendar of Events . 6
Specialty News
Ambulance ............................... 22
Laboratory ............................... 24
Reimbursement ............................ 27
Internet Spotlight ......................... 32
Fraud and Abuse .......................... 33
Claim Reporting ........................... 34
Medical Review Highlights .......... 42
Coverage Issues ........................... 45
Medical Policy ............................. 54
DMERC News .............................. 58
Request for Education .................. 60
Education & Training Feedback
Form ........................................ 61
EDI Xcellence ......................... Insert
Clinical Diagnostic Lab
Consolidated Billing/SNF
Diagnostic Testing
Eye Care
Non Physician Practitioners
Surgery
Therapy/Rehab (OT/PT)
Teaching Physicians
This bulletin should be shared with all health care practitioners
and managerial members of the physician/supplier staff.
Medicare Reports are available at no cost from our web site at
www.hgsa.com/professionals/med-reports.shtml
Happy Holidays!
Our office will be closed
Dec. 25th, Dec. 26th, and
Jan. 1st for the holidays.
Table of Contents
Medicare Report
December 1, 2003
The Medicare Report is
published quarterly as an
informational reference source
by HGSAdministrators for
health care professionals in
Pennsylvania. This material is
intended to complement and not
replace Medicare program
requirements as set forth in
statute, regulations and manual
instructions. It is the
responsibility of each healthcare
professional/supplier submitting
claims to HGSAdministrators to
familiarize themselves with
Medicare coverage
requirements.
HGSAdministrators makes
efforts to ensure the information
contained in this publication is
accurate and current. However,
because the Medicare program is
constantly changing, it is the
responsibility of each provider/
supplier to remain abreast of the
Medicare program requirements.
Questions concerning this
publication or its contents may
be directed in writing to:
HGSAdministrators
Medicare Professional Services
PO Box 890089
Camp Hill, PA 17089-0089
CPT codes, descriptors, and
other data only are copyright
2002 American Medical
Association. All Rights
Reserved. Applicable FARS/
DFARS apply.
Customer Service/ARU
1-866-488-0548
Telephone Appeals
1-866-488-0551
EDI Services
1-866-488-0546
Telecommunications
Devices for the Deaf
1-800-242-8471
Icons Identify Articles ........................................ 1
Carrier Medical Director Column
Save Your Vision Week—First Week of March ... 3
Low Vision Awareness Month—February .......... 3
News
Alien Beneficiaries Who are Not Lawfully
Present in the United States—Payment
Will Be Denied for Medicare Services ............ 5
CCI Version 10.0 ................................................ 5
Consolidated Billing for SNF—2004 Updates ....... 6
Educational Calendar of Events .......................... 6
CMS Paper Manuals Being Transitioned to
Web-Based System ......................................... 6
Freedom of Information Act (FOIA) Requests ... 8
Frequently Asked Questions ............................... 8
Holidays—2004 ............................................... 11
Home Health Consolidated Billing—2004
Update of HCPCS Codes ............................. 11
Mediation: The New Approach to Resolving
Quality of Care Concerns ............................. 14
Medicare Deductible, Coinsurance, and
Premiums for 2004 ....................................... 14
Medicare Secondary Payer (MSP) Working
Aged Provision Clarification ........................ 15
Provider Enrollment News ............................... 16
Psychotherapy Medical Record
Documentation—HIPAA Privacy Rule ......... 16
Psychotherapy Services and ‘Incident To’
Billing—Update ........................................... 17
Quarterly Provider Update ................................ 17
Remittance Advice Remark and Reason
Codes—New Codes ..................................... 18
Request for Hearing Form Developed for Your Use 18
Sign Up for a Listserv ...................................... 20
Timely Filing of Claims ................................... 20
Web Sites ......................................................... 22
Specialty News
Ambulance
Fee Information ................................................ 22
Payment Calculation for Ground Ambulance
Services Provided In Rural Areas for 2004 ....... 22
Policy Clarifications ......................................... 23
Laboratory
2004 Clinical Laboratory Fee Schedule ............ 24
Clinical Laboratory Test National Coverage
Determinations (NCDs) Changes .................... 25
Fecal Leukocyte Examination Reporting .......... 25
Guidelines for Medicare Part B Laboratory
Testing .......................................................... 26
GY Modifier Usage For Clinical Laboratory
Services ........................................................ 27
Reimbursement
Influenza Virus Vaccine—CMS Updates Fee .... 27
Medicare Physician Fee Schedule Database
Revisions ...................................................... 27
Drug Fees Revised ........................................... 28
Splint and Cast Fees for 2004 ........................... 32
Internet Spotlight
Twenty Interactive Training Modules Now
Available! ..................................................... 32
www.hgsa.com
2
Fraud and Abuse
Claim Reporting
2004 HCPCS Update ........................................ 34
Anesthesia Reimbursement Based on
Jurisdictional Payment .................................. 34
Beneficiary Signature on Claim Form .............. 34
Cataract Surgery—Co-Management ................. 35
Changes to Code List for Therapy Services ...... 36
Compounded Drugs—Billing for ..................... 36
Hepatitis B Vaccine—CPT Codes ..................... 37
Influenza Virus Vaccine—Use Diagnosis
Code V04.81 ................................................ 37
Mammography—Reporting CAD Codes ......... 37
Not Otherwise Classified (NOC) Codes for
Injections ...................................................... 38
Outpatient Rehabilitation Services Billing
Guidelines .................................................... 38
Quarterly Update of HCPCS Codes Used for
Home Health Consolidated Billing
Enforcement—Correction ............................ 41
Purchased Services—Jurisdictional Reporting
Clarification .................................................. 41
Radiation Therapy Modifier XJ ........................ 41
Transportation of Portable X-rays (R0075)—
Modifier Use ................................................ 42
Medical Review Highlights
Follow-up Consultations .................................. 42
Home Visit Codes (99347-99350) for
Established Patients ...................................... 42
Hospital Discharge Day Management .................. 43
Implantable Infusion Pumps ............................. 43
Modifiers 22, 23, 52 and 53 .............................. 44
Nurse Practitioner Services ............................... 44
PET Scans—Documentation Must Accompany
Claim ............................................................ 45
Coverage Issues
Artificial Hearts and Related Devices ............... 45
Drugs & Biologicals ......................................... 48
HBO Therapy—Expanded Coverage ................ 48
Implantable Automatic Defibrillators—National
Coverage Determination ............................... 48
Lipid Panels ...................................................... 50
Lung Volume Reduction Surgery ...................... 51
PET Scans—Expanded Coverage for Thyroid
Cancer and Perfusion of the Heart ................ 54
Medical Policy
Implementation of Local Medical Review
Policies (LMRPs) ......................................... 54
Local Medical Review Policy Updates ............. 55
Policies Revised Due to 2004 ICD-9-CM Update . 57
DMERC News
Individual Consideration (IC) Codes—Billing
Reminder ...................................................... 58
Interim Final Rule for Electronic Submission
of Medicare Claims ...................................... 58
Printed Copies of the DMERC A Supplier Manual 58
Region A Provider Information ........................ 58
Tips for Online Bulletins .................................. 59
Request for Education ................................ 60
Education & Training Feedback Form ...... 61
EDI Xcellence ........................................ Insert
Sanctioned Providers ........................................ 33
Medicare Report / December 1, 2003
Carrier Medical Director Column
Save Your Vision Week—First Week of March
Low Vision Awareness Month—February
The Congress, by joint resolution approved December 30, 1963, authorized and requested that the President of the
United States proclaim the first week in March of each year as “Save Your Vision Week.” In the March 2003
Proclamation, President George W. Bush encouraged “all Americans to learn more about ways to prevent eye
problems and to help others maintain the precious gift of sight.” President Bush also urged “all Americans to make
eye care and eye safety an important part of their lives and to include dilated eye examinations in their regular
health maintenance programs. I invite eye care professionals, teachers, the media, and all public and private organizations dedicated to preserving eyesight to join in activities that will raise awareness of measures all Americans
can take to protect and sustain our vision.”
In keeping with this Presidential directive many individuals and organizations in the next couple of months
will be sponsoring and promoting activities and education that encourages good eye health care. One of these
initiatives is the recognition of February as Low Vision Awareness Month, sponsored by Prevent Blindness
America.
HGSAdministrators recognizes the importance of these efforts. As the Presidential Proclamation states, “Our
sense of sight affects how we work, communicate, and learn.” However, “each year the number of Americans
who suffer from vision loss increases, yet half of all blindness can be prevented through early detection and
treatment.”
The Social Security Act and the Centers for Medicare and Medicaid Services (CMS) provides specific guidelines to
Medicare contractors related to routine eye services. The exclusions apply to eyeglasses or contact lenses and eye
examinations for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive errors.
The exclusions do not apply to physician services (and services incident to a physician’s service) performed in
conjunction with an eye disease (e.g., glaucoma or cataracts) or to postsurgical prosthetic lenses which are
customarily used during convalescence from eye surgery in which the lens of the eye was removed or to permanent
prosthetic lenses required by an individual lacking the organic lens of the eye, whether by surgical removal or
congenital disease. Such prosthetic lens is a replacement for an internal body organ (the lens of the eye).
In light of the President’s focus on eye health and our own interest in providing services that are statutorily covered
and beneficial to the health and well being of Pennsylvania’s Medicare population, HGSA is listing in this article
many of the services, drugs, and procedures related to eye care that are available to our Medicare beneficiaries in
Pennsylvania. These services include those that help diagnose and treat the leading causes of blindness – macular
degeneration and glaucoma. Macular degeneration is an incurable eye disease and is the leading cause of blindness
for those 55 years and older in the United States, affecting more than 10 million Americans. Glaucoma is a group
of eye diseases that gradually steals sight without warning and often without symptoms. Glaucoma vision loss is
caused by damage to the optic nerve. It is estimated that over 3 million Americans have glaucoma, but only half of
those know that they have glaucoma.
Medicare Report / December 1, 2003
3
The Benefits Improvements and Protection Act of 2000, §102, provides for the annual coverage for glaucoma
screening for eligible Medicare beneficiaries, i.e., those with diabetes mellitus, a family history of glaucoma,
African-Americans age 50 and over, and certain other individuals found to be at high risk for glaucoma.
Coverage applies to glaucoma screening examination services performed on eligible beneficiaries on or after
January 1, 2002.
Medicare will pay for glaucoma screening examinations where they are furnished by or under the direct supervision
of an ophthalmologist or optometrist, who is legally authorized to perform the services under State law. Screening
for glaucoma is defined to include (1) a dilated eye examination with an intraocular pressure measurement; and (2)
a direct ophthalmoscopy examination, or a slit-lamp biomicroscopic examination. Payment may be made for a
glaucoma screening examination that is performed on an eligible beneficiary after at least 11 months have passed
following the month in which the last covered glaucoma screening examination was performed.
Glaucoma screening is billed under the following HCPCS codes and “V” ICD-9 code:
G0117 Glaucoma screening for high-risk patients furnished by a physician
G0118 Glaucoma screening for high-risk patients furnished under the direct supervision of a physician
V80.1 Special screening for neurological, eye, and ear disease, glaucoma
The Local Medical Review Policies (LMRP) listed below provide the complete guidelines developed by HGSA in
conjunction with our Carrier Advisory Committee (CAC). All policies are available on our web site at http://
www.hgsa.com/professionals/med-policy.shtml.
LMRP G-38
LMRP M-36
LMRP M-37
LMRP M-42
LMRP M-44
LMRP M-47
LMRP M-62
LMRP M-63
LMRP M-65
LMRP S-14
LMRP S-41
LMRP S-112
LMRP S-134
LMRP X-7
LMRP Y-12
Photodynamic Therapy (PDT) – Specifically, Verteporfin (Visudyne)
Fluorescein Angiography
Fundus Photography
General Ophthalmological Services
Ophthalmoscopy, Extended
Visual Fields
Scanning Computerized Ophthalmic Diagnostic Imaging
Indocyanine Green Angiography
Corneal Pachymetry
Cataract Surgery
Corneal Surgery to Correct Refractive Errors
YAG Capsulotomy
Blepharoplasty/Blepharoptosis
Ophthalmic Echography
Visual Rehabilitation Program
Andrew Bloschichak, MD, MBA
Vice President and Carrier Medical Director
Pennsylvania Medicare Part B
HGSAdministrators
4
Medicare Report / December 1, 2003
N eew
ws
Alien Beneficiaries Who
are Not Lawfully Present
in the United States—
Payment Will Be Denied
for Medicare Services
Background
Section 401 of the Personal Responsibility and Work
Opportunity Reconciliation Act of 1996 (PRWORA)
prohibited aliens who are not “qualified aliens” from
receiving Federal public benefits including Medicare.
The term “qualified alien” is defined to include six
groups of aliens as follows:
(1) Aliens who are lawfully admitted for permanent
residence under the Immigration and Nationality
Act (Act);
(2) Aliens who are granted asylum under section 208
of the Act;
Medicare exemption to the prohibition on eligibility
for non-qualified alien beneficiaries, who are lawfully
present in the United States and who meet certain other
conditions.
Under the provisions of the final rule, payment may be
made for services furnished to an alien who is lawfully
present in the United States (and, provided that with
respect to benefits payable under Part A of Title XVIII
of the Social Security Act [42 U.S.C. 1395c et seq.],
who was authorized to be employed with respect to any
wages attributable to employment which are counted
for purposes of eligibility for Medicare benefits). The
definition for “lawfully present in the United States” is
found at 8 CFR 103.12.
Payment for Medicare Benefits
For claims processed, effective January 1, 2004,
payment will be denied for Medicare services furnished
to an alien beneficiary who is not lawfully present in
the United States. Denial of these services will include
the Medicare Summary Notice message, “Medicare
payment may not be made for the item or service
because, on the date of service, you were not lawfully
present in the United States.”
(3) Refugees admitted into the United States under
section 207 of the Act;
CCI Version 10.0
(4) Aliens who are paroled into the United States under
section 212(d)(5) of the Act for a period of at least
1 year;
The Centers for Medicare and Medicaid Services has
issued changes to the Correct Coding Initiative Edits.
This update is Version 10.0, and is effective for dates
of service on or after January 1, 2004.
(5) Aliens whose deportation is being withheld under
section 243(h) of the Act; or
(6) Aliens who are granted conditional entry pursuant
to section 203(a)(7) of the Act as in effect prior to
April 1, 1980.
Two groups of qualified aliens were added to the statute
after the original enactment of the restriction in the 1996
Welfare Reform statute. These groups are certain Cuban
and Haitian entrants to the United States and certain
“battered aliens.”
Under the terms of the PRWORA, non-qualified aliens
could not receive Medicare benefits.
Services previously reduced or denied due to edits
that have been deleted in Version 10.0 will not be
automatically reprocessed. Affected providers
should file a written or telephone appeal request.
Written requests should be submitted via the Medicare
Insurance Claim Review Request form and sent to
HGSAdministrators, PO Box 890413, Camp Hill, PA
17089-0413. Copies of this form can be printed from
our web site at http://www.hgsa.com/professionals/
forms.shtml. Telephone requests should be submitted
by calling Telephone Appeals at 1-866-488-0551.
Section 5561 of the Balanced Budget Act of 1997 (BBA)
amended section 401 of the PRWORA to create a
The NCCI edits are posted at http://cms.hhs.gov/
physicians/cciedits/default.asp as a spreadsheet that
allows users to sort by procedural code and by effective
date. A “Find” feature allows users to look for a specific
Medicare Report / December 1, 2003
5
code. The edit files are indexed by procedural code
ranges for easy navigation.
Copies of the National Correct Coding Policy Manual
for Part B Carriers and/or copies of Version 10.0 may
also be purchased by contacting the National Technical
Information Service. For the Sales Desk, call 800-5536847 or 703-605-6000; for subscriptions, call 800-3632068 or 703-605-6060.
Consolidated Billing for
SNF—2004 Updates
The coding files for skilled nursing facility consolidated
billing will be updated effective January 1, 2004. These
updates will appear on the CMS web site at http://
cms.hhs.gov/medlearn/snfcodes.asp on or about
December 1, 2003. In order to correctly bill services,
physicians, non-physician practitioners, and suppliers
should carefully review the revised codes files.
CMS Paper Manuals Being
Transitioned to Web-Based
System
Beginning October 1, 2003, the Centers for Medicare
and Medicaid Services will transition from a paperbased manual system to a web-based system. The
process includes the streamlining, updating, and
consolidating of CMS’ various program instructions into
an electronic web-based manual system for all users.
The new system is called the online CMS Manual
System and is located at http://www.cms.hhs.gov/
manuals. The new online CMS Manual System will be
organized by functional area, (e.g., eligibility,
entitlement, claims processing, benefit policy, program
integrity). The functional orientation of the new manual
will eliminate significant redundancy within the
manuals and will streamline the updating process, thus
making CMS program instructions available in a more
timely and accessible fashion. Access the CMS web
site for more information and to view the manuals.
Educational Calendar of Events
Teleconference (No Registration Required)
To participate, please dial the telephone number listed on the date of the teleconference and enter the participant
code when prompted. When the call has reached attendee capacity, you will hear the message, “Conference is full.”
Date
Topic
Time
Dial In #
Participant
Code
December 17
Medicare Updates
2-4 pm
5:30-7:30 pm
877-214-0402
877-214-0402
439847
439847
January 21
Medicare Updates
9-11 am
2-4 pm
888-296-1938
888-296-1938
923187
923187
February 25
To be Determined
9-11 am
2-4 pm
888-296-1938
888-296-1938
923187
923187
March 24
To be Determined
2-4 pm
5:30-7:30 pm
888-296-1938
888-296-1938
923187
923187
6
Medicare Report / December 1, 2003
Teleconference (Registration Required)
To participate, please register via the Online Registration at http://www.hgsa.com/professionals/events-tele.shtml
or by Paper/Fax Registration as indicated below. The telephone number and participant code will be provided to
you with your confirmation.
Date
December 9
Topic
E & M Services vs. Routine Foot Care
Time
9 am & 1 pm
January 6
Ophthalmology Services
9 am & 1 pm
January 7
New & Revised Local Medical Review Policies
9 am & 1 pm
February 4
Drugs & Biologicals
9 am & 1 pm
April 7
New & Revised Local Medical Review Policies
9 am & 1 pm
July 7
New & Revised Local Medical Review Policies
9 am & 1 pm
New Physician/Office Training
Date
Location
Time
December 4
February 27
Radisson, Monroeville
Eden Resort, Lancaster
9 am-12 pm*
9 am-12 pm*
* Registration begins at 8:30 am
Medicare Workshop—
Physician Assistants, Nurse Practitioners and Clinical Nurse Specialists
Date
Location
Time
January 28
February 18
March 18
Radisson Penn Harris, Camp Hill
Holiday Inn, Fort Washington
Radisson, Monroeville
9 am-12 pm*
9 am-12 pm*
9 am-12 pm*
* Registration begins at 8:30 am
Class - Evaluation and Management Services in the Office Setting
Date
Location
Time
March 3
Highmark Offices, Camp Hill
1-3 pm
Class - Emergency Department Services
Date
Location
Time
March 4
Highmark Offices, Camp Hill
1-3 pm
For additional information on all our events including registration and additional topics, visit our web site at
http://www.hgsa.com/professionals/events.shtml.
Medicare Report / December 1, 2003
7
Freedom of Information
Act (FOIA) Requests
The Freedom of Information Act (FOIA), found in Title
5 of the United States Code, section 552, was enacted
in 1966 and provides that, upon request from any person,
a Federal agency or Federal contractor must release any
record unless that record falls within one of the nine
statutory exemptions and three exclusions. The FOIA
binds only Federal agencies, and covers only records
in the possession and control of federal agencies.
Any individual may submit a FOIA request to
HGSAdministrators by mail, fax, or in person with an
original signature (stamped signatures are not
acceptable). We will not accept telephone requests. For
your convenience, a FOIA Document Request form is
now available to download from our web site at
www.hgsa.com/professionals/forms.shtml. You are not
required to use this form; it is intended to be a guide in
submitting a FOIA request. Address your request to:
HGSAdministrators
FOIA
PO Box 890700
Camp Hill, PA 17089-0700
Fax Number: (717) 302-3748
There may be a fee assessed for processing your request.
To help reduce cost, please identify the record that you
want. If you do not know the exact title of the record,
you should provide a reasonable description of the
record. The more details you can provide about the
record, the better. Not having a good description could
delay our response or prevent us from finding the
records you want. We may ask you to clarify your
request if we need more information to find the record.
Frequently Asked
Questions
The following are the frequently asked questions
identified during the last quarter through inquiries to
our staff, and through contacts with physicians and nonphysician providers. You can reference these, and many
more FAQs, on our web site at http://www.hgsa.com/
cgi-bin/faqmanager.cgi?toc=faq.
8
Q. When a non-physician practitioner functions as a
scribe (meaning that he/she writes notes in the
patient’s medical record while the physician is
personally performing an allowable service), does
Medicare consider this to be an ‘incident-to’
service?
A. No. However, there are certain documentation
requirements for non-physician practitioners acting
as scribes. The situation should be clearly indicated
so the reviewer can identify the provider who
performed the service, and both parties – the scribe
and the physician, should sign the record.
Q. Specifically, what types of non-physician
practitioners (NPP) does Medicare allow to provide
services under the “incident-to” provision?
A. Physician assistants, certified nurse midwives,
clinical psychologists, clinical social workers, nurse
practitioners, and clinical nurse specialists are
permitted to bill Medicare for ‘incident-to’ services
when all of the requirements are met.
Q. What documentation requirements are associated
with billing Medicare for ‘incident-to’ services?
A. The medical record must clearly document that the
service was reasonable and necessary and the
physician must document that the ‘incident-to’
requirements were all met.
Q. What is the Medicare definition of an ‘incident-to’
service?
A. Medicare defines ‘incident-to’ services as those
services furnished incident to a physician’s
professional services. This means that the services
or supplies are furnished as an integral, although
incidental, part of the physician’s professional
services in the course of the diagnosis and treatment
of an injury or illness.
Q. Why does the Local Medical Review Policies
(LMRP) contain only part of the description of the
procedure code?
A. The Current Procedural Terminology (CPT®) is
copyright by the American Medical Association
(AMA). The Centers for Medicare and Medicaid
Services (CMS) and the AMA have a signed
agreement regarding the use of this copyrighted
Medicare Report / December 1, 2003
material. As part of this agreement, CPT codes and
long descriptions may be used on contractors’ web
sites, as long as each document does not contain
over 30 percent of a section or subsection of the
CPT.
Because of this restriction
HGSAdministrators may only include short
descriptors in our LMRPs and any other materials
that are published on our web site.
Q. What is the definition of medical necessity?
A. Medical necessity is defined as the need for an item
or service to be reasonable and necessary for the
diagnosis or treatment of illness or injury or to
improve the functioning of a malformed body
member. The need for the item or service must be
clearly documented in the patient’s medical record.
Medically necessary services or items are:
„ appropriate for the symptoms and diagnosis
or treatment of the patient’s condition,
illness, disease or injury; and
„ provided for the diagnosis or the direct care
of the patient’s condition, illness, disease or
injury; and
„ in accordance with current standards of good
medical practice; and
„ not primarily for the convenience of the
patient or provider; and
„ the most appropriate supply or level of
service that can be safely provided to the
patient.
Q. Is a patient a new or an established patient when a
physician in one specialty transfers the patient to a
physician in a different specialty, and both
physicians are under the same tax identification
number?
A. In this scenario the patient is considered a new
patient. Please note that the CPT definitions for
new and established patients refer to services
rendered by physicians in the same specialty. When
a physician transfers a patient within the group
practice to a patient in another specialty (not subspecialty) the patient would be considered a new
patient. However, patients referred to a subspecialist are considered established, unless the subspecialist has a different tax identification number.
Medicare Report / December 1, 2003
Q. If the hospital determines that they cannot bill
Medicare Part A for a patient’s admission, is the
physician correct in billing Medicare Part B for the
services he rendered?
A. Medicare is best viewed as a physician directed health
program. The physician makes his/her diagnosis and
initiates the treatment. As such, the physician orders
the diagnostic tests and treatments that are vital to the
patient’s care. Therefore, as long as the medical record
documentation supports that the service(s) rendered
were “reasonable and necessary” as defined in Title
XVIII of the Social Security Act, Section
1862(a)(1)(A), it is appropriate for the physician to
bill Medicare Part B.
The fact that the hospital review process did not
indicate that the admission was appropriate is not
relevant to the billing of Medicare Part B. To
restate, the physician ordered the admission, and
as long as the medical record documentation
supports that the services meet the “reasonable and
necessary” guideline, the services may be billed to
Medicare.
Q. If we bill the patient’s primary insurance and the
claim is paid in full, should we send Medicare a
claim?
A. Yes. There is the potential that all or part of the
patient’s $100 Part B annual deductible may be
applied to the claim. Failure to submit a secondary
payer claim to Medicare can cheat the patient out
of these credits. In order for Medicare to determine
the amount that should be credited to the patient’s
deductible (if the deductible is outstanding), you
must attach a copy of the primary insurance claim
with the amount of payment received from the
primary insurer to the Medicare claim.
Q. May we use ‘rule out’ (R/O) as the reporting
diagnosis?
A. Providers should not code a disease or condition
unless there is a definitive diagnosis. If tests are
performed to rule out a diagnosis and the diagnosis
is not established when the claim is submitted, you
should only code the chief complaint, or signs and
symptoms related to the ‘rule out’ or ‘possible’
diagnosis.
9
Q. Is it compliant to obtain history/diagnosis for
diagnostic tests from the patient, and use that
information for diagnosis coding?
A. ICD-9-CM coding for diagnostic tests is either a
physician confirmed diagnosis based on the results
of the test, or sign(s) and/or symptom(s). The
sign(s) and/or symptom(s) may be obtained by
interfacing with the patient.
Q. Is there a policy related to sequencing diagnosis
codes?
A. Yes. Physicians may report a maximum of four
unique diagnosis codes per claim when billing for
their services. In addition, for each line of service,
the physician must indicate which one of the
reported diagnosis codes relates to the service(s)
reported on that line. Do not correlate more than
one diagnosis code per line of service. Of the
diagnosis codes reported, the physician must select
only the primary diagnosis that best describes the
reason for the procedure.
Any line of service reported on an assigned claim
that is not correlated to a primary diagnosis code
will be rejected. Non-assigned claims will be
delayed pending contact with the billing physician
to obtain clarification.
In instances where the patient has more than four
conditions present at the time of treatment, the
primary diagnosis code that is chiefly responsible
for the services reported on the claim is to be listed
in the first position. In selecting the other three
diagnosis codes, those conditions for which the
procedure codes are listed and to which the
procedures were directed should be reported.
Procedures that cannot be related to any of the four
diagnoses must be reported on a separate claim with
the appropriate diagnosis.
Q. Does the provider need to submit the National Drug
Code (NDC) when submitting claims for any drugs
or biologicals?
A. No. Neither HGSAdministrators, nor the Centers
for Medicare and Medicaid Services (CMS) require
10
submission of the NDC codes with the claim.
However, it may be a good practice to include this
information with the claim, particularly if the claim
is for an unlabeled or off-label use of an anti-cancer
drug.
Q. Can the E/M services of a hospital-employed
physician provided in the outpatient department be
billed on a CMS 1500 claim form to the carrier
(i.e., HGSAdministrators)?
A. Yes. However, services are only eligible if the group
is a hospital-based group that has a Medicare Part
B provider billing number.
Q. What are the guidelines when a patient is admitted
to and discharged from the hospital on the same
day and the stay was greater than 8 hours? Does
there have to be 2 separate entries (one admit note
and one discharge note), or is it acceptable for one
note to indicate both?
A. The CMS Online Manual, Pub. 100-4, Chapter 12,
Section 30.6.9C advises:
“Carriers pay only the initial hospital care code
when a patient is admitted as an inpatient and
discharged on the same day. They do not pay the
hospital discharge management code on the date
of admission. Carriers must instruct physicians that
they may not bill for both an initial hospital care
code and hospital discharge management code on
the same date.”
To further clarify, HGSA will allow payment for
the initial hospital service (admission) and deny the
discharge management service billed by a single
physician on one date of service. However, if both
of these services are billed on one date of service
by more than one physician, we will verify
specialties, and check to see if two hospital facilities
were involved. Based on the concurrent care
guidelines both services may be eligible for
reimbursement.
The documentation to support an admission and a
discharge day management service rendered on a
single date of service by the same physician may
Medicare Report / December 1, 2003
be provided in either separate or combined progress
note(s). However, no matter which format the
physician chooses, the admission service for which
Medicare can reimburse must be clearly and
thoroughly documented, and it must support the
level of care billed.
Finally, the possibility exists that Medicare Part A
may not reimburse for all of the Part A services
involved in your scenario. However, Medicare is
best viewed as a physician directed health program.
The physician makes his/her diagnosis and initiates
the treatment. Therefore, as long as the medical
record documentation supports that the service(s)
rendered were “reasonable and necessary” as
defined in Title XVIII of the Social Security Act,
Section 1862(a)(1)(A), it is appropriate for the
physician to bill Medicare Part B. The fact that the
hospital review process did not indicate that the
admission was appropriate is not relevant to the
billing of Medicare Part B. To restate, the physician
ordered the admission, and as long as the medical
record documentation supports that the services
meet the “reasonable and necessary” guideline, the
service(s) may be billed to Medicare.
Holidays—2004
HGSAdministrators’ offices will be closed on:
Thursday, January 1
New Year’s Day
Friday, April 9
Good Friday
Monday, May 31
Memorial Day
Monday, July 5
Independence Day
Monday, September 6
Labor Day
Thursday, November 25
Thanksgiving Day
Friday, November 26
Day after Thanksgiving
Thursday, December 23
Day before Christmas
Eve Day
Friday, December 24
Christmas Eve Day
Friday, December 31
New Year’s Eve Day
Medicare Report / December 1, 2003
Home Health Consolidated
Billing—2004 Update of
HCPCS Codes
The Centers for Medicare and Medicaid Services
periodically updates the lists of Healthcare Common
Procedure Coding System (HCPCS) codes that are
subject to the consolidated billing provision of the Home
Health Prospective Payment System (HH PPS). With
the exception of therapies performed by physicians,
supplies incidental to physician services and supplies
used in institutional settings, services appearing on this
list which are submitted on claims to Medicare
contractors will not be paid separately on dates when a
beneficiary for whom such a service is being billed is
in a home health episode (i.e., under a home health plan
of care administered by a home health agency).
Medicare will only directly reimburse the primary home
health agencies that have opened such episodes during
the episode periods. Therapies performed by
physicians, supplies incidental to physician services and
supplies used in institutional settings are not subject to
HH consolidated billing. Medicare contractors include
fiscal intermediaries (FIs), carriers, and durable medical
equipment regional carriers (DMERCs).
The HH consolidated billing code lists are updated
annually, to reflect the annual changes to the HCPCS
code set itself. Additional updates may occur as
frequently as quarterly in order to reflect the creation
of temporary HCPCS codes (e.g., ‘K’ codes) throughout
the calendar year. The new coding identified in each
update describes the same services that were used to
determine the applicable HH PPS payment rates. No
additional services will be added by these updates; that
is, new updates are required by changes to the coding
system, not because the services subject to HH
consolidated billing are being redefined.
This one-time notification provides the annual HH
consolidated billing update for calendar year 2004.
Quarterly updates may follow in the course of calendar
year 2004 if necessary. The specific changes are
described in the following code list.
11
Code Changes for January 2004 Annual Update of Medicare Home Health Consolidated Billing Code List
Code
Description
Action
Replacement Code or
Code Being Replaced
Delete
Delete
Delete
Delete
Delete
Delete
Delete
Delete
Delete
Delete
Delete
Delete
Delete
Delete
Delete
Delete
Delete
Add
Add
Add
Add
Add
Add
Add
Add
Add
Add
Add
Add
Add
Add
Add
Add
Add
Delete
Delete
Add
Add
Delete
Delete
Add
Add
Add
Add
Replacement Code: A4416
Replacement Code: A4417
Replacement Code: A4418
Replacement Code: A4419
Replacement Code: A4420
Replacement Code: A4423
Replacement Code: A4424
Replacement Code: A4425
Replacement Code: A4426
Replacement Code: A4427
Replacement Code: A4428
Replacement Code: A4429
Replacement Code: A4430
Replacement Code: A4431
Replacement Code: A4432
Replacement Code: A4433
Replacement Code: A4434
Replaces Code: K0581
Replaces Code: K0582
Replaces Code: K0583
Replaces Code: K0584
Replaces Code: K0585
Replaces Code: K0586
Replaces Code: K0587
Replaces Code: K0588
Replaces Code: K0589
Replaces Code: K0590
Replaces Code: K0591
Replaces Code: K0592
Replaces Code: K0593
Replaces Code: K0594
Replaces Code: K0595
Replaces Code: K0596
Replaces Code: K0597
Replacement codes: A4216 & A4217
Replacement codes: A4216 & A4217
Replaces A4319 & A4323
Replaces A4319 & A4323
Non-Routine Supplies
K0581
K0582
K0583
K0584
K0585
K0586
K0587
K0588
K0589
K0590
K0591
K0592
K0593
K0594
K0595
K0596
K0597
A4416
A4417
A4418
A4419
A4420
A4423
A4424
A4425
A4426
A4427
A4428
A4429
A4430
A4431
A4432
A4433
A4434
A4319
A4323
A4216
A4217
A4712
A4622
A7520
A7521
A7522
A7523
12
Ost pch clsd w barrier/filtr
Ost pch w bar/bltinconv/fltr
Ost pch clsd w/o bar w filtr
Ost pch for bar w flange/flt
Ost pch clsd for bar w lk fl
Ost pch for bar w lk fl/fltr
Ost pch drain w bar & filter
Ost pch drain for barrier fl
Ost pch drain 2 piece system
Ost pch drain/barr lk flng/f
Urine ost pouch w faucet/tap
Urine ost pouch w bltinconv
Ost urine pch w b/bltin conv
Ost pch urine w barrier/tapv
Os pch urine w bar/fange/tap
Urine ost pch bar w lock fln
Ost pch urine w lock flng/ft
Ost pch clsd w barrier/filtr
Ost pch w bar/bltinconv/fltr
Ost pch clsd w/o bar w filtr
Ost pch for bar w flange/flt
Ost pch clsd for bar w lk fl
Ost pch for bar w lk fl/fltr
Ost pch drain w bar & filter
Ost pch drain for barrier fl
Ost pch drain 2 piece system
Ost pch drain/barr lk flng/f
Urine ost pouch w faucet/tap
Urine ost pouch w bltinconv
Ost urine pch w b/bltin conv
Ost pch urine w barrier/tapv
Os pch urine w bar/fange/tap
Urine ost pch bar w lock fln
Ost pch urine w lock flng/ft
Sterile H2O irrigation solution
Saline irrigation solution
Sterile water/saline up to 10 ml
Sterile water/saline 500 ml
Sterile water injection, per 10 ml
Trachestomy or larngectomy
Tracheostomy/larynectomy tube, non-cuffed
Tracheostomy/larynectomy tube, cuffed
Tracheostomy/larynectomy tube, stainless steel
Tracheostomy shower protector, each
Replacement codes: A7520, 7521, & A7522
Replaces code: A4622
Replaces code: A4622
Replaces code: A4622
From or related to discontinued code, A4622 and/or
A4623: Tracheostomy
Medicare Report / December 1, 2003
A7524
Tracheostomy stent/stud/button, each
Add
A4623
A7525
A7526
K0621
A6407
A4248
A4366
A6025
A6441
Trachestomy, inner cannula
Tracheostomy mask, each
Tracheostomy tube collar/holder, each
Gauze, non-impreg packing strip
Packing strips, non-impregnated, up to 2 inches, per lin yd
Chlorhexidine containing anticeptic, 1 ml
Ostomy vent, any type, each
Gel sheet for dermal or epidermal application (e.g. Silicone, hydrogel, other)
Padding bandage, non-elastic, non-woven/non-knitted, width greater
than or equal to three inches and less than five inches, per yard
Add
Add Replaces code: A4623
Add Replaces code: A4623
Delete Replacement Code: A6407
Add Replaces: K0621
Add
Add
Add
A6442
Add
Conforming bandage, non-elastic, knitted/woven, non-sterile,
width less than three inches, per yard
Add
A6443
Conforming bandage, non-elastic, knitted/woven, non-sterile, width
greater than or equal to three inches and less than five inches, per yard
Add
A6444
Conforming bandage, non-elastic, knitted/woven, non-sterile,
width greater than or equal to 5 inches, per yard
Add
Conforming bandage, non-elastic, knitted/woven, sterile,
width less than three inches, per yard
Add
A6446
Conforming bandage, non-elastic, knitted/woven, sterile, width greater
than or equal to three inches and less than five inches, per yard
Add
A6447
Conforming bandage, non-elastic, knitted/woven, sterile,
width greater than or equal to five inches, per yard
Add
Light compression bandage, elastic, knitted/woven, width
less than three inches, per yard
Add
A6449
Light compression bandage, elastic, knitted/woven, width greater than
or equal to three inches and less than five inches, per yard
Add
A6450
Light compression bandage, elastic, knitted/woven, width
greater than or equal to five inches, per yard
Add
Moderate compression bandage, elastic, knitted/woven, load resistance
of 1.25 to 1.34 foot pounds at 50% maximum stretch, width greater
than or equal to three inches and less than five inches, per yard
Add
High compression bandage, elastic, knitted/woven, load resistance greater
than or equal to 1.35 foot pounds at 50% maximum stretch, width greater
than or equal to three inches and less than five inches, per yard
Add
Self-adherent bandage, elastic, non-knitted/non-woven,
width less than three inches, per yard
Add
A6454
Self-adherent bandage, elastic, non-knitted/non-woven, width greater
than or equal to three inches and less than five inches, per yard
Add
A6455
Self-adherent bandage, elastic, non-knitted/non-woven,
width greater than or equal to five inches, per yard
Add
A6445
A6448
A6451
A6452
A6453
A6456
From or related to discontinued code, A4622 and/
or A4623: Tracheostomy
Zinc paste impregnated bandage, non-elastic, knitted/woven, width
greater than or equal to three inches and less than five inches, per yard
Add
Therapies
97755
Assistive technology assessment (eg, to restore, augment or compensate for existing
function, optimize functional tasks and/or maximize environmental accessibility),
direct one-on-one contact by provider, with written report, each 15 minutes
Add
Medicare Report / December 1, 2003
13
Mediation: The New
Approach to Resolving
Quality of Care Concerns
Medicare Deductible,
Coinsurance, and
Premiums for 2004
Quality Insights of Pennsylvania — the Medicare Quality
Improvement Organization that works with medical
professionals, community organizations and Medicare
beneficiaries to improve the quality of health care — authored
this article.
Hospital Insurance (Part A)
Mediation is a new option available to Medicare beneficiaries to help resolve quality of care complaints. Historically, the Centers for Medicare & Medicaid Services
(CMS) has found that many quality of care complaints
have been borne out of miscommunication rather than
actual poor quality. Under the new process, when we receive a complaint, a physician reviewer determines if the
case meets CMS criteria for mediation. In the event that
the physician reviewer identifies an actual quality concern, the case goes through the standard process; mediation is not recommended.
Deductible:
$876.00 per benefit period
Coinsurance: $219.00 a day for days 61-90 in each
period
$438.00 a day for days 91-150 for each
“lifetime reserve” days used
$109.50 a day in a skilled nursing facility
for days 21-100 in each benefit period
Premium:
$343.00 per month for those who must
pay a premium
$377.30 per month for those who must
pay both a premium and a 10 percent
increase
For mediation to occur, the complainant and the provider
must both agree to the meeting. With the agreement of the
other party, each party may bring a designated representative to the session. A volunteer mediation advisor may also
be available for assistance. In addition to the presence of a
professional mediator, the mediation process differs from a
standard quality review in several key ways:
$189.00 per month for those who have
30-39 quarters of coverage
$207.90 per month for those who have
30-39 quarters of coverage and must pay
a 10 percent increase
„ The meeting is face-to-face, or by teleconference,
between the aggrieved party and the provider
against whom the complaint is lodged.
Medical Insurance (Part B)
„ The meeting is strictly confidential. No notes are
taken, and nothing that is discussed may be used for
litigation purposes.
Coinsurance: 20 percent
„ The complainant and the health care provider come
to agreement on an outcome with the help of the
mediator.
One concern of beneficiaries is that the mediation will
damage the patient/provider relationship. However, those
who have used mediation often report that their relationships have improved.
Mediation is voluntary. Whether the parties agree to mediation or not, Medicare benefits or provider agreements
are not affected. Mediation is available to both fee-forservice and managed care plan enrollees.
For more information on the mediation process, contact
CMS at 1-800-MEDICARE (1-800-633-4227), or visit the
web site at www.cms.hhs.gov.
14
Deductible:
Premium:
$100.00 per year
$66.60 per month
Background Information
Beneficiaries who use covered Part A services may be
subject to deductible and coinsurance requirements. A
beneficiary is responsible for an inpatient hospital deductible amount, which is deducted from the amount
payable by the Medicare program to the hospital, for
inpatient hospital services furnished in a spell of illness. When a beneficiary receives such services for
more than 60 days during a spell of illness, he or she is
responsible for a coinsurance amount equal to onefourth of the inpatient hospital deductible per-day for
the 61st-90th day spent in the hospital. An individual
has 60 lifetime reserve days of coverage, which they
may elect to use after the 90th day in a spell of illness.
Medicare Report / December 1, 2003
The coinsurance amount for these days is equal to onehalf of the inpatient hospital deductible. A beneficiary
is responsible for a coinsurance amount equal to oneeighth of the inpatient hospital deductible per day for
the 21st through the 100th day of skilled nursing facility services furnished during a spell of illness.
Individuals Not Subject to the Limitation on
Payment
Most individuals age 65 and older, and many disabled
individuals under age 65, are insured for Health Insurance (HI) benefits without a premium payment. The
Social Security Act provides that certain aged and disabled persons who are not insured may voluntarily enroll, but are subject to the payment of a monthly premium. Since 1994, voluntary enrollees may qualify
for a reduced premium if they have 30-39 quarters of
covered employment. When voluntary enrollment takes
place more than 12 months after a person’s initial enrollment period for HI benefits, the monthly premium
increases by 10 percent.
„ Individuals enrolled in Part A on the basis of a
monthly premium.
Under Supplementary Medical Insurance (SMI), all
enrollees are subject to a monthly premium. Most SMI
services are subject to an annual deductible and coinsurance (percent of costs that the enrollee must pay),
which are set by statute. When SMI enrollment takes
place more than 12 months after a person’s initial enrollment period, the monthly premium increases by 10
percent for each full 12-month period during which the
individual could have been enrolled, but was not.
„ Employees of employers of fewer than 20
employees who are covered by a single employer
plan.
Medicare Secondary Payer
(MSP) Working Aged
Provision Clarification
The Centers for Medicare and Medicaid Services has
updated the Medicare secondary payer provision for
working aged to include information on domestic partners who are given “spousal” coverage by the group
health plan. Information on the working aged provision was previously found in the Medicare Carriers
Manual (MCM) section 3336.1, but is now documented
in the online CMS Manual, Pub. 100-5. These sections
document indications when the working aged provision does not apply. For your convenience, we are printing Chapter 2, Section 10.2 in its entirety.
Medicare Report / December 1, 2003
The Medicare secondary provision for working aged
does not apply to:
„ Individuals enrolled in Part B only.
„ Anyone who is under age 65. (Medicare is
secondary to large group health plans that cover
at least one employer of 100 or more employees
for certain disabled individuals under age 65.)
„ Individuals covered by a health plan other than an
group health plan (GHP) as defined above, e.g.,
one that is purchased by the individual privately,
and not as a member of a group, and for which
payment is not made through an employer.
„ Members of multi-employer plans, which have been
approved by CMS for the “multi-employer
exemption”, whom the plan identified as employees
of employers with fewer than 20 employees.
„ Retired beneficiaries who are covered by GHPs
as a result of past employment and who do not
have GHP coverage as the result of their own or a
spouse’s current employment status.
„ Individuals enrolled in single employer GHPs of
employers of fewer than 20 employees.
„ Members of multi-employer plans whom the plan
identified as employees of employers with fewer
than 20 employees, provided the plan formally
elected to exempt the plan from making primary
payment for employees and spouses of
employees of specifically identified employers
with fewer than 20 employees.
„ Domestic partners who are given “spousal”
coverage by the group health plan. Federal law
defines spouse as a person of the opposite sex
who is a husband or a wife. Thus a domestic
partner cannot be recognized as a spouse. This
change is effective April 1, 2004.
15
Provider Enrollment News
Physician Assistants – Section 2J.1
Validation with the Social Security
Administration
The CMS 855I application designates section 2.J.1 for
the Physician Assistant’s (PA) Supervising Physician.
A recent update to Provider Enrollment guidelines
eliminated the requirement for PA’s to report supervising physicians in section 2.J.1. Therefore this section
may be left blank.
As part of the enrollment process, Medicare contractors
are required to validate a Social Security Number (SSN)
for the individual applicant and anyone else required to
list their SSN (i.e. supervising physician, owner, partner,
managing employee and etc.) on the application with
the Social Security Administration (SSA). Updates and/
or changes to a Medicare provider file will also require
verification of the data with the SSA. If the name, date
of birth, or Social Security Number reported on the
application does not match the SSA files, we will contact
you to coordinate any corrections required to your
application or the SSA files before we can finalize your
request. In order to avoid processing delays, please
ensure your reported information is consistent with SSA
records or SSA files are updated in advance.
Change in Tax Number Requires New
Provider Number
Clarification received from the Centers for Medicare
and Medicaid Services (CMS) requires that HGSA issue
a new Medicare Provider Identification Number (PIN)
when an entity obtains a new Tax Identification Number
(TIN), even if the legal business name and ownership
of the supplier has not changed. Therefore, requests to
update your Medicare file with a new TIN will require
that a new 855 application be submitted and processed
as an initial enrollment application.
Managing Employee Information for the CMS
855B Application
Medicare requires at least one managing employee be
reported in Section 6 when enrolling on the CMS 855B
application. A managing employee is defined as any
individual, including a general manager, business
manager, office manager or administrator, who exercises
operational or managerial control over the supplier, or
who conducts the day-to-day operations of the supplier.
For Medicare enrollment purposes, a managing
employee also includes individuals who are not actual
employees of the supplier but, either under contract or
through some other arrangement, manage the day-today operations of the supplier.
16
Psychotherapy Medical
Record Documentation—
HIPAA Privacy Rule
There is a growing concern among physicians and health
care providers regarding the balance of protecting the
patient’s privacy while at the same time, provide sufficient documentation to satisfy Medicare Part B billing
and audit requirements. The privacy rights of an individual become an even greater concern when the request for medical record information includes psychotherapy notes. As a result, health care professionals
have questioned HGSAdministrators on the need to
obtain beneficiary authorization prior to their release
of medical record documentation to us. The medical
record often includes the psychotherapy notes, which
may also include confidential information discussed
during the counseling session.
As a Medicare Part B contractor, it is HGSAdministrators’ responsibility to ensure the medical record supports the service that was rendered and billed to Medicare for reimbursement. Specifically, HIPAA privacy
guidelines permit HGSAdministrators, in its role as
administrator of the Part B Program in Pennsylvania, the access to psychotherapy notes without beneficiary authorization for the purpose of “oversight
activities” (45 CFR 164.508 (a)(2)(ii) and 45 CFR
164.512 (d).
Failure to provide the requested medical record information, including the psychotherapy notes, may result
in the inability of HGSAdministrators allowing payment for the service rendered.
A physician or health care provider is a covered entity
under the Privacy Rule if they transmit health information or health information is submitted on their behalf
in electronic standard format with any transaction referred to in section 1173(a)(1) of the Act. (45 CFR
164.104).
Medicare Report / December 1, 2003
Psychotherapy Services
and ‘Incident To’ Billing—
Update
HGSAdministrators published an article titled,
“Psychotherapy Is Not Billable ‘Incident To’” in the
December 1, 2002 issue of the Medicare Report (page
30). This article defined ‘incident to’ services as those
services and supplies furnished as an integral, although
incidental, part of the physician’s personal professional
services in the course of diagnosis or treatment of an
injury or illness. The article further explained that to
be covered ‘incident to’ the services of a physician,
services and supplies must be:
„ an integral, although incidental, part of the
physician’s professional service;
„ commonly rendered without charge or
included in the physician’s bill;
„ of a type that is commonly furnished in
physicians’ offices or clinics;
„ furnished under the physician’s direct
supervision; and
„ furnished by the physician or by an auxiliary
personnel acting under the direct supervision
of a physician, regardless of whether the
individual is an employee, leased employee,
or independent contractor of the physician.
The article further stated that the Centers for Medicare
and Medicaid Services issued a statement in a letter to
Medicare Carrier Medical Directors that,
“psychotherapy services are self-contained and too
significant to be considered an incidental service.”
Therefore, psychotherapy is considered a stand-alone
service and is not merely an incidental part of a patient’s
care. Consequently, HGSAdministrators instructions
per the December 1, 2002 notification were that
psychotherapy should not be reported ‘incident to’.
Since the publication of this article, HGSAdministrators
has been contacted by several specialty societies and
other interested parties expressing their concerns
regarding how this directive may potentially affect
Medicare Report / December 1, 2003
access to care for Pennsylvania’s Medicare patients in
need of psychotherapy services. In addition, we also
received CMS Transmittal, AB-03-037, Change Request
2520, published on our web site on March 28, 2003,
which clarifies CMS’ position on psychotherapy
services.
Psychotherapy services provided ‘incident to’ are
eligible for Medicare coverage, but must be in keeping
with the above stated ‘incident to’ guidelines, as well
as all national regulations, statutes, Local Medical
Review Policies (e.g. LMRP V-41 on Psychiatric
Therapeutic Procedures), and CMS directives, to
include the CMS Transmittal, AB-03-037, Change
Request 2520. There is no need to document that the
psychotherapy service is being provided ‘incident to’
due to access to care issues or concerns.
However, as communicated in past announcements,
LMRP V-41 states that psychotherapy services must be
performed by a person licensed by the state to perform
such services. Transmittal AB-03-037 on “Medicare
Payments for Part B Mental Health Services” adds to
this that “Certain nonphysician practitioners such as
clinical psychologists, nurse practitioners, clinical nurse
specialists, and physician assistants may have services
furnished ‘incident to’ their professional services. To
the extent that they are licensed or authorized by the
State to furnish mental health services, these
practitioners could have others provide some services
as ‘incident to’ overall mental health services.” As per
LMRP V-41 (for Pennsylvania Medicare Part B), the
supervised individual delivering (performing) the
service must be licensed or authorized by the State.
HGSAdministrators interprets “licensed or authorized
by the State” to include both individuals and facilities
licensed or authorized by the State of Pennsylvania to
perform such services.
Quarterly Provider Update
Don’t forget to check the CMS Quarterly Provider
Update, a source for national Medicare provider
information at http://www.cms.gov/providerupdate.
17
Remittance Advice Remark and Reason Codes—New
Codes
The Centers for Medicare and Medicaid Services has issued an updated listing of remark and reason codes. Listed
below are the new codes. Modified/retired codes have been listed on our web site. A complete listing of codes is
available at http://www.wpc-edi.com.
N202
Additional information/explanation will be sent separately
N203
Missing/incomplete/invalid anesthesia time/units
N204
Services under review for possible pre-existing condition. Send medical records for prior 12 months
N205
Information provided was illegible
N206
The supporting documentation does not match the claim
N207
Missing/incomplete/invalid birth weight
N208
Missing/incomplete/invalid DRG code
N209
Missing/invalid/incomplete taxpayer identification number (TIN)
N210
You may appeal this decision
N211
You may not appeal this decision
Request for Hearing Form Developed for Your Use
Since the reverse side of the review letter no longer provides space to request a hearing, the Hearing Office has
developed a form that will help ensure that all required information is submitted when you request a Medicare
hearing. The use of this form will help you verify that all requirements for a hearing have been met and that all
required information is submitted with your initial request.
The Request for Hearing Part B Medicare Claim(s) form found on the next page can be copied. A printable version
is also available on our web site at www.hgsa.com/professionals/forms.shtml.
18
Medicare Report / December 1, 2003
REQUEST FOR HEARING
PART B MEDICARE CLAIM(S)
Medicare Hearing Office
P. O. Box 890050
Camp Hill, PA 17089-0050
I disagree with the review determination(s) on my claim(s) and request a Medicare Part B Hearing on the
claims identified in this correspondence. My reasons are:
I am requesting the following type of hearing:
‡ An on-the-record hearing
‡ A telephone hearing
‡ An in-person hearing
Signature: _________________________________________
Title: _____________________________________________
Date: _____________________________________________
Telephone: ________________________________________
Checklist
You can help us expedite your request for a hearing by using the following checklist. It has been developed to
help you verify that all requirements for a hearing have been met and that all required information is submitted
with your initial request.
‡ Has the initial claim determination been reviewed?
‡ Is there $100.00 or more in controversy?
‡ Is the date of the Review Notice within six months?
‡ INCLUDE A COPY OF EACH REVIEW NOTICE WITH YOUR REQUEST.
‡ Is the reason for your request explained?
‡ If Medicare is not the primary payer, is the primary EOB attached?
‡ Have you included copies of all pertinent medical record documentation not previously submitted?
‡ Is the documentation legible? If not, include a transcription with the original copy of the medical
record.
Please refer to the Medicare Part B Reference Manual, Chapter 18.5 for further details regarding the hearing
process. This manual is available at: http://www.hgsa.com/professionals/refman.shtml.
Medicare Report / December 1, 2003
19
Sign Up for a Listserv
A listserv is an electronic mailing list that you choose
to subscribe to and can help you filter information to
receive only what is relevant to you. HGSAdministrators offers the following listservs as a free service:
„ Ambulance
„ Anesthesia (name changed from nurse
anesthetist to encompass a broader scope of
interest)
„ Ambulatory Surgical Centers
„ Chiropractic
„ Clinical Diagnostic Labs
„ Consolidated Billing
„ Eye Care (name changed from optometry to
encompass a broader scope of interest)
„ General*
„ Independent Diagnostic Testing Facilities
„ Nonphysician Practitioners
„ Physicians
„ Podiatry
„ Psychiatric Services (name changed from
psychology)
„ Therapy/Rehab
Deleted Listservs
„ CRNA (everyone on this list has been
automatically moved to the anesthesia
listserv)
„ LMRP (everyone on this list has been
automatically moved to the general listserv)
„ Occupational Therapy (everyone on this list
has been automatically moved to the
Therapy/Rehab listserv)
dated, then an article would be posted and those people
who have subscribed to the anesthesia or the general
listservs would receive an email message notifying them
that an article pertaining to an anesthesia related matter was being posted. As a side note, providers are
strongly encouraged to periodically review all web
site postings to identify other articles and information that may also pertain to their specific practice.
*The general listserv notifies subscribers each and every time an update is made to our web site. If you do
not sign up for specific listservs, then by default if you
subscribe to our web site, you will fall into the general
listserv category. If you want to continue to be notified
every time we update our site, then no action is necessary on your part and you will be on our general listserv.
If you elect to be on the general listserv, there is no
need to select an additional listserv as you will receive
all updates to the web site for all categories automatically.
You may choose to subscribe to as many listservs as
you want. (Again, if you sign up for the general listserv,
it is not necessary to sign up for any additional listservs.)
If you choose to sign up for multiple listservs, (that do
not include the general listserv) for example Clinical
Diagnostic Labs and Consolidated Billing and an article is posted which is considered to be of interest to
both listservs, you will receive one email notification
for each listserv resulting in two email notices for the
described scenario.
If you are interested in signing up for one or more
specific listservs, then go to http://www.hgsa.com/
mailinglist.shtml.
Timely Filing of Claims
When we post an article to our web site, we will exercise due diligence in identifying the listserv that will
have an interest in the information being posted. For
example, if the anesthesia conversion factor was up-
Instructions for submitting claims to Medicare are contained in the online CMS Manual, Pub. 100-04, Chapter 1, Section 70.1. In order for a request for payment
to be considered to have been filed timely in accordance with the Centers for Medicare and Medicaid Services instructions, the claim must not be considered to
be unprocessable under the definition of an
unprocessable claim found in the online CMS Manual,
20
Medicare Report / December 1, 2003
„ Physical Therapy (everyone on this list has
been automatically moved to the Therapy/
Rehab listserv)
The time limit on filing claims for service furnished in
the last 3 months of a year is the same as if the services
had been furnished in the subsequent year. Thus, the
time limit on filing claims for services furnished in the
last 3 months of the year is December 31 of the second
year following the year in which the services were rendered. Also note that a claim received by the contractor more than one year after the service has been rendered is subject to a 10 percent reduction. Example:
A beneficiary received surgery in August 2003. This
claim must be filed for payment for such services on or
before December 31, 2004. A service provided in October 2003 must be filed on or before December 31,
2005.
Pub. 100-04, Chapter 1, Section 80.3.1. HGSAdministrators returns unprocessable claims to the provider and
does not suspend claims for development to allow for
corrections. Such returned requests for payment do not
constitute claims nor satisfy the timely filing requirements. In those instances, a processable claim that conforms to the requirements of the online CMS Manual,
Pub. 100-04, Chapter 1, Section 80.3.1 at a minimum,
must be resubmitted within the timely filing period.
Medicare law prescribes specific time limits within
which claims for benefits may be submitted with respect to physician and other Part B services payable on
a reasonable charge or fee schedule basis (including
those services for which the charge is related to cost).
For these services, the terms of the law require that the
claim be filed no later than the end of the calendar year
following the year in which the service was furnished,
except as follows:
Claims Filing Time Limit Table Calculations
Date of Service in:
Jan
Feb
Mar
Apr
May
June
Timely Filing Date
Dec 31:
Service
year plus
1 year
Dec 31:
Service
year plus
1 year
Dec 31:
Service
year plus
1 year
Dec 31:
Service
year plus
1 year
Dec 31:
Service
year plus
1 year
Dec 31:
Service
year plus
1 year
Months to File
23
22
21
20
19
18
Date of Service in:
July
Aug
Sep
Oct
Nov
Dec
Timely Filing Date
Dec 31:
Service
year plus
1 year
Dec 31:
Service
year plus
1 year
Dec 31:
Service
year plus
1 year
Dec 31:
Service
year plus
2 years
Dec 31:
Service
year plus
2 years
Dec 31:
Service
year plus
2 years
Months to File
17
16
15
26
25
24
* The number specified in “Months to file” represents the number of full months remaining after the month in
which the service was rendered.
Medicare Report / December 1, 2003
21
Web Sites
The following important web sites are just a click away.
Use the direct link through the HGSA web site http://
www.hgsa.com/professionals/index.shtml to obtain
valuable information.
CMS
http://www.cms.hhs.gov
CMS Fee Schedule Link
http://www.cms.hhs.gov/physicians/mpfsapp/
step0.asp
CMS Quarterly Provider Update
http://www.cms.hhs.gov/providerupdate/
Correct Coding Initiative
http://www.cms.hhs.gov/physicians/cciedits/
default.asp
HIPAA Information
http://www.cms.gov/hipaa/
Med Learn
http://www.cms.hhs.gov/medlearn/
Pennsylvania Medicare
http://www.pennsylvaniamedicare.com
Reason and Remark Codes
http://www.wpc-edi.com/codes/codes.asp
SNF Consolidated Billing
http://www.cms.hhs.gov/medlearn/
Web Based CMS Manuals
http://www.cms.hhs.gov/manuals
Specialty Ne
ws
New
Ambulance
Fee Information
The ambulance fee schedule became effective for claims
with dates of service on or after April 1, 2002. The
payment amounts for the remaining three years will be
a blended payment amount — part ambulance fee
schedule and part reasonable charge reimbursement.
The blended rate percentages for the remainder of the
transition period are as follows:
Transition Year
Reasonable
Fee
Charge
Schedule
Percentage Percentage
1/1/2004 - 12/31/2004
1/1/2005 - 12/31/2005
1/1/2006 and after
40%
20%
0%
60%
80%
100%
Payment Calculation for
Ground Ambulance
Services Provided In Rural
Areas for 2004
The payment calculation for rural mileage for ground
ambulance services is changing for 2004. Payments
for dates of service in 2003 will be calculated using the
current three-tiered method. Effective January 1, 2004,
if the point of pick up is in a rural location, the
cumulative payment calculation for the ambulance
mileage will be as follows:
Reasonable Charge Portion of the Calculation
Provider’s lowest reasonable charge for A0425 x
mileage x 40%
Plus
Ambulance Fee Schedule Portion of the Calculation
First 17 miles (miles 1-17)
Ambulance fee schedule amount for A0425 x 150% x
number of miles up to 17 x 60%
22
Medicare Report / December 1, 2003
Plus
All Remaining Rural Miles (Miles 18 and Greater)
Ambulance fee schedule amount for A0425 x remaining miles x 60%
Equals
Total Blended Allowed Amount for A4025 in a
Rural Area
Policy Clarifications
During the implementation of the ambulance fee
schedule, issues concerning the interpretation of
Medicare policy arose which required clarification from
the Centers for Medicare and Medicaid Services (CMS).
Listed below are those issues that required HGSA to
revise their current policies:
Advance Beneficiary Notice (ABN)
Requirements
The Advanced Beneficiary Notice (ABN) is a written
notice a physician or provider/supplier gives to a
Medicare beneficiary before items or services are
furnished when the physician or provider/supplier
believes that Medicare probably or certainly will not
pay for some or all of the items or services on the basis
of certain Medicare statutory exclusions.
An ABN is rarely used for ambulance services, and may
only be issued for non-emergency transports. An
ABN may not be used when a beneficiary is under great
duress. A beneficiary is considered to be under great
duress when his or her medical condition requires
emergency care.
An ABN may be needed and may be used for nonemergency transports in the following situations:
„ A transport by air ambulance when the
transporting entity has a reasonable basis to
believe that the transport can be done safely
and effectively by ground ambulance
transportation.
„ A level of care downgrade, e.g., from ALS-2
to ALS-1, or from ALS to basic life support
(BLS), when the transport at the lower level
of care is a covered transport.
Medicare Report / December 1, 2003
An ABN is not needed, and should not be used, in
the following situations:
„ A transport where the patient could be
transported safely by other means
„ A transport that is based on not meeting an
origin or destination requirement
„ A transport for mileage that is beyond the
nearest appropriate facility
„ A transport where the physician certification
statement or accepted alternative is not
obtained
„ A convenience discharge, e.g., where the
patient is an inpatient at one hospital that can
care for their needs, but wants to be
transferred to a second hospital to be closer
to family
Ambulance transports that do not meet the medical
necessity requirements as in the patients condition at
the time of transport, such as, patient not bedbound or
not stretcherbound are denied in accordance with
Section 1861(s)(7) and therefore are not considered a
waiverable issue. In these instances, an Advanced
Notice is not required, and the patient is responsible
for the denied service. The GY modifier should be
applied in this situation.
Proof of Mailing PMNC
Before submitting a claim, ambulance suppliers must
obtain a signed certification statement from the
attending physician. If the ambulance supplier is unable
to obtain the signed certification statement from the
attending physician, a signed physician certification
statement must be obtained from either the PA, NP,
CNS, RN, or discharge planner, who has personal
knowledge of the beneficiary’s condition at the time
that the ambulance transport is ordered or the service is
furnished. This individual must be employed by the
beneficiary’s attending physician or by the hospital or
facility where the beneficiary is being treated and from
which the beneficiary is transported.
When a Physician’s Medical Necessity Certification/
Physician Certification Statement cannot be obtained,
a provider/supplier may send a letter via U.S. Postal
Service (USPS) certified mail with a return receipt proof
of mailing or other similar commercial service
23
demonstrating delivery of the letter as evidence of the
attempt to obtain the PMNC/PCS.
Billing for Air Mileage
Additional air mileage may be allowed by the contractor
in situations where additional mileage is incurred, due
to circumstances beyond the pilot’s control. These
circumstances include, but are not limited to, the
following:
„ Military base and other restricted zones, airdefense zones, and similar FAA restrictions
and prohibitions.
„ Hazardous weather.
„ Variances in departure patterns and clearance
routes required by an air traffic controller.
If the air transport meets the criteria for medical
necessity, Medicare claims for air transports may
account for all mileage from the point of pickup,
including where applicable: ramp to taxiway, taxiway
to runway, takeoff run, air miles, roll out upon landing,
and taxiing after landing.
PMNC/PCS Requirements for Repetitive
Ambulance Services
The regulations governing PCS requirements for
repetitive, scheduled, non-emergency ambulance
services are specified at 42 CFR §410.40(d)(2). A
repetitive ambulance service is defined as medically
necessary ambulance transportation that is furnished
three or more times during a 10-day period or at least
once per week for at least three weeks. Dialysis and
respiratory therapy are types of treatments for which
repetitive ambulance services are often necessary.
However, the requirement for submitting the PCS form
for repetitive, scheduled, non-emergency ambulance
services is based on the quantitative standard (three or
more times during a ten-day period or at least once per
week for at least three weeks). Similarly, regularly
scheduled ambulance services for follow-up visits,
whether routine or unexpected, are not “repetitive” for
purposes of this requirement unless one of the
quantitative standards is met.
Medical Policy Bulletins T-2 and T-3 have been updated
to reflect the above information. In addition, please
refer to the Ambulance Billing Guide on our web site
to ensure all documentation requirements are being met.
Unsuccessful ALS Interventions
An unsuccessful attempt to perform an ALS intervention
(e.g., endotracheal intubation was attempted, but was
unsuccessful) may qualify the transport for billing at
the appropriate ALS level provided that the intervention
would have been reasonable and necessary had it been
successful.
Intra-facility Transports
An intra-facility transport, i.e., a transport within the
certified campus of a facility, is not within the scope of
the Medicare ambulance benefit because it fails to meet
Medicare origin and destination requirements.
Medicare payment to a facility for the cost of facilitybased treatment includes an allowance for intra-facility
movement of the beneficiary. No separate Medicare
payment may be made for such a transport. Moreover,
it is improper for a provider to bill Medicare for an
intra-facility transport to receive a Medicare denial since
the Medicare facility payment constitutes payment in
full for all medically necessary, Medicare-covered
services furnished to the beneficiary while undergoing
treatment at the facility. As such, billing the beneficiary
or another insurer for such included services would be
similarly improper.
24
Laboratory
2004 Clinical Laboratory
Fee Schedule
The 2004 Clinical Laboratory Fee Schedule will only
be issued in hard copy to clinical laboratories (specialty
69). All other healthcare professionals may obtain an
electronic copy of the 2004 Clinical Laboratory Fee
Schedule on our web site at www.hgsa.com/
professionals/letter.shtml on or about December 1,
2003.
Medicare Report / December 1, 2003
Clinical Laboratory Test
National Coverage
Determinations (NCDs)
Changes
The Centers for Medicare and Medicaid Services
(CMS) has announced the following changes to the
clinical laboratory test NCDs. These changes will be
effective for dates of service on or after January 1, 2004.
NCD coding manuals and related CMS documents are
available at the following web site: http://
www.cms.hhs.gov/ncd/labindexlist.asp. The NCD
coding manuals, which are updated on a quarterly basis,
provide the current list of eligible and ineligible
diagnosis codes for the NCD procedure codes.
1. In accordance with the decision memorandum published on the CMS coverage Internet site on September 17, 2003 (http://cms.hhs.gov/mcd/
viewdecisionmemo.asp?id=97), the following diagnosis codes are being added to the list of ICD-9CM Codes Covered by Medicare for the prothrombin time (PT) and fecal occult blood test (FOBT)
NCDs:
„ 863.91, pancreas head with open wound into
cavity
„ 863.92, pancreas body with open wound into
cavity
„ 863.93, pancreas tail with open wound into
cavity
„ 863.94, pancreas multiple and unspecified
sites with open wound into cavity
„ 863.95, appendix with open wound into
cavity
„ 863.99, other gastrointestinal sites with open
wound into cavity
2. In accordance with the decision memorandum
published on the CMS coverage Internet site on
September 23, 2003 (http://cms.hhs.gov/mcd/
viewdecisionmem.asp?id=93), the following
diagnosis codes are being removed from the list of
ICD-9-CM Codes Covered by Medicare for PT and
partial thromboplastin time (PTT) NCDs:
Medicare Report / December 1, 2003
„ V72.81, pre-operative cardiovascular
examination (from PTT)
„ V72.83, other specified pre-operative
examination (from PTT)
„ V72.84, pre-operative examination,
unspecified (from PT and PTT)
3. As announced in our September Medicare Report,
diagnosis code 401.1, benign essential
hypertension, was added to the to the list of covered
diagnoses for lipid testing effective October 1, 2003.
The narrative of the lipid NCD has been revised to
coincide with the addition of this eligible diagnosis
code. The third bullet listed in the lipid NCD
indications section is amended to read:
“Any form of atherosclerotic disease, or any disease
leading to the formation of atherosclerotic disease.”
4. In our September Medicare Report, we announced
a number of ICD-9-CM codes that were deleted by
the update in ICD-9-CM codes that became
effective October 1, 2003. CMS provided a 90day grace period for the provider and laboratory
community to adapt to these changes. This grace
period expires effective January 1, 2004 and the
following ICD-9-CM codes will be denied: 282.4,
331.1, 348.3, 530.2, 600.0, 600.1, 600.2, 600.9,
767.1, 790.2, V04.8, V43.2, V53.9, V54.0, V65.1.
Fecal Leukocyte
Examination Reporting
The Clinical Laboratory Improvement Amendment
requires a facility to be appropriately certified for each
test performed. A facility that has a CLIA certificate
for physician-performed microscopy (PPM) procedures
may only perform tests that are categorized as either
PPM procedures or waived tests under CLIA.
HCPCS code G0026 (fecal leukocyte examination) was
discontinued on December 31, 2002. HCPCS code
89055 (fecal leukocyte count) was a possible code to
be used for the discontinued G0026. However, under
CLIA the fecal leukocyte examination permitted for a
PPM procedure certificate does not include a fecal
leukocyte count.
25
For services provided in 2003, facilities with a valid
PPM procedure CLIA certificate should use HCPCS
code Q0111 (Wet mounts, including preparations of
vaginal, cervical or skin specimens) to report fecal
leukocyte examination services.
For services provided in 2004, the wording of HCPCS
code 89055 was revised to read “Leukocyte assessment,
fecal, qualitative or semiquantitative.” he revised text
meets the CLIA definition of the PPM procedure for
the fecal leukocyte examination. Therefore, effective
for services provided on or after January 1, 2004,
facilities with a valid PPM procedure CLIA certificate
should use procedure code 89055 to report fecal
leukocyte examination services.
Guidelines for Medicare
Part B Laboratory Testing
This article explains the Centers for Medicare &
Medicaid Services’ (CMS) coverage policies for
diagnostic and screening prostate specific antigen (PSA)
laboratory tests under Medicare Part B. It also explains
the importance of including the date of service on orders
for laboratory testing.
Diagnostic PSA Laboratory Testing
„ Under §4554(b)(1) of the Balanced Budget
Act (BBA), Public Law 105-33 mandated the
use of negotiated rulemaking with interested
parties in the laboratory community in order
to promote uniformity, administrative
simplicity, and program integrity regarding
coverage and administrative policies for
clinical diagnostic laboratory services
payable under Medicare Part B. As a result
of this negotiated rulemaking, a National
Coverage Decision (NCD) was developed for
the diagnostic PSA test, which is a tumor
marker for adenocarcinoma of the prostate
and may be useful in the differential
diagnosis of men presenting with as yet
undiagnosed disseminated metastatic disease.
When used in conjunction with other prostate
cancer tests, such as digital rectal
examination, the PSA test may assist in the
decision-making process for diagnosing
26
prostate cancer. PSA also serves as a marker
in following the progress of most prostate
tumors once a diagnosis has been established,
as an aid in the management of prostate
cancer patients, and in detecting metastatic or
persistent disease in patients following
treatment. The test is of proven value in
differentiating benign from malignant disease
men with lower urinary tract signs and
symptoms (i.e., hematuria, slow urine stream,
hesitancy, urgency, frequency, nocturia, and
incontinence) as well as patients with
palpably abnormal prostate glands on
physical exam, and in patients with other
laboratory or imaging studies that suggest the
possibility of a malignant prostate disorder.
„ The NCD for diagnostic PSA tests does not
apply to screening PSA tests.
„ Use CPT/HCPCS code 84153 for diagnostic
PSA testing.
Screening PSA Laboratory Testing
„ Screening PSA testing measures the level of
prostate specific antigen in the patient’s
blood for the early detection of the marker
for adenocarcinoma of the prostate subject to
coverage, frequency, and payment limitations
as follows:
ƒ
Covered at a frequency of once every 12
months for men who have attained age 50
if at least 11 months have passed
following the month in which the last
Medicare-covered screening PSA test
was performed; and
ƒ
Must be ordered by the patient’s
physician, physician assistant, nurse
practitioner, clinical nurse specialist, or
certified nurse midwife who is authorized
under State law to perform the
examination, fully knowledgeable about
patient’s medical condition, and who
would be responsible for using the results
of any examination (test) performed in
the overall management of the patient’s
specific medical problem which includes
explaining the results of the test to the
patient.
Medicare Report / December 1, 2003
„ Use HCPCS code G0103 for the screening
PSA test.
Date of Service for Laboratory Testing
During the clinical diagnostic laboratory services
negotiated rulemaking, CMS learned that there was
considerable variability regarding the date of service
on laboratory claims. In order to promote uniformity,
the committee recommended a national policy related
to the date of service on laboratory claims. CMS
published a proposed rule for public comment on March
10, 2000 (65 FR 13082) and published the rule final on
November 23, 2001 (66 FR 58788). The final rule states
that:
„ The date of service for laboratory tests that is
reported on the claim is to be the date the
tested specimen was collected; and
„ The person obtaining the specimen must
furnish the date of collection of the specimen
to the entity billing Medicare.
Physicians or their staff who draw specimens for testing
must report the date of collection of the specimen on
orders for laboratory tests. Laboratories may refuse to
perform tests on orders for laboratory tests that do not
include the information they need in order to seek
payment for services performed, i.e., the date of
collection of the specimen.
GY Modifier Usage For
Clinical Laboratory
Services
Modifier GY should be used when submitting claims
for services that are statutorily non-covered or not a
Medicare benefit.
The clinical laboratory national coverage
determinations (NCDs) include lists of ICD-9-CM
codes that are eligible on the basis of medical necessity
and those that are not covered by Medicare. The ICD9-CM codes that are not covered by Medicare are codes
that are excluded from coverage based on technical
denials, such as routine screening services, rather than
lack of medical necessity.
Medicare Report / December 1, 2003
Laboratories should append the GY modifier to the CPT
procedure code for any service where the appropriate
diagnosis for that service is on the list of diagnoses that
are not covered by Medicare. Use of the GY modifier
will result in a non-covered denial. Laboratories are
permitted to bill beneficiaries for services that are noncovered by Medicare for reasons other than medical
necessity without providing an Advance Beneficiary
Notice (ABN).
Reimbursement
Influenza Virus Vaccine—
CMS Updates Fee
The Centers for Medicare and Medicaid Services has
announced an increase in the fee paid for the influenza
virus vaccine, CPT 90658. The new fee is $9.95 and is
effective for dates of service on or after September 1,
2003. CMS has also indicated that the whole virus
vaccine, CPT 90659 has not been produced for the 2003
flu season, thus providers should not be reporting 90659
when billing for the influenza virus vaccine. Providers
should only be using 90658 when billing for the
influenza virus vaccine.
Medicare Physician Fee
Schedule Database
Revisions
The Centers for Medicare and Medicaid Services has
announced changes to the 2003 Medicare Physician Fee
Schedule Database. Unless otherwise stated, these
changes are effective October 6, 2003 for dates of
service on or after March 1, 2003.
Bilateral Surgery
The bilateral surgery reduction will no longer apply for
procedure code 0025T for dates of service on or after
January 1, 2002.
27
The bilateral surgery reduction will no longer apply for
procedure code 92136 26. The relative value units are
already based on the procedure being performed as a
bilateral procedure.
Multiple Surgery
The multiple surgery reduction will no longer apply
for the following procedure codes:
78306
78306 TC
78306 26
78320
78320 TC
78320 26
Q4077
Loc 01
Loc 99
$37.05
$37.05
Drug Fees Revised
$248.41
$208.97
The endoscopic base code for procedure code 52347
has been changed to 52010.
Physician Supervision
The physician supervision level for procedure codes
G0248 and G0249 has changed to a level 1. This means
that the technical component of these procedures require
at least general physician supervision.
The following changes are effective for dates of service
on or after October 1, 2003.
Status Change
Status A (payable under the MPFSDB)
G0296 26
Loc 01
$103.33
Loc 99
$94.97
Status C (carrier priced)
28
$0.62
$0.62
Q4078
The relative value units have been changed for the
following procedure code.
G0296
G0296 TC
Q4076
Loc 01
Loc 99
Status X (statutory exclusion)
Relative Value Change
93012
Loc 01
Loc 99
Status E (excluded from the MPFSDB)
Fees for the following procedure codes have been
recalculated by the Single Drug Pricer to reflect changes
in the average wholesale price (AWP). The new fees
are effective for claims processed on or after October
1, 2003 for dates of service on or after January 1,
2003.
Note:
The presence or absence of a particular drug on the
SDP file does not represent a determination that the
Medicare program either covers or does not cover that
drug. The amounts shown on the SDP file indicate the
maximum Medicare payment allowance, if the
Medicare contractor determines that the drug meets the
program’s requirements for coverage. Similarly, the
absence of a particular drug from the SDP file means
that if the Medicare contractor determines that the drug
is covered by Medicare, the local contractor must then
determine the program’s payment allowance by
applying the program’s standard drug payment policy
rules. Medicare contractors separately determine
whether a particular drug meets the program’s general
requirements for coverage and, if so, whether payment
may be made for the drug in the particular circumstance
under which it was furnished. Examples of this latter
determination include but are not limited to
determinations as to whether a particular drug and route
of administration are reasonable and necessary to treat
the beneficiary’s condition, whether a drug may be
excluded from payment because it is usually selfadministered, and whether a least costly alternative to
the drug exists.
Medicare Report / December 1, 2003
Code
Description
90385
RHO(D) IG (RHLG), MINIDOSE, IM
90645
HEMOPHILUS INFLUENZA B VACCINE, HBOC, IM
Per dose
25.38
H
90704
MUMPS VACCINE, SC
Per dose
19.43
H
90705
MEASLES VACCINE, SC
Per dose
15.03
H
90732
PNEUMOCOCCAL VACCINE
Per dose
18.62
H
30 mg
15.94
H
Up to 125 mg
2.66
H
J0282
INJECTION, AMIODARONE HYDROCHLORIDE, 30 MG
J0300
INJECTION, AMOBARBITAL, UP TO 125 MG
J0456
INJECTION, AZITHROMYCIN, 500 MG
J0500
INJECTION, DICYCLOMINE HCL, UP TO 20 MG
Unit of
95% of
*Price
Measure
AWP
Change
Per dose
34.77
L
500 mg
25.55
H
Up to 20 mg
17.06
H
J0592
INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG
0.1 mg
1.03
H
J0600
INJECTION, EDETATE CALCIUM DISODIUM, UP TO 1000 MG
Up to 1000 mg
44.10
H
J0620
INJECTION, CALCIUM GLYCEROPHOSPHATE AND CALCIUM
LACTATE, PER 10 ML
INJECTION, LEUCOVORIN CALCIUM, PER 50 MG
Per 10 ml
50 mg
6.42
3.71
H
L
10 ml
2.15
H
500 mg
2.25
H
J0640
J0670
INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML
J0690
INJECTION, CEFAZOLIN SODIUM, 500 MG
J0725
INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS Per 1,000 USP units
3.09
L
J0745
INJECTION, CODEINE PHOSPHATE, PER 30 MG
Per 30 mg
0.50
H
J0780
INJECTION, PROCHLORPERAZINE, UP TO 10 MG
Up to 10 mg
4.18
L
J0850
J1020
INJECTION, CYTOMEGALOVIRUS IMMUNE GLOBULIN INTRAVENOUS
(HUMAN), PER VIAL
INJECTION, METHYLPREDNISOLONE ACETATE, 20 MG
Per vial
20 mg
712.07
2.68
H
H
J1030
INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG
40 mg
4.13
L
J1040
INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG
80 mg
8.27
L
J1051
INJECTION, MEDROXYPROGESTERONE ACETATE, 50 MG
50 mg
5.04
H
J1056
J1070
INJECTION, MEDROXYPROGESTERONE ACETATE / ESTRADIOL
CYPIONATE, 5MG / 25MG
INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG
5 mg/25 mg
Up to 100 mg
24.61
4.95
L
L
J1080
INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG
1 cc, 200 mg
9.43
H
J1120
INJECTION, ACETAZOLAMIDE SODIUM, UP TO 500 MG
Up to 500 mg
20.52
L
J1170
INJECTION, HYDROMORPHONE, UP TO 4 MG
Up to 4 mg
1.55
H
J1190
INJECTION, DEXRAZOXANE HYDROCHLORIDE, PER 250 MG
Per 250 mg
233.97
H
J1245
INJECTION, DIPYRIDAMOLE, PER 10 MG
Per 10 mg
5.70
L
J1410
INJECTION, ESTROGEN CONJUGATED, PER 25 MG
Per 25 mg
61.51
H
J1460
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC
1 cc
12.17
H
J1470
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 2 CC
2 cc
24.35
H
J1480
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 3 CC
3 cc
36.56
H
J1490
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 4 CC
4 cc
48.69
H
J1500
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 5 CC
5 cc
60.87
H
J1510
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 6 CC
6 cc
72.88
H
J1520
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 7 CC
7 cc
85.12
H
J1530
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 8 CC
8 cc
97.38
H
J1540
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 9 CC
9 cc
109.66
H
10 cc
J1550
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 10 CC
121.72
H
J1580
INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG
Up to 80 mg
1.90
H
J1630
INJECTION, HALOPERIDOL, UP TO 5 MG
Up to 5 mg
6.83
L
J1631
INJECTION, HALOPERIDOL DECANOATE, PER 50 MG
Per 50 mg
9.12
L
J1644
INJECTION, HEPARIN SODIUM, PER 1000 UNITS
Per 1000 units
0.40
H
Medicare Report / December 1, 2003
**Status
29
Code
Description
Unit of
95% of
J1645
INJECTION, DALTEPARIN SODIUM, PER 2500 IU
J1650
J1655
J1670
INJECTION, TETANUS IMMUNE GLOBULIN, HUMAN, UP TO 250 UNITS
Up to 250 units
J1720
INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP TO 100 MG
Up to 100 mg
J1742
INJECTION, IBUTILIDE FUMARATE, 1 MG
J1885
INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG
J1940
INJECTION, FUROSEMIDE, UP TO 20 MG
J1950
INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3.75 MG
J2000
INJECTION, LIDOCAINE HCL, 50 CC
J2010
INJECTION, LINCOMYCIN HCL, UP TO 300 MG
*Price **Status
Measure
AWP
Change
Per 2500 IU
15.69
H
INJECTION, ENOXAPARIN SODIUM, 10 MG
10 mg
6.47
H
INJECTION, TINZAPARIN SODIUM, 1000 IU
1000 IU
3.83
H
119.70
H
2.49
H
251.35
L
3.56
L
1 mg
Per 15 mg
Up to 20 mg
3.75 mg
0.98
L
517.32
H
50 cc
3.99
H
Up to 300 mg
3.18
L
J2020
INJECTION, LINEZOLID, 200MG
200 mg
36.80
L
J2150
INJECTION, MANNITOL, 25% IN 50 ML
25% in 50 ml
3.27
H
J2210
INJECTION, METHYLERGONOVINE MALEATE, UP TO 0.2 MG
Up to 0.2 mg
4.10
H
J2250
INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG
Per 1 mg
1.28
H
J2270
INJECTION, MORPHINE SULFATE, UP TO 10 MG
0.77
H
J2324
INJECTION, NESIRITIDE, 0.5 MG
151.62
H
J2370
INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML
J2440
INJECTION, PAPAVERINE HCL, UP TO 60 MG
Up to 10 mg
0.5 mg
Up to 1 ml
1.28
L
Up to 60 mg
3.56
H
J2510
INJECTION, PENICILLIN G PROCAINE, AQUEOUS, UP TO 600,000 UNITS Up to 600,000 units
9.60
H
J2515
INJECTION, PENTOBARBITAL SODIUM, PER 50 MG
Per 50 mg
1.32
H
J2545
J2590
PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, PER 300 MG,
ADMINISTERED THROUGH
INJECTION, OXYTOCIN, UP TO 10 UNITS
Per 300 mg
Up to 10 units
50.77
1.72
L
H
J2650
INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML
J2680
INJECTION, FLUPHENAZINE DECANOATE, UP TO 25 MG
J2690
INJECTION, PROCAINAMIDE HCL, UP TO 1 GM
J2760
INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG
J2765
INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG
J2770
INJECTION, QUINUPRISTIN/DALFOPRISTIN, 500 MG (150/350)
500 mg
J2788
INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 MCG
50 mcg
34.77
L
J2910
INJECTION, AUROTHIOGLUCOSE, UP TO 50 MG
50 mg
17.31
H
J2920
INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 40 MG
Up to 40 mg
1.95
H
J2930
INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG Up to 125 mg
3.24
H
J2941
INJECTION, SOMATROPIN, 1 MG
J2993
INJECTION, RETEPLASE, 18.1 MG
J2997
INJECTION, ALTEPLASE RECOMBINANT, 1 MG
1 mg
J3100
INJECTION, TENECTEPLASE, 50MG
50 mg
J3120
INJECTION, TESTOSTERONE ENANTHATE, UP TO 100 MG
Up to 100 mg
8.98
H
J3130
INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG
Up to 200 mg
17.96
H
J3265
INJECTION, TORSEMIDE, 10 MG/ML
10 mg/ml
1.56
H
J3301
INJECTION, TRIAMCINOLONE ACETONIDE, PER 10MG
Per 10 mg
1.60
H
J3315
INJECTION, TRIPTORELIN PAMOATE, 3.75 MG
3.75 mg
398.62
L
J3320
INJECTION, SPECTINOMYCIN DIHYDROCHLORIDE, UP TO 2 GM
Up to 2 g
28.27
H
J3360
INJECTION, DIAZEPAM, UP TO 5 MG
J3395
INJECTION, VERTEPORFIN, 15MG
J3475
INJECTION, MAGNESIUM SULFATE, PER 500 MG
30
Up to 1 ml
0.31
L
Up to 25 mg
9.42
L
Up to 1 g
1.43
L
Up to 5 mg
31.92
L
Up to 10 mg
1 mg
18.1 mg
Up to 5 mg
15 mg
Per 500 mg
1.99
L
114.58
H
45.92
H
1364.44
H
36.70
H
2690.88
H
0.86
L
1603.13
H
0.27
L
Medicare Report / December 1, 2003
Code
Description
J7051
STERILE SALINE OR WATER, UP TO 5 CC
J7317
J9000
SODIUM HYALURONATE, PER 20 TO 25 MG DOSE FOR INTRAARTICULAR INJECTION
LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN,
EQUINE, PARENTERAL, 250 MG
LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN,
RABBIT, PARENTERAL, 25MG
DOXORUBICIN HCL, 10 MG
J9040
BLEOMYCIN SULFATE, 15 UNITS
J9060
CISPLATIN, POWDER OR S0LUTION, PER 10 MG
J9062
CISPLATIN, 50 MG
J9065
INJECTION, CLADRIBINE, PER 1 MG
J9070
CYCLOPHOSPHAMIDE, 100 MG
J9080
J9090
J9091
J9092
J9093
CYCLOPHOSPHAMIDE, LYOPHILIZED, 100 MG
J9094
CYCLOPHOSPHAMIDE, LYOPHILIZED, 200 MG
J9100
J9110
J7504
J7511
Unit of
95% of
*Price **Status
Measure
AWP
Up to 5 cc
0.76
L
20 to 25 mg
138.71
L
250 mg
278.70
L
25 mg
10 mg
357.58
9.69
H
L
15 units
182.40
L
Change
Per 10 mg
15.96
L
50 mg
79.80
L
Per 1 mg
51.30
L
100 mg
5.73
L
CYCLOPHOSPHAMIDE, 200 MG
200 mg
10.89
L
CYCLOPHOSPHAMIDE, 500 MG
500 mg
22.86
L
CYCLOPHOSPHAMIDE, 1.0 GRAM
1g
45.73
L
CYCLOPHOSPHAMIDE, 2.0 GRAM
2g
91.45
L
100 mg
5.59
L
200 mg
11.17
L
CYTARABINE, 100 MG
100 mg
3.19
L
CYTARABINE, 500 MG
500 mg
8.55
L
J9140
DACARBAZINE, 200 MG
200 mg
22.06
L
J9150
DAUNORUBICIN, 10 MG
10 mg
74.23
L
J9160
DENILEUKIN DIFTITOX, 300 MCG
300 mcg
1330.95
H
J9180
EPIRUBICIN HYDROCHLORIDE, 50 MG
50 mg
690.99
L
J9181
ETOPOSIDE, 10 MG
10 mg
1.71
L
J9182
ETOPOSIDE, 100 MG
100 mg
17.10
L
J9185
FLUDARABINE PHOSPHATE, 50 MG
50 mg
356.07
H
J9190
FLUOROURACIL, 500 MG
500 mg
2.07
L
J9200
FLOXURIDINE, 500 MG
500 mg
136.80
H
J9206
IRINOTECAN, 20 MG
20 mg
145.74
L
J9214
INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS
1 million units
14.88
H
J9216
INTERFERON, GAMMA 1-B, 3 MILLION UNITS
3 million units
209.22
H
J9218
LEUPROLIDE ACETATE, PER 1 MG
J9266
PEGASPARGASE, PER SINGLE DOSE VIAL
J9280
MITOMYCIN, 5 MG
J9290
MITOMYCIN, 20 MG
J9291
MITOMYCIN, 40 MG
40 mg
285.00
L
J9310
RITUXIMAB, 100 MG
100 mg
501.13
H
1 mg
70.28
H
1543.75
H
5 mg
63.84
L
20 mg
207.48
L
Per single dose vial
J9320
STREPTOZOCIN, 1 GM
1g
141.47
H
J9355
TRASTUZUMAB, 10 MG
10 mg
58.13
H
J9390
VINORELBINE TARTRATE, PER 10 MG
10 mg
89.36
L
P9048
INFUSION, PLASMA PROTEIN FRACTION (HUMAN), 5%, 250ML
5%, 250 ml
29.10
L
Q0187
FACTOR VIIA (COAGULATION FACTOR, RECOMBINANT) PER 1.2 MG
Per 1.2 mg
1681.50
H
Q4076
DOPAMINE HYDROCHLORIDE, PER 40 MG
40 mg
0.62
A
Q4077
TREPROSTINIL, PER 1 MG
1 mg
37.05
A
* H = Higher; L = Lower
** A = New Code; D = Discontinued Code
Medicare Report / December 1, 2003
31
Splint and Cast Fees for
2004
Internet Spotlight
Payments for splints and casts furnished in 2004 will
continue to be based on gap-filled amounts. The 2004
gap-filled amounts for splints and casts are based on
the 2003 amounts increased by 2.1%. The 2004 fees
for splint and cast procedure codes are as follows:
www.hgsa.com
Splints and Casts Used to Reduce a Fracture or
Dislocation
Procedure
Code
A4565
Q4001
Q4002
Q4003
Q4004
Q4005
Q4006
Q4007
Q4008
Q4009
Q4010
Q4011
Q4012
Q4013
Q4014
Q4015
Q4016
Q4017
Q4018
Q4019
Q4020
Q4021
Q4022
Q4023
Q4024
32
2004
Fee
Procedure
Code
2004
Fee
6.50
37.05
140.02
26.61
92.13
9.81
22.11
4.91
11.06
6.54
14.74
3.27
7.37
11.91
20.11
5.96
10.05
6.90
10.99
3.45
5.50
5.10
9.21
2.56
4.60
Q4025
Q4026
Q4027
Q4028
Q4029
Q4030
Q4031
Q4032
Q4033
Q4034
Q4035
Q4036
Q4037
Q4038
Q4039
Q4040
Q4041
Q4042
Q4043
Q4044
Q4045
Q4046
Q4047
Q4048
Q4049
28.61
89.32
14.31
44.66
21.87
57.58
10.94
28.79
20.40
50.75
10.21
25.38
12.45
31.18
6.23
15.60
15.13
25.84
7.57
12.92
8.78
14.13
4.39
7.07
1.60
Twenty
Interactive
Training
Modules Now
Available!
As part of our continuing initiative to educate Medicare
providers, we are proud to announce that
HGSAdministrators interactive training module system
has now grown to a catalog of 20 available modules.
These are now available, free of charge, at the HGSA
web site under the “Provider Education and Training”
area. This web-based application allows providers
access to an interactive multimedia training system,
which includes material organized by modules and
topics. Throughout each module, you will be quizzed
on what you’ve read to test your skills.
The twenty modules cover the following topics:
„
„
„
„
„
„
„
„
„
„
„
„
„
„
„
„
„
„
„
„
Advanced Beneficiary Notice
Anesthesia Modifiers
Care Plan Oversight
Chiropractic Services
Consultations
Determining Medical Necessity
Drugs & Biologicals
E&M Advanced
E&M Introduction
Eye Care Services.
“Incident To” Services
Medicare Preventive Services
Nursing Facility
Physical Medicine & Rehabilitation Services
Podiatry Services
Psychiatric Services
Purchased Diagnostic Services
Split E&M
Teaching Physician Services
The Medicare Coverage Process
Medicare Report / December 1, 2003
Providers who have had experience in any of these
topics may also skip directly to quiz questions to test
their knowledge, or read topics only of interest to them.
Visual enhancements as well as more modules will be
added to the system later this year.
The system is compatible with all computer types. All
that’s required is a web browser and a connection to
the Internet. To interact with the modules properly, your
screen resolution must be set to a size of at least 800
pixels wide by 600 pixels tall. Most computers made
in the past few years default to this setting, but if your
machine isn’t one of them, the software will instruct
you how to make the change.
Access to the training system is completely anonymous.
Your quiz results will not be tracked and will be
viewable only by yourself. These modules are provided
as a training tool, and do not replace official Medicare
program requirements.
You can find instructions and a direct link to the new
modules on our web site at http://www.hgsa.com/
professionals/training.shtml. If you have sound
available, turn it on, as the modules do contain audio
along with a very colorful navigation system. See you
on the web!
Fraud and Abuse
Sanctioned Providers
HGSAdministrators will not issue payments for services
performed, ordered, or referred by these providers after
the indicated dates.
Provider
Effective
Date
Stephen Batoff, CP
13050 Bustleton Ave
Philadelphia, PA 19116
1/30/03
Bruce Bodganoff, MD
Crozer Chester Med
15th St and Upland Ave
Chester, PA 19013
6/19/03
Medicare Report / December 1, 2003
Provider
Effective
Date
Toby Brandt, CSW
2610 Walbert Avenue
Allentown, PA 18104
4/20/03
Ilona Dolinish, CRNA
25 Heckel Rd
McKees Rocks, PA 15136
9/19/03
John Gain, MD
3 Hospital Drive
Lewisburg, PA 17837
4/20/03
Scott H. Katine, DPM
2031 Locust Street
Philadelphia, PA 19103
5/20/03
Joel Levin, CP
Suite 110 A
7900 Old York Road
Elkins Park, PA 19027
5/20/03
Paula A. Levin, Psy
Suite 110 A
7900 Old York Road
Elkins Park, PA 19027
5/20/03
John McIntyre, DDS
1336 Bristol Pke
Bensalem, PA 19020
8/20/03
Constance Rambo-Murawski, CNM
3300 Henry Avenue
Philadelphia, PA 19129
9/19/03
Peter Schmidt, CRNA
4800 Friendship Ave.
Pittsburgh, PA 15224
6/19/03
J. Evans Thompson, Sr., DC
6161 Chestnut St.
Philadelphia, PA 19139
6/19/03
Janie Vaughan-Schreiber, DC
Suite H2
2370 York Road
Jamison, PA 18929
5/20/03
33
Claim Reporting
2004 HCPCS Update
The new Healthcare Common Procedure Coding
System (HCPCS) becomes effective for dates of service
January 1, 2004 and after. A 3-month grace period will
apply to the discontinued codes for dates of service
January 1 to March 31, 2004 for claims received prior
to April 1, 2004. This means that Medicare will accept
both the 2003 discontinued codes and the new 2004
codes during the January-March 2004 grace period. For
claims received April 1, 2004 and after, for dates of
service January 1, 2004 and after, Medicare will only
accept the new codes.
Anesthesia
Reimbursement Based on
Jurisdictional Payment
Effective April 1, 2004 reimbursement for anesthesia
services will be based on the zip code where the service
was furnished. Services paid under the Medicare
Physician Fee Schedule Data Base (MPFSDB), are
subject to jurisdictional payment per the online CMS
Manual, Pub. 100-4, Chapter 1, Section 10.1.1;
anesthesia services were previously excluded from this
requirement.
Reporting
Effective for paper claims received on or after April 1,
2004, Item 32 of the CMS-1500 claim form must
contain the name, address and zip code where the
service was rendered, for any place of service other than
the beneficiary’s home, or the claim will be returned as
unprocessable per the online CMS Manual, Pub. 1004, Chapter 1, Section 80.3.1. It is acceptable for claims
to contain place of service (POS) home and one
additional POS code, provided the appropriate
information is entered in Item 32 for the additional POS
code submitted. This allows payment to be made based
on the correct locality rate where the service was
rendered.
For electronic claims received on or after April 1, 2004,
any number of additional POS codes will be accepted
34
per claim submission provided a corresponding service
facility location and address is provided for each service
at the line level if that location is different from the
billing provider, pay-to-provider or claim level service
facility location. Services will be reimbursed based on
the zip code of the service facility location, billing
provider address, or pay-to provider address depending
upon which information is submitted at the
corresponding line level.
Beneficiary Signature on
Claim Form
Items 12 and 13 on the CMS-1500 claim form are for
the patient’s or authorized representative’s signature.
Item 12 requires a signature and six-digit (MMDDYY)
date and authorizes the release of medical information
necessary to process the claim. It also authorizes
payment of benefits to the provider of service or supplier
when the provider of service or supplier accepts
assignment on the claim.
In lieu of signing the claim in Item 12, the patient may
sign a statement to be retained in the provider, physician,
or supplier file in accordance with the online CMS
Manual, Pub. 100-04, Chapter 1, Sections 50.1 and
80.3.2.C. In that case, this item on the claim form should
contain the statement “signature on file.” Chapter 9 of
Medicare Part B Reference Manual contains additional
information regarding signature requirements, including
information regarding patients who are unable to sign
or who sign via a mark (x).
Failure to include an appropriate signature and six-digit
date or a “signature on file” statement in Item 12 will
result in a claim rejection.
A signature in Item 13 on the CMS-1500 claim form
authorizes payment of mandated Medigap benefits to
the participating physician or supplier if required
Medigap information is included in Item 9 (and its
subdivisions). The patient or his/her authorized
representative signs this item, or the signature must be
on file as a separate Medigap authorization. The
Medigap assignment on file in the participating provider
of service/supplier’s office must be insurer specific. It
may state that the authorization applies to all occasions
of service until it is revoked.
Medicare Report / December 1, 2003
Because signatures in Items 12 and 13 mean different
things, a signature (or statement) in one does not apply
to the other. Therefore, all claims must have Item 12
completed, and claims with Medigap information in
Item 9 must have Items 12 and 13 completed. Claims
will be rejected when necessary signatures (or
acceptable statements) are missing from these Items.
Cataract Surgery—CoManagement
The performing surgeon has the primary responsibility
for the preoperative assessment and post-operative care
for his/her patients. The decision to co-manage patient
care should be the result of a determination which is
best for the patient.
As a result of an increase in billing for co-management
of cataract surgery, we are re-publishing the June 2002
Medicare Report article, “Modifiers 54 and 55 (Post
Operative Care)—Reporting” (page 26) in it’s entirety.
When the surgical procedure and post-operative care
are co-managed between different physicians, use the
following guidelines to correctly report the services.
HCFA-1500 claim form. Only the range of
dates is needed. Do not report each date for
each visit performed.
When the physician provides only post-op care
when “split” between physicians
„ Report the date of service using the date the
surgery was performed.
„ Report the procedure code for the surgical
procedure performed.
„ Report the 55 modifier with the procedure
code.
„ Report the range dates that post-op care was
provided in the procedure description field on
the electronic claims, or in block 19 of the
HCFA-1500 claim form. Only the range of
dates is needed. Do not report each date for
each visit performed.
Note: Post-op care begins the day after the surgery.
Example:
„ Report the date the surgery was performed.
Dr. Smith rendered cataract surgery on October 15,
2001. He provided the post-op care until November 4,
2001. Dr. Brown then assumed the patient’s post-op
care and continued to do so until the end of the post-op
period. The post-op period would end on January 13,
2002 (90 days).
„ Report the procedure code for the surgical
procedure performed.
How should each physician report?
When the physician renders only the surgical
care
„ Report the 54 modifier with the procedure
code.
Dr. Smith:
Line 1:
Date surgery was performed (101501)
Procedure code for surgical procedure
along with modifier 54 for surgical care
only (6698454)
Line 2:
„ Report the procedure code for the surgical
procedure performed.
Date surgery was performed (101501)
Procedure code for surgical procedure
along with modifier 55 for post-op care
provided (6698455)
„ Report the 55 modifier with the procedure
code.
Narrative or 101601 - 110401 (post-op care provided,
Block 19:
or first 20 days would be acceptable).
When the surgeon provides only a part of the
post-op care
„ Report the date the surgery was performed.
„ Report the range dates that post-op care was
provided in the procedure description field on
the electronic claims, or in block 19 of the
Medicare Report / December 1, 2003
35
Dr. Brown:
Line 1:
Date surgery was performed (101501)
Procedure code for surgical procedure
along with modifier 55 for post-op care
provided (6698455)
Narrative or 110501 - post-op care provided from
Block 19:
110501 - 011302, or post-op care
provided from 110501 until end of the
post-op period would be acceptable.
When the post-op care is “split” between two
physicians, payment is based on the percentage of postop care that each physician provides, not the number of
visits performed during the post-op period.
Failure to report the split of post-op care dates may
result in denial of your claim. And, if you are
performing post-op care only, failure to list the date of
surgery as the date of service will also result in a denial.
Changes to Code List for
Therapy Services
97530 97532 97533 97535 97537 97542
97703 97750 97799 V5362 V5363 V5364
G0281 G0283
Codes requiring the GN, GO, or GP modifier, and
appropriate plan of care, except if performed by an
audiologist include:
92601 92602 92603 92604
Codes requiring the GN, GO, or GP modifier, and
appropriate plan of care if reported by a physical
therapist or occupational therapist (specialties 65, 67,
73 & 74) are listed below. Physician and non-physician
practitioners should only use these therapy modifiers
with the codes below when the services are provided
under a therapy plan of care:
29065 29075 29085 29086 29105 29125
29126 29130 29131 29200 29220 29240
29260 29280 29345 29355 29365 29405
29425 29445 29505 29515 29520 29530
29540 29550 29580 29590 64550 90901
90911 92610 92611 92612 92614 92616
The Centers for Medicare and Medicaid Services has
modified the list of HCPCS codes for physical therapy,
occupational therapy, and speech-language pathology,
that require the use of modifiers GN, GO, and GP when
submitting claims for Medicare beneficiaries. These
modifications are effective July 1, 2003, and are being
implemented on September 1, 2003.
95831 95832 95833 95834 95851 95852
96000 96001 96002 96003 96105 96110
There are three lists of codes that apply to therapy
services. The first list requires the use of the GN, GO,
or GP modifier on all claim submissions. There must
also be a plan of care on file for these outpatient therapy
services. The second and third lists require the use of
the modifiers under certain conditions as are listed.
Any claims that were rejected for missing modifiers
during July and August 2003 for codes in this third list
may be resubmitted.
Codes always requiring the GN, GO, or GP modifier,
and appropriate plan of care include:
96111 96115 97601 G0279 G0280 0020T
0029T
Remember, a plan of care must be on file, when
appropriate, for all outpatient therapy services.
Compounded Drugs—
Billing for
97036 97039 97110 97112 97113 97116
97124 97139 97140 97150 97504 97520
Compounded drugs created by a pharmacist in
accordance with the Federal Food, Drug, and Cosmetic
Act may be covered under Medicare under certain
conditions. The following provides a clarification on
the correct billing method for compounded drugs. Since
these drugs are used frequently in implantable infusion
pumps, this article also addresses the billing of the
refilling and maintenance of the implantable pump.
36
Medicare Report / December 1, 2003
92506 92507 92508 92526 92597 92607
92608 92609 97001 97002 97003 97004
97012 97016 97018 97020 97022 97024
97026 97028 97032 97033 97034 97035
Only compounded medications that are not selfadministered are reimbursed by Medicare Part B. In
addition, these drugs must represent an expense to the
physician; therefore, drugs administered in a skilled
nursing facility or hospital setting, or those that have
not been purchased by the billing physician are noncovered under Medicare Part B. In a skilled nursing
facility or hospital setting the compounded drug is a
Medicare Part A service. Therefore, compounded drugs
administered by the physician at a cost to the physician
are considered for reimbursement under Medicare Part B.
Most of the drugs used in compounding have valid
HCPCS “J” codes specific to the drug and a particular
dosage. The issue in billing the compounded
medications is whether the dosage utilized by the
pharmacist in the creation of the compounded drug
equates with the code description. For example, if the
compounded medication includes 5 mg of Baclofen, it
is not appropriate to bill J0475 (injection, Baclofen, 10
mg); but rather, J3490 (unclassified drug) should be
billed for the Baclofen component of the compounded
drug.
This said, it is appropriate to bill Medicare for each of
the drugs used in a compounded drug on a separate line
item of the CMS-1500 claim form or the electronic
claim form. If one of the drugs utilized in the
compounded medication is appropriately represented
by a specific HCPCS code (name of the drug and dosage
utilized coincides exactly with the code description),
utilize the specific HCPCS code for that drug. If one
of the drugs is not exactly represented by a specific
HCPCS code, bill that component of the compounded
drug under J3490. If two or more of the drugs are not
exactly represented by a specific HCPCS code(s), bill
each drug on separate lines under J3490. When utilizing
J3490 report the name of each drug with its
corresponding dosage in block 19 of the CMS-1500
claim form, or in the narrative area of the electronic
claim. The descriptions listed in block 19 should
correspond to the sequence of the J3490 codes in block
24D. Drugs billed under J3490 will be individually
priced based on the information supplied on the claim.
If the compounded drug is for the refilling of an
implantable infusion pump, CPT code 95990 should
be billed on the same claim as the compounded
medication. It is always preferable that services
rendered on the same day by the same physician be
billed on a single claim.
Medicare Report / December 1, 2003
95990 Refilling and maintenance of implantable pump
or reservoir for drug delivery, spinal
(intrathecal, epidural) or brain (intraventricular)
Hepatitis B Vaccine—CPT
Codes
Continue to use CPT procedure codes 90740, 90743,
90744, 90746 and 90747 when billing for the Hepatitis
B vaccine. The “Q” codes, which were established in
January 2003 (Q3021-Q3023), were deleted by the
Centers for Medicare and Medicaid Services. Please
refer to our Medical Policy Bulletin I-6 for further
information regarding coverage and billing procedures.
Influenza Virus Vaccine—
Use Diagnosis Code
V04.81
All Medicare institutional providers, Part B physicians,
non-physician practitioners, and suppliers who
administer the influenza virus vaccine must use the new
diagnosis code ICD-9-CM, V04.81 for claims with dates
of service on and after October 1, 2003.
Mammography—Reporting
CAD Codes
Claims with Dates of Service January 1, 2004
and Later
Diagnostic Mammography - HCPCS code 76082 has
been established for diagnostic mammography CAD
services. List this new code separately in addition to
the primary diagnostic mammography procedure code
(76090, 76091, G0204, G0206). HCPCS CAD code
G0236 is deleted as of December 31, 2003.
Screening Mammography - HCPCS code 76083 has
been established for screening mammography CAD
services. List this new code separately in addition to
the primary screening mammography procedure code
(76092 and G0202). CAD code 76085 is deleted as of
December 31, 2003.
37
Claims with Dates of Service January 1, 2002
through December 31, 2003
Diagnostic Mammography - HCPCS code G0236
(CAD code for diagnostic mammography) must be
billed as a separate line in conjunction with the primary
service diagnostic mammography code 76090 or 76091.
Note: For claims with dates of service April 1, 2003 December 31, 2003, add G0204 and G0206 to the list
of codes to be billed in conjunction with G0236
(diagnostic mammography).
Screening Mammography - Use HCPCS Code 76092
with CAD code 76085.
Note: For claims with dates of service April 1, 2003 December 31, 2003, add G0202 to the list of codes to
be billed in conjunction with 76085 (screening
mammography).
Screening and diagnostic mammographies (film and
digital) are subject to the FDA certification. However,
CAD codes are not subject to the FDA certification.
Not Otherwise Classified
(NOC) Codes for Injections
Always report a ‘1’ in the number of units field when
reporting a “not otherwise classified” (NOC) code for
an injection. Include a detailed narrative description
of the service (e.g., drug name and dosage for drug) in
block 19 of the CMS-1500 claim form or the appropriate
electronic claim record as indicated below. This will
help expedite processing of the claim. Refer to Chapter
9 of the Medicare Part B Reference Manual for more
information.
Outpatient Rehabilitation
Services Billing Guidelines
This provider education article discusses the
background of the outpatient rehabilitation services
limitation regulation, therapy modifiers, applicable
outpatient rehabilitation Healthcare Common Procedure
Coding System (HCPCS) and revenue codes, and billing
instructions. In addition, it includes information
resources for outpatient rehabilitation services.
Background
Section 4541(a)(2) of the Balanced Budget Act (BBA)
(P.L. 105-33) of 1997 required payment under a
prospective payment system for outpatient rehabilitation
services, which includes the following services:
„ Physical therapy, including outpatient
speech-language pathology; and
„ Occupational therapy.
Section 4541(c) of the BBA required application of a
financial limitation to all outpatient rehabilitation
services. These limits do not apply to therapy rendered
by outpatient departments of hospitals unless the
beneficiary is a resident of either a Medicare-certified
skilled nursing facility or a Medicare-certified portion
of a skilled nursing facility. These limits were applied
in 1999. However, due to a Congressionally imposed
moratorium, the limits have not been effective during
the years 2000, 2001, or 2002. The outpatient
rehabilitation services financial limitations were
initially planned to resume on July 1, 2003, but their
implementation has been delayed. The limitations on
outpatient rehabilitation therapy services have been
implemented again on September 1, 2003.
Therapy Modifiers
Narrative
Information
X12N 837
Versions
4010, 4010.A1
Paper Claim
Claim Level
2300-NTE02
Block 19
Line Level
2400-NTE02
„ For any applicable rehabilitation therapy service
that is rendered, providers/suppliers must report
one of the following therapy modifiers, which
were effective on January 1, 2003:
GN Services delivered under an outpatient
speech-language pathology plan of care.
GO Services delivered under an outpatient
occupational therapy plan of care.
GP
38
Services delivered under an outpatient
physical therapy plan of care.
Medicare Report / December 1, 2003
Note: These therapy modifiers do not allow a provider
to deliver services that they are not recognized by
Medicare to perform.
*
The physician fee schedule abstract file does
not contain a price for codes 96110, 97799,
V5362, V5363, and V5364, since they are
priced by the carrier. Therefore, contact the
carrier to obtain the appropriate fee schedule
amount in order to make proper payment for
these codes.
**
Code 97504 should not be reported with code
97116. However, if code 97504 was
performed on an upper extremity and code
97116 (gait training) was also performed,
both codes may be billed with modifier 59 to
denote a separate anatomic site.
Applicable Outpatient Rehabilitation HCPCS
and Revenue Codes
„ The HCPCS code list for outpatient
rehabilitation services was revised in
Transmittal B-03-065 to include additional
codes that will not apply to the financial
limitations when billed by physicians and
non-physician practitioners, as appropriate.
„ These codes supersede the codes listed in
§3653 of the Medicare Part A Intermediary
Manual, Part 3.
„ This listing of HCPCS codes does not imply
that services are covered.
„ HCPCS codes apply to each financial
limitation except as noted below.
29065+
29125+
29075+ 29085+
29126+ 29130+
29086+
29131+
29105+
29200+
29220+
29355+
29240+ 29260+
29365+ 29405+
29280+
29425+
29345+
29445+
29505+
29550+
29515+ 29520+
29580+ 29590+
29530+
64550+
29540+
90901+
90911+
92597
92506
92507
92601++ 92602++
92508
92603++
92526
92604++
92607
92612+
92608
92609
92614+ 92616+
92610+
95831+
92611+
95832+
95833+
96001+
95834+ 95851+
96002+ 96003+
95852+
96105+
96000+
96110+*
96111+
97004
96115+ 97001
97012
97016
97002
97018
97003
97020
97022
97033
97024
97034
97026
97035
97028
97036
97032
97039
97110
97139
97112
97140
97113
97150
97116
97504**
97124
97520
97530
97542
97532 97533
97601+ 97703
97535
97750
97537
97799*
V5362*
G0281
V5363* V5364*
G0279+*** 0280+***
G0283 0020T+*** 0029T+***
Medicare Report / December 1, 2003
*** The physician fee schedule abstract file does
not contain a price for codes G0279, G0280,
0020T, 0029T since they are priced by the
carrier. In addition, coverage for these codes
is determined by the carrier. Therefore,
contact the carrier to obtain the appropriate
fee schedule amount.
+
These codes will not apply to the financial
limits when they are not done under a therapy
plan of care and they are billed by providers
of services who are represented by any
specialty codes except 65 and 67 (PT in
Private Practice, OT in Private Practice), also
73 and 74 (which were incorrectly noted in
AB-03-018 and have since been reassigned
to specialties that are not therapy services.)
Specialty codes 73 and 74 will be removed
in a future instruction. Physicians and nonphysician practitioners should only use
therapy modifiers (GN, GO, GP) with the
above codes when the services are provided
under a therapy plan of care.
++
If an audiology procedure (HCPCS) code is
performed by an audiologist, the above
modifiers should not be reported, as these
procedures are not subject to the financial
limitation. When these HCPCS codes are
billed under a speech-language pathology
plan of care, they should be accompanied
with a GN modifier and applied to the
financial limitation.
39
practitioners who are licensed to provide
therapy services and the services are not
isolated medical services (e.g., a cast) but
part of an episode of care whose goal is
rehabilitation. When outpatient rehabilitation
therapy services are billed, therapy modifiers
must be used and all requirements for
rehabilitation therapy services must be
followed, including a plan of care.
Carrier Billing Instructions
„ Claims must include PT, OT, or SLP
modifiers (GP, GO, and GN) when any of the
HCPCS codes listed above are used (see
exceptions noted by + and ++ in the footnote
following the list above). Claims will be
returned to providers/suppliers and
processing will be delayed if the modifiers
are not included.
„ In addition, it has been noted that some
providers are using modifiers inappropriately
with HCPCS codes that are not on the above
list. As a result, charges will be incorrectly
applied to therapy caps.
Intermediary Billing Instructions
If the PT, OT, and SLP modifiers (GP, GO, and GN) are
not billed with revenue codes 42x, 43x, or 44x, the claim
will be returned to the provider.
Claims with the appropriate modifiers under revenue
codes 42x, 43x or 44x, but with HCPCS other than those
identified above, may result in charges being incorrectly
applied to the therapy caps.
General Billing Instructions
„ Providers should be aware that billing a
modifier inappropriately with HCPCS or
revenue codes that are not listed above may
result in charges incorrectly applied to
whichever therapy cap the modifier denotes.
This incorrect billing deprives the recipient
of benefits to which they are entitled and
which are not subject to the financial
limitation.
„ The HCPCS codes marked + on the list above
may or may not be considered outpatient
rehabilitation services, depending on the
circumstances and the practitioners involved.
These codes always represent therapy
services when done by therapists. They also
represent rehabilitation therapy services
when done by physicians and non-physician
40
„ Diagnostic audiology codes do not require
therapy modifiers (see audiology procedure
footnote ++ in above list). Audiology
services are not subject to therapy caps.
Speech-language pathologists are not
qualified to perform diagnostic audiology
services. The audiology codes will be
removed from the list in a future instruction.
Outpatient Rehabilitation Services
Information Resources
„ Program Memorandums
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
Transmittal B-03-065 dated August 22, 2003
Transmittal B-03-051 dated July 16, 2003
Transmittal AB-03-097 dated July 3, 2003
Transmittal AB-03-085 dated June 10, 2003
Transmittal AB-03-073 dated May 23, 2003
Transmittal AB-03-057 dated May 2, 2003
Transmittal AB-03-018 dated February 7,
2003
„ Therapy Resources Web Site
www.cms.hhs.gov/medlearn/therapy
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
Medicare therapy news
Frequently asked questions
General information documents
Therapy medical review operations
General research tools for therapy topics
Research tools for specific therapy topics
Evidence-based literature review
Join therapy cap listserv (electronic mailing
list)
Medicare Report / December 1, 2003
Quarterly Update of
HCPCS Codes Used for
Home Health Consolidated
Billing Enforcement—
Correction
Program Memorandum AB-03-096, the third quarterly
home health consolidated billing update for calendar
year 2003, was published on July 3, 2003. Among other
changes, it removed code A4421 from the list of supply
codes subject to home health consolidated billing.
Removing code A4421 was an error.
This instruction is to notify providers that A4421
(Ostomy Supply misc) will not be deleted from home
health consolidated billing enforcement
Providers and suppliers interested in an updated
complete list of codes subject to home health
consolidated billing should refer to the home health
consolidated billing master code list available at http:/
/cms.hhs.gov/providers/hhapps/.
Purchased Services—
Jurisdictional Reporting
Clarification
Diagnostic tests and the associated interpretations are
paid from the Medicare Physician Fee Schedule Data
Base, and are subject to the same jurisdictional payment
rules as all other services. As with any service, suppliers
must meet current enrollment criteria as stated in
Chapter 10 of the Program Integrity Manual in order to
enroll and bill for purchased tests and interpretations.
Physicians or other suppliers who furnish the technical
component must also be enrolled in the Medicare
program to be eligible for payment. In order to purchase
a diagnostic test, the purchaser must perform the
interpretation. The fact that these services are purchased
does not negate the need for appropriate enrollment
procedures with the carrier that has jurisdiction over
the geographic area where the services were rendered.
In order for the carrier to determine jurisdiction, price
correctly, and apply the purchase price limitations, the
following guidelines must be utilized to allow payment
for purchased services on electronic or paper claim formats:
Medicare Report / December 1, 2003
„ Item 32 of the CMS-1500 paper claim form
is limited to one service facility location
name and address. In most cases when a test
is purchased, it has been rendered at a
different service facility location from where
the interpretation is performed. Therefore,
physicians may only bill for a purchased test
and an interpretation on the same claim when
the services are rendered on the same date, at
the same facility location, and include the
same place of service codes. Otherwise,
providers billing for purchased tests on the
CMS-1500 paper claim form, per the online
CMS Manual, Pub. 100-4, Chapter 1, Section
30.2.9, must submit each test on a separate
claim form. This will allow carriers to pay at
the correct reimbursement rate based on the
appropriate facility location zip code and
purchase price of each test. If more than one
purchased test is submitted, the claim will be
returned as unprocessable.
„ For electronic claims, multiple purchased
tests may be submitted on one claim as long
as the appropriate service facility location
information and total purchased service
amounts for each purchased test are entered
at the line level when services are rendered at
different locations.
„ For paper and electronic claims, the technical
and professional components of the service
must be submitted on separate lines of the
claim in order for services to be paid. If a
global service is reported, but only one of the
services was purchased, the claim will be
returned as unprocessable.
Radiation Therapy
Modifier XJ
Effective immediately, modifier XJ should no longer
be reported for radiation therapy treatments (77427) to
indicate that the course of treatment has ended. When
the treatment ends, providers may bill for three or four
fractions as an entire week. The statement “course of
treatment has ended” must be indicated in block 19
of the 1500 claim form or the electronic equivalent.
41
Transportation of Portable
X-rays (R0075)—Modifier
Use
Effective January 1, 2004, one of five modifiers will
be required on Medicare claims when reporting HCPCS
code R0075 (Transportation of portable x-ray
equipment and personnel to home or nursing home, per
trip to facility or location, more than one patient seen).
Only a single transportation payment for each trip the
portable x-ray supplier makes to a particular location
is allowed. When reporting a transportation service and
more than one Medicare patient is x-rayed at the same
location, payment of R0075 is prorated among all
patients receiving the services.
R0075 must be billed in conjunction with the CPT
radiology codes (70000 series) and only when the xray equipment used was actually transported to the
location where the x-ray was taken.
Below are the definitions for each modifier that must
be reported with procedure code R0075. Only one of
these modifiers can be reported with R0075. Failure to
submit one of these new modifiers may result in a
rejection/denial of your claim:
UN
UP
UQ
UR
US
Two patients served
Three patients served
Four patients served
Five patients served
Six patients or more served
Medical Re
vie
w Highlights
Revie
view
Follow-up Consultations
Follow-up consultations, procedure codes 99261-99263,
are visits to complete the initial consultation or a
subsequent consultation visit requested by the attending
physician.
„ Follow-up inpatient consultation codes are to
be used for hospital inpatients and nursing
facility residents only.
procedure codes for subsequent hospital care,
99231-99233, or subsequent nursing facility
care, 99311-99313, should be used.
All documentation requirements as outlined in
Medicare Medical Policy Bulletin, C-2, “Consultations”
need to be met to appropriately bill the follow-up
consultation codes. This policy is available on the
HGSAdministrators web site at www.hgsa.com.
„ If the consultant is unable to complete the
initial consultation on the first day, and a
follow-up visit is required on another day, the
appropriate follow-up consultation code
should be billed for the follow-up visit.
Home Visit Codes (9934799350) for Established
Patients
„ If the visit is a subsequent consultation visit
and the attending physician has requested the
consultant to see the patient again (e.g. reconsult), the follow-up consultation codes
should be used.
HGSAdministrators would like to emphasize the
importance of including the required components for
billing established patient home visits, procedure codes
99347-99350.
„ If subsequent to the completion of a
consultation, the consultant assumes
responsibility for the management of all or a
portion of the patient’s care, the follow-up
consultation codes should not be used. The
42
It is important that all physician/non-physician
practitioners who perform home visits bill for these
services according to the parameters outlined in the
Medicare Part B Reference Manual, Chapter 23.7,
“Documentation Guidelines for Evaluation and
Management Services.” These guidelines clearly define
the level of history, physical examination, and medical
Medicare Report / December 1, 2003
decision making that must be present in the
documentation to support the service billed. During a
review, HGSAdministrators will evaluate all evaluation
and management (E/M) services according to these
parameters, and may reduce or deny services as
appropriate. All E/M services should be clearly and
completely documented in the patient’s medical record
to reflect the level of service billed.
The modifier ‘-25’ may be reported with an E/M service
when it was rendered in conjunction with a procedure
only if a separately identifiable E/M service occurred
during the visit. The medical record must clearly reflect
the procedure rendered and all documentation
requirements for the level of the E/M service billed.
For additional information regarding E/M services,
please refer to the Medicare Part B Reference Manual,
Chapter 23.7, “Documentation Guidelines for
Evaluation and Management Services.” This
information can be found on the HGSA web site at
www.hgsa.com.
Hospital Discharge Day
Management
Hospital discharge day management codes (99238, 30
minutes or less; 99239, more than 30 minutes) are to
be used to report the total duration of time spent by a
physician, or non-physician practitioner, for final
hospital discharge of the patient. These procedure codes
include, as appropriate, final examination of the patient,
discussion of the hospital stay, even if the time spent
by the physician on that date is not continuous,
instructions for continuing care to all relevant
caregivers, and preparation of discharge records,
prescriptions, and referral forms.
When reporting procedure codes 99238 or 99239, the
medical record documentation should specify the amount
of time involved in completing the patient’s hospital
discharge day management. From a review perspective,
if a physician or non-physician practitioner bills the higher
level of discharge day management, procedure code 99239,
based on the amount of time spent rendering this service,
the total time must be documented in the patient’s medical
record. If procedure code 99239 is billed and no time is
documented in the patient’s medical record, HGSA may
reduce the service to the lower level of care, procedure
code 99238.
Medicare Report / December 1, 2003
Implantable Infusion
Pumps
An implantable infusion pump is a delivery system used
to provide a continuous infusion of a specific medication
(e.g. morphine, baclofen, heparin, chemotherapy) at a
precise rate. Implantable infusion pumps are indicated
in the Medicare population for patients with liver cancer,
severe spasticity, or chronic intractable pain. Individual
consideration may be given for other uses.
Supporting documentation, as indicated for each of the
conditions listed, must be submitted when billing for
implantable infusion pumps.
„ Liver cancer - indicated for intra-arterial
infusion of 5FU or 5FUdr in patients with
primary hepato-cellular carcinoma or Duke’s
Class D colorectal cancer, in whom the
metastases are limited to the liver, and where
the disease is un-resectable or where the
patient refuses surgical excision of the tumor.
„ Anti-spasmodics - indicated for patients who
cannot be maintained on noninvasive
methods of spasm control, such as oral antispasmodic drugs, either because these
methods fail to adequately control the
spasticity or produce intolerable side effects
(as indicated by at least a six (6) week trial)
and have responded favorably to a trial
intrathecal dose of the anti-spasmodic drug,
prior to installation of the pump.
„ Opioid drugs - indicated for patients who
have a life expectancy of at least three (3)
months, have not responded adequately to
non-invasive methods of pain control, such as
systemic opioids (including attempts to
eliminate physical and behavioral
abnormalities which may cause an
exaggerated reaction to pain), and have had a
preliminary trial of intraspinal opioids drug
administration undertaken with a temporary
intrathecal/epidural catheter to substantiate
adequately acceptable pain relief and degree
of side effects (including effects on the
activities of daily living) and patient
acceptance.
43
„ Other uses - indicated when the drug is
reasonable and necessary for the treatment of
the patient; it is medically necessary for the
drug to be administered by an implanted
infusion pump; and the FDA approved
labeling specifies that the drug and its
purposes be indicated for use by an
implantable infusion pump.
If insufficient documentation is received, the services
may be denied. Please see Medicare Medical Policy
Bulletin (MMPB), S-40, “Implantable Infusion Pumps”
for additional information regarding coding guidelines,
coverage issues, reasons for denial, etc. MMPB S-40,
can be found on our web site at www.hgsa.com.
Modifiers 22, 23, 52 and 53
Modifiers provide the means for indicating that a service
or procedure that has been performed was altered by
some specific circumstance but not changed in its
definition or code. The application of modifiers
eliminates the need for separate procedure listings that
may describe the modifying circumstance.
Modifier 22 (unusual procedure service) is indicated
when the service provided was greater than usually
required for the listed procedure.
Note: For services on the physician fee schedule,
modifier 22 is applicable only to those procedure codes
for which the global surgery concept applies, whether
the procedure code is surgical in nature or not.
Supportive documentation, e.g., operative reports,
progress notes, order sheets, pathology reports, etc.,
must be submitted with the claim.
Modifier 23 (unusual anesthesia service) Occasionally, a procedure that usually requires either
no anesthesia or local anesthesia, because of unusual
circumstances, must be performed under general
anesthesia. This circumstance may be reported by
adding modifier 23 to the procedure code of the basic
service.
Modifier 52 (reduced service) is used to indicate that a
service has been partially reduced or eliminated at the
physician’s discretion. Under these circumstances, the
service can be identified by its usual procedure code
and the addition of modifier 52, signifying that the
service was reduced.
44
Modifier 53 (discontinued procedure) is used to
indicate that the physician has elected to terminate a
surgical or diagnostic procedure. Due to extenuating
circumstances or those that threaten the well being of
the patient, it may be necessary to indicate that the
surgical or diagnostic procedure was started but
discontinued. Under these circumstances, modifier 53
is appended to the basic service, signifying the service
was discontinued.
Note: This modifier is not used to report the elective
cancellation of a procedure prior to the patient’s
anesthesia induction and/or surgical preparation in the
operating suite. For outpatient hospital/ambulatory
surgery center (ASC) reporting of a previously
scheduled procedure/service that is partially reduced
or cancelled as a result of extenuating circumstances
or those that threaten the well being of the patient prior
to or after administration of anesthesia, see modifiers
73 and 74 (see modifiers approved for ASC hospital
outpatient use).
To ensure prompt processing of claims and undue
denials, supporting documentation must be attached
when submitting services with the above modifiers. For
additional information regarding modifiers, please refer
to the Medicare Part B Reference Manual, Appendix
B or the Current Procedural Terminology Manual
(CPT).
Nurse Practitioner
Services
As a result of a recent medical record review,
HGSAdministrators has identified that services
performed by nurse practitioners (NP) in the hospital
or nursing facility setting are being rendered in
collaboration with the physician but, when billing
Medicare, do not identify themselves as the rendering
practitioner. The collaborating physician is billing
Medicare for services wherein the documentation
supports the services were rendered by NPs. Further,
the documentation does not support physician presence
or a face-to-face physician/patient visit as required per
the evaluation and management (E/M) guidelines in
order to bill Medicare under the physician’s rendering
number. Services rendered by a NP in the hospital or
nursing facility setting should be billed under the NP
rendering number.
Medicare Report / December 1, 2003
Medicare Medical Policy Bulletin, V-21, “Nurse
Practitioner Services,” outlines the indications and
limitations of coverage, as well as the general billing
and coverage guidelines for nurse practitioners and the
services they render.
The services of a NP may be covered under Part B if all
of the following conditions are met:
„ They are the types of services that are
considered as physician’s services if furnished by a doctor of medicine or osteopathy
(MD/DO);
„ They are furnished by a person who meets
the NP qualifications;
„ The NP is legally authorized to furnish the
services in the State in which they are
performed;
„ They are furnished in collaboration with an
MD/DO as required by State law; and
„ They are not otherwise precluded from
coverage because of one of the statutory
exclusions.
Services rendered by a NP as ‘incident to’ a physician’s
services are only applicable in the office setting.
Outside the office setting, direct supervision requires
the physician to have face-to-face contact with the
patient and be present in the room while the auxiliary
personnel is rendering the service. Therefore,
subsequent hospital visits rendered by a NP, supported
by the co-signature of the physician and billed to
Medicare under the physician’s rendering number do
not meet Medicare guidelines for ‘incident to’ services.
These services should be billed to Medicare utilizing
the NP’s rendering number.
In the event that a non-physician practitioner, e.g. NP,
acts as a scribe (writes notes in the medical records
while the physician is personally performing the
service), the documentation should clearly indicate this
situation and be signed by both the “scribe” and the
physician. A reviewer must be able to clearly identify
the provider who performed the service in order to
determine the appropriate payment for the service.
Section F, “Documentation of ‘Incident to’ Services”
which are available on our web site at www.hgsa.com.
Also, refer to the June 2003 Medicare Report for
information regarding split E/M services in an article
entitled, “Billing Shared/Split E/M Services - Update.”
PET Scans—
Documentation Must
Accompany Claim
Individual consideration will be given for PET scans
performed for the diagnosis of lung cancer, colorectal
cancer, lymphoma, head and neck cancer, esophageal
cancer and melanoma (G0210, G0213, G0216, G0220,
G0223, and G0226). Medical record documentation
must accompany the claim to support that the scan is
reasonable and necessary, per Medicare Medical Policy
Bulletin X-29. Claims submitted without supporting
documentation will be denied.
Please refer to Medicare Medical Policy Bulletin X-29.
C oovv erage Issues
Artificial Hearts and
Related Devices
The Centers for Medicare & Medicaid Services (CMS)
has revised its National Coverage Decision (NCD) to
reflect an expansion in Medicare coverage for artificial
hearts and related devices. This information was
previously found in the Medicare Coverage Issues
Manual (CIM) section 65-15 but is now documented in
the online CMS Manual, Pub. 100-3, Chapter 1, Section
20.9.
For additional information, refer to Medicare Medical
Policy Bulletin, V-21, “Nurse Practitioner Services” and
the Medicare Part B Reference Manual, Chapter 3,
For services performed on or after October 1, 2003,
Ventricular Assist Devices (VADs) are covered when
used as destination therapy if they have received
approval from the Food and Drug Administration
(FDA), the VAD is used according to FDA-approved
labeling instructions, the patient meets specified criteria,
and the procedure is performed in specified facilities.
All other indications for use of VADs remain the same.
Medicare Report / December 1, 2003
45
For your convenience, we are printing the NCD in its
entirety below.
In addition to the expanded coverage for ventricular
assist devices (VADs), Medicare will pay providers on
a fee-for-service basis for the new indication of
destination therapy when the beneficiary is enrolled in
a risk Medicare+Choice (M+C) plan. Payment will be
made in this manner until the capitation rates for M+C
organizations are adjusted to account for the expanded
coverage. Because the fee-for–service claims
processing system automatically excludes claim
services provided for risk M+C beneficiaries except in
certain circumstances for which editing has been
created, special billing instructions are required. These
instructions are listed below.
Coverage Guidelines
A ventricular assist device (VAD) or left ventricular
assist device (LVAD) is used to assist a damaged or
weakened heart in pumping blood. These devices are
used for support of blood circulation post-cardiotomy,
as a bridge to a heart transplant, or as destination
therapy.
Covered Indications
Post-cardiotomy (effective for services performed on
or after October 18, 1993)
Post-cardiotomy is the period following open-heart
surgery. VADs used for support of blood circulation
post-cardiotomy are covered only if they have received
approval from the Food and Drug Administration (FDA)
for that purpose, and the VADs are used according to
the FDA- approved labeling instructions.
Bridge-to-Transplant (effective for services
performed on or after January 22, 1996)
VADs used for bridge-to-transplant are covered only if
they have received approval from the FDA for that
purpose, and the VADs are used according to the FDAapproved labeling instructions. All of the following
criteria must be fulfilled in order for Medicare coverage
to be provided for a VAD used as a bridge-to-transplant:
a. The patient is approved and listed as a candidate
for heart transplantation by a Medicare-approved
heart transplant center; and,
46
b. The implanting site, if different than the Medicareapproved transplant center, must receive written
permission from the Medicare-approved heart
transplant center under which the patient is listed
prior to implantation of the VAD.
The Medicare-approved heart transplant center
should make every reasonable effort to transplant
patients on such devices as soon as medically
reasonable. Ideally, the Medicare-approved heart
transplant centers should determine patient-specific
timetables for transplantation, and should not
maintain such patients on VADs if suitable hearts
become available.
Destination Therapy (effective for services
performed on or after October 1, 2003)
Destination therapy is for patients that require
permanent mechanical cardiac support. VADs used for
destination therapy are covered only if they have
received approval from the FDA for that purpose, and
the device is used according to the FDA-approved
labeling instructions. VADs are covered for patients
who have chronic end-stage heart failure (New York
Heart Association Class IV end-stage left ventricular
failure for at least 90 days with a life expectancy of
less than 2 years), are not candidates for heart
transplantation, and meet all of the following
conditions:
a. The patient’s Class IV heart failure symptoms have
failed to respond to optimal medical management,
including dietary salt restriction, diuretics, digitalis,
beta-blockers, and ACE inhibitors (if tolerated) for
at least 60 of the last 90 days;
b. The patient has a left ventricular ejection fraction
(LVEF) < 25%;
c. The patient has demonstrated functional limitation
with a peak oxygen consumption of < 12 ml/kg/
min; or the patient has a continued need for
intravenous inotropic therapy owing to
symptomatic hypotension, decreasing renal
function, or worsening pulmonary congestion; and,
d. The patient has the appropriate body size (≥ 1.5
m²) to support the VAD implantation.
In addition, the Centers for Medicare & Medicaid
Services (CMS) has determined that VAD implantation
as destination therapy is reasonable and necessary only
Medicare Report / December 1, 2003
when the procedure is performed in a Medicareapproved heart transplant facility that, between January
1, 2001, and September 30, 2003, implanted at least 15
VADs as a bridge-to-transplant or as destination therapy.
These devices must have been approved by the FDA
for destination therapy or as a bridge-to-transplant, or
have been implanted as part of an FDA investigational
device exemption (IDE) trial for one of these two
indications. VADs implanted for other investigational
indications or for support of blood circulation postcardiotomy do not satisfy the volume requirement for
this purpose. Since the relationship between volume
and outcomes has not been well established for VAD
use, facilities that have minimal deficiencies in meeting
this standard may apply and include a request for an
exception based upon additional factors. Some of the
factors CMS will consider are geographic location of
the center, number of destination procedures performed,
and patient outcomes from VAD procedures completed.
Also, this facility must be an active, continuous member
of a national, audited registry that requires submission
of health data on all VAD destination therapy patients
from the date of implantation throughout the remainder
of their lives. This registry must have the ability to
accommodate data related to any device approved by
the FDA for destination therapy regardless of
manufacturer. The registry must also provide such
routine reports as may be specified by CMS, and must
have standards for data quality and timeliness of data
submissions such that hospitals failing to meet them
will be removed from membership. CMS believes that
the registry sponsored by the International Society for
Heart and Lung Transplantation is an example of a
registry that meets these characteristics.
Hospitals also must have in place staff and procedures
that ensure that prospective VAD recipients receive all
information necessary to assist them in giving
appropriate informed consent for the procedure so that
they and their families are fully aware of the aftercare
requirements and potential limitations, as well as
benefits, following VAD implantation.
CMS plans to develop accreditation standards for
facilities that implant VADs and, when implemented,
VAD implantation will be considered reasonable and
necessary only at accredited facilities.
A list of facilities eligible for Medicare reimbursement
for VADs as destination therapy will be maintained on
Medicare Report / December 1, 2003
our web site and available at www.cms.hhs.gov/
coverage/lvadfacility.asp. In order to be placed on this
list, facilities must submit a letter to the Director,
Coverage and Analysis Group, 7500 Security Blvd, Mail
stop C1-09-06, Baltimore, MD 21244. This letter must
be received by CMS within 90 days of the issue date on
this transmittal. The letter must include the following
information:
„ Facility’s name and complete address;
„ Facility’s Medicare provider number;
„ List of all implantations between Jan. 1,
2001, and Sept. 30, 2003, with the following
information:
ƒ
ƒ
Date of implantation,
Indication for implantation (only
destination and bridge-to-transplant can
be reported; post-cardiotomy VAD
implants are not to be included),
ƒ Device name and manufacturer, and,
ƒ Date of device removal and reason (e.g.,
transplantation, recovery, device
malfunction), or date and cause of
patient’s death;
„ Point-of-contact for questions with telephone
number;
„ Registry to which patient information will be
submitted; and,
„ Signature of a senior facility administrative
official.
Facilities not meeting the minimal standards and
requesting exception should, in addition to supplying
the information above, include the factors that they
deem critical in requesting the exception to the
standards.
CMS will review the information contained in the above
letters. When the review is complete, all necessary
information is received, and criteria are met, CMS will
include the name of the newly Medicare-approved
facility on the CMS web site. No reimbursement for
destination therapy will be made for implantations
performed before the date the facility is added to the
CMS web site. Each newly approved facility will also
receive a formal letter from CMS stating the official
approval date it was added to the list.
47
Noncovered Indications (effective for services
performed on or after May 19, 1986)
Drugs & Biologicals
Artificial Heart
Supplies usually furnished by the physician in the course
of performing his/her services, such as gauze, ointments,
bandages, and oxygen, are also covered. Charges for
such services and supplies must be included in the
physicians’ bills. To be covered, supplies, including
drugs and biologicals, must be an expense to the
physician or legal entity billing for the services or
supplies. For example, where a patient purchases a drug
and the physician administers it, the drug is not covered.
However, the administration of the drug, regardless of
the source, is a service that represents an expense to
the physician. Therefore, the administration of the drug
is payable if the drug would have been covered if the
physician purchased it.
Since there is no authoritative evidence substantiating
the safety and effectiveness of a VAD used as a replacement for the human heart, Medicare does not cover this
device when used as an artificial heart.
All Other Indications
All other indications for the use of VADs not otherwise
listed remain noncovered, except in the context of Category B IDE clinical trials (42 CFR 405) or as a routine
cost in clinical trials defined under section 310.1 of the
NCD manual (old CIM 30-1).
Billing Instructions for Providers Who Render
Services to Managed Care Patients
The following instructions apply to providers who
render expanded destination therapy services to
managed care patients:
„ Providers are encouraged not to submit claims
for services rendered on or after October 1,
2003, because Medicare will not be able to
process the claims until January 5, 2004.
„ Physicians must use modifier KZ (new
coverage not implemented by managed care)
when billing for services rendered on and
after October 1, 2003 for destination therapy.
Services rendered to managed care patients
with existing covered indications should not
report modifier KZ or submit their claims to
fee-for-service Medicare.
„ The physician should bill for the appropriate
service with procedure code 33975 or 33976.
„ Patients who receive these services must pay
any applicable coinsurance amounts.
Billing Instructions for Providers Who Render
Services to Fee-for- Service Patients
The following instructions apply to providers who
render expanded destination therapy services to fee-forservice patients:
„ Claims for these services cannot be billed
using modifier KZ.
48
This additional clarification has been included in
Medical Policy Bulletin I-6.
HBO Therapy—Expanded
Coverage
All Medicare contractors have been advised that the
“Conditions of Coverage” for Hyperbaric Oxygen
Therapy has been expanded to include diagnosis code
707.15 (Ulcer of other part of foot) for the treatment of
diabetic wounds of the lower extremities. In accordance
with this directive, Medical Policy Bulletin Z-3 has been
revised to reflect this change.
Implantable Automatic
Defibrillators—National
Coverage Determination
This article discusses the background of the National
Coverage Determination (NCD) to expand coverage of
implantable automatic defibrillators for services
rendered on or after October 1, 2003, coverage
guidelines, billing instructions for providers who render
services to managed care patients, and billing
instructions for providers who render services to feefor-service patients.
Background
The NCD will be effective on October 1, 2003, to
expand coverage of implantable automatic defibrillators
Medicare Report / December 1, 2003
for Medicare managed care and fee-for-service patients.
Providers will be reimbursed for services provided to
managed care patients for implantable automatic
defibrillators that fall under the expanded coverage
indications effective October 1, 2003, according to the
NCD on a fee-for-service basis until capitation rates
are adjusted to account for this expanded coverage.
Coverage Guidelines
The following service is covered when rendered on or
after July 1, 1991:
„ Documented episode of cardiac arrest due to
ventricular fibrillation (VF), not due to a
transient or reversible cause.
The following services are covered when rendered on
or after July 1, 1999:
„ Documented sustained ventricular
tachyarrhythmia (VT), either spontaneous or
induced by an electrophysiology (EP) study,
not associated with an acute myocardial
infarction (MI) and not due to a transient or
reversible cause.
„ Documented familial or inherited indications
with a high risk of life-threatening VT, such
as long QT syndrome or hypertropic
cardiomyopathy.
As stated in the NCD, the following indications will be
covered when rendered on or after October 1, 2003:
„ Coronary artery disease with a documented
prior MI, a measured left ventricular ejection
fraction ≤ 0.35, and inducible, sustained VT
or VF at EP study. (The MI must have
occurred more than 4 weeks prior to
defibrillator insertion. The EP test must be
performed more than 4 weeks after the
qualifying MI.)
„ Documented prior MI and a measured left
ventricular ejection fraction ≤ 0.30 and a
QRS duration of > 120 milliseconds.
Patients must not have any of the following:
a) New York Heart Association classification IV;
b) Cardiogenic shock or symptomatic
hypotension while in a stable baseline
rhythm;
Medicare Report / December 1, 2003
c) Had a coronary artery bypass graft (CABG)
or percutaneous transluminal coronary
angioplasty (PTCA) within past 3 months;
d) Had an enzyme-positive MI within past
month;
e) Clinical symptoms or findings that would
make them a candidate for coronary
revascularization; or
f) Any disease, other than cardiac disease
(e.g., cancer, uremia, liver failure),
associated with a likelihood of survival less
than 1 year.
As stated in the NCD, effective October 1, 2003, the
following additional coverage guidelines apply:
„ All patients considered for implantation of a
defibrillator must not have irreversible brain
damage, disease, or dysfunction that
precludes the ability to give informed
consent;
„ MIs must be documented by elevated cardiac
enzymes or Q-waves on an
electrocardiogram. Ejection fractions must
be measured by angiography, radionuclide
scanning, or echocardiography; and
„ All other indications remain noncovered
except in Category B IDE clinical trials (60
CFR 48417) or as a routine cost in clinical
trials defined under Coverage Issues Manual,
30-1.
Note: Refer to Coverage Issues Manual, Section 3585 (revisions effective October 1, 2003).
Billing Instructions for Providers Who Render
Services to Managed Care Patients
The following instructions apply to providers who
render expanded implantable automatic defibrillator
services to managed care patients:
„ Providers are encouraged not to submit
claims for services rendered on or after
October 1, 2003, because Medicare will not
be able to process the claims until January 5,
2004.
49
„ Physicians must use modifier KZ (new
coverage not implemented by managed care)
when billing for services rendered on and
after October 1, 2003.
Note: The physician should bill for the appropriate
service from the range of CPT codes below. These
services should be billed to the appropriate Medicare
carrier for payment.
„ Providers billing fiscal intermediaries on or
after October 1, 2003, must use condition
code 78 (payment for coverage not
implemented by HMO).
33240
33241
33243
33244
33245
33246
33249
„ Providers who are paid under the Outpatient
Prospective Payment System (OPPS) must
bill all services related to this expanded
coverage on one claim and for the same date
of service, using condition code 78.
„ Providers billing carriers and providers who
are paid under the OPPS must split the bills if
they overlap September 2003 and October
2003.
„ Patients who receive these services must pay
any applicable coinsurance amounts.
„ For services rendered to managed care
patients whose indications fall outside this
expanded coverage, providers must not bill
using condition code 78 or modifier KZ.
Billing Instructions for Providers Who Render
Services to Fee-for-Service Patients
The following instructions apply to providers who
render expanded implantable automatic defibrillator
services to fee-for-service patients:
„ Claims for these services cannot be billed
using modifier KZ, condition code 78, or for
services outside of this expanded coverage.
Procedure Codes
Note: The new G codes listed below are payable under
OPPS effective October 1, 2003. These new G codes
are not payable under the Medicare Physician Fee
Schedule and, therefore, should not be billed to
Medicare carriers.
G0297
G0298
G0299
G0300
ICD-9-CM Procedure Code 37.94 (for 11X TOBs)
50
Lipid Panels
HGSAdministrators has identified an increase in the
number of lipid panels being rendered. Reimbursement
for lipid panels is based on the National Coverage
Decision (NCD) policy, found in the online CMS
Manual Pub. 100-3, Chapter 1, Section 40-12 at http://
cms.hhs.gov/manuals/103_cov_determ/
ncd103index.asp. NCDs are available in the Medicare
Coverage Database at http://www.cms.gov/mcd/
indexes.asp.
Medicare recognizes that some provider offices may
utilize laboratory equipment that can perform lipid
testing only as a panel and not as individual components.
However, it is the provider’s responsibility to bill
Medicare only for the individual component that is
necessary for the monitoring and/or treatment of the
patient’s signs and symptoms regardless of whether or
not a whole panel was performed using this type of
equipment.
The following are the individual components of a lipid
panel (procedure code 80061).
82465 Cholesterol, serum, total
83718 Lipoprotein, direct measurement; high-density
cholesterol (HDL cholesterol)
84478 Triglycerides
Per the NCD for lipid testing, any one component of
the panel or a measured LDL may be medically
necessary up to six times the first year for monitoring
dietary or pharmacologic therapy. More frequent total
cholesterol HDL cholesterol, LDL cholesterol and
triglyceride testing may be indicated for marked
Medicare Report / December 1, 2003
elevations or for changes to anti-lipid therapy due to
inadequate initial patient response to dietary or
pharmacologic therapy. The LDL cholesterol or total
cholesterol may be measured three times yearly after
treatment goals have been achieved. If no dietary or
pharmacological therapy is advised, monitoring is not
necessary.
is expanded to include patients who are: (1) Non highrisk and present with severe, upper-lobe emphysema;
or, (2) Non high-risk and present with severe, non upperlobe emphysema with low exercise capacity. Patients
must also meet all other criteria outlined in the National
Coverage Decision. For your convenience, we are
printing the NCD in its entirety below.
When monitoring long-term anti-lipid dietary or
pharmacologic therapy and when following patients
with borderline high total or LDL cholesterol levels, it
may be reasonable to perform the lipid panel annually.
A lipid panel at a yearly interval will usually be adequate
while measurement of the serum total cholesterol or a
measured LDL should suffice for interim visits if the
patient does not have hypertriglyceridemia.
In addition to the expanded coverage for lung volume
reduction surgery (LVRS), Medicare will pay providers
on a fee-for-service basis for the new coverage when
the beneficiary is enrolled in a risk Medicare+Choice
(M+C) plan. Payment will be made in this manner until
the capitation rates for M+C organizations are adjusted
to account for the expanded coverage. Because the feefor-service claims processing system automatically
excludes claim services provided for risk M+C
beneficiaries except in certain circumstances for which
editing has been created, special billing instructions are
required. These instructions are listed below.
If a provider orders a lipid panel at a frequency greater
than listed above, then medical record documentation
must be submitted with the claim to justify the medical
necessity of the increased frequency. Failure to provide
documentation of the medical necessity of tests may
result in a denial of claims. The documentation may
include notes documenting relevant signs, symptoms,
or abnormal findings that substantiate the medical
necessity for ordering the tests.
Routine screening and prophylactic testing for lipid
disorders is not covered by Medicare. While lipid
screening may be medically appropriate, Medicare does
not pay for it. Lipid testing in asymptomatic individuals
is considered to be screening regardless of the presence
of other risk factors such as family history, tobacco use,
etc. Tests that are not reasonable and necessary for the
diagnosis or treatment of an illness or injury are not
covered.
Lung Volume Reduction
Surgery
The Centers for Medicare & Medicaid Services has
revised its National Coverage Decision (NCD) to reflect
an expansion in Medicare coverage for lung volume
reduction surgery (LVRS). Information can be found
in the online CMS Manual, Publication 100-03, Section
240.1.
For services performed on or after January 1, 2004,
Medicare coverage for lung volume reduction surgery
Medicare Report / December 1, 2003
Coverage Guidelines
Lung volume reduction surgery (LVRS) or reduction
pneumoplasty, also referred to as lung shaving or lung
contouring, is performed on patients with severe
emphysema in order to allow the remaining compressed
lung to expand, and thus, improve respiratory function.
A. Covered Indications
Medicare-covered LVRS approaches are limited to
bilateral excision of a damaged lung with stapling
performed via median sternotomy or video-assisted
thoracoscopic surgery.
1. National Emphysema Treatment Trial (NETT)
participants (effective for services performed on or
after August 11, 1997):
Medicare provides coverage to those beneficiaries
who are participating in the NETT trial for all
services integral to the study and for which the
Medicare statute does not prohibit coverage.
2. Medicare will only consider LVRS reasonable and
necessary when all of the following requirements
are met (effective for services performed on or after
January 1, 2004):
a. The patient satisfies all the criteria outlined
below:
51
Assessment
Criteria
History and physical examination
Consistent with emphysema
BMI, < 31.1 kg/m2 (men) or < 32.3 kg/m2 (women)
Stable with < 20 mg prednisone (or equivalent) qd
Radiographic
High Resolution Computer Tomography (HRCT) scan
evidence of bilateral emphysema
Pulmonary function (pre-rehabilitation)
Forced expiratory volume in one second (FEV1) < 45%
predicted (> 15% predicted if age > 70 years)
Total lung capacity (TLC) > 100% predicted postbronchodilator
Residual volume (RV) > 150% predicted postbronchodilator
Arterial blood gas level (pre-rehabilitation)
PCO2 < 60 mm Hg (PCO2 < 55 mm Hg if 1-mile above
sea level)
PO2 > 45 mm Hg on room air (PO2 > 30 mm Hg if 1-mile
above sea level)
Cardiac assessment
Approval for surgery by cardiologist if any of the following
are present: Unstable angina; left-ventricular ejection
fraction (LVEF) cannot be estimated from the
echocardiogram; LVEF < 45%; dobutamine-radionuclide
cardiac scan indicates coronary artery disease or
ventricular dysfunction; arrhythmia (> 5 premature
ventricular contractions per minute; cardiac rhythm other
than sinus; premature ventricular contractions on EKG at
rest)
Surgical assessment
Approval for surgery by pulmonary physician, thoracic
surgeon, and anesthesiologist post-rehabilitation
Exercise
Post-rehabilitation 6-min walk of > 140 m; able to
complete 3 min unloaded pedaling in exercise tolerance
test (pre- and post-rehabilitation)
Consent
Signed consents for screening and rehabilitation
Smoking
Plasma cotinine level < 13.7 ng/mL (or arterial
carboxyhemoglobin < 2.5% if using nicotine products)
Nonsmoking for 4 months prior to initial interview and
throughout evaluation for surgery
Preoperative diagnostic and therapeutic
program adherence
52
Must complete assessment for and program
of preoperative services in preparation for surgery
Medicare Report / December 1, 2003
b. In addition, the patient must have:
„ Severe upper lobe predominant
emphysema (as defined by radiologist
assessment of upper lobe predominance
on CT scan), or
„ Severe non-upper lobe emphysema with
low exercise capacity.
Patients with low exercise capacity are
those whose maximal exercise capacity is
at or below 25 watts for women and 40
watts for men after completion of the
preoperative therapeutic program in
preparation for LVRS. Exercise capacity
is measured by incremental, maximal,
symptom-limited exercise with a cycle
ergometer utilizing 5 or 10 watt/minute
ramp on 30% oxygen after 3 minutes of
unloaded pedaling.
c. The surgery must be performed at facilities that
were identified by the National Heart, Lung,
and Blood Institute to meet the thresholds for
participation in the NETT, and at sites that have
been approved by Medicare as lung transplant
facilities. These facilities are listed on the CMS
web site at http://www.cms.hhs.gov/coverage/
lvrsfacility.pdf. CMS is currently working to
develop accreditation standards for facilities to
perform LVRS and when implemented, will
consider LVRS to be reasonable and necessary
only at accredited facilities.
d. The surgery must be preceded and followed by
a program of diagnostic and therapeutic
services consistent with those provided in the
NETT and designed to maximize the patient’s
potential to successfully undergo and recover
from surgery. The program must include a 6 to
10-week series of at least 16, and no more than
20, preoperative sessions, each lasting a
minimum of 2 hours. It must also include at
least 6, and no more than 10, postoperative
sessions, each lasting a minimum of 2 hours,
within 8 to 9 weeks of the LVRS. This program
must be consistent with the care plan developed
by the treating physician following
performance of a comprehensive evaluation of
the patient’s medical, psychosocial and
nutritional needs, be consistent with the
Medicare Report / December 1, 2003
preoperative and
provided in the
monitored, and
coordination of the
takes place.
postoperative services
NETT, and arranged,
performed under the
facility where the surgery
B. Noncovered Indications
1. LVRS is not covered in any of the following
clinical circumstances:
a. Patient characteristics carry a high risk for
perioperative morbidity and/or mortality;
b. The disease is unsuitable for LVRS;
c. Medical conditions or other circumstances
make it likely that the patient will be unable
to complete the preoperative and
postoperative pulmonary diagnostic and
therapeutic program required for surgery;
d. The patient presents with FEV1 ≤ 20% of
predicted value, and either homogeneous
distribution of emphysema on CT scan, or
carbon monoxide diffusing capacity of ≤
20% of predicted value (high-risk group
identified October 2001 by the NETT); or
e. The patient satisfies the criteria outlined
above in section 2(a), and has severe, nonupper lobe emphysema with high exercise
capacity. High exercise capacity is defined
as a maximal workload at the completion
of the preoperative diagnostic and
therapeutic program that is above 25 watts
for women and 40 watts for men (under
the measurement conditions for cycle
ergometry specified above).
2. All other indications for LVRS not otherwise
specified remain noncovered.
Billing Instructions for Providers Who Render
Services to Managed Care Patients
The following instructions apply to providers who
render lung volume reduction surgery to managed care
patients:
„ Providers are encouraged not to submit
claims for services rendered on or after
January 1, 2004 through March 31, 2004
53
Policy
because Medicare will not be able to process
the claims until April 5, 2004.
„ Physicians must use modifier KZ (new
coverage not implemented by managed care)
when billing for services rendered on and
after January 1, 2004.
„ The physician should bill for the appropriate
service with procedure code 32491.
„ Patients who receive these services must pay
any applicable coinsurance amounts.
Billing Instructions for Providers Who Render
Services to Fee-for-Service Patients
The following instructions apply to providers who
render lung volume reduction surgery to fee-for-service
patients:
„ Claims for these services cannot be billed
using modifier KZ.
„ The physician should bill for the appropriate
service with procedure code 32491.
PET Scans—Expanded
Coverage for Thyroid
Cancer and Perfusion of
the Heart
Thyroid Cancer
Effective for services furnished on or after October 1, 2003,
Medicare covers the use of FDG Positron Emission
Tomography for thyroid cancer only for restaging of
recurrent or residual thyroid cancers of follicular cell origin
that have been previously treated by thyroidectomy and
radioiodine ablation and have a serum thyroglobulin greater
than 10ng/ml and negative I-131 whole body scan. All
other uses of FDG PET in the diagnosis and treatment of
thyroid cancer remain noncovered. Use the new HCPCS
code G0296 to report this service.
HCPCS codes G0030-G0047. The Centers for
Medicare and Medicaid Services (CMS) has established
two codes when billing for these radio-tracers. Use
procedure code Q4078 to report Ammonia N-13 and
A4641 to report Rubidium 82. In addition, also report
your acquisition cost in block 24D of the 1500 claim
form or the EMC narrative line. All other tracers will
be considered an integral part of the diagnostic test and
therefore not separately payable.
This information will be added to our Medical Policy
Bulletin X-29 during the next scheduled update.
Medical Policy
Implementation of Local
Medical Review Policies
(LMRPs)
The Centers for Medicare and Medicaid Services
(CMS) instructs contractors to provide a forty-five (45)
day comment period and a notification period of fortyfive (45) days prior to implementing LMRPs which fall
into one of the following categories:
1. New LMRP
2. Revised LMRP that restricts an existing LMRP
3. Revised LMRP that makes a substantive correction
During the comment period recommendations and
comments are solicited from:
„ Carrier Advisory Committee members
„ Appropriate groups of health professionals
and provider organizations
„ Representatives of specialty societies
„ Other carriers/intermediaries
„ Quality Improvement Organizations
(formerly known as PROs) within the region
Perfusion of the Heart Using Ammonia N-13
or Rubidium 82
„ Other Contractor Medical Directors within
the region
Effective for services performed on or after October 1,
2003, only two radiopharmaceutical tracers will be
covered for PET scans for the perfusion of the heart —
„ General public through the contractor draft
LMRP web site
54
Medicare Report / December 1, 2003
„ Presenters at draft LMRP Open Sessions
The mandated notification has traditionally been
provided through full-text publication of the policies
in this quarterly newsletter. Recent directions from
CMS revise the method by which notification will be
provided. Beginning with publication of the September
2002 Medicare Report, HGSA will print only a
summary of the policies. The full-text version, however,
will be posted to our web site at http://www.hgsa.com/
professionals/policy-notice.shtml.
You may also obtain copies of current policies by writing
to HGSAdministrators, PO Box 890413, Camp Hill, PA
17089-0413 or calling 1-866-488-0548. Some copies of
previous versions and recently retired policies are also
available on our web site at http://www.hgsa.com/
professionals/retiredpolicy.shtml. Those that are not may
be obtained by writing to the address above.
Title
Rationale/Summary
Body Surface Mapping (M-68)
New policy to describe non-coverage.
Bortezo mib (Velcade™ (I-55)
New policy identifying coverage requirements.
Brachytherapy (X-41)
New policy to identify billing and documentation requirements.
Chemotherapy Services (G-16Q)
Revised policy to clarify documentation and billing requirements for
unlabeled uses of drugs in an anti-cancer chemotherapeutic regimen.
C-Reactive Protein Testing (L-69)
New policy to provide coverage and address screening.
Oprelvekin (Neumega®) (I-54)
New policy establishing coverage criteria.
Urinary Tumor Markers for Bladder Revised policy to address the major tumor markers used to monitor
Cancer Monitoring (L-33G)
patients with previously diagnosed bladder cancer.
Transpupillary Thermotherapy
(TTT) (S-135)
New policy to create coverage guidelines for this procedure.
Local Medical Review Policy Updates
Policy Title
Update Rationale
Office-Based Anesthesia (A-16)
Policy revised to define “direct supervision” CMS Online Manual,
Pub. 100-2, Chapter 15, Section 60.1B. Revision effective
06/30/2003.
Hemophilia Clotting Factors (I-4)
Revised to include procedure code J7197 for coverage effective for
dates of service on or after January 1, 2003. Also revised to include
procedure code Q2022 for coverage effective for dates of service on or
after January 1, 2001.
Pegfilgrastim (Neulasta™ (I-45)
Clarification that as per CMS Transmittal #B-03-048, CR 2798, added
new Q code Q4053 for the reporting of Pegfilgrastim injection.
Effective for dates of service on or after 07/01/03. This new code
revision was incorrectly reported in the September 2003 Medicare
Report as Q4052.
Medicare Report / December 1, 2003
55
Policy
„ CMS Regional Office, associate regional
administrator
Having satisfied the mandated 45-day comment period,
the required 45-day notice period relative to the following
policies begins with their posting to the HGSA web site.
They will become effective on December 29, 2003.
Policy
Policy Title
Update Rationale
Amevive® for Injection (Alefacept)
(I-49A)
Revised to include information on the discontinuance of the
intravenous form of the drug by the manufacturer effective
October 3, 2003.
Screening Pap Smears and Pelvic
Examinations (L-1)
Revised policy to expand coverage for low risk pap smears and low
risk pelvic examinations. Effective for claims processed on or after
10/01/2003, the list of eligible diagnosis codes has been expanded to
include V76.49 for screening pap smears and V76.47 for both pap
smears and screening pelvic examinations as per Transmittal
AB-03-054, CR 2637.
Medical Necessity Guidelines for
Corrected typographical error in ICD-9 code from incorrect 196.82
Prostate Specific Antigen (PSA) and to correct 198.82 as published in prior policy versions.
Prostate Cancer Screening (L-52)
Implantable Cardiac Loop Recorder Revised policy to clarify the “Indications and Limitations of Coverage
(M-50)
and/or Medical Necessity” section and to provide reference to other
Carrier’s policies on this topic. This revision is effective 09/02/2003.
Transesophageal Echocardiography
(TEE) (M-51F)
Revised to include ICD-9 codes 423.0-423.9 for coverage effective for
dates of service on or after October 13, 2003.
Single Photon Emission Computed
Tomography (SPECT) (R-6)
Revised policy to provide coverage for SPECT studies of the kidneys
(78710) and clarify non-coverage of SPECT studies for inflammatory
processes (78807). Revision effective for services provided on or
after 07/09/2003.
Implantable Infusion Pump (S-40)
Procedure code 95990 added for coverage indications effective for
dates of service on or after January 1, 2003.
Treatment of Varicose Veins of the
Lower Extremities (S-55)
Effective for dates of service on or after 9/18/2003 endovenous laser
ablation has been added for coverage.
Cochlear Implantation (S-67)
Code 92510 removed from policy, code no longer valid for Medicare.
Code status change effective 03/01/2003.
Cryosurgical Ablation of the Prostate Removed outdate information referring to services provided prior to
(CSAP) (S-108)
1/1/2001 and codes G0160 & G0161. Added reference to NCD for
Cryosurgery of Prostate. The revision effective date is 10/13/2003.
Cystourethroscopy with Insertion of Procedure codes 52310 and 52315 removed from policy effective for
Urethral Stent (S-121)
dates of service on or after 10/07/2003.
Clinical Psychologist Services (V-10) Policy revised to include CPT codes 96150-96155.
Physical Therapy and Rehabilitation Revised policy to correctly list the following ICD-9 codes: 045.00Services (Y-1)
045.93, 494.0-494.1, 712.10, 716.89, 720.9, 730.00-730.99, 805.9,
807.6, 820.9, 839.9, 880.00, and 928.8. These corrections are
effective for services provided on or after 10/02/03.
56
Medicare Report / December 1, 2003
Policies Revised Due to
2004 ICD-9-CM Update
Stem Cell Transplantation
S-97E
Laser Ablation of the Prostate
S-110E
Transurethral Microwave Thermotherapy
of the Prostate (TUMT)
S-120A
Transurethral Radiofrequency
Thermotherapy of the Prostate (TUNA)
S-121C
Cystourethroscopy with Insertion of
Urethral Stent
S-131B
Water-induced Thermotherapy (WIT)
S-142A
Treatment of Gastroesophageal Reflux
Disease (GERD)
A-4F
Monitored Anesthesia Care (MAC)
G-24F
Obesity
I-8M
Immunizations
X-2L
Magnetic Resonance Imaging (MRI)
L-31E
Medical Necessity Guidelines for
Magnesium Testing
X-3J
Computerized Axial Tomography (CT)
Scan
L-42G
Molecular Diagnostics
X-16G
Low Osmolar Contrast Medium (LOCM)
L-52G
Medical Necessity Guidelines for
Prostatic Specific Antigen (PSA) and
Prostate Cancer Screening
X-24N
Bone Mass Measurements
X-25G
Transrectal Ultrasound
X-29H
Positron Emission Tomography (PET)
Scans
X-31I
Radiologic Examination of the Chest
X-32G
Pelvic Ultrasound Procedures
X-34F
Magnetic Resonance Imaging (MRI) of
the Head and Neck
X-36F
Computerized Axial Tomography (CT)
Scan, Abdominal and Pelvic
X-37E
Computerized Axial Tomography (CT)
Scan, Heal or Brain
X-38C
Bladder Capacity Ultrasound
X-39F
Diagnostic Mammography
Y-10K
Respiratory Therapy Services
Z-5B
External Ocular Photography
L-60E
Hepatitis Testing
L-66B
Morphometric Analysis
M-28F
Electromyography (EMG) Studies
M-34I
Nerve Conduction Velocity Studies
M-36B
Fluorescein Angiography
M-38K
Transthoracic Echocardiography (TTE)
M-42G
General Ophthalmological Services
M-45F
Electrocardiography
M-49H
Cardiovascular Stress Testing
M-51E
Transesophageal Echocardiography (TEE)
P-3I
Debridement of Mycotic Nails
R-11B
Myocardial SPECT (Single Photon
Emission Computed Tomography)
S-11H
Pheresis Therapy (Apheresis)
Medicare Report / December 1, 2003
57
Policy
The following medical policies have been revised as a
result of the 2004 ICD-9-CM update effective for claims
received on or after January 1, 2004 (for dates of service
on and after October 1, 2003). A 90-day grace period
will apply. For claims received for dates of service
October 1, 2003 through December 31, 2003 both the
old and the updated ICD-9-CM codes will be accepted.
S-73F
DMERC Ne
ws
New
HealthNow, the Region A Durable Medical Equipment
Regional Carrier, has asked us to publish the following
articles. Please address all inquiries concerning
DMERC issues to HealthNow, PO Box 6800, WilkesBarre, PA 18773-6800, or call 1-866-419-9458.
Individual Consideration
(IC) Codes—Billing
Reminder
When submitting claims for items considered as
Individual Consideration codes (codes without a
reimbursement amount on the fee schedule, codes with
‘IC’ on the fee schedule, or codes with zeros on the fee
schedule), include the manufacturer’s name and
product name/model number for the item. Failure
to furnish this information will result in a denial.
Interim Final Rule for
Electronic Submission of
Medicare Claims
On August 15, 2003, the Department of Health and
Human Services (HHS) published the Final Rule for
Electronic Submission of Medicare Claims. This rule
implements the statutory requirement found in the
Administrative Simplification Compliance Act (ASCA).
ASCA requires (with a few exceptions) all claims sent
to the Medicare program be submitted electronically
starting October 16, 2003. ASCA was enacted by
Congress to improve the administration of the Medicare
program by increasing efficiencies gained through
additional electronic claims submission. Although 86.1
percent of Medicare claims are submitted electronically,
the volume of paper claims is substantial, and moving
from paper to electronic submissions has the potential
for significant savings for Medicare physicians,
practitioners, suppliers, and other healthcare providers,
as well as for the program itself. This Rule sets forth
the details for implementation of the Medicare
electronic claims submission requirement and who may
be exempt from these requirements.
58
The rule is available at http://a257.g.akamaitech.net/7/
257/2422/14mar20010800/edocket.access.gpo.gov/
2003/pdf/03-20955.pdf
Printed Copies of the
DMERC A Supplier Manual
The current stock of supplier manuals has been depleted,
therefore, the Region A Durable Medical Equipment
Regional Carrier (DMERC A) will not offer additional
copies for a fee until further notice. Current suppliers,
including those enrolled in the Medicare Program
during fiscal year 2002, must access the supplier manual
on our Web site at www.umd.nycpic.com/
suppmancopy.html.
The new edition of the supplier manual was targeted to
be posted to our Web site by July 1, 2003. Due to
circumstances beyond our control, the new edition will
not be posted until further notice. Notification of its
availability will be posted to the “What’s New” page at
www.umd.nycpic.com/dme_what’s_new.html. Newly
enrolled providers will receive hardcopy manuals, as
mandated by the Centers for Medicare & Medicaid
Services (CMS), once the new edition is available. The
new edition will only be available to current providers
via our Web site. We apologize for this inconvenience.
Region A Provider
Information
Both the Region A Durable Medical Equipment
Regional Carrier (DMERC A) and Program Safeguard
Contractor (PSC), TriCenturion, LLC, maintain separate
Web sites. Providers should visit the DMERC A Web
site (www.umd.nycpic.com) for information regarding
billing, educational updates and events, electronic data
interchange (EDI), fee schedules, what’s new, etc.
Online versions of the DMERC Medicare News are also
available via this Web site.
Providers can gain access to the PSC Web site via the
TriCenturion, LLC link on the DMERC A Web site
(www.umd.nycpic.com/dmprovlink.html) or directly at
www.tricenturion.com. Providers should access the PSC
Web site for information on Fraud and Abuse,
Healthcare Common Procedure Coding System
(HCPCS), and Local Medical Review Policies
Medicare Report / December 1, 2003
(LMRPs). Recent updates involving medical policy
development, medical review, or benefit integrity are
under
the
PSC
what’s
new
section
(www.tricenturion.com/content/whatsnew_dyn.cfm).
Providers can obtain additional information by visiting
the following Centers for Medicare & Medicaid
Services (CMS) Web sites:
www.cms.hhs.gov/medicare (Medicare Professional
and Technical Information)
„ Choose “Save Link As...” or “Save Target
As...”
„ Choose the location on your computer where
you’d like to save the PDF. It is important
that you remember this location because you
will need it to open the PDF.
„ Click on “Save.”
To open a PDF:
www.cms.hhs.gov/coverage (Medicare Coverage
Database)
„ Open the Adobe Acrobat Reader software.
www.cms.hhs.gov/manuals/memos (Program Memos)
„ Find the location on your computer where
you saved the PDF file.
www.cms.hhs.gov/manuals/transmittals (Program
Transmittals)
www.cms.hhs.gov/manuals/108_pim (Medicare
Program Integrity Manual)
www.cms.hhs.gov/manuals/14_car (Medicare Carriers
Manual)
www.cms.hhs.gov/manuals/06_cim
Coverage Issues Manual)
(Medicare
„ From the “File” menu, choose “Open.”
„ Click “Open.”
Once you have the PDF file open, you can print the
entire bulletin or select pages using the print option
within the Adobe Acrobat Reader software.
To print a PDF:
„ From the “File” menu, choose “Print.” A
menu will pop up on the screen.
Tips for Online Bulletins
„ Under the section for “Print Range,” choose
the option you prefer.
The Region A Durable Medical Equipment Regional
Carrier (DMERC A) provides the DMERC Medicare
News in two formats on our Web site. Both contain the
same information, however, they will look different
when viewing and printing. One format is Web-based.
The second format is Adobe’s Portable Document
Format (PDF), which maintains the look of printed
bulletins.
„ Click “OK.”
To properly view PDF bulletins on the DMERC A Web
site, it is strongly recommended that you download the
PDF to your computer first, then open the PDF with
Adobe Acrobat Reader(R), rather than opening it within
your Web browser.
To download a PDF:
„ Right click on the link for the PDF you wish
to download. A menu will pop up on the
screen.
Medicare Report / December 1, 2003
If you select the “All” option for your print range, you
can save paper by specifying odd or even page printing
and print on both sides; thereby, making your printed
copy look similar to a printed bulletin. If your printer
cannot accommodate duplex printing, you will need to
feed the paper through twice; once for the odd pages,
and again for the even pages. (Note: Make sure you
put the pages in the correct order and face them in the
proper direction for printing on the reverse side).
Another way to save paper is by choosing specific pages
to print, when you don’t need to read or refer to the
entire bulletin. This way, you will have just the pertinent
information on hand when it is needed.
While visiting the DMERC A Web site, please take a
few moments to complete our Online Newsletter Survey
at www.umd.nycpic.com/dmercbulletinsurvey.html.
Your responses will assist us in meeting your needs and
improving our online bulletins.
59
Request for Education
Training and education is paramount to the overall success of administering the
Medicare program. To that end, HGSAdministrators is committed to educating
healthcare professionals and their staff about:
™ Fundamental Medicare programs and policies
™ New Medicare initiatives
™ Significant changes to the Medicare program
We also focus on training for new healthcare professionals and office staff.
Our objectives are to inform and educate our customers through mass media
including printed and electronic communications, Internet, workshops, classes and
meetings.
Our Education Specialists will be happy to educate healthcare practitioners/
professionals and/or office personnel. In order to optimize our resources, we
generally prefer groups of 10 or more. To request such education, please complete
the information below and mail to:
HGSAdministrators
Attn: PET Coordinator
PO Box 890089
Camp Hill, PA 17089-0089
Name _______________________________________________________
Office Name _________________________________________________
Provider # ________________ Phone # ____________________________
Topic Requested for Education ___________________________________
60
Medicare Report / December 1, 2003
Education & Training Feedback
Training and education is paramount to the overall success of administering the Medicare program. To that end,
HGSAdministrators is committed to educating healthcare professionals and their staff about fundamental Medicare
programs and policies, new Medicare initiatives and significant changes to the Medicare program. We also focus
on training for new healthcare professionals and office staff.
In order to determine the effectiveness of our efforts we need feedback from you. Tell us how we are doing and
what we can do better. Your comments can make a difference in how we design our programs and publications. We
would very much appreciate your taking the time to answer a few questions to let us know how you really feel.
Medicare Report
Do you read it?
† Always
† Occasionally
† Never
Do you prefer to read the paper copy or the copy on our web site?
† Paper
† Web Site
† Both
How satisfied are you with the Medicare Report?
† Very
† Somewhat
† Not at all
Did you find that the information you read is accurate and up-to-date?
† Always
† Usually
† Occasionally†
† Rarely
Are the articles clear and easy to read and understand?
† Mostly
† Sometimes
† Never
How easy is it to find the information you’re looking for?
† Very
† Somewhat
† Not at all
What topics are most important to you?
† Claim Reporting
† Coverage Issues
† EDI
† Fraud & Abuse
† Internet Spotlight
† Medical Director Column
† Medical Review Highlights
† News
† Policy
† Reimbursement
† Specialty News
Web Site
How often do you visit our web site at www.hgsa.com?
† Daily
† Several Times a Week
† Occasionally
† Never
What topics are you looking for when you visit our web site?
† Policy
† Billing
† Contacts
† What’s New
† Medical Review
† Forms
† Education and Training
† Electronic Data Interchange
† Manuals/Publications
† Reimbursement
† Enrollment
† Using the Search Feature to find a topic, article or reference
How easy is it to find the information you’re looking for?
† Very
† Somewhat
† Not at all
How useful did you find our web-based training modules in developing a better understanding of that
topic?
† Very
† Somewhat
† Not at all
Medicare Report / December 1, 2003
61
Part B Reference Manual
Do you subscribe to our Medicare Part B Reference Manual?
† Yes
† No
How often do you use the Medicare Part B Reference Manual?
† Often
† Occasionally
† Never
Do you prefer to read the paper copy or the copy on our web site?
† Paper
† Web Site
† Both
What information are you looking for when using the Medicare Part B Reference Manual?
† Appeals
† Coding
† Completion of the Claim Form
† Coverage Issues
† Diagnosis Coding
† EDI Services
† Enrollment
† Medigap
† Patient Eligibility
† Reimbursement
† Secondary Payer
† Other_____________________
Billing Guides
Do you refer to any of our Billing Guides?
† Yes
† No
Which of our Billing Guides do you use?
† ASC
† Ambulance
† Chiropractic
† Clinical Lab
† Flu & Pneumonia Vaccine
† IDTF
† Occupational Therapy
† Optometry
† Podiatry
† Portable X-Ray
How helpful do you find the Billing Guides?
† Very
† Somewhat
† Not at all
†
†
†
†
†
Anesthesia
ESRD
Nurse Practitioner
Physical Therapy
Teaching Physician
Seminars/Meetings
In the past year, how many of our seminars/meetings have you attended?
† More than 2
† 1 or 2
† None
If you attended any of our seminars/meetings, how helpful did you find them?
† Very
† Somewhat
† Not at all?
Who generally attends?
† Healthcare Practitioner/Professional † Office Staff
Provide any additional comments and/or suggestions regarding the above education activities:
Optional
Name ___________________________________________________
Provider # _____________________
Office Name ______________________________________________
Phone # _____________________
Mail to:
HGSAdministrators
Attn: PET Coordinator
PO Box 890089
Camp Hill, PA 17089-0089
62
Medicare Report / December 1, 2003
ate
D
B
o
-T art
p
P
?
d U are tion
e
Medicare Part B Reference Manual Subscription Coupon
Ne edic rma
M nfo
I
Subscriber’s Name _______________________________________________________________
Business Name _________________________________________________________________
Mailing Address (no PO Boxes) ____________________________________________________
_____________________________________________________________________________
(Manuals are shipped viaFedEx Ground. FedEx Ground cannot deliver to PO Boxes)
City ________________________________________ State ______________ Zip ___________
Telephone ( ________ ) ______________________________
Please send me the following:
ˆ Medicare Part B Reference Manual only ($50)
ˆ Medicare Part B Reference Manual and quarterly revisions ($150)
Return this form with your payment to: HGSAdministrators
Medicare Professional Services
PO Box 890162
Camp Hill, PA 17089-0162
Medicare Report / December 1, 2003
63
Have a safe
and enjoyable
holiday!
P.O. Box 890089
Camp Hill, PA 17089-0089
PRSRT STD
U.S. POSTAGE
PAID
HARRISBURG, PA
Permit No. 320