OHIO Part B Medicare Bulletin

Transcription

J15
MAY 2013
HOT TOPIC
INSIDE THIS ISSUE
CPT Code 88305: Results of Progressive Corrective Action (PCA) . . 4 0
1st Quarter Update Part B Not Otherwise Classified Drug Fee Schedule 2013 Payment
Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs Effective January 1,
2013 through March 31, 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Revised: MM7492 - Medicare Fee-For-Service (FFS) Claims Processing
Guidance for Implementing International Classification of Diseases,
10th Edition (ICD-10) . . . . . . . . . . . . . . . . . . . . . . 7 9
INSERT TOPICS: General Part B
2013 Therapy Cap Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2nd Quarter Update Part B Not Otherwise Classified Drug Fee Schedule 2012 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs’Effective April 1, 2012
through June 30, 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 0
2nd Quarter Update Part B Not Otherwise Classified Drug Fee Schedule 2013 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs Effective April 1, 2013
through June 30, 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 8
3rd Quarter Update Part B Not Otherwise Classified Drug Fee Schedule 2012 Payment Allowance
Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs Effective July 1, 2012 through
September 30, 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 4
4th Quarter Update Part B Not Otherwise Classified Drug Fee Schedule 2012 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs Effective October 1, 2012
through December 31, 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2
Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/C) Testing: Coding and
Claim Submission Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 9
Aspartoacyclase (ASPA) 2 Deficiency Testing: Coding and Claims Submission Guidelines . . . 4 0
CPT Code 88305: Results of Progressive Corrective Action (PCA) . . . . . . . . . . . . . . 4 0
CPT Code 99310: Prepayment Edit Implemented . . . . . . . . . . . . . . . . . . . . . 4 1
REACHING OUT TO THE MEDICARE COMMUNITY
WWW.CGSMEDICARE.COM
Implementation for the Award for Jurisdiction E Part A\Part B Medicare Hospital Inpatient Claims
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Local Carrier Payment Allowance Limits for Medicare Part B Drugs Effective April 1, 2013 through
June 30, 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 2
Local Carrier Payment Allowance Limits for Medicare Part B Drugs Effective July 1, 2012 through
September 30, 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 5
Mitochondrial Nuclear Gene Tests: Coding and Claim Submission Guidelines . . . . . . . . . 4 8
MM7727 - Medicare Quality Reporting Incentive Programs Manual Update . . . . . . . . . 4 9
MM7818 - International Classification of Diseases, 10th Edition (ICD)-10 Conversion from (ICD-9)
and Related Code Infrastructure of the Medicare Shared Systems as They Relate to CMS National
Coverage Determinations (NCDs) (CR 1 of 3) (ICD-10) . . . . . . . . . . . . . . . . . . . 5 0
MM7824 - Reorganization of Chapter 13 . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2
MM8121 - Clarification of Detection of Duplicate Claims Section of the CMS Internet Only Manual
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
MM8166 - Outpatient Therapy Functional Reporting Non-Compliance Alerts . . . . . . . . 5 6
MM8203 - Clinical Laboratory Fee Schedule - Medicare Travel Allowance Fees for Collection of
Specimens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 8
MM8212 - New Waived Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 0
Bold, italicized material is excerpted from the American Medical Association Current
Procedural Terminology CPT codes. Descriptions and other data only are copyrighted
2009 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.
MM8213 - Autologous Platelet-Rich Plasma (PRP) for Chronic Non-Healing Wounds . . . . 6 2
MM8237 - April 2013 Update of the Ambulatory Surgical Center (ASC) Payment System . . . 6 6
J15
MAY 2013
A service of CGS
Kentucky General Release
MM8246 - Quarterly Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
MM8247 - July 2013 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions
to Prior Quarterly Pricing Files . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 0
Ordered and Referred Services (Phase II): Immediate Action Needed to Prevent Claim Rejections . . . 7 2
PAX6 Gene Sequencing: Coding and Claim Submission Guidelines . . . . . . . . . . . . . . . . . 7 3
Pervenio Lung RS Assay: Coding and Claim Submission Guidelines . . . . . . . . . . . . . . . . . 7 4
PreDx Diabetes Risk Score (DRS): Coding and Claim Submission Guidelines . . . . . . . . . . . . . 7 4
Reduced Services (CPT Modifier 52) and Discontinued Procedures (CPT modifier 53): Coding, Documenting, and Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 4
Revised: MM7260 - Modification to CWF, FISS, MCS and VMS to Return Submitted Information When
There is a CWF Name and HIC Number Mismatch . . . . . . . . . . . . . . . . . . . . . . . . . . 7 6
REVISED: MM7441 - Magnetic Resonance Imaging (MRI) in Medicare Beneficiaries with Food and
Drug Administration (FDA)-Approved Implanted Permanent Pacemakers (PMs) for Use in the MRI
Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 7
Revised: MM7492 - Medicare Fee-For-Service (FFS) Claims Processing Guidance for Implementing International Classification of Diseases, 10th Edition (ICD-10) . . . . . . . . . . . . . . . . . . . . . . 7 9
Revised: MM8010 - Update To Publication 100-04, Claims Processing Instructions For Chapter 12,
Non-Physician Practitioners (NPPs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 3
Revised: MM8127 - Manual Updates to Clarify Inpatient Rehabilitation Facility (IRF) Claims Processing
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
REACHING OUT TO THE MEDICARE COMMUNITY
WWW.CGSMEDICARE.COM
Revised: MM8147 - Quarterly Update to Correct Coding Initiative (CCI) Edits, Version 19.1, Effective April
1, 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 8
Revised: MM8169 - April Update to the CY 2013 Medicare Physician Fee Schedule Database (MPFSDB)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Revised: MM8197 - International Classification of Diseases (ICD)-10 Conversion from ICD-9 and Related Code Infrastructure of the Medicare Shared Systems as They Relate to CMS National Coverage
Determinations (NCDs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2
Revised: SE0711 - Reminder - Medicare Now Provides Coverage for Eligible Medicare Beneficiaries of a
One-Time Ultrasound Screening for Abdominal Aortic Aneurysms (AAA) When Referred for this Screening as a Result of the Initial Preventive Physical Examination (“Welcome to Medicare” Physical Exam)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
REVISED: SE1029 - 5010 Requirement for Ambulance Suppliers . . . . . . . . . . . . . . . . . . . 9 7
SE1305 - Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME, and
Part A Home Health Agency (HHA) Claims (Change Requests 6417, 6421, 6696, and 6856) . . . . . . 9 9
SE1308 - Physician Delegation of Tasks in Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Subsequent Nursing Facility Care (CPT Codes 99307-99310): Claim Submission and Documentation . . . 109
Transitional Care Management (TCM): Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 0
UGT1A1 Gene Analysis: Coding and Claim Submission Guidelines . . . . . . . . . . . . . . . . . . 1 1 0
Vysis Kit by Abbott: Coding and Claim Submission Guidelines . . . . . . . . . . . . . . . . . . . . 1 1 1
1st Quarter Update Part B Not Otherwise Classified Drug Fee
Schedule 2013 Payment Allowance Limits for Medicare Part B Not
Otherwise Classified (NOC) Drugs Effective January 1, 2013 through
March 31, 2013
Revision: 4/1/2013
Name of Drug and EXACT Dosage Given MUST be in Block 19 (paper), as an Attachement, or Narrative
Field (EMC)
NOTE 1: Payment allowance limits subject to the ASP methodology are based on 2Q12 ASP data.
NOTE 2: Providers should contact their local Medicare contractor processing the claim for the most appropriate
unlisted/unclassified HCPCS code to use in reporting these drugs to Medicare.
NOTE 3: The absence or presence of a HCPCS code and the payment allowance limits in this table does not
indicate Medicare coverage of the drug. Similarly, the inclusion of a payment allowance limit within a specific
column does not indicate Medicare coverage of the drug in that specific category. These determinations shall
be made by the local Medicare contractor processing the claim.
Note 4: ** - Carrier Priced
Changes In Bold
DRUG NAME
Abatacept (Orencia) The subcutaneous form of
abatacept is considered self-administered
Ado-Trastuzumab Emtansine (Kadcyla) covered
indications: HER2 -positive, metastatic breast cancer
(174.0-175.9)
Alfentanil Hydrochloride (Alfenta)
Alglucosidase Alfa (Myozyme)
Allopurinol Sodium (Aloprim) ICD-9’s 274.9 or 790.6
plus the ICD-9 for the neoplasm. Need name of
chemotherapy agent causing the elevation of uric acid
and a statement as to why patient can not tolerate oral
form of the drug.
Afinitor (see Everolimus)
Aflibercept (see EYLEA)
Amidate (see Etomidate)
Amino Acid
Amino Acid
Aminocaproic Acid
Arginine Hydrochloride (R-Gene 10)
Arzerra (see Ofatumumab)
** Ascorbic Acid (Vitamin C) Non-covered by Carrier
** Atenolol (Tenormin) ICD-9’s = 401.0 - 429.9
Atropine Sulfate / Edrophonium Chloride
Avastin (See Bevacizumab)
Aztreonam (Azactam)
** Bacitracin (Bacim)
Belimumab (Benlysta) Covered ICD-9: 710.0
Beltatacept (Nulojix) Covered indications: V420 and 075
or 996.52
Benlysta (see Belimumab)
Berinert (see C1 Esterase Inhibitor)
DOSAGE
Current
PAR
Current NONPAR
Notes
10 mgs.
$293.998
$279.298
500 mcg/5 ml
10 mg
$2.143
$2.036
Added
March
2013
500 mg/SDV
$317.236
$301.374
2 mg vial
500 ml
1000 ml
250 mg
300 ml
0.5 mg / ml
10 mg
500 mg
50,000 U
10 mg
$1,961.000
$21.110
$35.190
$0.040
$11.225
$0.800
$1.651
$13.653
$10.170
$1,862.950
$20.055
$33.431
$0.038
$10.664
$0.760
$1.568
$12.970
$9.662
250 mg.
$978.380
$929.461
This newsletter should be shared with all health care practitioners and managerial members of the provider/supplier staff.
Newsletters issued after January 1997 are available at no cost from our website at www.cgsmedicare.com.
Medicare Bulletin – GR 2013-05
- page 3 -
May 2013
Bevacizumab (Avastin) CPT 67028 must be on claim or
in history; allow if billed with J3490 or J3590 and the
ICD-9 requirements from one of the following codes:
115.02, 115.12, 115.92, 362.01 - 362.07 (any), 362.16,
362.35 - 362.37 (any), 362.42, 362.52 or 362.83.
Bretylium Tosylate (Bretylol)
Brevibloc (see Esmolol Hydrochloride)
Brovana (see Arformoterol Tartrate)
Bumetanide (Bumex)
Bupivacaine Hcl, 0.25%, 2 ml (Considered Part of
Procedure)
Procedure)
Bupivacaine, Sterile, 0.25%/10ml (Sensorcaine, Sterile)
Allowed when billed with 51700, 51720, 62310, 62311,
62318, 62319, 62368, 64400 - 64484, 64505 - 64530,
77003, 95990, or 96530. When billed with other
procedures, considered part of procedure performed.
62318, 62319, 62368, 64400 - 64484, 64505 - 64530,
62318, 62319, 62368, 64400 - 64484, 64505 - 64530,
Cabazitaxel (Jevtana®)
Calciferol (see Ergocalciferol D2)
Calcium Chloride
Cardizem IV (see Diltiazem Hydrochloride)
Carfilzomib (Kyprolis) covered ICD-9 203.00 or 203.02
** Cefamanadole Nafate (Mandol)
** Cefoperazone Sodium (Cefobid)
Cefotetan Disodium (Cefotan)
Chirocaine (see Levobupivacaine Hydrochloride)
Cimetidine Hcl. (Tagamet)
Cimzia (see Certolizumab Pegol)
Clavulanate Potassium / Ticarcillin Disodium
Clevidipine Butyrate
Clindamycin Phosphate (Cleocin)
Clorpactin WCS-90 (see Oxychlorosene Sodium)
Copper Sulfate
Cystografin (see Diatrizoate Meglumine)
Dantrolene Sodium
Depacon (see Valproate Sodium)
Denileukin Difitox (Ontak) (For 300 mcg, use code J9160)
Denosumab (Prolia ™ or Xgeva) If Prolia ™, covered ICD9 = 733.01; if Xgeva, covered ICD-9 = 198.5.
Dextrose 2.5%
Dextrose 5%
Dextrose 10%
Dextrose 50%
** Dextrose / Nitroglycerin 5%-20 mg/ 100 ml/250 ml
** Dextrose 5% / Sodium Chloride
Diatrizoate Meglumine (Cystografin)
Diltiazem Hydrochloride (Cardizem IV)
N/A
$60.000
$57.000
5 mg
0.25 mg
$0.175
$0.171
$0.166
$0.162
0.25% - 1 ml
$0.077
$0.073
0.50% - 1 ml
$0.077
$0.073
0.75% - 1 ml
$0.077
$0.073
1 mg
100 mg / ml
60 mg
1 gm
1 gm
1 gm
150 mg
0.1 - 3 gm
1 mg
150 mg
0.4 mg
20 mg
150 mcg
$0.159
$1,669.606
$8.610
$16.380
$11.376
$1.064
$9.618
$2.957
$1.618
$0.125
$78.800
$595.430
$0.151
$8.180
$15.561
$10.807
$1.011
$9.137
$2.809
$1.537
$0.119
$74.860
$565.659
1 mg
2.50%
5%
500 ml
50 ml
20 mg/100
ml/250 ml
1000 ml
10 ml
5 mg
$7.680
$7.860
$10.000
$0.101
$7.296
$7.467
$9.500
$0.096
$6.320
$6.004
$11.220
$2.10
$0.209
$10.659
$2.00
$0.199
May 2013
- page 4 -
Diprivan (see Propofol)
Doxapram Hydrochloride (Dopram)
Doxycycline Hyclate
Edecrin Sodium (see Ethacrynate Sodium)
Edrophonium Chloride (Tensilon) (Allow for ICD9 - 358.0)
Elaprase (see Idursulfase)
Emend for Injection (see Fosaprepitant Dimeglumine)
Enalaprilat (Vasotec IV)
Eovist (see Gadoxetate Disodium)
Ergocalciferol D2 (Calciferol) ICD-9’s = 579.8 or 579.9
Allowed when administered in physician’s office
Eribulin Mesylate (Halaven) - Covered ICD-9’s = 174.0 174.9
Esmolol Hydrochloride (Brevibloc) Covered ICD-9 =
427.89 (Dosage change from 100 mg to 10 mg.)
Esomeprazole Sodium (Nexium IV) Covered ICD-9’s =
530.10 - 530.19 or 530.81 when administered in the
physician’s office.
Estradiol
** Estradiol Pellets
Ethacrynate Sodium (Edecrin Sodium)
** Ethiodized Oil (Ethiodol)
Etomidate (Amidate)
Everolimus (Afinitor / Zortress) - Non-Covered; Oral drug
considered as self-administered.
EYLEA (see Aflibercept)
Famotidine (Pepcid)
Firazyr (see Icantibant)
Firmagon (see Degarelix)
Flagyl IV (see Metronidazole In Nacl.)
Floxin IV (see Ofloxacin)
Flumazenil (Mazicon, Romazicon)
Folic Acid
Folotyn (see Pralatrexate)
Fospropofol Disodium injection (Lusedra)
Gammaked injection
Gammaplex (see Human Immune Globulin Intravenous)
Glucarpidase
Glycopyrrolate (Robinul)
Halaven (see Eribulin Mesylate)
** Heparin Sodium
Hetastarch Sodium Cl., 6 gm/500 ml
Hexaminolevulinate Hydrochloride - Covered for ICD-9’s
188.0 through 188.9
Hizentra (see Immune Globulin Subcutaneous)
Human Immune Globulin Intravenous (Gammaplex)
Hydroxocobalamin - Covered when billed with J9305.
Icantibant (Firazyr) - Usually considered selfadministered
Ilaris (see Canakinumab)
** Inamrinone Lactate
IncobotulinumtoxinA (Xeomin) - Covered for the
treatment of Genetic torsion dystonia (333.6) and
Blepharospasm (333.81)
20 mg
100 mg
10 mg
1.25 mg
$2.195
$11.195
$2.420
$1.142
$2.085
$10.635
$2.299
$1.085
500,000 IU/ 1ml
$29.840
$28.348
0.1 mg
10 mg
$0.797
$0.757
20 MG
$1.770
$1.682
1 gram
Per Pellet
50 mg
1 ml
2 mg
$13.300
Invoice
$19.040
$8.060
$0.695
$12.635
Invoice
$18.088
$7.657
$0.660
10 mg
0.1 mg
0.5 mg
5 mg
35 mg
500 mg
10 units
0.2 mg
100 units
6 gm
100 mg, per study
dose
IV
1000 mcg/ml
$0.389
$1.179
$42.830
$2.353
$1.272
$37.484
$233.730
$0.375
$0.032
$23.040
$0.370
$1.120
$40.689
$2.235
$1.208
$35.610
$222.044
$0.356
$0.030
$21.888
$741.576
$704.497
$1.212
$1.151
5 mg
$4.050
$3.848
1 Unit
- page 5 -
May 2013
INTEGRA™ Bilayer Matrix Wound Dressing - Covered
Indications = 757.39, 941.20-941.21, 941.24-941.31,
941.34-941.41, 941.44-941.51, 941.54-941.59, 942.20942.59, 943.20-943.59, 944.20-944.58, 945.20-945.59,
946.2-946.5, 948.00-948.99
Invega® Sustenna® (see Paliperidone Palmitate injection)
Ipilimumab (Yervoy) - Covered for unresectable or
metastatic melanoma.
Isoproterenol Hydrochloride (Isuprel)
Isoptin IV (see Verapamil Hydrochloride)
Istodax (see Romidepsin)
Isuprel (see Isoproterenol Hydrochloride)
Jetrea (Ocriplasmin)
Jevtana® (see Cabazitaxel)
1 sq cm
$24.609
$23.379
1mg
0.2 mg
0.2 ml SDV
$2.250
$4,187.000
$2.138
$3,977.650
Kadcyla (see Ado-Trastuzumab Emtansine)
Kalbitor (see Ecallantide)
Kenalog (see Triamcinolone Acetonide)
Keppra intraveneous (see Levetiracetam)
Ketamine Hydrochloride (Ketalar) Allowed when billed
on same day as 20550-20610, 62289, 62298, 62368,
95990, or 96530.
Kyprolis (see Carfilzomib)
Krystexxa (see Pegloticase)
Labetalol Hydrochloride (Trandate, Normodyne)
Covered if given IV in the office for control of BP in
severe hypertension. Patient is normally switched to oral
for maintainance doses.
** Levobupivacaine Hydrochloride (Chirocaine) Allowed
separately when billed on same day as 51700, 51720,
62310, 62311, 62318, 62319, 62368, 64400 - 64484,
64505-64530, 76003, 95990, or 96530. Not payable
separately when billed with any other procedures
** Levophed Bitartrate (see Norepinephrine Bitartrate)
** Levothyroxine Sodium (Synthroid) Need statemnt on
claim as to why patient can’t take oral form of drug.
Lidocaine - Allowed separately when billed on same day
as 51700, 51720, 62310, 62311, 62318, 62319, 62368,
64400 - 64484, 64505 - 64530, 77033, 95990, or 96530.
Not payable when billed with any other procedure.
Lopressor (see Metoprolol Tartrate)
Lusedra (see Fospropofol Disodium injection)
Mandol (see Cefamanadole Nafate)
Marqibo (see Vincristine sulfate Liposome)
Mazicon (see Flumazenil)
Methylnaltrexone Bromide (Relistor) Non-covered by
carrier.
Metoprolol Tartrate (Lopressor) Covered when given IV
with Dobutamine J1250 during Dobutamine Stress Test.
Metronidazole Hcl. (Flagyl IV) IV in the office. Covered
for ICD-9’s= 001.0-009.3, 040.0-041.9, 481-482.9, 567.0567.9, 599.0-599.9, 615.0-615.9.
Miconazole (Monistat IV) 10 mg
Minocycline Hydrochloride (Non-covered oral drug)
Monistat IV (see Miconazole)
Morrhuate Sodium
Myozyme (see Alglucoside Alfa)
Nafcillin Sodium (Nallpen) (Dosage Change from 500 mg
to 1 gm)
Nalmefene Hydrochloride (Revex)
Added
March
2013
10 mg
$0.067
$0.064
5 mg
$0.149
$0.142
2.5 mg/ml
$0.310
$0.295
0.5 mg
$62.010
$58.910
1 ml
$0.143
$0.136
1 mg
$0.159
$0.151
500 mg
$1.091
$1.036
50 mg
Invoice
$2.105
Invoice
$2.000
1 gm
$8.058
$7.655
10 mcg
$0.276
$0.262
May 2013
- page 6 -
Netilmicin Sulfate (Netromycin), 150 mg
Nexium IV (see Esomeprazole Sodium)
Nitroglycerin IV – Allowed in emergency situations.
Nodolo & Tusal (see Sodium Thiosalicylate)
** Norepinephrine Bitartrate (Levophed Bitartrate) Allow
in emergency situations.
Norcuron (see Vecuronium Bromide)
Normal Saline (Sterile Water)
Normodyne (see Labetalol Hydrochloride)
Nplate™ (see Romiplostim)
Nulojix (see Beltatacept)
Ofloxacin (Floxin IV), 20 mg
Olanzapine short-acting intramuscular injection
(Zyprexa IM) Covered indications = 295.01 - 295.84 when
administered in the physicians office.
Omacetaxine Mepesuccinate (Synribo) covered
indications 205.10 without having achieved remission,
failed remission or 205.12 in relapse
Ontak (see Denileukin Difitox)
Optison
Orencia (see Abatacept)
** Oxychlorosene Sodium (Clorpactin WCS-90)
Ozurdex (see Dexamethasone Intravitreal Implant)
Pantoprazole Sodium, IV (Protonix IV) Need statement as
to why patient is not able to take oral form.
** Peginterferon Alfa-2A/Isopropyl Alchol (Pegasys®)
Covered indication 070.54 when administered in the
office.
Peginterferon Alfa-2B (PEG-Intron) 50 mcg Covered
indication 070.54 when administered in the office.
** Peginterferon Alfa-2B, 80mcg
Pegloticase (Krystexxa) When billed with J3490 or J3590,
covered for chronic gout, ICD-9’s 274.00 through 274.03
** Pegvisomant for Injection (Somavert) Considered
Usually Self-Administered
Pepcid (see Famotidine)
Perjeta (see Pertuzumab)
Pertuzumab (Perjeta) Covered ICD-9 174.0 - 175.9 in
combination with Trastuzumab J9355 and Docetaxel
J9171
Potassium Acetate
Potassium Phosphate
Procaine Hydrochloride
Prolia ™ (see Denosumab)
Propofol (Diprivan)
Protonix IV (see Pantoprazole Sodium)
Provenge (see Sipuleucel-T)
Qutenza (see Capsaicin 8% Patch)
** R-Gene 10 (see Arginine Hcl.)
Relistor (see Methylnaltrexone Bromide)
Revex (see Nalmefene Hydrochloride)
Rexolate & Arthrolate (see Sodium Thiosalicylate)
RiaSTAP (see Fibrinogen Concentrate Human)
Rifampin
Robinul (see Glycopyrrolate)
5 mg
Invoice
$0.374
Invoice
$0.355
1 mg
$2.161
$2.053
50 ml
$1.430
Invoice
$1.359
Invoice
0.5 mg
$1.632
$1.550
3.5 mg
$885.100
$840.845
1 gm
Invoice
$1.850
Invoice
$1.758
Added
March
2013
40 mg
$4.511
$4.285
180mcg/ml
$480.273
$456.259
50 mcg
$320.610
$304.580
80 mcg
120 mcg
150 mcg
$336.600
$353.460
$371.120
$319.770
$335.787
$352.564
1mg
10 mg/ml
$102.327
$97.211
2 meq
3 mmol
1%
2%
10 mg
600 mg
$0.027
$0.043
$2.360
$3.400
$0.118
$41.855
$0.026
$0.041
$2.242
$3.230
$0.112
$39.762
- page 7 -
May 2013
Per infusion
(minimum 50
million cells)
2 meq
7.5%/50 ml
50 ml
250 cc
$0.043
$2.730
$0.122
$0.705
Invoice
$0.041
$2.594
$0.116
$0.670
Invoice
50 mg
$0.970
$0.922
100 mg
5 cc
1000 ml
50mcg/ml
$0.155
$0.052
$5.640
$9.810
$0.147
$0.049
$5.358
$9.320
400 - 80 mg
$0.311
$0.295
0.5 sq cm
$11.776
$11.187
Synribo (see Omacetaxine Mepesuccinate)
Synthroid (see Levothyroxine Sodium)
Synvisc-One (see Hylan G-F 20)
Tagamet (see Cimetidine Hydrochloride)
Taliglucurase Alfa
Tenormin (see Atenolol)
Tensilon (see Edrophonium Chloride)
Testosterone
** Testosterone Pellets (Testopel)
Tetanus Toxoid (use codes 90702, 90703, or 90718)
Tetracycline
Torisel (see Temsirolimus)
Trandate (see Labetalol Hydrochloride)
Treanda (see Bendamustine Hydrochloride)
Truxton (see Prednisolone Acetate)
Tyvaso (see Treprostinil inhalation)
Vaccinia IVIG (see Human Immune Globulin Intravenous)
Valproate Sodium (Depacon) IV, Covered ICD9’s =
345.00 - 345.91, Allowed when administered IV, in the
physician’s office. (Dosage change from 500 mg to 100
mg)
Vasopressin
Vasotec IV (see Enalaprilat)
Vectibix (see Panitumumab)
Vecuronium Bromide (Norcuron)
10 units
37.5 mg
Per Pellet
$30.904
$0.110
Invoice
Invoice
$0.105
Invoice
Invoice
Added
March
2013
100 mg
$0.558
$0.530
20 units
1 mg
$1.254
$0.487
$1.191
$0.463
Romazicon (see Flumazenil)
Sarracenia Purpura Non-covered by Carrier
Sensorcaine, Sterile (see Bupivicaine, Sterile)
Sipuleucel-T (Provenge) ICD-9 = 185
Sodium Acetate
** Sodium Bicarbonate, PF (NACH03)
Sodium Bicarbonate, 8.4% (NACH03)
Sodium Chloride, Hypertonic
** Sodium Tetradecyl Sulfate (Sotradecol)
** Sodium Thiosalicylate (Rexolate & Arthrolate, Nodolo
& Tusal)
Sodium Thiosulfate
Soliris (see Eculizumab)
Somatuline Depot (see Lanreotide)
** Somavert (see Pegvisomant for Injection)
Stelara (see Ustekinumab)
Sterile Saline / Water
** Sterile Saline / Water, 1000 ml
** Sufentanil Citrate (Sufenta) Separate payment allowed
when billed with 62310, 62311, 62318, 62319, 76005,
95990, or 96530. If billed with any other procedures, it
will be considered part of the procedure and separate
payment will not be allowed.
Sulfamethoxazole/Trimethoprim (SMZ-TMP)
Documentation as to why the patient needs to be on IV
infusion instead of oral medication, must be in block 19
or as an attachment for paper claims or in the notepad
for EMC claims.
SurgiMend
May 2013
- page 8 -
Verapamil Hydrochloride (Isoptin IV)
VIBATIV™ (see Telavancin Injection)
Vincristine Sulfate Liposome (Marquibo) covered ICD-9:
204.00-204.02
** Vitamin B Complex
** Vitamin C (see Ascorbic Acid) Non-covered by Carrier
Vivaglobin (see Immune Globulin Subcutaneous)
VPRIV™ (see Velaglucerase alfa for injection)
Wilate (Human coagulation factor VIII (FVIII) and von
Willebrand factor (VWF) powder and solvent for solution
for injection) Covered ICD-9: 286.4
Xeomin (see IncobotulinumtoxinA)
Xgeva (see Denosumab)
Xiaflex (see Collagenase Clostridum Histolyticum)
Xyntha (see Antihemophilic Factor (Recomb) Plasma/
Albumin-Free)
Yervoy (see Ipilimumab)
Zaltrap (see Ziv-Aflibercept)
Ziv-Aflibercept (Zaltrap) covered ICD-9 153.0 - 153.7 or
154.0 - 154.2
Zortress (see Everolimus)
Zyprexa IM (see Olanzapine)
HOCM <= 149 MG/ML
HOCM 200 - 249 MG/ML
HOCM >= 400 MG/ML
2.5 mg
$3.167
$3.009
2.25 mg.
Invoice
Up to 3 ml
$0.930
$0.884
1 IU VWF:RCO
100 mg.
$1,611.200
1 ml
1 ml
1 ml
1 ml
1 ml
1 ml
$0.041
$0.093
$0.100
$0.104
$0.107
$0.191
$0.039
$0.088
$0.095
$0.099
$0.102
$0.181
2013 Therapy Cap Process
For dates of service January 1, 2013 through December 31, 2013, all outpatient therapy claims submitted above
the $3,700 threshold will be subject to prepayment medical review. CGS will send Additional Documentation
Requests (ADRs) for all claims above the $3,700 threshold. In these ADRs, CGS will request the following
documentation:
Justification;
Evaluation or reevaluation(s) for Plan(s) or Care;
Certification of the Plan of Care;
Objectives and measurable goals and any other documentation requirements of the Local Coverage
Determination (LCDs) (note: objectives and goals should also include an estimation of reasonable time
frame in which the patient could be expected to achieve the stated goals);
Progress reports;
Treatment notes;
Certification or recertification for therapy services;
Any orders, if applicable, for additional therapy services; and
Any additional information requested by CGS.
Follow the instructions provided on the ADRs when sending documentation.
**To the extent possible, CGS will complete the prepayment review of therapy claims within 10 business days
from the date we receive the requested records. If we cannot review the claims within 10 business days of the
date of receipt, we will complete the review within the 60 day medical review timeframe as mandated by the
CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 3, section 3.3.1.1(f ).
- page 9 -
May 2013
2nd Quarter Update Part B Not Otherwise Classified Drug Fee Schedule
2012 Payment Allowance Limits for Medicare Part B Not Otherwise
Classified (NOC) Drugs’Effective April 1, 2012 through June 30, 2012
Revision Date: 4/1/2013
Field (EMC)
Changes In Bold
DRUG NAME
DOSAGE
Abatacept (Orencia) The subcutaneous form of abatacept
is considered self-administered
Actemra (see Tocilizumab)
Adcetris (see Brentuximab Vedotin)
500 mcg/5 ml
Allopurinol Sodium (Aloprim) ICD-9’s 274.9 or 790.6 plus
the ICD-9 for the neoplasm. Need name of chemotherapy
agent causing the elevation of uric acid and a statement
as to why patient can not tolerate oral form of the drug.
Amino Acid
Amino Acid
Aminocaproic Acid
Antihemophilic Factor (Recomb) Plasma/Albumin-Free
(Xyntha)
Arformoterol Tartrate (Brovana)
Aztreonam (Azactam)
Current
PAR
Current NONPAR
$1.418
$1.347
$336.189
$319.380
2 mg vial
$1,961.000
$1,862.950
500 ml
1000 ml
250 mg
$21.110
$35.190
$0.050
$20.055
$33.431
$0.048
300 ml
$11.225
$10.664
0.5 mg / ml
10 mg
$0.800
$1.651
$0.760
$1.568
500 mg
50,000 U
$14.165
$10.170
$13.457
$9.662
10 mg
500 mg/SDV
1 IU
15 mcg
10 mg
Notes
Code for
2012: J0221
Added
December
2011
Code for
2011: J7185
Code for
2011: J7605
Code for
2012: J0490
May 2013
- page 10 -
Beltatacept (Nulojix) Covered indications: V420 and 075
or 996.52
Bendamustine Hydrochloride (Treanda) Covered
indications: 204.10 - lymphoid leukemia, chronic, without
mention of remission or 204.11 - lymphoid leukemia,
chronic, in remission
Bevacizumab (Avastin) CPT 67028 must be on claim or in
history; allow if billed with J3490 or J3590 and the ICD-9
requirements from one of the following codes: 115.02,
115.12, 115.92, 362.01 - 362.07 (any), 362.16, 362.35 362.37 (any), 362.42, 362.52 or 362.83.
Brentuximab Vedotin (Adcetris) Covered indications
200.60-200.68 or 201.00-201.98
Bumetanide (Bumex)
Procedure)
Procedure)
62318, 62319, 62368, 64400 - 64484, 64505 - 64530,
62318, 62319, 62368, 64400 - 64484, 64505 - 64530,
62318, 62319, 62368, 64400 - 64484, 64505 - 64530,
C1 Esterase Inhibitor (Berinert) - For the treatment
of acute abdominal or facial attacks of hereditary
angioedema in adult and adolescent patients (277.6)
Calcium Chloride
Canakinumab (Ilaris) - For Cryopyrin-associated periodic
syndromes
Capsaicin 8% Patch (Qutenza) - Must be administered
under provider supervision.
Certolizumab Pegol (Cimzia)
250 mg.
$978.380
$929.461
1 mg
Code for
2011: J9033
N/A
Updated
ICD-9
Coverage
Effective: 01
/01/2011
New Unit
Price Per
Carrier
Medical
Director
Effective:
05/01/2011
$60.000
$57.000
50 mg
$4,770.000
$4,531.500
5 mg
$0.175
$0.166
0.25 mg
$0.131
$0.124
0.25% - 1 ml
$0.072
$0.068
0.50% - 1 ml
$0.072
$0.068
0.75% - 1 ml
$0.072
$0.068
10 units
Code for
2011: J0597
1 mg
Code for
2012: J9043
100 mg / ml
$0.183
$0.174
$8.610
$16.380
$11.376
$8.180
$15.561
$10.807
$1.064
$1.011
1 mg
10 sq cm
1 gm
1 gm
1 gm
1 mg
150 mg
Code for
2011: J0638
Code for
2011: J7335
Code for
2011: J0718
- page 11 -
May 2013
Collagenase Clostridium Histolyticum (Xiaflex)
Covered for Contracture of palmar fascia (Dupuytren’s
concracture) ICD-9 728.6.
Copper Sulfate
Cosyntropin IV
0.1 - 3 gm
1 mg
150 mg
0.4 mg
Degarelix (Firmagon)
1 mg
Code for
2011: J0775
$0.109
$0.104
$78.800
$74.860
$595.430
$565.659
0.25 mg
20 mg
$9.867
$2.849
$1.573
0.1 mg
Dantrolene Sodium
Denosumab (Prolia ™ or Xgeva) If Prolia ™, covered ICD-9
= 733.01; if Xgeva, covered ICD-9 = 198.5.
Dexamethasone Intravitreal Implant (Ozurdex)
If billed under J3490 or J3590, with CPT code
67028 & 1 of the following ICD-9 combinations:
1) 362.83 plus 362.35 or 362.36; or
2) 362.30
Dextrose 2.5%
Dextrose 5%
Dextrose 10%
Dextrose 50%
$10.386
$2.999
$1.656
150 mcg
Code for
2011: J9155
1 mg
Code for
2012: J0897
0.1 mg
Code for
2011: J7312
2.50%
5%
500 ml
50 ml
20 mg/100
ml/250 ml
1000 ml
$7.680
$7.860
$10.000
$0.101
$7.296
$7.467
$9.500
$0.096
$6.320
$6.004
$11.220
$10.659
10 ml
$2.10
$2.00
5 mg
$0.161
$0.153
Doripenem (Doribax)
10 mg
Doxycycline Hyclate
Ecallantide (Kalbitor) Covered Indications - 277.6 (accute
attack of hereditary angioedema)
20 mg
100 mg
Eculizumab (Soliris)
10 mg
Ergocalciferol D2 (Calciferol) ICD-9’s = 579.8 or 579.9
Allowed when administered in physician’s office
Eribulin Mesylate (Halaven) - Covered ICD-9’s = 174.0 174.9
Estradiol
Code for
2011: J0833
$2.200
$11.424
$2.090
$10.853
Effective
05/01/2011
Code for
2011: J1267
Code for
2011: J1290
Code for
2011: J1300
1 mg
10 mg
$2.420
$2.299
1.25 mg
$1.643
$1.561
500,000 IU/
1ml
$29.840
$28.348
Code for
2012 J9179
0.1 mg
10 mg
$0.799
$0.759
20 MG
$2.802
$2.662
1 gram
Per Pellet
50 mg
1 ml
$13.300
Invoice
$19.040
$8.060
$12.635
Invoice
$18.088
$7.657
May 2013
- page 12 -
Etomidate (Amidate)
2 mg
$0.379
$0.360
Famotidine (Pepcid)
10 mg
Ferumoxytol (Feraheme)
1 mg
$0.414
$0.393
Fibrinogen Concentrate Human (RiaSTAP)
Fludarabine phosphate, oral - Not Covered by Part B
10 mg
Folic Acid
Fosaprepitant Dimeglumine (Emend) Allowed when
billed on the same day as chemotherapy.
0.1 mg
0.5 mg
5 mg
Gadoxetate Disodium (Eovist)
$0.764
$42.830
$1.728
$0.726
$40.689
$1.642
$0.201
$0.191
1 ml
Gammaked injection
500 mg
$37.484
$35.610
0.2 mg
$0.442
$0.420
$0.032
$23.040
$0.030
$21.888
$623.280
$592.116
Graftjacket Gel
** Heparin Sodium
Hexaminolevulinate Hydrochloride - Covered for ICD-9’s
188.0 through 188.9
1 cc
100 units
6 gm
100 mg, per
study dose
IV
1000 mcg/ml
Hylan G-F 20 (Synvisc-One)
$1.212
$1.151
48 mg
Icantibant (Firazyr) - Usually considered self-administered
Idursulfase (Elaprase)
IncobotulinumtoxinA (Xeomin) - Covered for the
treatment of Genetic torsion dystonia (333.6) and
Blepharospasm (333.81)
Code for
2011: J8562
Code for
2011: A9581
Added
October
2011
Code for
2011:
Q4113
Code for
2012: J1557
Effective
06/01/2011
Code for
2011: J7325
1 mg
Code for
2011: J1743
100 mg
Code for
2011: J0597
Immune Globulin Subcutaneous (Hizentra)
Codes
for 2011:
Q0138
(non-esrd)
& Q0139
(esrd)
Code for
2011: J1680
Code for
2011: J1453
1 mg
35 mg
Code for
2012: J8561
Added
December
2011
5 mg
1 Unit
$4.050
$3.848
New Code
for 2012:
J0588
- page 13 -
May 2013
Indications = 757.39, 941.20-941.21, 941.24-941.31,
941.34-941.41, 941.44-941.51, 941.54-941.59, 942.20942.59, 943.20-943.59, 944.20-944.58, 945.20-945.59,
946.2-946.5, 948.00-948.99
Ipilimumab (Yervoy) - Covered for unresectable or
metastatic melanoma.
Ixabepilone (Ixempra) Covered for metastatic or locally
advanced breast cancer (ICD-9 codes 174.0 - 175.9)
Ketamine Hydrochloride (Ketalar) Allowed when billed on
same day as 20550-20610, 62289, 62298, 62368, 95990,
or 96530.
Labetalol Hydrochloride (Trandate, Normodyne) Covered
if given IV in the office for control of BP in severe
hypertension. Patient is normally switched to oral for
maintainance doses.
Lanreotide (Somatuline Depot)
Levetiracetam (Keppra intraveneous)
separately when billed on same day as 51700, 51720,
62310, 62311, 62318, 62319, 62368, 64400 - 64484,
64505-64530, 76003, 95990, or 96530. Not payable
separately when billed with any other procedures
** Levothyroxine Sodium (Synthroid) Need statemnt on
claim as to why patient can’t take oral form of drug.
Lexiscan (see Regadenoson)
Lidocaine - Allowed separately when billed on same day
as 51700, 51720, 62310, 62311, 62318, 62319, 62368,
64400 - 64484, 64505 - 64530, 77033, 95990, or 96530.
Not payable when billed with any other procedure.
Lucentis (see Ranibizumab)
Methylnaltrexone Bromide (Relistor) Non-covered by
carrier.
Metronidazole Hcl. (Flagyl IV) IV in the office. Covered for
ICD-9’s= 001.0-009.3, 040.0-041.9, 481-482.9, 567.0-567.9,
599.0-599.9, 615.0-615.9.
1 sq cm
$18.680
$17.746
1mg
0.2 mg
$2.250
$2.138
Code for
2011: J9207
1 mg
10 mg
$0.067
$0.064
5 mg
$0.456
$0.433
Code for
2011: J1930
Code for
2011: J1953
1 mg
10 mg
2.5 mg/ml
$0.310
$0.295
0.5 mg
$62.010
$58.910
1 ml
$0.143
$0.136
1 mg
$0.144
$0.137
500 mg
$1.053
$1.000
Invoice
Invoice
50 mg
$2.085
$1.981
1 gm
$8.058
$7.655
Morrhuate Sodium
Nafcillin Sodium (Nallpen) (Dosage Change from 500 mg
to 1 gm)
Code for
2012: J9228
Code for
2012: J2265
May 2013
- page 14 -
** Norepinephrine Bitartrate (Levophed Bitartrate) Allow
in emergency situations.
Ofatumumab (Arzerra) Covered indications - 204.10 or
204.12
Olanzapine long-acting intramuscular injection
Covered indications = 295.00 - 295.95 or 296.40 - 296.66
when administered in the physicians office.
Optison
Paliperidone Palmitate injection (Invega® Sustenna®)
Covered indications: 295.00-295.95, 296.40-296.46,
296.50-296.56, or 296.60-296.66
10 mcg
$0.276
Invoice
$0.262
Invoice
5 mg
$0.397
$0.377
1 mg
$2.161
$2.053
50 ml
$1.430
$1.359
1 mg
Code for
2011: J2426
Panitumumab (Vectibix) Covered indications-153.0-154.8
10 mg
Code for
2011: J9303
Pantoprazole Sodium, IV (Protonix IV) Need statement as
to why patient is not able to take oral form.
** Peginterferon Alfa-2A/Isopropyl Alchol (Pegasys®)
Covered indication 070.54 when administered in the
office.
Peginterferon Alfa-2B (PEG-Intron) 50 mcg Covered
** Pegvisomant for Injection (Somavert) Considered
Usually Self-Administered
Potassium Acetate
Potassium Phosphate
Pralatrexate (Folotyn) - Covered indications: 202.70 202.78
Prednisolone Acetate
Propofol (Diprivan)
10 mg
Invoice
Invoice
Code for
2011: J2358
1 mg
0.5 mg
1 gm
40 mg
$2.083
$1.979
Invoice
Invoice
$1.850
$1.758
$4.511
$4.285
180mcg/ml
$480.273
$456.259
50 mcg
$320.610
$304.580
80 mcg
120 mcg
150 mcg
$336.600
$353.460
$371.120
$319.770
$335.787
$352.564
Code for
2012: J2507
1mg
2 meq
3 mmol
Code for
2011: J9302
$0.027
$0.043
$0.026
$0.041
1%
2%
$2.360
$3.400
$2.242
$3.230
10 mg
$0.122
$0.116
1 mg
1 ml
Code for
2011: J9307
Code for
2010: J2650
- page 15 -
May 2013
Ranibizumab Injection (Lucentis)
1 mcg
Regadenoson (Lexiscan)
0.1 mg
Rifampin
Romidepsin (Istodax) Covered indications: 202.70 202.78
Romiplostim (Nplate™)
600 mg
Code for
2011: J2778
Code for
2011: J2785
$45.806
$43.516
Code for
2011: J9315
Code for
2011: J2796
1 mg
10 mcg
Secretin (SecreFlo) Used in secretin stimulation testing
Code for
2011: J2850
1 mcg
Sodium Acetate
** Sodium Thiosalicylate (Rexolate & Arthrolate, Nodolo
& Tusal)
Sodium Thiosulfate
when billed with 62310, 62311, 62318, 62319, 76005,
95990, or 96530. If billed with any other procedures, it
will be considered part of the procedure and separate
payment will not be allowed.
or as an attachment for paper claims or in the notepad
for EMC claims.
SurgiMend
Telavancin Injection (VIBATIV™)
Temsirolimus (Torisel) Covered indication is for the
treatment of advanced renal cell carcinoma (189.0
Malignant neoplasm of kidney, except pelvis).
Testosterone
Tetracycline
Per infusion
(minimum 50
million cells)
2 meq
7.5%/50 ml
50 ml
250 cc
New Code
for 2012:
Q2043
$0.037
$2.730
$0.122
$0.759
Invoice
$0.035
$2.594
$0.116
$0.721
Invoice
50 mg
$0.970
$0.922
100 mg
$0.155
$0.147
5 cc
$0.052
$0.049
1000 ml
50mcg/ml
$5.640
$9.810
$5.358
$9.320
400 - 80 mg
$0.275
$0.261
0.5 sq cm
$11.335
$10.768
10 mg
Code for
2011: J3095
1 mg
Code for
2011: J9330
37.5 mg
Per Pellet
$0.110
Invoice
$0.105
Invoice
Invoice
Invoice
May 2013
- page 16 -
Tocilizumab (Actemra) Covered Indications: 714.0, 714.1
or 714.2.
Treprostinil inhalation (Tyvaso) - If administered in-office,
considered part of service performed. If administered
at-home, not covered by Part B.
1 mg
Code for
2011: J3262
1.74 mg
Code for
2011: J7686
Triamcinolone Acetonide, Preservative Free
1 mg
Triamcinolone Acetonide (Kenalog)
10 mg
Ustekinumab (Stelara) - For the treatment of adults
(18+) with moderate to severe plaque psoriasis who are
candidates for phototherapy or systemic therapy (696.1)
Valproate Sodium (Depacon) IV, Covered ICD9’s = 345.00
- 345.91, Allowed when administered IV, in the physician’s
office. (Dosage change from 500 mg to 100 mg)
Vasopressin
Velaglucerase alfa for injection (VPRIV™)
Willebrand factor (VWF) powder and solvent for solution
for injection) Covered ICD-9: 286.4
Albumin-Free)
HOCM <= 149 MG/ML
HOCM >= 400 MG/ML
Code for
2011: J3300
Code for
2011: J3301
Code for
2011: J3357
1 mg
100 mg
$0.558
$0.530
20 units
$1.631
$1.549
1 mg
$0.697
$0.662
2.5 mg
$3.167
$3.009
Up to 3 ml
$0.930
$0.884
100 units
New Code
for 2012:
J7183
1 IU VWF:RCO
1 ml
1 ml
1 ml
1 ml
1 ml
1 ml
Code for
2011: J3385
$0.041
$0.093
$0.100
$0.104
$0.107
$0.191
$0.039
$0.088
$0.095
$0.099
$0.102
$0.181
- page 17 -
May 2013
2nd Quarter Update Part B Not Otherwise Classified Drug Fee
Otherwise Classified (NOC) Drugs Effective April 1, 2013 through
June 30, 2013
Revision: 4/1/2013
Field (EMC)
Changes In Bold
DRUG NAME
Abatacept (Orencia) The subcutaneous form of abatacept is
considered self-administered
Ado-Trastuzumab Emtansine (Kadcyla) covered indications
HER2-positive, metastatic breast cancer (174.0-175.9)
Allopurinol Sodium (Aloprim) ICD-9’s 274.9 or 790.6 plus the
ICD-9 for the neoplasm. Need name of chemotherapy agent
causing the elevation of uric acid and a statement as to why
patient can not tolerate oral form of the drug.
Amino Acid
Amino Acid
Aminocaproic Acid
Aztreonam (Azactam)
Beltatacept (Nulojix) Covered indications: V420 and 075 or
996.52
DOSAGE
Current
PAR
Current
NON-PAR
Notes
10 mgs.
$293.998
Added
March 2013
$279.298
500 mcg/5 ml
10 mg
$1.887
$1.793
500 mg/SDV
$303.245
$288.083
2 mg vial
500 ml
1000 ml
250 mg
300 ml
0.5 mg / ml
10 mg
500 mg
50,000 U
10 mg
$1,961.000
$21.110
$35.190
$0.081
$11.225
$0.800
$1.651
$13.804
$10.170
$1,862.950
$20.055
$33.431
$0.077
$10.664
$0.760
$1.568
$13.114
$9.662
$978.380
$929.461
250 mg.
May 2013
- page 18 -
requirements from one of the following codes: 115.02, 115.12,
115.92, 362.01 - 362.07 (any), 362.16, 362.35 - 362.37 (any),
362.42, 362.52 or 362.83.
Bumetanide (Bumex)
Bupivacaine Hcl, 0.25%, 2 ml (Considered Part of Procedure)
Bupivacaine, Sterile, 0.25%/10ml (Sensorcaine, Sterile) Allowed
when billed with 51700, 51720, 62310, 62311, 62318, 62319,
62368, 64400 - 64484, 64505 - 64530, 77003, 95990, or 96530.
When billed with other procedures, considered part of
procedure performed.
when billed with 51700, 51720, 62310, 62311, 62318, 62319,
62368, 64400 - 64484, 64505 - 64530, 77003, 95990, or 96530.
when billed with 51700, 51720, 62310, 62311, 62318, 62319,
62368, 64400 - 64484, 64505 - 64530, 77003, 95990, or 96530.
Calcium Chloride
Copper Sulfate
Dantrolene Sodium
Denosumab (Prolia ™ or Xgeva) If Prolia ™, covered ICD-9 =
733.01; if Xgeva, covered ICD-9 = 198.5.
Dextrose 2.5%
Dextrose 5%
Dextrose 10%
Dextrose 50%
N/A
$60.000
$57.000
5 mg
0.25 mg
$0.175
$0.215
$0.166
$0.204
0.25% - 1 ml
$0.087
$0.083
0.50% - 1 ml
$0.087
$0.083
0.75% - 1 ml
$0.087
$0.083
$0.159
$1,669.606
$8.610
$16.380
$11.376
$1.064
$10.790
$2.873
$1.822
$0.125
$78.800
$595.430
$0.151
$8.180
$15.561
$10.807
$1.011
$10.251
$2.729
$1.731
$0.119
$74.860
$565.659
$7.680
$7.860
$10.000
$0.101
$7.296
$7.467
$9.500
$0.096
$6.320
$6.004
$11.220
$2.10
$0.212
$2.195
$10.659
$2.00
$0.201
$2.085
1 mg
100 mg / ml
60 mg
1 gm
1 gm
1 gm
150 mg
0.1 - 3 gm
1 mg
150 mg
0.4 mg
20 mg
150 mcg
1 mg
2.50%
5%
500 ml
50 ml
20 mg/100
ml/250 ml
1000 ml
10 ml
5 mg
20 mg
- page 19 -
May 2013
Doxycycline Hyclate
Ergocalciferol D2 (Calciferol) ICD-9’s = 579.8 or 579.9 Allowed
when administered in physician’s office
Eribulin Mesylate (Halaven) - Covered ICD-9’s = 174.0 - 174.9
Esmolol Hydrochloride (Brevibloc) Covered ICD-9 = 427.89
(Dosage change from 100 mg to 10 mg.)
Esomeprazole Sodium (Nexium IV) Covered ICD-9’s = 530.10 530.19 or 530.81 when administered in the physician’s office.
Estradiol
Etomidate (Amidate)
Famotidine (Pepcid)
Folic Acid
Gammaked injection
Glucarpidase
** Heparin Sodium
Hexaminolevulinate Hydrochloride - Covered for ICD-9’s 188.0
through 188.9
IncobotulinumtoxinA (Xeomin) - Covered for the treatment of
Genetic torsion dystonia (333.6) and Blepharospasm (333.81)
Indications = 757.39, 941.20-941.21, 941.24-941.31, 941.34941.41, 941.44-941.51, 941.54-941.59, 942.20-942.59, 943.20943.59, 944.20-944.58, 945.20-945.59, 946.2-946.5, 948.00948.99
Ipilimumab (Yervoy) - Covered for unresectable or metastatic
melanoma.
100 mg
10 mg
1.25 mg
500,000 IU/
1ml
0.1 mg
$12.774
$2.420
$1.142
$12.135
$2.299
$1.085
$29.840
$28.348
10 mg
$0.781
$0.742
20 MG
$2.422
$2.301
1 gram
Per Pellet
50 mg
1 ml
2 mg
$13.300
Invoice
$19.040
$8.060
$0.655
$12.635
Invoice
$18.088
$7.657
$0.622
$0.366
$1.039
$42.830
$2.276
$1.272
$37.484
$233.730
$0.622
$0.032
$23.040
$0.348
$0.987
$40.689
$2.162
$1.208
$35.610
$222.044
$0.591
$0.030
$21.888
$741.576
$704.497
$1.212
$4.050
$1.151
$3.848
$27.536
$26.159
1mg
10 mg
0.1 mg
0.5 mg
5 mg
35 mg
500 mg
10 units
0.2 mg
100 units
6 gm
100 mg, per
study dose
IV
1000 mcg/ml
5 mg
1 Unit
1 sq cm
May 2013
- page 20 -
Jetrea (Ocriplasmin)
0.2 mg
0.2 ml SDV
$2.250
$4,187.000
$2.138
$3,977.650
Added
March 2013
Kadcyla (see Ado-Trastuzumab Emtansine)
same day as 20550-20610, 62289, 62298, 62368, 95990, or
96530.
$0.067
$0.064
5 mg
$0.211
$0.200
2.5 mg/ml
$0.310
$0.295
0.5 mg
$62.010
$58.910
1 ml
$0.143
$0.136
1 mg
$0.270
$0.257
500 mg
$1.128
$1.072
50 mg
Invoice
$2.105
Invoice
$2.000
1 gm
$8.058
$7.655
10 mcg
5 mg
$0.276
Invoice
$0.362
$0.262
Invoice
$0.344
1 mg
$2.161
$2.053
50 ml
$1.430
$1.359
10 mg
Labetalol Hydrochloride (Trandate, Normodyne) Covered if
given IV in the office for control of BP in severe hypertension.
Patient is normally switched to oral for maintainance doses.
separately when billed on same day as 51700, 51720, 62310,
62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530,
76003, 95990, or 96530. Not payable separately when billed
with any other procedures
** Levothyroxine Sodium (Synthroid) Need statemnt on claim
as to why patient can’t take oral form of drug.
Lidocaine - Allowed separately when billed on same day as
51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 64484, 64505 - 64530, 77033, 95990, or 96530. Not payable
when billed with any other procedure.
Methylnaltrexone Bromide (Relistor) Non-covered by carrier.
Metoprolol Tartrate (Lopressor) Covered when given IV with
Dobutamine J1250 during Dobutamine Stress Test.
Metronidazole Hcl. (Flagyl IV) IV in the office. Covered for ICD9’s= 001.0-009.3, 040.0-041.9, 481-482.9, 567.0-567.9, 599.0599.9, 615.0-615.9.
Morrhuate Sodium
Nafcillin Sodium (Nallpen) (Dosage Change from 500 mg to 1
gm)
** Norepinephrine Bitartrate (Levophed Bitartrate) Allow in
emergency situations.
- page 21 -
May 2013
Olanzapine short-acting intramuscular injection (Zyprexa IM)
Covered indications = 295.01 - 295.84 when administered in
the physicians office.
Omacetaxine Mepesuccinate (Synribo) covered indications
205.10 without having achieved remission, failed remission or
205.12 in relapse
Optison
Pantoprazole Sodium, IV (Protonix IV) Need statement as to
why patient is not able to take oral form.
** Peginterferon Alfa-2A/Isopropyl Alchol (Pegasys®) Covered
Peginterferon Alfa-2B (PEG-Intron) 50 mcg Covered indication
070.54 when administered in the office.
** Pegvisomant for Injection (Somavert) Considered Usually
Self-Administered
combination with Trastuzumab J9355 and Docetaxel J9171
Potassium Acetate
Potassium Phosphate
Propofol (Diprivan)
Rifampin
Sodium Acetate
October 2012
Invoice
Invoice
0.5 mg
$1.598
$1.518
3.5 mg
$885.100
$840.845
1 gm
Invoice
$1.850
Invoice
$1.758
40 mg
$4.511
$4.285
180mcg/ml
$480.273
$456.259
50 mcg
$320.610
$304.580
80 mcg
120 mcg
150 mcg
$336.600
$353.460
$371.120
$319.770
$335.787
$352.564
1mg
10 mg/ml
$102.269
$97.156
2 meq
3 mmol
1%
2%
10 mg
600 mg
Per infusion
(minimum 50
million cells)
2 meq
7.5%/50 ml
50 ml
250 cc
$0.027
$0.043
$2.360
$3.400
$0.123
$38.934
$0.026
$0.041
$2.242
$3.230
$0.117
$36.987
$0.043
$2.730
$0.122
$0.703
$0.041
$2.594
$0.116
$0.668
- page 22 -
** Sodium Thiosalicylate (Rexolate & Arthrolate, Nodolo &
Tusal)
Sodium Thiosulfate
when billed with 62310, 62311, 62318, 62319, 76005, 95990, or
96530. If billed with any other procedures, it will be considered
part of the procedure and separate payment will not be
allowed.
Sulfamethoxazole/Trimethoprim (SMZ-TMP) Documentation
as to why the patient needs to be on IV infusion instead of oral
medication, must be in block 19 or as an attachment for paper
claims or in the notepad for EMC claims.
SurgiMend
Synribo (see Omacetaxine Mepesuccinate)
Taliglucurase Alfa
Testosterone
Tetracycline
Valproate Sodium (Depacon) IV, Covered ICD9’s = 345.00 345.91, Allowed when administered IV, in the physician’s office.
(Dosage change from 500 mg to 100 mg)
Vasopressin
204.00-204.02
Willebrand factor (VWF) powder and solvent for solution for
injection) Covered ICD-9: 286.4
Invoice
Invoice
50 mg
$0.970
$0.922
100 mg
5 cc
1000 ml
50mcg/ml
$0.155
$0.052
$5.640
$9.810
$0.147
$0.049
$5.358
$9.320
400 - 80 mg
$0.311
$0.295
0.5 sq cm
10 units
37.5 mg
Per Pellet
$11.885
$30.904
$0.110
Invoice
Invoice
$11.291
$0.105
Invoice
Invoice
100 mg
$0.558
$0.530
20 units
1 mg
2.5 mg
$1.214
$0.433
$3.167
$1.153
$0.411
$3.009
2.25 mg.
Invoice
Up to 3 ml
$0.930
$0.884
1 IU VWF:RCO
- page 23 -
October 2012
Xyntha (see Antihemophilic Factor (Recomb) Plasma/AlbuminFree)
Ziv-Aflibercept (Zaltrap) covered ICD-9 153.0 - 153.7 or 154.0
- 154.2
HOCM <= 149 MG/ML
HOCM >= 400 MG/ML
$1,611.200
$0.041
$0.093
$0.100
$0.104
$0.107
$0.191
$0.039
$0.088
$0.095
$0.099
$0.102
$0.181
100 mg.
1 ml
1 ml
1 ml
1 ml
1 ml
1 ml
3rd Quarter Update Part B Not Otherwise Classified Drug Fee
Otherwise Classified (NOC) Drugs Effective July 1, 2012 through
September 30, 2012
Revision: 4/1/2013
Field (EMC)
DRUG NAME
Abatacept (Orencia) The subcutaneous form of abatacept is
considered self-administered
Allopurinol Sodium (Aloprim) ICD-9’s 274.9 or 790.6 plus
the ICD-9 for the neoplasm. Need name of chemotherapy
agent causing the elevation of uric acid and a statement
as to why patient can not tolerate oral form of the drug.
Amino Acid
DOSAGE
Current
PAR
Current NONPAR
Notes
500
mcg/5 ml
10 mg
$1.626
$1.545
500 mg/
SDV
$336.086
$319.282
2 mg vial
500 ml
$1,961.000
$1,862.950
$21.110
$20.055
increase
Code for 2012:
J0221
decrease
Added
December 2011
May 2013
- page 24 -
Amino Acid
Aminocaproic Acid
Antihemophilic Factor (Recomb) Plasma/Albumin-Free
(Xyntha)
Arformoterol Tartrate (Brovana)
1000 ml
250 mg
Aztreonam (Azactam)
Beltatacept (Nulojix) Covered indications: V420 and 075 or
996.52
Bendamustine Hydrochloride (Treanda) Covered indications:
204.10 - lymphoid leukemia, chronic, without mention
of remission or 204.11 - lymphoid leukemia, chronic, in
remission
$35.190
$0.058
$33.431
$0.055
1 IU
15 mcg
300 ml
0.5 mg
/ ml
10 mg
500 mg
50,000 U
$11.225
$10.664
$0.800
$0.760
$1.651
$13.934
$10.170
$1.568
$13.237
$9.662
$978.380
$929.461
1 mg
10 mg
250 mg.
increase
Code for 2011:
J7185
Code for 2011:
J7605
decreased
Code for 2012:
J0490
Code for 2011:
J9033
requirements from one of the following codes: 115.02,
115.12, 115.92, 362.01 - 362.07 (any), 362.16, 362.35 - 362.37
(any), 362.42, 362.52 or 362.83.
N/A
$60.000
$57.000
Brentuximab Vedotin (Adcetris) Covered indications
200.60-200.68 or 201.00-201.98
1mg
$95.400
$90.630
5 mg
0.25 mg
$0.175
$0.129
$0.166
$0.123
Updated ICD9 Coverage
Effective: 01
/01/2011
New Unit Price
Per Carrier
Medical
Director
Effective:
05/01/2011
effective
7/1/2012 new
dosage and
unit price
decrease
0.25% - 1
ml
$0.058
$0.055
decrease
0.50% - 1
ml
$0.058
$0.055
decrease
0.75% - 1
ml
$0.058
$0.055
decrease
Bumetanide (Bumex)
62318, 62319, 62368, 64400 - 64484, 64505 - 64530,
Allowed when billed with 51700, 51720, 62310, 62311, 62318,
62319, 62368, 64400 - 64484, 64505 - 64530, 77003, 95990, or
96530. When billed with other procedures, considered part of
62318, 62319, 62368, 64400 - 64484, 64505 - 64530,
C1 Esterase Inhibitor (Berinert) - For the treatment of acute
abdominal or facial attacks of hereditary angioedema in adult
and adolescent patients (277.6)
10 units
Code for 2011:
J0597
- page 25 -
May 2013
1 mg
Calcium Chloride
Canakinumab (Ilaris) - For Cryopyrin-associated periodic
syndromes
Capsaicin 8% Patch (Qutenza) - Must be administered under
provider supervision.
100 mg
/ ml
1 mg
$0.169
$0.161
10 sq cm
60 mg
$1,669.606
1 gm
1 gm
1 gm
$8.610
$16.380
$11.376
$8.180
$15.561
$10.807
Certolizumab Pegol (Cimzia)
1 mg
$1.064
$10.933
$2.964
$1.488
$1.011
$10.386
$2.816
$1.414
0.1 mg
0.4 mg
$0.116
$0.110
0.25 mg
Collagenase Clostridium Histolyticum (Xiaflex) Covered for
Contracture of palmar fascia (Dupuytren’s concracture) ICD-9
728.6.
Copper Sulfate
Cosyntropin IV
150 mg
0.1 - 3 gm
1 mg
150 mg
Code for 2012:
J9043
decrease
Code for 2011:
J0638
Code for 2011:
J7335
Added
September
2012
Code for 2011:
J0718
increase
decrease
decrease
Code for 2011:
J0775
increase
Code for 2011:
J0833
Code for 2011:
J9155
Code for 2012:
J0897
Dantrolene Sodium
20 mg
$78.800
$74.860
Degarelix (Firmagon)
1 mg
$595.430
$565.659
1 mg
0.1 mg
$7.680
$7.860
$10.000
$0.101
$7.296
$7.467
$9.500
$0.096
$6.320
$6.004
$11.220
$10.659
Effective
05/01/2011
decrease
Code for 2011:
J1267
increase
decrease
Code for 2011:
J1290
Denosumab (Prolia ™ or Xgeva) If Prolia ™, covered ICD-9 =
733.01; if Xgeva, covered ICD-9 = 198.5.
Dexamethasone Intravitreal Implant (Ozurdex) If
billed under J3490 or J3590, with CPT code
67028 & 1 of the following ICD-9 combinations:
1) 362.83 plus 362.35 or 362.36; or
2) 362.30
Dextrose 2.5%
Dextrose 5%
Dextrose 10%
Dextrose 50%
150 mcg
2.50%
5%
500 ml
50 ml
20
mg/100
ml/250 ml
1000 ml
10 ml
$2.10
$2.00
5 mg
$0.156
$0.148
Doripenem (Doribax)
10 mg
$2.212
$10.990
$2.101
$10.441
Doxycycline Hyclate
Ecallantide (Kalbitor) Covered Indications - 277.6 (accute
attack of hereditary angioedema)
20 mg
100 mg
1 mg
Code for 2011:
J7312
May 2013
- page 26 -
Eculizumab (Soliris)
10 mg
$2.420
$1.640
$2.299
$1.558
Code for 2011:
J1300
decrease
$29.840
$28.348
Ergocalciferol D2 (Calciferol) ICD-9’s = 579.8 or 579.9 Allowed
when administered in physician’s office
10 mg
1.25 mg
500,000
IU/ 1ml
Eribulin Mesylate (Halaven) - Covered ICD-9’s = 174.0 - 174.9
0.1 mg
10 mg
$0.722
$0.686
decrease
20 MG
$3.938
$3.741
increase
1 gram
Per Pellet
50 mg
1 ml
2 mg
$13.300
Invoice
$19.040
$8.060
$0.584
$12.635
Invoice
$18.088
$7.657
$0.555
$0.373
$0.354
1 mg
Fibrinogen Concentrate Human (RiaSTAP)
Estradiol
Etomidate (Amidate)
Code for 2012
J9179
Gammaked injection
500 mg
$37.484
$35.610
0.2 mg
$0.317
$0.301
$0.032
$23.040
$0.030
$21.888
increase
Code for 2012:
J8561
Added
December 2011
decrease
Codes for 2011:
Q0138
(non-esrd) &
Q0139 (esrd)
Code for 2011:
J1680
Code for 2011:
J8562
increase
increase
Code for 2011:
J1453
Code for 2011:
A9581
Added October
2011
decrease
Code for 2011:
Q4113
$623.280
$592.116
Famotidine (Pepcid)
10 mg
Ferumoxytol (Feraheme)
Fludarabine phosphate, oral - Not Covered by Part B
10 mg
Folic Acid
Fosaprepitant Dimeglumine (Emend) Allowed when billed on
the same day as chemotherapy.
0.1 mg
0.5 mg
5 mg
Gadoxetate Disodium (Eovist)
Hexaminolevulinate Hydrochloride - Covered for ICD-9’s 188.0
through 188.9
$0.799
$40.689
$1.643
1 mg
35 mg
$0.201
$0.191
1 cc
** Heparin Sodium
$0.841
$42.830
$1.729
1 ml
Graftjacket Gel
100 units
6 gm
100 mg,
per study
dose
- page 27 -
May 2013
IV
1000
mcg/ml
48 mg
Hylan G-F 20 (Synvisc-One)
Idursulfase (Elaprase)
IncobotulinumtoxinA (Xeomin) - Covered for the treatment of
Genetic torsion dystonia (333.6) and Blepharospasm (333.81)
Indications = 757.39, 941.20-941.21, 941.24-941.31,
941.34-941.41, 941.44-941.51, 941.54-941.59, 942.20942.59, 943.20-943.59, 944.20-944.58, 945.20-945.59,
946.2-946.5, 948.00-948.99
Ipilimumab (Yervoy) - Covered for unresectable or metastatic
melanoma.
Ixabepilone (Ixempra) Covered for metastatic or locally
advanced breast cancer (ICD-9 codes 174.0 - 175.9)
same day as 20550-20610, 62289, 62298, 62368, 95990, or
96530.
$1.212
$1.151
1 mg
100 mg
5 mg
$4.050
$3.848
1 Unit
$19.391
$18.421
Immune Globulin Subcutaneous (Hizentra)
1 sq cm
1mg
$2.250
$2.138
1 mg
$0.067
$0.064
0.2 mg
10 mg
Code for 2012:
J1557
Effective
06/01/2011
Code for 2011:
J7325
Code for 2011:
J1743
Code for 2011:
J0597
New Code for
2012: J0588
increase
Code for 2012:
J9228
Code for 2011:
J9207
Added
September
2012
Labetalol Hydrochloride (Trandate, Normodyne)
Covered if given IV in the office for control of BP in severe
hypertension. Patient is normally switched to oral for
maintainance doses.
Lanreotide (Somatuline Depot)
5 mg
$0.248
$0.236
1 mg
10 mg
$0.310
$0.295
$62.010
$58.910
$0.143
$0.136
Levetiracetam (Keppra intraveneous)
separately when billed on same day as 51700, 51720, 62310,
62311, 62318, 62319, 62368, 64400 - 64484, 64505-64530,
76003, 95990, or 96530. Not payable separately when billed
with any other procedures
** Levothyroxine Sodium (Synthroid) Need statemnt on claim
as to why patient can’t take oral form of drug.
Lidocaine - Allowed separately when billed on same day as
51700, 51720, 62310, 62311, 62318, 62319, 62368, 64400 64484, 64505 - 64530, 77033, 95990, or 96530. Not payable
2.5 mg/ml
0.5 mg
1 ml
decrease
Code for 2011:
J1930
Code for 2011:
J1953
May 2013
- page 28 -
Methylnaltrexone Bromide (Relistor) Non-covered by carrier.
Metronidazole Hcl. (Flagyl IV) IV in the office. Covered
for ICD-9’s= 001.0-009.3, 040.0-041.9, 481-482.9, 567.0567.9, 599.0-599.9, 615.0-615.9.
1 mg
$0.160
$0.152
increase
500 mg
$1.056
$1.003
increase
Invoice
Invoice
50 mg
$2.105
$2.000
Code for 2012:
J2265
increase
1 gm
$8.058
$7.655
10 mcg
5 mg
$0.276
Invoice
$0.337
$0.262
Invoice
$0.320
decrease
1 mg
$2.161
$2.053
50 ml
$1.430
$1.359
Ofatumumab (Arzerra) Covered indications - 204.10 or 204.12
10 mg
Olanzapine long-acting intramuscular injection
Covered indications = 295.00 - 295.95 or 296.40 - 296.66 when
Optison
Paliperidone Palmitate injection (Invega® Sustenna®) Covered
indications: 295.00-295.95, 296.40-296.46, 296.50-296.56, or
296.60-296.66
Invoice
Invoice
0.5 mg
$1.703
$1.618
decrease
1 gm
Invoice
$1.850
Invoice
$1.758
1 mg
Code for 2011:
J2426
10 mg
Code for 2011:
J9303
40 mg
$4.511
$4.285
180mcg/
ml
$480.273
$456.259
50 mcg
$320.610
$304.580
80 mcg
120 mcg
150 mcg
$336.600
$353.460
$371.120
$319.770
$335.787
$352.564
Morrhuate Sodium
Nafcillin Sodium (Nallpen) (Dosage Change from 500 mg to 1
gm)
** Norepinephrine Bitartrate (Levophed Bitartrate) Allow in
emergency situations.
Panitumumab (Vectibix) Covered indications-153.0-154.8
Pantoprazole Sodium, IV (Protonix IV) Need statement as to
why patient is not able to take oral form.
** Peginterferon Alfa-2A/Isopropyl Alchol (Pegasys®) Covered
Peginterferon Alfa-2B (PEG-Intron) 50 mcg Covered indication
070.54 when administered in the office.
1 mg
Added
September
2012
Code for 2011:
J9302
Code for 2011:
J2358
- page 29 -
May 2013
** Pegvisomant for Injection (Somavert) Considered Usually
Self-Administered
1mg
Code for 2012:
J2507
Added
September
2012
Added
September
2012
Code for 2011:
J9307
Code for 2010:
J2650
combination with Trastuzumab J9355 and Docetaxel J9171
1mg/ml
$9.704
$9.219
Potassium Acetate
Potassium Phosphate
2 meq
3 mmol
$0.027
$0.043
$0.026
$0.041
Pralatrexate (Folotyn) - Covered indications: 202.70 - 202.78
1 mg
Prednisolone Acetate
1 ml
Propofol (Diprivan)
1%
2%
10 mg
$2.360
$3.400
$0.103
$2.242
$3.230
$0.098
Ranibizumab Injection (Lucentis)
1 mcg
Regadenoson (Lexiscan)
0.1 mg
Rifampin
600 mg
$31.692
$30.107
1 mg
10 mcg
1 mcg
Per
infusion
(minimum
50 million
cells)
2 meq
7.5%/50
ml
50 ml
250 cc
$0.037
$0.035
$2.730
$2.594
$0.122
$0.683
Invoice
$0.116
$0.649
Invoice
decrease
50 mg
$0.970
$0.922
100 mg
5 cc
$0.155
$0.052
$0.147
$0.049
Romidepsin (Istodax) Covered indications: 202.70 - 202.78
Romiplostim (Nplate™)
Secretin (SecreFlo) Used in secretin stimulation testing
Sodium Acetate
** Sodium Thiosalicylate (Rexolate & Arthrolate, Nodolo &
Tusal)
Sodium Thiosulfate
decrease
Code for 2011:
J2778
Code for 2011:
J2785
decrease
Code for 2011:
J9315
Code for 2011:
J2796
Code for 2011:
J2850
New Code for
2012: Q2043
May 2013
- page 30 -
when billed with 62310, 62311, 62318, 62319, 76005, 95990,
or 96530. If billed with any other procedures, it will be
considered part of the procedure and separate payment will
not be allowed.
or as an attachment for paper claims or in the notepad for
EMC claims.
SurgiMend
Telavancin Injection (VIBATIV™)
Temsirolimus (Torisel) Covered indication is for the treatment
of advanced renal cell carcinoma (189.0 Malignant neoplasm
of kidney, except pelvis).
Testosterone
Tetracycline
Tocilizumab (Actemra) Covered Indications: 714.0, 714.1 or
714.2.
Treprostinil inhalation (Tyvaso) - If administered in-office,
considered part of service performed. If administered athome, not covered by Part B.
1000 ml
50mcg/ml
$5.640
$9.810
$5.358
$9.320
400 - 80
mg
$0.221
$0.210
decrease
0.5 sq cm
$11.874
$11.280
10 mg
increase
Code for 2011:
J3095
1 mg
$0.110
Invoice
Invoice
$0.105
Invoice
Invoice
1 mg
37.5 mg
Per Pellet
1.74 mg
Code for 2011:
J9330
Code for 2011:
J3262
Code for 2011:
J7686
Code for 2011:
J3300
Code for 2011:
J3301
Triamcinolone Acetonide, Preservative Free
1 mg
Triamcinolone Acetonide (Kenalog)
10 mg
1 mg
Code for 2011:
J3357
Ustekinumab (Stelara) - For the treatment of adults (18+) with
moderate to severe plaque psoriasis who are candidates for
phototherapy or systemic therapy (696.1)
Valproate Sodium (Depacon) IV, Covered ICD9’s = 345.00
- 345.91, Allowed when administered IV, in the physician’s
office. (Dosage change from 500 mg to 100 mg)
Vasopressin
100 mg
$0.558
$0.530
20 units
1 mg
$2.251
$0.535
$2.138
$0.508
Velaglucerase alfa for injection (VPRIV™)
100 units
increase
decrease
Code for 2011:
J3385
Added
September
2012
2.5 mg
$3.167
$3.009
204.00-204.02
2.25 mg.
Invoice
Up to 3 ml
$0.930
$0.884
- page 31 -
May 2013
Willebrand factor (VWF) powder and solvent for solution for
injection) Covered ICD-9: 286.4
Albumin-Free)
1 IU
VWF:RCO
New Code for
2012: J7183
$1,611.200
$0.041
$0.093
$0.100
$0.104
$0.107
$0.191
$0.039
$0.088
$0.095
$0.099
$0.102
$0.181
Added
September
2012
Added
September
2012
Ziv-Aflibercept (Zaltrap) covered ICD-9 153.0 - 153.7 or 154.0
- 154.2
HOCM <= 149 MG/ML
HOCM >= 400 MG/ML
100 mg.
1 ml
1 ml
1 ml
1 ml
1 ml
1 ml
4th Quarter Update Part B Not Otherwise Classified Drug Fee
Otherwise Classified (NOC) Drugs Effective October 1, 2012 through
December 31, 2012
Revision: 4/1/2013
Field (EMC)
Changes In Bold
DRUG NAME
Abatacept (Orencia) The subcutaneous form
of abatacept is considered self-administered
DOSAGE
Current
PAR
Current NON-PAR
Notes
500 mcg/5 ml
$1.809
$1.719
Increase
May 2013
- page 32 -
Allopurinol Sodium (Aloprim) ICD-9’s 274.9
or 790.6 plus the ICD-9 for the neoplasm.
Need name of chemotherapy agent causing
the elevation of uric acid and a statement as
to why patient can not tolerate oral form of
the drug.
Amino Acid
Amino Acid
Aminocaproic Acid
** Ascorbic Acid (Vitamin C) Non-covered
by Carrier
** Atenolol (Tenormin) ICD-9’s = 401.0 429.9
Aztreonam (Azactam)
Beltatacept (Nulojix) Covered indications:
V420 and 075 or 996.52
Bevacizumab (Avastin) CPT 67028 must be
on claim or in history; allow if billed with
J3490 or J3590 and the ICD-9 requirements
from one of the following codes: 115.02,
115.12, 115.92, 362.01 - 362.07 (any), 362.16,
362.35 - 362.37 (any), 362.42, 362.52 or
362.83.
Brentuximab Vedotin (Adcetris) Covered
indications 200.60-200.68 or 201.00-201.98
Bumetanide (Bumex)
Bupivacaine Hcl, 0.25%, 2 ml (Considered
Part of Procedure)
Bupivacaine Hcl, 0.50%, 2 ml (Considered
Part of Procedure)
Bupivacaine, Sterile, 0.25%/10ml
(Sensorcaine, Sterile) Allowed when billed
with 51700, 51720, 62310, 62311, 62318,
62319, 62368, 64400 - 64484, 64505 - 64530,
77003, 95990, or 96530. When billed with
other procedures, considered part of
with 51700, 51720, 62310, 62311, 62318,
62319, 62368, 64400 - 64484, 64505 - 64530,
10 mg
$328.177
$311.768
Decrease
$1,961.000
$21.110
$35.190
$0.049
$11.225
$1,862.950
$20.055
$33.431
$0.047
$10.664
Decrease
0.5 mg / ml
$0.800
$0.760
10 mg
500 mg
50,000 U
10 mg
$1.651
$13.997
$10.170
$1.568
$13.297
$9.662
Increase
Code for 2012: J0490
250 mg.
$978.380
$929.461
N/A
$60.000
$57.000
1mg
$95.400
$90.630
5 mg
0.25 mg
$0.175
$0.182
$0.166
$0.173
Increase
0.25% - 1 ml
$0.091
$0.086
Increase
0.50% - 1 ml
$0.091
$0.086
Increase
500 mg/SDV
2 mg vial
500 ml
1000 ml
250 mg
300 ml
Updated ICD-9
Coverage Effective:
01/01/2011
New Unit Price Per
Carrier Medical
Director Effective:
05/01/2011
- page 33 -
May 2013
with 51700, 51720, 62310, 62311, 62318,
62319, 62368, 64400 - 64484, 64505 - 64530,
Calcium Chloride
Carfilzomib (Kyprolis) covered ICD-9 203.00
or 203.02
Chirocaine (see Levobupivacaine
Hydrochloride)
Clorpactin WCS-90 (see Oxychlorosene
Sodium)
Copper Sulfate
Dantrolene Sodium
Denileukin Difitox (Ontak) (For 300 mcg, use
code J9160)
Denosumab (Prolia ™ or Xgeva) If Prolia ™,
covered ICD-9 = 733.01; if Xgeva, covered
ICD-9 = 198.5.
Dextrose 2.5%
Dextrose 5%
Dextrose 10%
Dextrose 50%
** Dextrose / Nitroglycerin 5%-20 mg/ 100
ml/250 ml
Doxycycline Hyclate
Edrophonium Chloride (Tensilon) (Allow for
ICD9 - 358.0)
Emend for Injection (see Fosaprepitant
Dimeglumine)
Ergocalciferol D2 (Calciferol) ICD-9’s = 579.8
or 579.9 Allowed when administered in
physician’s office
Eribulin Mesylate (Halaven) - Covered ICD9’s = 174.0 - 174.9
Esmolol Hydrochloride (Brevibloc) Covered
ICD-9 = 427.89 (Dosage change from 100
mg to 10 mg.)
$0.091
$0.086
Increase
$0.159
$0.151
60 mg
$1,669.606
1 gm
1 gm
1 gm
$8.610
$16.380
$11.376
$8.180
$15.561
$10.807
Decrease
Added September
2012
$1.064
$11.704
$2.958
$2.009
$1.011
$11.119
$2.810
$1.909
0.4 mg
20 mg
$0.111
$78.800
$0.105
$74.860
Decrease
150 mcg
$595.430
$565.659
2.50%
5%
500 ml
50 ml
20 mg/100
ml/250 ml
1000 ml
10 ml
5 mg
20 mg
100 mg
$7.680
$7.860
$10.000
$0.101
$7.296
$7.467
$9.500
$0.096
$6.320
$6.004
$11.220
$2.10
$0.167
$1.695
$10.885
$10.659
$2.00
$0.159
$1.610
$10.341
Increase
Decrease
Decrease
10 mg
$2.420
$2.299
1.25 mg
$1.142
$1.085
Decrease
500,000 IU/ 1ml
$29.840
$28.348
0.1 mg
10 mg
$0.778
$0.739
0.75% - 1 ml
1 mg
100 mg / ml
150 mg
0.1 - 3 gm
1 mg
150 mg
1 mg
Increase
Decrease
Increase
Increase
May 2013
- page 34 -
Esomeprazole Sodium (Nexium IV) Covered
ICD-9’s = 530.10 - 530.19 or 530.81 when
administered in the physician’s office.
Estradiol
Etomidate (Amidate)
Everolimus (Afinitor / Zortress) - NonCovered; Oral drug considered as selfadministered.
Famotidine (Pepcid)
Folic Acid
Gammaked injection
Gammaplex (see Human Immune Globulin
Intravenous)
** Heparin Sodium
Hexaminolevulinate Hydrochloride Covered for ICD-9’s 188.0 through 188.9
Hizentra (see Immune Globulin
Subcutaneous)
Human Immune Globulin Intravenous
(Gammaplex)
Hydroxocobalamin - Covered when billed
with J9305.
Icantibant (Firazyr) - Usually considered selfadministered
IncobotulinumtoxinA (Xeomin) - Covered
for the treatment of Genetic torsion
dystonia (333.6) and Blepharospasm
(333.81)
INTEGRA™ Bilayer Matrix Wound Dressing
- Covered Indications = 757.39, 941.20941.21, 941.24-941.31, 941.34-941.41,
941.44-941.51, 941.54-941.59, 942.20942.59, 943.20-943.59, 944.20-944.58,
945.20-945.59, 946.2-946.5, 948.00-948.99
Invega® Sustenna® (see Paliperidone
Palmitate injection)
Ipilimumab (Yervoy) - Covered for
unresectable or metastatic melanoma.
20 MG
$1.904
$1.809
Decrease
1 gram
Per Pellet
50 mg
1 ml
2 mg
$13.300
Invoice
$19.040
$8.060
$0.699
$12.635
Invoice
$18.088
$7.657
$0.664
Increase
$0.446
$2.005
$42.830
$2.179
$1.048
$37.484
$0.424
$1.905
$40.689
$2.070
$0.996
$35.610
$0.614
$0.032
$23.040
$0.583
$0.030
$21.888
$660.677
$627.643
IV
$1.212
$1.151
5 mg
$4.050
$3.848
1 Unit
$24.147
$22.940
1mg
$2.250
$2.138
10 mg
0.1 mg
0.5 mg
5 mg
35 mg
500 mg
0.2 mg
100 units
6 gm
100 mg, per study
dose
1000 mcg/ml
1 sq cm
0.2 mg
Increase
Increase
Increase
Increase
Increase
Increase
New Code for 2012:
J0588
Increase
- page 35 -
May 2013
Ketamine Hydrochloride (Ketalar) Allowed
when billed on same day as 20550-20610,
62289, 62298, 62368, 95990, or 96530.
Labetalol Hydrochloride (Trandate,
Normodyne) Covered if given IV in the office
for control of BP in severe hypertension.
Patient is normally switched to oral for
maintainance doses.
** Levobupivacaine Hydrochloride
(Chirocaine) Allowed separately when billed
on same day as 51700, 51720, 62310, 62311,
62318, 62319, 62368, 64400 - 64484, 6450564530, 76003, 95990, or 96530. Not payable
separately when billed with any other
procedures
** Levophed Bitartrate (see Norepinephrine
Bitartrate)
** Levothyroxine Sodium (Synthroid) Need
statemnt on claim as to why patient can’t
take oral form of drug.
Lidocaine - Allowed separately when billed
on same day as 51700, 51720, 62310, 62311,
62318, 62319, 62368, 64400 - 64484, 64505 64530, 77033, 95990, or 96530. Not payable
Lusedra (see Fospropofol Disodium
injection)
Methylnaltrexone Bromide (Relistor) Noncovered by carrier.
Metoprolol Tartrate (Lopressor) Covered
when given IV with Dobutamine J1250
during Dobutamine Stress Test.
Metronidazole Hcl. (Flagyl IV) IV in the
office. Covered for ICD-9’s= 001.0-009.3,
040.0-041.9, 481-482.9, 567.0-567.9, 599.0599.9, 615.0-615.9.
Minocycline Hydrochloride (Non-covered
oral drug)
Morrhuate Sodium
Nafcillin Sodium (Nallpen) (Dosage Change
from 500 mg to 1 gm)
Nitroglycerin IV – Allowed in emergency
situations.
** Norepinephrine Bitartrate (Levophed
Bitartrate) Allow in emergency situations.
$0.067
$0.064
5 mg
$0.240
$0.228
Decrease
2.5 mg/ml
$0.310
$0.295
$62.010
$58.910
$0.143
$0.136
Added September
2012
1 mg
$0.163
$0.155
Increase
500 mg
$1.069
$1.016
Increase
Invoice
Invoice
50 mg
$2.105
$2.000
1 gm
$8.058
$7.655
10 mcg
$0.276
Invoice
$0.262
Invoice
5 mg
$0.345
$0.328
Increase
1 mg
$2.161
$2.053
50 ml
$1.430
$1.359
10 mg
0.5 mg
1 ml
Added September
2012
May 2013
- page 36 -
Olanzapine short-acting intramuscular
injection (Zyprexa IM) Covered indications
= 295.01 - 295.84 when administered in the
physicians office.
Optison
** Oxychlorosene Sodium (Clorpactin WCS90)
Ozurdex (see Dexamethasone Intravitreal
Implant)
Pantoprazole Sodium, IV (Protonix IV) Need
statement as to why patient is not able to
take oral form.
** Peginterferon Alfa-2A/Isopropyl Alchol
(Pegasys®) Covered indication 070.54 when
administered in the office.
Peginterferon Alfa-2B (PEG-Intron) 50
mcg Covered indication 070.54 when
administered in the office.
Pegloticase (Krystexxa) When billed with
J3490 or J3590, covered for chronic gout,
ICD-9’s 274.00 through 274.03
** Pegvisomant for Injection (Somavert)
Considered Usually Self-Administered
Pertuzumab (Perjeta) Covered ICD-9 174.0
- 175.9 in combination with Trastuzumab
J9355 and Docetaxel J9171
Potassium Acetate
Potassium Phosphate
Propofol (Diprivan)
Rexolate & Arthrolate (see Sodium
Thiosalicylate)
RiaSTAP (see Fibrinogen Concentrate
Human)
Rifampin
Invoice
Invoice
0.5 mg
$1.705
$1.620
Increase
Invoice
Invoice
1 gm
$1.850
$1.758
$4.511
$4.285
180mcg/ml
$480.273
$456.259
50 mcg
$320.610
$304.580
80 mcg
120 mcg
150 mcg
$336.600
$353.460
$371.120
$319.770
$335.787
$352.564
1mg
1mg/ml
$9.704
$9.219
Added September
2012
Added September
2012
2 meq
3 mmol
1%
2%
10 mg
$0.027
$0.043
$2.360
$3.400
$0.103
$0.026
$0.041
$2.242
$3.230
$0.098
40 mg
600 mg
$32.776
$31.137
Increase
- page 37 -
May 2013
Sodium Acetate
** Sodium Thiosalicylate (Rexolate &
Arthrolate, Nodolo & Tusal)
Sodium Thiosulfate
** Sufentanil Citrate (Sufenta) Separate
payment allowed when billed with 62310,
62311, 62318, 62319, 76005, 95990, or
96530. If billed with any other procedures,
it will be considered part of the procedure
and separate payment will not be allowed.
Sulfamethoxazole/Trimethoprim (SMZTMP) Documentation as to why the patient
needs to be on IV infusion instead of oral
medication, must be in block 19 or as
an attachment for paper claims or in the
notepad for EMC claims.
SurgiMend
Testosterone
Tetanus Toxoid (use codes 90702, 90703, or
90718)
Tetracycline
Vaccinia IVIG (see Human Immune Globulin
Intravenous)
Valproate Sodium (Depacon) IV, Covered
ICD9’s = 345.00 - 345.91, Allowed when
administered IV, in the physician’s office.
(Dosage change from 500 mg to 100 mg)
Vasopressin
Vincristine Sulfate Liposome (Marquibo)
covered ICD-9: 204.00-204.02
Per infusion
(minimum 50
million cells)
2 meq
7.5%/50 ml
50 ml
250 cc
$0.031
$2.730
$0.122
$0.708
Invoice
$0.029
$2.594
$0.116
$0.673
Invoice
Decrease
Increase
50 mg
$0.970
$0.922
100 mg
5 cc
1000 ml
50mcg/ml
$0.155
$0.052
$5.640
$9.810
$0.147
$0.049
$5.358
$9.320
400 - 80 mg
$0.276
$0.262
Increase
0.5 sq cm
37.5 mg
Per Pellet
$12.026
$0.110
Invoice
$11.425
$0.105
Invoice
Increase
Invoice
Invoice
100 mg
$0.558
$0.530
20 units
1 mg
2.5 mg
$2.310
$0.499
$3.167
$2.195
$0.474
$3.009
2.25 mg.
Invoice
Up to 3 ml
$0.930
$0.884
Increase
Decrease
Added September
2012
New Code for 2012:
Q2043
May 2013
- page 38 -
** Vitamin C (see Ascorbic Acid) Noncovered by Carrier
Vivaglobin (see Immune Globulin
Subcutaneous)
Wilate (Human coagulation factor VIII (FVIII)
and von Willebrand factor (VWF) powder
and solvent for solution for injection)
Covered ICD-9: 286.4
Xiaflex (see Collagenase Clostridum
Histolyticum)
Xyntha (see Antihemophilic Factor
(Recomb) Plasma/Albumin-Free)
Ziv-Aflibercept (Zaltrap) covered ICD-9
153.0 - 153.7 or 154.0 - 154.2
HOCM <= 149 MG/ML
HOCM >= 400 MG/ML
1 IU VWF:RCO
New Code for 2012:
J7183
$1,611.200
$0.041
$0.093
$0.100
$0.104
$0.107
$0.191
$0.039
$0.088
$0.095
$0.099
$0.102
$0.181
Added September
2012
Added September
2012
100 mg.
1 ml
1 ml
1 ml
1 ml
1 ml
1 ml
Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy
(ARVD/C) Testing: Coding and Claim Submission Guidelines
ARVD/C, characterized by fatty replacement of heart cells predominantly in the right ventricle of the heart, is
most often inherited as an autosomal dominant disease that may be associated with testing in at least seven
genes (RYR2, TMEM43, DSP, PKP2, DSG2, DSC2 and JUP). Genetic testing may be performed in panels of 5-7 of
these genes, and disease-causing mutation is expected to be identified in 42-55% of cases. Testing would be
performed to confirm an established diagnosis or on individuals already diagnosed with ARVD/C to identify
family members at risk. CGS has determined that testing for ARVD/C does not support the required clinical
utility for the established Medicare benefit category and is a statutorily excluded test.
The following ARVD/C test has been identified as non-covered:
Test
ARVC Sequencing Panel
Health care providers are not required to submit claims to Medicare for statutorily non-covered services; however,
you may choose to submit claims (e.g., at the patient’s request). Claims for ARVC sequencing panels must include:
• For dates of service prior to January 1, 2013: use the appropriate CPT code stack for the test
• For dates of service on or after January 1, 2013: CPT code 81479
• HCPCS modifier GY (statutorily non-covered service)
• The appropriate ICD-9-CM code(s)
• The name of the test (ARVC sequencing panel):
o Electronic claims: Loop 2400, NTE02, or SV101-7 field
o Paper claims: Box 19
Reference:
• Definition of “reasonable and medically necessary”: Social Security Act, section 1862(a)(1)(A)
• Exception to mandatory claim submission for “categorically excluded services”: CMS MLN Matters
article SE0908, “Mandatory Claims Submission and Its Enforcement”
• Guidance on issuing Advance Beneficiary Notices of Noncoverage (ABNs) on a voluntary basis for
statutorily excluded services: CMS Beneficiary Notices Initiative webpage – Fee-For-Service (FFS) ABN
- page 39 -
May 2013
Aspartoacyclase (ASPA) 2 Deficiency Testing: Coding and Claims
Submission Guidelines
Asparoacyclase 2 Deficiency, also known as Canavan Disease, is an autosomal recessive degenerative disorder
that causes progressive nerve damage to nerve cells in the brain. Genetic testing identifies parents that may be
at risk for conceiving a child with the disease. CGS has determined that Asparatoacyclase 2 deficiency testing is
not a Medicare benefit and is a statutorily excluded test.
The following Aspartoacyclase 2 deficiency tests have been identified as non-covered:
Test
Canavan (ASPA) 4 Mutations, Fetal
Canavan Disease (ASPA) 4 Mutations
Canavan Disease
Canavan Disease, Mutation Analysis, ASPA
Canavan Disease Targeted Mutation Analysis
Health care providers are not required to submit claims to Medicare for statutorily non-covered services;
however, you may choose to submit claims (e.g., at the patient’s request). Claims for Aspartoacyclase 2
deficiency tests must include:
• For dates of on or after January 1, 2013: CPT code 81200
• The name of the test (ASPA ):
o Electronic claims : Loop 2400, NTE02, or SV101-7 field o Paper claims: Box 19
Reference:
statutorily excluded services: CMS Beneficiary Notices Initiative webpage – Fee-For-Service
(FFS) ABN
CPT Code 88305: Results of Progressive Corrective Action (PCA)
CPT code 88305: Level IV-Surgical pathology and microscopic examination
CGS conducted probe reviews on providers that submitted claims for CPT code 88305; providers were selected
for these reviews based on their allowed services and charges. The overall error rate for Kentucky exceeded
21%, and the overall Ohio error rate exceeded 56.39%.
Based on our review of 200 claims, we identified the following issues.
• The documentation did not support CPT code 88305 (a different surgical pathology code should
have been submitted based on these records)
• No documentation was present to support the order/intent to order
In our review of documentation, we found that while a signed pathology report was present, documentation of
the order was missing. According to Medicare guidelines, either a signed order from the treating physician or
progress notes documenting his/her intent to order must be present.
CGS has provided education to providers that were impacted, and we have begun the process of collecting any
identified overpayments.
For more information on documentation requirements, please refer to:
o Correct coding policy: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12, section 30
o Signature requirements in medical records: CMS Medicare Program Integrity Manual (Pub. 100-08),
chapter 3, section 3.3.2.4
May 2013
- page 40 -
o Medical review probe review process: CMS Medicare Program Integrity Manual (Pub. 100-08),
chapter 3, sections 3.6.1-3.6.9
o Requirements for diagnostic tests: CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 15,
sections 80.6.1-80.6.5
o CMS Medicare Learning Network publication, “Medicare Claim Review Programs: MR, NCCI Edits,
MUEs, CERT and Recovery Audit Program”
o CGS web article, “Documentation Related to Diagnostic Tests”
CPT Code 99310: Prepayment Edit Implemented
Based on CGS data analysis and findings in our review of claims for CPT code 99310, we have noted that claims
are being submitted inappropriately with this CPT code. CGS will be implementing a prepayment edit for CPT
code 99310 in Ohio.
CPT code 99310 “requires at least 2 of these 3 key components: a comprehensive interval history; a comprehensive
examination; medical decision making of high complexity. Counseling and/or coordination of care with other
providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s
needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician
attention. Physicians typically spend 35 minutes at the bedside and on the patient’s facility floor or unit.”
For guidance regarding documentation guidelines for Evaluation & Management (E/M) services, refer to:
•
CMS Medicare Learning Network Evaluation and Management Services Guide
•
1995 Documentation Guidelines for Evaluation and Management Services
•
1997 Documentation Guidelines for Evaluation and Management Services
•
CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12, section 30.6
•
CGS Medical Review checklists
Upon request from CGS, submit documentation to support the level of service and medical necessity.
Implementation for the Award for Jurisdiction E Part A\Part B
Medicare Hospital Inpatient Claims
Implementation for the Award for Jurisdiction E Part A\Part B Medicare Hospital Inpatient Claims: The Centers
for Medicare & Medicaid Services (CMS) has awarded the JE A/B MAC contract for the administration of the Part
A and Part B Medicare fee-for-service claims in the states and territories of California, Hawaii, Nevada, American
Somoa, Guam and the Northern Marianas to Noridian Administrative Services, LLC (NAS). (For complete
information see CMS Transmittal CR8226 R1201OTN: http://www.cms.gov/Regulations-and-Guidance/
Guidance/Transmittals/2013-Transmittals-Items/R1201OTN.html)
- page 41 -
May 2013
Local Carrier Payment Allowance Limits for Medicare Part B Drugs
Effective April 1, 2013 through June 30, 2013
Revision: 4/1/2013
Note 1: The complete ASP Payment Allowance Limits list can be accessed at the following link:
http://www.cms.gov/McrPartBDrugAvgSalesPrice/01a18_2011ASPFiles.asp#TopOfPage
Note 2: Payment allowance limits subject to the ASP methodology are based on 2Q12 ASP data.
Note 3: The absence or presence of a HCPCS code and the payment allowance limits in this table does not
indicate Medicare coverage of the drug.
Similarly, the inclusion of a payment allowance limit within a specific column does not indicate Medicare
coverage of the drug in that specific category. These determinations shall be made by the local Medicare
contractor processing the claim.
Note 4: ** - Carrier-priced
HCPCS Code
90396**
90396**
Short Description
90736**
varicella-zoster immune globulin
Flu vaccine, derived from cell cultures,
subunit
Zostavax
J0135**
J0200**
J0270**
J0275**
J0364**
J0380**
J0390**
J0395**
Adalimumab, 20 MG
Alatrofloxacin mesylate
Alprostadil, 1.25 MCG
Alprostadil Urethral Suppository
Apomorphine / Hydrochloride
metaraminol bitartrate, inj
Chloroquine injection
Arbutamine HCl injection
J0520**
Bethanechol chloride inject
J0620**
J0630**
J0715**
J1060**
J1324**
J1438**
J1590**
J1595**
J1675**
J1680**
J1700**
J1710**
J1725**
J1830**
J1890**
J1960**
J1990**
J2170**
J2265**
Calcium glycerophosphate/Calcium lactate
Calcitonin Salmon
Ceftizoxime sodium / 500 MG
Testosterone cypionate 1 ML
Enfuvirtide
Etanercept
Gatifloxacin injection
Injection glatiramer acetate
Histrelin Acetate
fibrinogen concentrate human
Hydrocortisone acetate inj
Hydrocortisone sodium ph inj
Hydroxyprogesterone Caporate
Interferon beta-1b / .25 MG
Cephalothin sodium injection
Levorphanol tartrate
Chlordiazepoxide injection
Mecasermin
Minocycline Hydrochloride
90661**
HCPCS Code
Payment Limit
Dosage
125 U / 1.25 ML
Invoice
625 U / 6.25 ML
Invoice
Per Carrier Medical Director not covered
by Part B.
Per Carrier Medical Director not covered
by Part B.
Considered self-administered.
100 MG
Invoice
10 MG
Invoice
250 MG
Invoice
1 MG
Invoice
Notes
Added January
2013
Oral drug considered part of procedure in
10 ML
Invoice
500 MG
Invoice
1 ML
Invoice
100 MG
$ 103.550
25 MG
$
0.360
50 MG
Invoice
1 MG
Invoice
Not covered by carrier.
1G
Invoice
2 MG
$
3.765
100 MG
Invoice
May 2013
- page 42 -
J2278KD**
J2320**
J2354**
J2513**
J2650**
J2670**
J2940**
J2941**
J3030**
J3110**
J3140**
J3150**
J3265**
J3280**
J7130**
J7180**
J7191**
J7500**
J7502**
J7506**
J7507**
J7509**
J7510**
J7515**
J7517**
J7518**
J7520**
Ziconotide injection
Nandrolone decanoate 50 MG
Octreotide Acetate
Pentastarch 10% solution
Prednisolone acetate
Tolazoline hcl injection
Somatrem injection
Somatropin injection
Sumatriptan Succinate
Teriparatide injection
Testosterone suspension
Testosterone propionate
Injection torsemide 10 mg/ml
Thiethylperazine maleate, inj
Hypertonic saline solution
Factor XIII
Factor viii (porcine)
Azathioprine oral 50 mg
Cyclosporine oral 100 mg
Prednisone oral
Tacrolimus oral per 1 MG
Methylprednisolone oral
Prednisolone oral per 5 mg
Mycophenolate mofetil oral
Mycophenolic acid
Sirolimus, oral
J7604**
Acetylcystein
J7605**
Arformoterol non-comp unit
J7606**
Formoterol fumarate, inh
J7608**
Acetylcystein non-comp unit
J7611**
Albuterol non-comp con
J7612**
Levalbuterol non-comp con
J7613**
Albuterol non-comp unit
J7614**
Levalbuterol non-comp unit
J7620**
Albuterol ipratrop non-comp
J7622**
Beclomethasone inhalation sol
J7624**
Betamethasone inhalation sol
J7626**
Budesonide non-comp unit
J7628**
Bitolterol mes inhal sol con
J7629**
Bitolterol mes inh sol u d
J7631**
Cromolyn sodium non-comp unit
J7633**
Budesonide concentrated sol
J7639**
Dornase alfa non-comp unit
J7641**
Flunisolide, inhalation sol
J7644**
Ipratropium bromide non-comp
1 MCG
Invoice
50 MG
$
4.452
10%
Invoice
1 ML
$
0.342
25 MG
Invoice
50 MG
$
0.420
100 MG
$
0.798
10 MG
$
4.000
10 MG
Invoice
20 CC
Invoice
1 I.U.
Invoice
1 IU
Invoice
Should be billed to DMAC
Considered part of procedure in
- page 43 -
May 2013
J7648**
Isoetharine hcl inh sol con
J7649**
Isoetharine hcl inh sol u d
J7658**
Isoproterenol hcl inh sol con
J7659**
Isoproterenol hcl inh sol ud
J7665**
Mannitol inh sol
J7668**
Metaproterenol inh sol con
J7669**
Metaproterenol non-comp unit
J7674**
Methacholine chloride, neb
J7680**
Terbutaline so4 inh sol con
J7681**
Terbutaline so4 inh sol u d
J7682**
Tobramycin non-comp unit
J7683**
Triamcinolone inh sol con
J7684**
Triamcinolone inh sol u d
J7686**
Treprostinil non-comp unit
J8501**
J8510**
J8520**
J8521**
J8530**
J8540**
J8560**
J8561**
J8562**
J8600**
J8610**
J8700**
J8705**
J9165**
J9213**
J9215**
J9218**
J9270**
J9600**
Q0163**
Q0164**
Q0165**
Q0166**
Q0167**
Q0168**
Q0169**
Q0170**
Q0174**
Q0179**
Q0180**
Oral aprepitant
Oral busulfan
Capecitabine, oral 150 mg
Cyclophosphamide oral 25 MG
Oral dexamethasone
Etoposide oral 50 MG
Everolimus, 0.25 MG
Oral fludarabine phosphate
Melphalan oral 2 MG
Methotrexate oral 2.5 MG
Temozolomide
Topotecan oral
Diethylstilbestrol diphosphate injection
Interferon alfa-2a inj
Interferon, alfa-n3
Leuprolide Acetate
Plicamycin (mithramycin) inj
Porfimer Sodium injection
Diphenhydramine HCI 50 mg
Prochlorperazine maleate 5 mg
Granisetron hcl 1 mg oral
Dronabinol 2.5 mg oral
Dronabinol 5 mg oral
Promethazine HCI 12.5 mg oral
Promethazine HCI 25 mg oral
Thiethylperazine maleate, 10mg
Ondansetron hcl 9 mg oral
Dolasetron mesylate oral
Unspecified oral dosage form, FDA approved
presription anti-emetic
Radiesse injection
Sculptra injection
Agriflu
Q0181**
Q2026**
Q2027**
Q2034**
Should be billed to DMAC.
250 MG
Invoice
3 MIL UNITS
Invoice
250,000 IU
$
23.834
2.5 MG
Invoice
75 MG
$ 3,004.740
0.1 ML
0.1 ML
0.05 ML
Invoice
Invoice
Invoice
May 2013
- page 44 -
Q4074**
Not Otherwise Classified flu vacc, 3 yrs & >,
im
Iloprost non-comp unit dose
Q4118**
Q4119**
Q4122**
Q4124**
Q4125**
Q4126**
Q4127**
Q4128**
Q4129**
Q4130**
Q9955**
Matristem Micromatrix
Dermacell
Oasis Ultra Tri-Layer Wound Matrix
Arthroflex
Memoderm
Talymed
Flex HD or Allopatch HD
Unite Biomatrix
Strattice TM
Inj perflexane lip micros, ml
Q2039**
0.5 ML
$
12.375
1 MG
$
2.433
1 SQ CM
$
2.470
1 SQ CM
Invoice
1 SQ CM
$
11.400
1 SQ CM
Invoice
1 SQ CM
Invoice
1 SQ CM
Invoice
1 SQ CM
Invoice
1 SQ CM
Invoice
1 SQ CM
Invoice
1 ML
Invoice
Local Carrier Payment Allowance Limits for Medicare Part B Drugs
Effective July 1, 2012 through September 30, 2012
Revision: 4/1/2013
Note 1: The complete ASP Payment Allowance Limits list can be accessed at the following link: http://www.cms.gov/McrPartBDrugAvgSalesPrice/01a18_2011ASPFiles.asp#TopOfPage Note 2: Payment allowance limits subject to the ASP methodology are based on 1Q11 ASP data.
Note 3: The absence or presence of a HCPCS code and the payment allowance limits in this table does not
indicate Medicare coverage of the drug.
Similarly, the inclusion of a payment allowance limit within a specific column does not indicate Medicare
coverage of the drug in that specific category. These determinations shall be made by the local Medicare
contractor processing the claim. Note 4: ** - Carrier-priced
HCPCS Code
90396**
90396**
90661**
90736**
Short Description
HCPCS Code Dosage
Payment
Limit
Notes
Flu vaccine, derived from cell
cultures, subunit
Zostavax
125 U / 1.25 ML
625 U / 6.25 ML
Invoice
Invoice
Per Carrier Medical Director not covered by Part B.
Per Carrier Medical Director not covered by Part B.
A9505
Thallium TI201
J0135**
J0200**
J0270**
J0275**
J0364**
J0380**
J0390**
J0395**
Adalimumab, 20 MG
Alatrofloxacin mesylate
Alprostadil, 1.25 MCG
Alprostadil Urethral Suppository
Apomorphine / Hydrochloride
metaraminol bitartrate, inj
Chloroquine injection
Arbutamine HCl injection
100 MG
10 MG
250 MG
1 MG
J0520**
Bethanechol chloride inject
Oral drug considered part of procedure in
J0620**
Calcium glycerophosphate/Calcium
lactate
10 ML
Invoice
Invoice
Invoice
Invoice
Invoice
Added
January 2013
added March
2012
Invoice
- page 45 -
May 2013
J0630**
J0715**
J1060**
J1324**
J1438**
J1590**
J1595**
J1675**
Calcitonin Salmon
Ceftizoxime sodium / 500 MG
Testosterone cypionate 1 ML
Enfuvirtide
Etanercept
Gatifloxacin injection
Injection glatiramer acetate
Histrelin Acetate
J1680**
fibrinogen concentrate human
J1700**
Hydrocortisone acetate inj
J1710**
J1725**
J1830**
J1890**
Hydrocortisone sodium ph inj
Hydroxyprogesterone Caporate
Interferon beta-1b / .25 MG
Cephalothin sodium injection
J1960**
Levorphanol tartrate
J1990**
J2170**
J2278KD**
Chlordiazepoxide injection
Mecasermin
Ziconotide injection
J2320**
Nandrolone decanoate 50 MG
J2354**
J2513**
Octreotide Acetate
Pentastarch 10% solution
J2650**
Prednisolone acetate
J2670**
J2940**
J2941**
J3030**
J3110**
Tolazoline hcl injection
Somatrem injection
Somatropin injection
Sumatriptan Succinate
Teriparatide injection
J3140**
Testosterone suspension
J3150**
Testosterone propionate
J3265**
Injection torsemide 10 mg/ml
J3280**
J7130**
J7191**
J7500**
J7502**
J7506**
J7507**
J7509**
J7510**
J7515**
J7517**
J7518**
J7520**
J7604**
J7605**
J7606**
J7608**
J7611**
J7612**
J7613**
J7614**
Thiethylperazine maleate, inj
Hypertonic saline solution
Factor viii (porcine)
Azathioprine oral 50 mg
Prednisone oral
Tacrolimus oral per 1 MG
Methylprednisolone oral
Prednisolone oral per 5 mg
Mycophenolate mofetil oral
Mycophenolic acid
Sirolimus, oral
Acetylcystein
Arformoterol non-comp unit
Formoterol fumarate, inh
Acetylcystein non-comp unit
Albuterol non-comp con
Levalbuterol non-comp con
Albuterol non-comp unit
Levalbuterol non-comp unit
500 MG
Invoice
1 ML
Invoice
$
100 MG
103.550
$
25 MG
0.360
50 MG
Invoice
1 MG
Invoice
Not covered by carrier.
1G
Invoice
$
2 MG
3.765
100 MG
Invoice
1 MCG
Invoice
$
50 MG
4.452
10%
Invoice
$
1 ML
0.342
25 MG
Invoice
$
50 MG
0.420
$
100 MG
0.798
$
10 MG
4.000
10 MG
Invoice
20 CC
Invoice
1 IU
Invoice
Considered part of procedure in physician’s office.
May 2013
- page 46 -
J7620**
J7622**
J7624**
J7626**
J7628**
J7629**
J7631**
J7633**
J7639**
J7641**
J7644**
J7648**
J7649**
J7658**
J7659**
J7668**
J7669**
J7674**
J7680**
J7681**
J7682**
J7683**
J7684**
J7686**
J8501**
J8510**
J8520**
J8521**
J8530**
J8540**
J8560**
J8562**
J8600**
J8610**
J8700**
J8705**
J9213**
Albuterol ipratrop non-comp
Beclomethasone inhalation sol
Betamethasone inhalation sol
Budesonide non-comp unit
Bitolterol mes inhal sol con
Bitolterol mes inh sol u d
Cromolyn sodium non-comp unit
Budesonide concentrated sol
Dornase alfa non-comp unit
Flunisolide, inhalation sol
Ipratropium bromide non-comp
Isoetharine hcl inh sol con
Isoetharine hcl inh sol u d
Isoproterenol hcl inh sol con
Isoproterenol hcl inh sol ud
Metaproterenol inh sol con
Metaproterenol non-comp unit
Methacholine chloride, neb
Terbutaline so4 inh sol con
Terbutaline so4 inh sol u d
Tobramycin non-comp unit
Triamcinolone inh sol con
Triamcinolone inh sol u d
Treprostinil non-comp unit
Oral aprepitant
Oral busulfan
Cyclophosphamide oral 25 MG
Oral dexamethasone
Etoposide oral 50 MG
Oral fludarabine phosphate
Melphalan oral 2 MG
Methotrexate oral 2.5 MG
Temozolomide
Topotecan oral
Diethylstilbestrol diphosphate
injection
Interferon alfa-2a inj
J9215**
Interferon, alfa-n3
J9218**
J9270**
Leuprolide Acetate
Plicamycin (mithramycin) inj
J9600**
Porfimer Sodium injection
Q0163**
Q0164**
Q0165**
Q0166**
Q0167**
Q0168**
Q0169**
Q0170**
Q0174**
Q0179**
Q0180**
Diphenhydramine HCI 50 mg
Granisetron hcl 1 mg oral
Dronabinol 2.5 mg oral
Dronabinol 5 mg oral
Promethazine HCI 12.5 mg oral
Promethazine HCI 25 mg oral
Thiethylperazine maleate, 10mg
Ondansetron hcl 9 mg oral
Dolasetron mesylate oral
J9165**
250 MG
Invoice
3 MIL UNITS
Invoice
$
23.834
250,000 IU
2.5 MG
Invoice
$
75 MG
3,004.740
- page 47 -
May 2013
Q4074**
Unspecified oral dosage form, FDA
approved presription anti-emetic
Radiesse injection
Sculptra injection
Agriflu
Not Otherwise Classified flu vacc, 3
yrs & >, im
Iloprost non-comp unit dose
Q4118**
Q4119**
Q4122**
Dermacell
Q4124**
Oasis Ultra Tri-Layer Wound Matrix
Q4125**
Q4126**
Q4127**
Q4128**
Q4129**
Q4130**
Q9955**
Arthroflex
Memoderm
Talymed
Flex HD or Allopatch HD
Unite Biomatrix
Strattice TM
Inj perflexane lip micros, ml
Q0181**
Q2026**
Q2027**
Q2034**
Q2039**
0.1 ML
0.1 ML
.05 ML
Invoice
Invoice
Invoice
$
0.5 ML
12.375
$
1 MG
2.433
$
1 SQ CM
2.470
1 SQ CM
Invoice
$
1 SQ CM
11.400
1 SQ CM
Invoice
1 SQ CM
Invoice
1 SQ CM
Invoice
1 SQ CM
Invoice
1 SQ CM
Invoice
1 SQ CM
Invoice
1 ML
Invoice
Mitochondrial Nuclear Gene Tests: Coding and Claim Submission
Guidelines
Mitochondrial disorders are a group of conditions caused by dysfunction in the mitochondrial respiratory chain.
Current genetic testing methods are unable to detect mutations in all individuals with suspected mitochondrial
disease, and there is no proven effective treatment for persons with a known mitochondrial disease. Therefore,
CGS has determined mitochondrial nuclear gene tests do not support the required clinical utility for the
established Medicare benefit category and are statutorily excluded tests.
The following mitochondrial nuclear gene tests have been identified as non-covered:
Comprehensive Mitochondrial Nuclear Gene Panel
Mitochondrial Genome Sequence
Test
however, you may choose to submit claims (e.g., at the patient’s request). Claims for mitochondrial nuclear
gene tests must include:
• The appropriate ICD-9-CM code(s)The name of the test:
o Paper claims: Block 19
Reference:
• Guidance on issuing Advance Beneficiary Notices of Noncoverage (ABNs) on a voluntary basis
for statutorily excluded services: CMS Beneficiary Notices Initiative webpage – Fee-ForService (FFS) ABN
May 2013
- page 48 -
MM7727 - Medicare Quality Reporting Incentive Programs
Manual Update
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
News Flash – Recently, the Centers for Medicare & Medicaid Services (CMS) released its quarterly enhancement
to the Physician Compare website. Improvements were based on recommendations made during July 2011
testing as well as suggestions from users and stakeholders. This is part of CMS’ ongoing effort to improve
the Physician Compare website’s data accuracy and ease of use. The feedback tool now allows providers and
beneficiaries to contact Physician Compare administrators directly with questions or concerns. For additional
information on future new releases and updates visit the Physician Compare website.
Note: This article was revised on March 26, 2013, to reflect a revised CR7727 issued on March 26, 2013.
In this article, the CR transmittal number, CR release date, and the Web address for accessing the CR are
revised. All other information remains the same.
Provider Types Affected
This MLN Matters® Article is intended for physicians and other Eligible Professionals (EPs) who bill Medicare
contractors (carriers or Medicare Administrative Contractors (A/B MACs)) for providing certain services to
Medicare beneficiaries.
What You Need to Know
This article is based on Change Request (CR) 7727, which informs you that a third chapter has been
added to the “Medicare Quality Reporting Programs Manual.”
•
•
This chapter describes the yearly payment instructions used by the Medicare contractors when making
incentive payments described in the “Medicare Quality Reporting Incentives Manual.”
CR7727 manualizes existing requirements contained in existing CRs and Medicare Physician Fee
Schedule (MPFS) legislation, but does not establish any new requirements for the Physician Quality
Reporting System (PQRS) and E-Prescribing (eRX) Incentive Programs.
Background
The 2006 Tax Relief and Health Care Act (TRHCA) (P.L. 109-432) required the establishment of a Physician Quality
Reporting System, including an incentive payment for eligible professionals who satisfactorily report data on
quality measures for covered professional services furnished to Medicare beneficiaries during the second half
of 2007 (the 2007 reporting period). The Centers for Medicare & Medicaid Services (CMS) named this program
the Physician Quality Reporting Initiative (PQRI). The PQRI was further modified as a result of the Medicare,
Medicaid, and State Children’s Health Insurance Program (SCHIP) Extension Act of 2007 (MMSEA) (P. L. 110-275)
and the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (P. L. 110-275). In 2011, the
program name was changed to Physician Quality Reporting System (Physician Quality Reporting). All publicly
available information on the PQRS Incentive Program can be found at http://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment- Instruments/PQRS/index.html on the CMS website.
Section 132 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (P.L. 110-173) (MMSEA) authorized
a new and separate incentive program for Eligible Professionals (EPs) who are successful e-prescribers, the
E-Prescribing (eRx) Incentive program, as defined by the Medicare Improvements for Patients and Providers
Act (P.L. 110-275) (MIPPA). While this program has similarities to the Physician Quality Reporting System (PQRS)
incentive payment program, it is a stand-alone program with distinct reporting requirements and a separate
incentive payment. All publicly available information on the eRx Incentive Program can be found at http://
www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/index.html on the
CMS website.
CR7727 manualizes the information contained in existing CRs and MPFS legislation. Changes to the programs
are described in the annual MPFS legislation.
- page 49 -
May 2013
Additional Information
The official instruction, CR7727, issued to your carrier or A/B MAC regarding this change, may be viewed at
http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R11QR1.pdf on the
CMS website.
If you have any questions, please contact your carrier or A/B MAC at their toll-free number, which may be found
at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider- complianceinteractive-map/index.html on the CMS website.
MM7818 - International Classification of Diseases, 10th Edition (ICD)10 Conversion from (ICD-9) and Related Code Infrastructure of the
Medicare Shared Systems as They Relate to CMS National Coverage
Determinations (NCDs) (CR 1 of 3) (ICD-10)
News Flash –
NEW products from the Medicare Learning Network® (MLN)
• “Cardiovascular Disease Services,” Booklet, ICN 907784, Downloadable
• “Screening Pap Tests,” Booklet, ICN 907791, Downloadable
Note: This article was revised on March 27, 2013, to add a reference to article MM8207 (http://www.cms.gov/
Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM8207.pdf )
to alert DMEPOS providers and suppliers of modifications being made to the claims processing systems to
report the appropriate NCD/LCD captured during claims processing based on their associations with either
ICD-9 or ICD-10 diagnosis codes, the claim line service date, and the ICD-10 diagnosis code effective date. It
was previously revised, to add information on accessing the attachment to CR7818. All other information is
unchanged.
This MLN Matters® Article for Change Request (CR) 7818 is intended for physicians, other providers, and
suppliers who submit claims to Medicare contractors (carriers and A/B Medicare Administrative Contractors
(A/B MACs)) for services provided to Medicare beneficiaries.
Provider Action Needed
This article is based on Change Request (CR) 7818 which creates and updates National Coverage Determination
(NCD) hard-coded Medicare shared system edits that contain ICD-9 diagnosis codes with comparable ICD-10
diagnosis codes. The requirements described in CR7818 reflect the operational changes that are necessary to
implement the conversion of the Medicare shared system diagnosis codes specific to numerous Medicare NCDs,
which are identified in an attachment to CR7818. In order to be prepared to meet the timeline to implement the
new ICD-10 diagnosis codes on October 1, 2014, the Medicare shared systems will begin implementation of the
necessary changes to the NCDs in the January 2013 systems release. No DME MAC edits are included in this CR
but will be addressed in subsequent CRs. All remaining changes to the Medicare shared systems, as they relate to
Medicare NCDs, will be made in subsequent releases. See the Background and Additional Information Sections of
this article for further details regarding these changes and be sure that you are ready for ICD-10 implementation.
Background
On October 1, 2014, all Medicare claims submissions will convert from the International Classification of
Diseases, 9th Edition (ICD-9) to the 10th Edition (ICD-10). The transition will require business and systems
changes throughout the health care industry. All covered entities, as defined by the Health Insurance Portability
and Accountability Act (HIPAA), must adhere to the conversion.
In accordance with HIPAA, the Secretary of the Department of Health and Human Services adopts standard
medical data code sets for use in standard transactions adopted under this law. According to the ICD-10 Final
May 2013
- page 50 -
Rule, published in the Federal Register of January 16, 2009 (see http://www.gpo.gov/fdsys/pkg/FR-2009-0116/pdf/E9-743.pdf on the Internet), the Secretary adopts the ICD-10-CM and ICD-10-PCS code sets for use
in appropriate HIPAA standard transactions. Entities covered under HIPAA (which include Medicare and its
providers submitting claims electronically) are bound by these requirements and must comply. Medicare
will also require submitters of paper claims to use ICD-10 codes on their claims according to the same
compliance date.
The purpose of CR7818 is to both create and update NCD hard-coded Medicare shared system edits that
contain ICD-9 diagnosis codes with comparable ICD-10 diagnosis codes, plus all associated editing such as
procedure codes, HCPCS/CPT codes, denial messages, frequency edits, Place of Service (POS)/Type of Bill (TOB)/
provider specialty editing, etc. The requirements described in CR7818 reflect the operational changes that are
necessary to implement the conversion of the Medicare shared system diagnosis codes specific to the Medicare
NCDs listed as an attachment to CR7818. To access that attachment, visit http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/2012-Transmittals-Items/R1122OTN.html on the CMS website.
Note: This exercise is in no way intended to expand, restrict, or alter existing Medicare national coverage. Also,
it is not intended to minimize the authority granted to Medicare Administrative Contractors (MACs) in their
discretionary implementation of NCDs or Local Coverage Determinations (LCDs). However, where hard-coded
edits were not initially implemented due to time and/or resource constraints, doing so at this time will better
serve the intent and integrity of national coverage and the Medicare Program overall.
The official instruction, CR7818 issued to your carrier or A/B MAC regarding this change may be viewed at
http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R1122OTN.pdf on the
CMS website. To access the attachment to CR7818, visit http://www.cms.gov/Regulations-and- Guidance/
Guidance/Transmittals/2012-Transmittals-Items/R1122OTN.html on the CMS website.
at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring- Programs/provider-complianceinteractive-map/index.html on the CMS website.
News Flash - Influenza Season is Around the Corner - As your patients age, their immune systems may
weaken. This weakening can make seniors more susceptible to complications from seasonal influenza (flu). Now
is the perfect time to remind your patients that seasonal influenza vaccination is the best defense against the
flu. Medicare provides coverage for one flu vaccine and its administration per influenza season for seniors and
other Medicare beneficiaries with no co-pay or deductible. Talk with your Medicare patients about their risk for
getting the flu and start protecting your patients as soon as your 2012-2013 seasonal flu vaccine arrives. And,
don’t forget to immunize yourself and your staff. Know what to do about the flu.
Remember – Influenza vaccine plus its administration is a covered Part B benefit. Influenza vaccine is NOT a Part
D covered drug. CMS will provide information and a link to the 2012-2013 Influenza Vaccine prices when they
are available.
For more information on coverage and billing of the flu vaccine and its administration, please visit the CMS
Medicare Learning Network® Preventive Services Educational Products and CMS Immunizations web
pages. And, while some providers may offer the flu vaccine, others can help their patients locate a vaccine
provider within their local community. HealthMap Vaccine Finder is a free, online service where users can
search for locations offering flu vaccines.
- page 51 -
May 2013
MM7824 - Reorganization of Chapter 13
News Flash –
Text-Only Rural Health Fact Sheets – Released - To assist rural providers who have limited internet access, the
following rural health publications are now available in text-only format:
• Telehealth Services Text-Only
• Swing Bed Services Text-Only
• Rural Health Clinic Text-Only
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare
Carriers, Fiscal Intermediaries (FIs), and/or A/B Medicare Administrative Contractors (A/B MACs) for services
provided in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) to Medicare
beneficiaries.
What you need to know
This article is based on Change Request (CR) 7824, which updates and reorganizes Chapter 13 of the “Medicare
Benefit Policy Manual.” This chapter deals with Medicare RHCs and FQHCs. Chapter
13 is reorganized for easier use and updated to include more comprehensive information. There are
no new policies contained in the manual.
The official instruction, CR 7824 issued to your FI, carrier, or A/B MAC regarding this change may be viewed
at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R166BP.pdf on the
CMS website.
If you have any questions, please contact your FI, carrier, or A/B MAC at their toll-free number, which may
be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring- Programs/providercompliance-interactive-map/index.html on the CMS website.
News Flash - Flu Season Isn’t Over – Continue to Recommend Vaccination - While each flu season is
different, flu activity typically peaks in February. Yet, even in February, the flu vaccine is still the best defense
against the flu. The CDC recommends yearly flu vaccination for everyone 6 months of age and older;
and although anyone can get the flu, adults 65 years and older are at greater risk for serious flu-related
complications that can lead to hospitalization and death. Every office visit is an opportunity to check your
patients’ vaccination status and encourage flu vaccination when appropriate. And getting vaccinated is just
as important for health care personnel who can get sick with the flu and spread it to family, colleagues and
patients. Be an example by getting your flu vaccine and know that you’re helping to reduce the spread of flu in
your community. Note: influenza vaccines and their administration fees are covered Part B benefits. Influenza
vaccines are NOT Part D-covered drugs. For More Information:
•
•
•
•
•
2012-2013 Seasonal Influenza Vaccines Pricing.
MLN Matters® Article MM8047, “Influenza Vaccine Payment Allowances - Annual Update for 20122013 Season.”
CMS Medicare Learning Network® 2012-2013 Seasonal Influenza Virus Educational Products and
Resources and CMS Immunizations web pages for information on coverage and billing.
HealthMap Vaccine Finder – a free, online service where users can find nearby locations offering flu
vaccines as well as other vaccines for adults.
The CDC’s website offers a variety of provider resources for the 2012-2013 flu season.
May 2013
- page 52 -
MM8121 - Clarification of Detection of Duplicate Claims Section of
the CMS Internet Only Manual
News Flash –
REVISED products from the Medicare Learning Network® (MLN)
“The Basics of Medicare Enrollment for Physicians and Other Part B Suppliers,” Fact Sheet, ICN 903768,
Downloadable only.
contractors (carriers, Fiscal Intermediaries (FIs), A/B Medicare Administrative Contractors (A/B MACs), Durable
Medical Equipment Medicare Administrative Contractors (DME MACs), and/or Regional Home Health
Intermediaries (RHHIs)) for services provided to Medicare beneficiaries.
STOP – Impact to You
The purpose of this Change Request (CR) is for clarification only and does not constitute any change in
Medicare policy. The Centers for Medicare & Medicaid Services (CMS) is alerting providers to the update of the
Medicare Internet-Only Manual (IOM), Chapter 1, Section 120: “Detection of Duplicate Claims.”
CAUTION – What You Need to Know
Change Request (CR) 8121, from which this article is taken, alerts providers that the claims processing systems
contain edits which identify duplicate claims and suspect duplicate claims. All exact duplicate claims or claim
lines are auto-denied or rejected (absent appropriate modifiers). Suspect duplicate claims and claim lines are
suspended and reviewed by the Medicare contractors to make a determination to pay or deny the claim or
claim line.
GO – What You Need to Do
Please be aware that Medicare contractors examine and compare to the prior bill any bill that is identified
as a suspect duplicate. If the services (revenue or HCPCS codes) on a claim duplicate the services for the
other, contractors will check the diagnosis. If the diagnosis codes are duplicates, contractors will request
an explanation before making payment. The official instruction for CR8121 spells out what your Medicare
contractor looks for when analyzing the history of paid and pending claims, duplicate claims and the criteria for
detecting suspect duplicate claims.
Background
Some claims that appear to be duplicates are actually claims or claim lines that contain an item or service,
or multiple instances of an item or service, for which Medicare payment may be made. Correct coding rules
applicable to all billers of health care claims encourage the appropriate use of condition codes or modifiers to
identify claims that may appear to be duplicates, but are in fact, not.
For example, there are some Healthcare Common Procedure Coding System (HCPCS) modifiers that are
appropriate to be appended to some services and can indicate that a claim line is not a duplicate of a previous
line on the claim. Level I modifiers would typically be used by a biller to indicate that a potential duplicate claim
or claim line is not, in fact, a duplicate. Level II modifiers may also be used. The Level II modifiers “RT” and “LT,” for
example, indicate that a service was performed on the right and left side of the body, respectively.
However, not every HCPCS code has an appropriate modifier to indicate that a claim line is not a duplicate.
In that case, the claims and claim lines are reviewed by Medicare Contactors’ local software modules for a
determination, or they suspend for contractor review.
- page 53 -
May 2013
Key Points of CR8121
Exact Duplicates
A. Submission of Institutional Claims
Claims or claim lines that have been determined an exact duplicate are rejected and do not have appeal rights.
An exact duplicate for institutional claims is a claim or claim line that exactly matches another claim or claim
line with respect to the following elements:
 Health Insurance Claim (HIC) number;
 Type of Bill;
 Provider Identification Number;
 From Date of Service;
 Through Date of Service;
 Total Charges (on the line or on the bill); and
 HCPCS, CPT-4, or Procedure Code modifiers.
Whenever any of the following claim situations occur, your Medicare contractor develops procedures to
prevent duplicate payment of claims. This includes, but is not limited to:
 Outpatient payment is claimed where the date of service is totally within inpatient dates of service
at the same or another provider.
 Outpatient bill is submitted for services on the day of an inpatient admission or the day before the
day of admission to the same hospital.
 Outpatient bill overlaps an inpatient admission period.
 Outpatient bill for services matches another outpatient bill with a service date for the same
revenue code at the same provider or under a different provider number.
B. Claims Submitted by Physicians, Practitioners, and other Suppliers (except DMEPOS Suppliers)
Claims or claim lines that have been determined an exact duplicate are denied. Such denials may be appealed.
An exact duplicate for physician and other supplier claims submitted to a MAC or carrier is a claim or claim line
that exactly matches another claim or claim line with respect to the following elements:
 HIC Number;
 Provider Number;
 Type of Service;
 Procedure Code;
 Place of Service; and
 Billed Amount.
May 2013
- page 54 -
C. Claims Submitted by DMEPOS Suppliers
Claims or claim lines that have been determined an exact duplicate are denied. Such denials may not be
appealed. An exact duplicate for DMEPOS Supplier claims submitted to a DME MAC is a claim or claim line that
exactly matches another claim or claim line with respect to the following elements:
 HIC Number;
 Place of service;
 HCPCS;
 Type of Service;
 Billed Amount; and
 Supplier.
Suspect Duplicat es
Suspect duplicates are claims or claim lines that contain closely aligned elements and require that the claim be
reviewed.
A. Criteria for Detecting Suspect Duplicates on Institutional Claims
A “suspect duplicate” claim is a claim being processed which, when compared to Medicare’s history or pending
files, begins with these characteristics:
•
•
•
Match on the beneficiary information;
Match on provider identification; and
Same date of service or overlapping dates of service.
B. Suspect Duplicate Claims Submitted by Physicians and other Suppliers (including DMEPOS Claims)
The criteria for identifying suspect duplicate claims submitted by physicians and other suppliers vary according
to the type of billing entity, type of item or service being billed, and other relevant criteria. The denial of claim
as a duplicate of another claim may be appealed when the denial is based on criteria other than those specified
above for exact duplication.
You can find the official instruction, CR8121, issued to your FI, carrier, A/B MAC, RHHI, or DME MAC by visiting
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2678CP.pdf on the CMS
website.
If you have any questions, please contact your FI, carrier, A/B MAC, RHHI, or DME MAC at their toll- free number,
which may be found at http://www.cms.gov/Research-Statistics-Data-and- Systems/Monitoring-Programs/
provider-compliance-interactive-map/index.html on the CMS website.
- page 55 -
May 2013
MM8166 - Outpatient Therapy Functional Reporting NonCompliance Alerts
News Flash Re-released (new) product from the Medicare Learning Network® (MLN)
• “Intensive Behavioral Therapy (IBT) for Obesity,” Booklet, ICN 907800, Downloadable and Hard Copy.
This MLN Matters® Article is intended for physicians and other providers who submit claims to Medicare
contractors (carriers or Part B Medicare Administrative Contractors (B MACs)) for outpatient therapy services
provided to Medicare beneficiaries.
Change Request (CR) 8166, from which this article is taken implements alert messaging that conveys
supplemental information regarding your claims for outpatient therapy from April 1, 2013, through
June 30, 2013.
For therapy claims, with dates of service on and after January 1, 2013, processed on and after April 1,
2013, through June 30, 2013, you will receive a Remittance Advice (RA) message to alert you to include the
applicable new functional limitation G-codes (from the list of 42) and the appropriate severity/complexity
modifier (from the list of 7) on future specified therapy claims.
Your carrier or B MAC will continue to process and adjudicate your therapy claims without the
required G-codes and severity/complexity modifier.
Please note that no changes are being made to the policy on the claims-based data collection for outpatient therapy.
Background
Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act of 2012 (MCTRJCA) (see http://www.gpo.gov/
fdys/pkg/CRPT-112hrpt399/pdf/CRPT-112hrpt399.pdf) states that “The Secretary of Health and Human Services shall
implement, beginning on January 1, 2013, a claims-based data collection strategy that is designed to assist in reforming
the Medicare payment system for outpatient therapy services subject to the limitations of Section 1833(g) of the Social
Security Act (42 U.S.C.1395l(g)). Such strategy shall be designed to provide for the collection of data on patient function
during the course of therapy services in order to better understand patient condition and outcomes.”
In response, CMS issued regulations on November 1, 2012 creating such a system The Centers for Medicare &
Medicaid Services (CMS implemented a new claims-based data submission requirement for outpatient therapy
services, effective January 1, 2013. It requires reporting with 42 new non-payable functional Healthcare
Common Procedure Coding System (HCPCS) G-codes and 7 new severity/complexity modifiers on claims for
Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP) services. (You can
find the associated MLN Matters® Article at http://www.cms.gov/outreach-and-education/medicare-learningnetwork- mln/mlnmattersarticles/downloads/MM8005.pdf on the CMS website.
Dates to Remember
A testing period is in effect from January 1, 2013, through June 30, 2013, during which claims without the
required G-codes and severity/complexity modifier will be processed to allow providers to use the new coding
requirements to assure that your systems work. During the testing period, your carrier or B MAC will continue to
process and adjudicate your therapy claims without the required G-codes and severity/complexity modifier.
For therapy claims, with dates of service on and after January 1, 2013, processed on and after April 1, 2013,
through June 30, 2013, contractors will send alerts reminding you to include the new functional limitation
G-codes (from the list of 42) and the appropriate severity/complexity modifier (from the list of 7) on future
specified therapy claims through a new RA message. The scenarios below illustrate what will be effective April
1, 2013.
May 2013
- page 56 -
Effective April 1, 2013 to June 30, 2013
1. Effective for therapy claims with dates of service on or after January 1, 2013 and processed on and after
April 1, 2013 through June 30, 2013, contractors will alert providers, who submit claims containing functional
G-codes (G8978-G8999, G9158-G9176, and G9186) without a severity/complexity modifier (CH-CN), that
functional G-codes require a severity/complexity modifier, and effective July 1, 2013, claims that do not include
required functional reporting information will be returned or rejected. The following Claim Adjustment Reason
Code (CARC) and RA Remark Code (RARC) will be used as the alert message:
• CARC 246 – “This non-payable code is for required reporting only” and
•
RARC N565- “Alert: This non-payable reporting code requires a modifier. Future claims containing
this non-payable reporting code must include an appropriate modifier for the claim to be processed.”
when nonpayable HCPCS codes G8978 to G8999, G9158 to G9176, or G9186 are submitted without the
appropriate modifier (CH – CN).
2. Effective for therapy claims with dates of service on or after January 1, 2013 and processed on and after
April 1, 2013, through June 30, 2013, contractors will alert providers, who submit claims containing any of the
following CPT evaluation/re-evaluation therapy codes 92506, 92597, 92607, 92608, 92610, 92611, 92612, 92614,
92616, 96105, 96125, 97001, 97002, 97003, 97004 without functional information, that these codes require
functional G-code(s) and appropriate severity/complexity modifier (s), and effective July 1, 2013, claims that
do not include required functional reporting information will be returned or rejected. The following CARC and
RARC will be used as the alert message:
•
CARC 246- “This non-payable code is for required reporting only.” and
•
RARC N566- “Alert: This procedure code requires functional reporting. Future claims containing this
procedure code must include an applicable non-payable code and appropriate modifiers for the claim
to be processed.”” when CPT codes 92506, 92597, 92607, 92608, 92610, 92611, 92612, 92614,
92616, 96105, 97001, 97002, 97003, or 97004 are submitted without the nonpayable HCPCS
codes G8978 to G8999, G9158 to G9176, or G9186 and the appropriate modifier (CH – CN).
Beginning July 1, 2013
• Beginning July 1, 2013, your claims will be returned or rejected using a new RA message when you do
not comply with these reporting requirements.
Note: CR8166 is not applicable to institutional claims. There will be no alert messaging for institutional claims
between April 1, 2013, and July 1, 2013.
You can find more information about outpatient therapy functional reporting non-compliance alerts by going
to CR 8166, located at http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/
R1196OTN.pdf on the CMS website.
You may want to refer to CR 8005, Pub 100-04, Transmittal 2622, dated December 21, 2012, for detailed
instructions on the implementation of the 42 nonpayable G-codes and 7 severity/complexity modifiers. You can
find this at http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2622CP.pdf
on the CMS website. The related MLN article may be found at http://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM8005.pdf on the CMS website.
For more information, please see the 2013 Physician Fee Schedule Final Rule in the Federal Register, dated
November 16, 2013, at http://www.gpo.gov/fdsys/pkg/FR-2012-11-16/pdf/2012-26900.pdf on the Internet.
If you have any questions, please contact your carrier or B MAC at their toll-free number, which may be found
- page 57 -
May 2013
Flu Activity Continues: Prompt Antiviral Treatment is Crucial for Seniors Sick with Flu
This season, flu activity started early and has placed a significant burden on people 65 years of age and older.
In fact, so far this season, CDC has reported nearly four times more hospitalizations among people 65 and older
than occurred during the entire 2011-2012 season. The CDC recommends that vaccination efforts continue as
long as influenza viruses are circulating. People 65 years of age and older, as well as their close contacts and
caregivers, should be vaccinated; and should seek medical treatment with antiviral drugs as soon as symptoms
appear in order to reduce serious complications from flu infection, including hospitalizations, intensive care unit
(ICU) admissions and deaths.
Note: Influenza vaccine and its administration is a Medicare Part B covered benefit. Influenza vaccines are NOT
Part D-covered drugs.
For More Information:
•
•
•
•
•
•
2012-2013 Seasonal Influenza Vaccines Pricing list.
MLN Matters® Article #MM8047, “Influenza Vaccine Payment Allowances - Annual Update for 20122013 Season”.
Visit the CMS Medicare Learning Network® 2012-2013 Seasonal Influenza Virus Educational
Products and Resources and CMS Immunizations web pages for information on coverage and
billing of the flu vaccines and their administration fees.
HealthMap Vaccine Finder is a free, online service where users can find locations offering flu vaccines
as well as other vaccines for adults.
CDC website offers a variety of provider resources for the 2012-2013 flu season.
CDC article Seniors among Groups Hardest Hit by Flu this Season
M8203 - Clinical Laboratory Fee Schedule - Medicare Travel
Allowance Fees for Collection of Specimens
• News Flash Re-released (new) product from the Medicare Learning Network® (MLN)
• “Intensive Behavioral Therapy (IBT) for Obesity,” Booklet, ICN 907800, Downloadable and Hard Copy.
This MLN Matters® Article is intended for clinical diagnostic laboratories submitting claims to Medicare
contractors (carriers and A/B Medicare Administrative Contractors (MACs)) for services to Medicare beneficiaries.
This article is based on Change Request (CR) 8203 which informs Medicare contractors and providers about
changes to the Clinical Lab Fee Schedule related to travel allowances and specimen collection fees.
CR8203 revises the payment of travel allowances when billed on a per mileage basis using Health Care
Common Procedure Coding System (HCPCS) code P9603 and when billed on a flat rate basis using HCPCS code
P9604 for CY 2013.
Make sure that your billing staffs are aware of these changes. See the Background and Additional Information
Sections of this article for further details regarding these changes.
May 2013
- page 58 -
Background
Travel codes allow for payment either on a per mileage basis (P9603) or on a flat rate per trip basis (P9604).
Payment of the travel allowance is made only if a specimen collection fee is also payable. The travel allowance
is intended to cover the estimated travel costs of collecting a specimen including the laboratory technician’s
salary and travel expenses. Medicare contractor discretion allows Medicare contractors to choose either
a mileage basis or a flat rate, and how to set each type of allowance. Because of audit evidence that some
laboratories abused the per mileage fee basis by claiming travel mileage in excess of the minimum distance
necessary for a laboratory technician to travel for specimen collection, many Medicare contractors established
local policy to pay on a flat rate basis only.
Under either method, when one trip is made for multiple specimen collections (e.g., at a nursing home), the
travel payment component is prorated based on the number of specimens collected on that trip, for both
Medicare and non-Medicare patients, either at the time the claim is submitted by the laboratory or when the
flat rate is set by the contractor.
Medicare Part B, allows payment for a specimen collection fee and travel allowance, when medically necessary,
for a laboratory technician to draw a specimen from either a nursing home patient or homebound patient under
Section 1833(h)(3) of the Act. Payment for these services is made based on the clinical laboratory fee schedule.
New Mileage Rates
The new rate for HCPCS Code P9603, where the average trip to patients’ homes exceeds 20 miles round trip, is
$0.565 per mile, plus an additional $0.45 per mile to cover the technician’s time and travel costs, for a total of
$1.015 per mile. The actual total of $1.015 is then rounded up to $1.02 due to processing systems capabilities.
Higher rates may be established if local conditions warrant it.
The new rate for HCPCS Code P9604 is paid on a flat-rate trip basis travel allowance of $10.15.
Note: Claims for these services will not be automatically adjusted. Providers must bring any previously paid
claims to their contractors’ attention.
The official instruction, CR 8203, issued to your carrier and A/B MAC regarding this change may be viewed at
http://www.cms.hhs.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2675CP.pdf on the
CMS website.
More information may be found in Chapter 16, Section 60.2 of the Medicare Claims Processing Manual at http://
www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/clm104c16.pdf on the CMS website.
appear in order to reduce serious complications from flu infection, including hospitalizations, intensive care
unit (ICU) admissions and deaths.
Part D- covered drugs.
• 2012-2013 Seasonal Influenza Vaccines Pricing list.
• MLN Matters® Article #MM8047, “Influenza Vaccine Payment Allowances - Annual Update for 20122013 Season”.
- page 59 -
May 2013
•
•
•
•
Products and Resources and CMS Immunizations web pages for information on coverage and billing
of the flu vaccines and their administration fees.
CDC article Seniors among Groups Hardest Hit by Flu this Season.
MM8212 - New Waived Tests
News Flash Revised product from the Medicare Learning Network® (MLN)
• “Medicare Vision Services,” Fact Sheet, ICN 907165, Downloadable only.
This MLN Matters® Article is intended for clinical diagnostic laboratories submitting claims to Medicare
contractors (carriers and A/B Medicare Administrative Contractors (A/B MACs)) for services provided to
This article is based on Change Request (CR) 8212 which informs Medicare contractors of the nine newly added
waived tests under the Clinical Laboratory Improvement Amendments of 1998 (CLIA) .
CLIA requires that for each test it performs, a laboratory facility must be appropriately certified. The Current
Procedural Terminology (CPT) codes that the Centers for Medicare & Medicaid Services (CMS) consider to be
laboratory tests under CLIA (and thus requiring certification) change each year. CR 8212, from which this article
is taken, informs carriers and MACs about the latest new CPT codes that are subject to CLIA edits.
Make sure that your billing staffs are aware of these CLIA-related changes for 2012 and 2013 and that you
remain current with certification requirements. See the Background and Additional Information Sections of this
article for further details regarding these changes.
Background
CLIA regulations require a facility to be appropriately certified for each test performed. To ensure that Medicare
& Medicaid only pay for laboratory tests categorized as waived complexity under CLIA in facilities with a CLIA
certificate of waiver, laboratory claims are currently edited at the CLIA certificate level.
Listed below are the latest tests approved by the Food and Drug Administration (FDA) as waived tests under
CLIA. The CPT codes for the following new tests must have the modifier QW to be recognized as a waived test.
Waived Tests (QW Modifier Required)
CPT Code
Effective Date
Description
82055QW
April 30, 2012
Germaine Laboratories AimStrip Alcohol Saliva
G0434QW
November 29, 2012
Chemtron Biotech, Inc. Chemtrue Single/Multi-Panel Drug
Screen Cassette Tests
May 2013
- page 60 -
G0434QW
November 29, 2012
Chemtron Biotech, Inc. Chemtrue Single/Multi-Panel Drug
Screen Dip Card Tests
G0434QW
January 4, 2013
American Screening Corporation, Inc., Multi-Drug Testing
Cards
G0434QW
January 4, 2013
American Screening Corporation, Inc., Multi-Drug Testing
Cups
G0434QW
January 10, 2013
UCP Biosciences, Inc. UCP Compact Drug Test Cards
G0434QW
January 10, 2013
UCP Biosciences, Inc. UCP Compact Drug Test Cups
85610QW
January 16, 2013
Coag-Sense Prothrombin Time (PT/INR) Monitoring System
(Professional use)
81003QW
January 23, 2013
CLIA waived Inc. Automated Urinalysis Test System
Note that the tests mentioned on the first page of the list attached to CR8212 (CPT codes:
81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651) do not require a QW
modifier to be recognized as a waived test.
Note: Medicare contractors will not search files to either retract payment or retroactively pay claims based on
the changes in CR8212, however, claims should be adjusted if you bring them to your contractor’s attention.
The official instruction, CR 8212, issued to your carrier and A/B MAC regarding this change, may be viewed at http://
www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/downloads/R2671CP.pdf on the CMS website.
• Visit the CMS Medicare Learning Network® 2012-2013 Seasonal Influenza Virus Educational
• HealthMap Vaccine Finder is a free, online service where users can find locations offering flu vaccines
• CDC website offers a variety of provider resources for the 2012-2013 flu season.
• CDC article Seniors among Groups Hardest Hit by Flu this Season
- page 61 -
May 2013
MM8213 - Autologous Platelet-Rich Plasma (PRP) for Chronic NonHealing Wounds
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services
News Flash - Effective May 1, 2013, CMS will instruct contractors to turn on Phase 2 denial edits on the
following claims to check for a valid individual National Provider Identifier (NPI) and to deny the claim when this
information is missing:
• Medicare Part B laboratory and imaging claims and Durable Medical Equipment, Orthotics, and
Supplies (DMEPOS) claims that require an ordering or referring physician/non-physician provider; and
• Part A Home Health Agency (HHA) claims that require an attending physician provider.
For more information see MLN Matters® Article #SE1305 and Register for the National
Provider Call on March 20 from 3-4:30ET.
Note: This article was revised on March 13, 2013, to add the full description of HCPCS code G0460 on page 5. All
other information remains unchanged
This MLN Matters® Article is intended for physicians and other providers submitting claims to
Medicare contractors (fiscal intermediaries (FIs), carriers, and A/B Medicare Administrative
Contractors (MACs)) for services to Medicare beneficiaries.
If you provide Medicare beneficiaries PRP for the treatment of chronic non-healing wounds, this
National Coverage Determination (NCD) could impact your reimbursement.
Effective for claims with dates of service on or after August 2, 2012, CMS will cover PRP for the treatment of
chronic non-healing diabetic, venous and/or pressure wounds only when provided under a clinical research
study that meets specific requirements to assess the health outcomes of PRP for the treatment of chronic nonhealing diabetic, venous and/or pressure wounds.
Please refer to the Background section, below for details.
Background
PRP is produced by centrifuging a patient’s own blood to yield a concentrate that is high in both platelets and
plasma proteins; and includes whole white and red cells, fibrinogen, stem cells, macrophages, and fibroblasts.
Frequently administered as a spray, or a gel; physicians have used it in clinical or surgical settings, for a variety of
purposes such as an adhesive in plastic surgery and filler for acute wounds. In addition, it is being used, now, on
chronic, non-healing cutaneous wounds that persist for 30 days or longer.
Since 1992, the Centers for Medicare & Medicaid Services (CMS) has issued national non-coverage
determinations for platelet-derived wound healing formulas intended to treat patients with chronic, nonhealing wounds. In December 2003, CMS issued a national non-coverage determination specifically for the use
of autologous PRP in treating chronic non-healing cutaneous wounds except for routine costs when used in
accordance with the clinical trial policy defined in section 310.1 (Routine Costs in Clinical Trials (Effective July
9, 2007)) of the “National Coverage Determinations (NCD) Manual”. Currently, as of March 2008, CMS has noncoverage determinations for the use of autologous blood-derived products for the treatment of acute wounds
where PRP is applied directly to the closed incision site, and for dehiscent wounds, as well as non-coverage for
chronic, non-healing cutaneous wounds.
On October 4, 2011, CMS accepted a formal request to reopen and revise Section 270.3 of the “Medicare NCD
Manual”, which addresses Autologous Blood-Derived Products for Chronic Non- Healing Wounds. The request
May 2013
- page 62 -
was for a reconsideration of the coverage of autologous PRP for the treatment of the following chronic wounds:
diabetic, venous, and/or pressure ulcers. It was requested
that CMS cover PRP through an NCD with data collection as a condition of coverage; and requested that this
would provide a practical means by which CMS could obtain the necessary data to evaluate the performance of
PRP and to confirm the outcomes presented in their request.
Effective August 2, 2012, upon reconsideration, CMS determined that PRP is covered for the treatment of
chronic non-healing diabetic, venous and/or pressure wounds only when the following conditions are met:
1. The patient is enrolled in a randomized clinical trial that addresses the questions listed below using
validated and reliable methods of evaluation. Clinical study applications for coverage pursuant to this National
Coverage Determination (NCD) must be approved by August 2, 2014. Any clinical study approved by August 2,
2014, will adhere to the timeframe designated in the approved clinical study protocol.
If there are no approved clinical studies on or before August 2, 2014, CED for PRP only for the treatment of
chronic non-healing diabetic, venous and/or pressure wounds will expire.
2. The clinical research study must meet the requirements specified below to assess PRP’s effect on the
treatment of chronic non-healing diabetic, venous and/or pressure wounds.
The clinical study must address:
• Prospectively, do Medicare beneficiaries, with chronic non-healing diabetic, venous and/or pressure wounds,
who receive well-defined optimal usual care along with PRP therapy, experience clinically significant health
outcomes compared to patients who receive only well- defined optimal usual care for such wounds; as
indicated by addressing at least one of the following:
a. Complete wound healing?
b. Ability to return to previous function and resumption of normal activities?
c. Reduction of wound size or healing trajectory which results in the patient’s ability to return to previous
function and resumption of normal activities?
3. The required PRP clinical trial must adhere to the following standards of scientific integrity and relevance to
the Medicare population:
• Its principal purpose is to test whether PRP improves the participants’ health outcomes;
•
It is well supported by available scientific and medical information or it is intended to clarify or establish the
health outcomes of interventions already in common clinical use;
•
It does not unjustifiably duplicate existing studies;
•
Its design is appropriate to answer the research question being asked in the study;
•
It is sponsored by an organization or individual capable of executing the proposed study successfully;
•
It is in compliance with all applicable Federal regulations concerning the protection of human subjects
found at 45 CFR Part 46;
•
All of its aspects are conducted according to appropriate standards of scientific integrity set by the
International Committee of Medical Journal Editors (http://www.icmje.org);
•
It has a written protocol that clearly addresses, or incorporates by reference, the standards listed here as
Medicare requirements for coverage with evidence development (CED);
•
It is not designed to exclusively test toxicity or disease pathophysiology in healthy individuals.
•
Trials of all medical technologies measuring therapeutic outcomes as one of the objectives meet this
standard only if the disease or condition being studied is life threatening as defined in 21 CFR §312.81(a)
and the patient has no other viable treatment options;
- page 63 -
May 2013
•
•
It is registered on the ClinicalTrials.gov website (http://www.clinicaltrials.gov/) by the principal sponsor/
investigator prior to the enrollment of the first study subject;
Its study protocol:
a. Specifies the method and timing of public release of all pre-specified outcomes to be measured,
including the release of outcomes that are negative or that the study is terminated early;
The results must be made public within 24 months of the end of data collection. If a report is planned
to be published in a peer reviewed journal, then that initial release may be an abstract that meets the
requirements of the International Committee of Medical Journal Editors (http://www.icmje.org). However
a full report of the outcomes must be made public no later than three (3) years after the end of data
collection;
b. Must explicitly discuss: 1) Subpopulations affected by the treatment under investigation, particularly
traditionally underrepresented groups in clinical studies; 2) How the inclusion and exclusion criteria effect
enrollment of these populations, and 3) A plan for the retention and reporting of said populations on the
trial.
If the inclusion and exclusion criteria are expected to have a negative effect on the recruitment or retention
of underrepresented populations, the protocol must discuss why these criteria are necessary.
c. Explicitly discusses how the results are, or are not, expected to be generalizable to the Medicare
population to infer whether Medicare patients may benefit from the intervention. Separate discussions
in the protocol may be necessary for populations eligible for Medicare due to age, disability or Medicaid
eligibility.
Note: Consistent with Section 1142 of the Social Security Act (the Act), the Agency for Healthcare Research and
Quality (AHRQ) supports clinical research studies that CMS determines meet the above-listed standards and
address the above-listed research questions.
Coding and Payment Details
Healthcare Common Procedure Coding System (HCPCS) Codes
Effective for claims with dates of service on or after August 2, 2012, contractors will accept and pay PRP claims,
HCPCS code G0460 – Autologous platelet rich plasma for chronic wounds/ulcers, including phlebotomy,
centrifugation, and all other preparatory procedures, administration and dressings, per treatment”,
for the treatment of chronic non-healing diabetic, venous and/or pressure wounds only in the context of an
approved clinical study, when all of the following are present:
• ICD-9/ICD-10 CM Diagnosis code from the list of diagnosis codes to be maintained by the contractors
• Diagnosis code V70.7 (secondary dx) (ICD-10 Z00.6)
• Condition code 30 (institutional claims only)
• Clinical trial modifier Q0 (Investigational clinical service provided in a clinical research study that is in
an approved research study)
• Value Code D4 with an 8-digit clinical trial number (optional, institutional claims only)
Medicare contractors will return to provider/return as unprocessable your PRP claims that do not include
ALL these diagnosis coding and additional billing requirements:
Should they return your PRP claims for the treatment of chronic non-healing diabetic, venous and/or pressure
wounds only in the context of an approved clinical study, they will use the following messages:
• CARC 16 - “Claim/service lacks information which is needed for adjudication.”
• RARC M16 - “Alert: See our Web site, mailings, or bulletins for more details concerning this policy/
procedure/decision.” and
• RARC MA130 – “Your claim contains incomplete and/or invalid information, and no appeal rights are
afforded because the claim is unprocessable. Please submit a new claim with the complete/correct
information.”
May 2013
- page 64 -
Type of Bill
Your contractor will pay claims for PRP services in the following settings:
• Hospital outpatient departments Type of Bills (TOB) 12X and 13X based on OPPS;
• Skilled Nursing Facilities (SNF) TOBs 22X and 23X based on MPFS;
• Rural Health Clinics (RHC) TOB 71X based on all inclusive;
• Comprehensive Outpatient Rehabilitation Facilities (CORF) TOB 75X based on MPFS;
• Federally Qualified Health Centers (FQHC) TOB 77X based on all-inclusive,
• Critical Access Hospitals (CAH) TOB 85X based on reasonable cost, and
• CAHs TOB 85X and revenue codes 096X, 097X, or 098X based on MPFS.
They will pay for PRP services in Maryland hospitals under the jurisdiction of the Health Services Cost Review
Commission (HSCRC) on an outpatient basis, TOB 13X, in accordance with the terms of the Maryland waiver.
Contractors will deny claims for PRP services (HCPCS code G0460) when provided on other than TOBs 12X, 13X,
22X, 23X, 71X, 75X, 77X, and 85X using:
• CARC 58 – “Treatment was deemed by the payer to have been rendered in an inappropriate or invalid
place of service. NOTE: Refer to the 832 Healthcare Policy Identification Segment (loop 2110 Service
payment Information REF), if present”;
• RARC N428 – “Service/procedure not covered when performed in this place of service”; and
• Group Code: CO
Place of Service (POS) Professional Claims
Effective for claims with dates of service on or after August 2, 2012, you should use place of service (POS)
codes 11 (Office), 22 (Outpatient Hospital), and 49 (Independent Clinic) for PRP services. Your contractor will
deny all other POS codes using the following messages:
• CARC 58 – “Treatment was deemed by the payer to have been rendered in an inappropriate or invalid
place of service”;
• RARC N428 – “Service/procedure not covered when performed in this place of service”; and
• Group Code: CO.
Note: Contractors will not retroactively adjust claims from August 2, 2012, through the implementation
of this CR. However, contractors may adjust claims that are brought to their attention.
CR 8213 is being released in two transmittals which may be found at:
• http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R152NCD.pdf and
• http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2666CP.pdf on
the CMS website.
Both transmittals (R152NCD and R2666CP) contain a listing of relevant ICD-9 and ICD-10 diagnostic codes.
You can find information regarding clinical trials in the Claims Processing Manual, Chapter 32, Section 69
(Qualifying Clinical Trails), for information regarding clinical trials, at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c32.pdf on the CMS
website.
If you have any questions, please contact your FI, carrier or A/B MAC at their toll-free number, which may
This season, flu activity started early and has placed a significant burden on people 65 years of age and older. In fact,
so far this season, CDC has reported nearly four times more hospitalizations among people 65 and older than occurred
during the entire 2011-2012 season. The CDC recommends that vaccination efforts continue as long as influenza viruses
are circulating. People 65 years of age and older, as well as their close contacts and caregivers, should be vaccinated;
and should seek medical treatment with antiviral drugs as soon as symptoms appear in order to reduce serious
complications from flu infection, including hospitalizations, intensive care unit (ICU) admissions and deaths.
- page 65 -
May 2013
• MLN Matters® Article #MM8047, “Influenza Vaccine Payment Allowances - Annual Update for
• 2012-2013 Season”.
• CDC article Seniors among Seniors among Groups Hardest Hit by Flu this Season
MM8237 - April 2013 Update of the Ambulatory Surgical Center
(ASC) Payment System
News Flash –
Revised product from the Medicare Learning Network® (MLN)
• “Ambulatory Surgical Center Fee Schedule,” Fact Sheet, ICN 006819, downloadable
This MLN Matters® article is intended for Ambulatory Surgical Centers (ASCs) submitting claims to Medicare
Contractors (Carriers or Part B Medicare Administrative Contractors (Part B MACs)) for ASC payment system-paid
services provided to Medicare beneficiaries.
Change Request (CR) 8237 describes changes to and billing instructions for various payment policies
implemented in the April 2013 Ambulatory Surgical Center (ASC) payment system update, and it applies to the
“Medicare Claims Processing Manual,” Chapter 14, section 10. See the Background and Additional Information
Sections of this article for further details regarding these changes.
Background
CR8237 describes changes to and billing instructions for various payment policies implemented in the April
2013 ASC payment system update. Key changes to and billing instructions for various payment policies
implemented in the April 2013 ASC payment system update are as follows:
N ew H ealt h care Com m on P rocedu re Codin g Sy st em (H CP CS) P rocedu re
Codes
The new HCPCS procedure code listed in Table 1 below (also included as Attachment A of CR8237)
is assigned for payment under the ASC Payment System effective April 1, 2013.
Table 1 – New HCPCS Procedure Code
HCPCS
Effective
Date
Short
Descriptor
Long Descriptor
ASC PI
C9735
04-01-13
Anoscopy,
submucosal inj
Anoscopy; with directed submucosal
injection(s), any substance
G2
May 2013
- page 66 -
Billing for Drugs, Biologicals, and Radiopharmaceuticals
Drugs and Biologicals with Payments Based on Average Sales Price (ASP) Effective April 1, 2013
Payments for separately payable drugs and biologicals based on ASPs are updated on a quarterly basis as later
quarter ASP submissions become available. In cases where adjustments to payment rates are necessary based
on the most recent ASP submissions, the Centers for Medicare & Medicaid Services (CMS) will incorporate
changes to the payment rates in the April 2013 ASC DRUG FILE. The updated payment rates, effective April 1,
2013, will be included in the April 2013 update of the ASC Addendum BB, which will be posted at http://www.
cms.gov/Medicare/Medicare-Fee-for-Service- Payment/ASCPayment/ASC-Regulations-and-Notices.html on the
Centers for Medicare & Medicaid Services (CMS) website.
Drugs and Biologicals with OPPS Pass-Through Status Effective April 1, 2013
Five drugs and biologicals have been granted ASC payment status effective April 1, 2013. These items, along
with their descriptors and APC assignments, are identified in Table 2, below (also included as Attachment A,
CR8237).
Table 2 – New HCPCS Codes Effective for Certain Drugs, Biologicals, and
Radiopharmaceuticals Effective April 1, 2013
HCPCS Code
Long Descriptor
ASC PI
C9130*
Injection, immune globulin (Bivigam), 500 mg
K2
C9297*
Injection, omacetaxine mepesuccinate, 0.01 mg
K2
C9298*
Injection, ocriplasmin, 0.125 mg
K2
J7315
Mitomycin, ophthalmic, 0.2 mg
K2
Q4127
Talymed, per square centimeter
K2
Note: The HCPCS codes identified with an “*” indicate that these are new codes effective April 1, 2013.
Additional Information on HCPCS Code C9298 (Injection, Ocriplasmin, 0.125 mg):
Jetrea (ocriplasmin) is packaged in a sterile, single-use vial containing 0.5 mg ocriplasmin in a 0.2 mL solution
for intravitreal injection (2.5 mg/mL). As approved by the U.S. Food and Drug Administration (FDA), the
recommended dose for Jetrea (NDC 24856-0001-00) is 0.125 mg. Use of the contents of an entire single-use
vial to obtain one recommended dose for one eye of one patient per the FDA- approved label would result in
reporting 4 units of C9298 on a claim.
In addition, as indicated in the Code of Federal Regulations, Title 42 (Public Health), Part 414 (Payment for Part B
Medical and Other Health Services), Subpart K (Payment for Drugs and Biologicals Under Part K), CMS calculates
an average sales price (ASP) payment limit based on the amount of product included in a vial or other container
as reflected on the FDA-approved label, and any additional product contained in the vial or other container
does not represent a cost to providers and is not incorporated into the ASP payment limit. In addition, no
payment is made for amounts of product in excess of that reflected on the FDA-approved label. See 42 CFR
414.904 at http://www.ecfr.gov/cgi-bin/text- idx?c=ecfr&SID=95a35802cef2dd89565a03c3542c5b18&rg
n=div5&view=text&node=42:3.0.1.1.1&idno=42 on the Internet.
Additional Information Related to HCPCS Code J7315 (Mitomycin, ophthalmic, 0.2 mg):
HCPCS Code J7315 should only be used for Mitosol and should not be used for compounded mitomycin or
other forms of mitomycin.
- page 67 -
May 2013
Flucelvax (Influenza virus vaccine)
Flucelvax (Influenza virus vaccine) was approved by the FDA on November 20, 2012. Although this vaccine
recently received FDA approval, CPT code 90661, which was established by the CPT Editorial Panel effective
January 1, 2008, describes Flucelvax. Since January 1, 2008, CPT code
90661 (Flu vacc cell cult prsv free) has been assigned to ASC payment indicator “Y5” (Nonsurgical procedure/
item not valid for Medicare purposes because of coverage, regulation and/or statute; no payment made)
because the product associated with this code had not received FDA approval until recently. CMS is revising
the ASC payment indicator for CPT code 90661 from “Y5” to “L1” (Influenza vaccine; pneumococcal vaccine.
Packaged item/service; no separate payment made.) effective
November 20, 2012. This change will be reflected in the April 2013 ASC PI file.
Updated Payment Rates for Certain Drug, Biological, and Radiopharmaceutical HCPCS Codes
Effective January 1, 2013, through March 31, 2013
The payment rates for two HCPCS codes: J9263 and Q4106 were incorrect in the January 2013 ASC Drug File.
The corrected payment rates are listed in Table 3 below (also included as Attachment A of CR8237), and they
have been installed in the revised January 2013 ASC Drug File, effective for services furnished on January 1,
2013, through March 31, 2013. Suppliers who received an incorrect payment for dates of service between
January 1, 2013, and March 31, 2013, may request contractor adjustment of the previously processed claims.
Table 3 – Updated Payment Rates for Certain Drugs, Biologicals, and Radiopharmaceuticals
HCPCS Codes Effective January 1, 2013 through March 31, 2013
HCPCS Code
Short Descriptor
Corrected
Payment Rate
ASC PI
J9263
Oxaliplatin
$3.95
K2
Q4106
Dermagraft
$42.55
K2
The official instruction, CR 8237 issued to your carrier and Part B MAC, regarding this change may be viewed at http://
www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2662CP.pdf on the CMS website.
If you have any questions, please contact your carrier or Part B MAC at their toll-free number, which may
MM8246 - Quarterly Update of HCPCS Codes Used for Home Health
Consolidated Billing Enforcement
News Flash REVISED products from the Medicare Learning Network® (MLN)
“Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services”, Fact Sheet, ICN 904084,
Downloadable
This MLN Matters® Article is intended for providers and suppliers who submit claims to Medicare contractors
(Durable Medical Equipment Medicare Administrative Contractors (DME MACs), Fiscal Intermediaries (FIs), A/B
Medicare Administrative Contractors (A/B MACs), and/or Regional Home Health Intermediaries (RHHIs)) for
services provided to Medicare beneficiaries.
May 2013
- page 68 -
This article is based on Change Request (CR) 8246 which provides the annual update to Home Health (HH)
consolidated billing effective July 1, 2013. CR 8246 adds the following HCPCS codes to the HH consolidated
billing therapy code list: G0456 (Negative pressure wound therapy, (e.g., vacuum assisted drainage collection)
using a mechanically-powered device, not durable medical equipment, including provision of cartridge and
dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total
wound(s) surface area less than or equal to 50 square centimeters) and G0457 (Negative pressure wound
therapy, (e.g., vacuum assisted drainage collection) using a mechanically-powered device, not durable medical
equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and
instructions for ongoing care, per session; total wound(s) surface area greater than 50 sq cm).
Background
The Social Security Act (Section 1842(b)(6); see http://www.ssa.gov/OP_Home/ssact/title18/1842.htm on
the Internet) requires that payment for home health services provided under a home health plan of care is
made to the home health agency (HHA). This requirement is found in Medicare regulations at 42 CFR 409.100
(see http://www.ecfr.gov/cgi-bin/text- idx?c=ecfr&SID=e49c86165ce00a5c3e044053adf4c2d0&rgn=div5&view
=text&node=42:2.0.1.2.9&idno=42 on the Internet) and in the Medicare Claims Processing Manual (Chapter 10,
Section 20; see http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c10.pdf
on the Centers for Medicare & Medicaid Services (CMS) website).
CMS 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).
Services appearing on this list (that 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 an HHA), with the exception of the following:
•
Therapies performed by physicians;
•
Supplies incidental to physician services; and
•
Supplies used in institutional settings.
Medicare will only directly reimburse the primary HHAs that have opened such episodes during the episode periods.
The following are not subject to HH consolidated billing:
•
Therapies performed by physicians,
•
Supplies incidental to physician services, and
•
Supplies used in institutional settings.
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.
These new codes were effective January 1, 2013, but were overlooked in the annual HH consolidated billing
update published in CR8043 (see the related article at http://www.cms.gov/Outreach-and- Education/
Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8043.pdf on the CMS website).
The following HCPCS codes are added to the HH consolidated billing therapy code list effective for claims with
dates of service on or after July 1, 2013:
•
G0456 - Negative pressure wound therapy, (e.g., vacuum assisted drainage collection) using a
mechanically-powered device, not durable medical equipment, including provision of cartridge and
dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session;
total wound(s) surface area less than or equal to 50 square centimeters;
- page 69 -
May 2013
•
G0457 - Negative pressure wound therapy, (e.g., vacuum assisted drainage collection) using a
mechanically-powered device, not durable medical equipment, including provision of cartridge and
dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session;
total wound(s) surface area greater than 50 sq cm.
The official instruction, CR8246 issued to your DME MACs, FIs, RHHIs, and A/B MACs regarding this change, may
be viewed at http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2672CP.pdf
on the CMS website.
If you have any questions, please contact your DME MAC, FI, RHHI or A/B MAC at their toll-free number, which
may be found at http://www.cms.gov/Research-Statistics-Data-and- Systems/Monitoring-Programs/providercompliance-interactive-map/index.html on the CMS website.
long as influenza
viruses are circulating. People 65 years of age and older, as well as their close contacts and caregivers, should
be vaccinated; and should seek medical treatment with antiviral drugs as soon as symptoms appear in order to
reduce serious complications from flu infection, including hospitalizations, intensive care unit (ICU) admissions
and deaths.
Part D- covered drugs.
• CDC article Seniors among Groups Hardest Hit by Flu this Season
MM8247 - July 2013 Quarterly Average Sales Price (ASP) Medicare
Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
News Flash Revised product from the Medicare Learning Network® (MLN)
• “Medicare Vision Services,” Fact Sheet, ICN 907165, Downloadable only.
contractors (carriers, Fiscal Intermediaries (FIs), A/B Medicare Administrative Contractors (A/B MACs), Durable
Medical Equipment Medicare Administrative Contractors (DME MACs), and/or Regional Home Health
Intermediaries (RHHIs)) for services provided to Medicare beneficiaries.
May 2013
- page 70 -
Medicare will use the July 2013 quarterly Average Sales Price (ASP) Medicare Part B drug pricing files to
determine the payment limit for claims for separately payable Medicare Part B drugs processed or reprocessed
on or after July 1, 2013, with dates of service July 1, 2013, through September 30, 2013.
Also, Change Request (CR) 8247, from which this article is taken, instructs your Medicare contractors to
download and implement the July 2013 ASP Medicare Part B drug pricing file for Medicare Part B drugs and, if
released by the Centers for Medicare & Medicaid Services (CMS), to also download and implement the revised
April 2013, January 2013, October 2012, and July 2012 files.
Make sure that your billing staffs are aware of the release of these July 2013 ASP Medicare Part B drug files.
Background
The ASP methodology is based on quarterly data submitted to CMS by manufacturers. CMS will supply
Medicare contractors with the ASP and Not Otherwise Classified (NOC) drug pricing files for Medicare Part B
drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment System (OPPS)
are incorporated into the Outpatient Code Editor (OCE) through separate instructions that can be located in the
Medicare Claims Processing Manual (Chapter 4 (Part B Hospital (Including Inpatient Hospital Part B and OPPS)),
Section 50 (Outpatient PRICER); see http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/
downloads/clm104c04.pdf on the CMS website.
The following table shows how the quarterly payment files will be applied:
Files
July 2013 ASP and ASP NOC
Effective for Dates of Service
July 1, 2013, through September 30, 2013
April 2013 ASP and ASP NOC
April 1, 2013, through June 30, 2013
January 2013 ASP and ASP NOC
January 1, 2013, through March 31, 2013
October 2012 ASP and ASP NOC
October 1, 2012, through December 31, 2012
July 2012 ASP and ASP NOC
July 1, 2012, through September 30, 2012
The official instruction, CR 8247 issued to your FI, carrier, A/B MAC, RHHI or DME/MAC regarding this change
may be viewed at http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/
R2676CP.pdf on the CMS website.
If you have any questions, please contact your FI, carrier, A/B MAC, RHHI, or DME/MAC at their toll- free number,
which may be found at http://www.cms.gov/Research-Statistics-Data-and- Systems/Monitoring-Programs/
provider-compliance-interactive-map/index.html on the CMS website.
- page 71 -
May 2013
•
•
•
•
•
•
2012-2013 Seasonal Influenza Vaccines Pricing list.
MLN Matters® Article #MM8047, “Influenza Vaccine Payment Allowances - Annual Update for 20122013 Season”.
CDC article Seniors among Groups Hardest Hit by Flu this Season
Ordered and Referred Services (Phase II): Immediate Action Needed
to Prevent Claim Rejections
If you order or refer Medicare patients for services, or if you perform services based on these orders, please
review the following information closely. There are changes in the way the Medicare claims system will handle
claims for ordered and referred services. This includes, but is not limited to, claims for clinical laboratory tests
and radiology and imaging services.
Effective for dates of service on or after May 1, 2013: if the referring provider’s information (National
Provider Identifier (NPI) and name) is missing, incomplete, or invalid, or the ordering/referring provider
is not eligible to order or refer services under Medicare, claims for ordered/referred services will be
returned as unprocessable. These claims must be corrected and filed as new claims; they cannot be
appealed.
Who may order or refer items or services for Medicare beneficiaries?
• Physicians (MD, DO, DDS, DMD, DPM, OD (optometrists may only order and refer DMEPOS products/
services and laboratory and x-ray services under Medicare Part B))
• Physician Assistants
• Clinical Nurse Specialists
• Nurse Practitioners
• Clinical Psychologists
• Interns, Residents, and Fellows
• Certified Nurse Midwives
• Clinical Social Workers
Other important notes:
• Chiropractors are not eligible to order or refer supplies or services for Medicare beneficiaries.
• Services of Home Health Agencies may only be ordered or referred by an MD, DO, or DPM.
What this means to ordering/referring providers:
• Testing entities and other health care providers that perform services based on orders or referrals rely
on the information from the ordering/referring provider in order to file Medicare claims.
• Verify that your specialty is permitted to order or refer the services.
• You must be enrolled in in the CMS Provider Enrollment Chain and Ownership System (PECOS). If you
are not sure you are enrolled in this system, you may:
o Download the Medicare Ordering and Referring File from the CMS website and look for your
name and NPI, or
o Call the CGS Provider Contact Center at 866.276.9558 and ask if you have an enrollment record
that contains your NPI, or
o Access Internet PECOS for your record (no record means you do not have an enrollment record
in Medicare)
• Provide your individual NPI and the exact spelling of your name, as listed in PECOS, to the provider
who is performing services based on your order or referral.
May 2013
- page 72 -
What this means to providers who perform services based on orders or referrals (including laboratory,
radiology, and imaging services):
• Since October 2009 (Phase I), Medicare has included “warning messages” on remittance advices (RAs)
for claims that have a missing, incomplete, or invalid ordering provider name or NPI or that include
ordering/referring provider information for a provider specialty that is not eligible to order or refer:
o N264: missing/incomplete/invalid ordering provider name
o N265: missing/incomplete/invalid ordering provider primary identifier
• Effective for dates of service on or after May 1, 2013, these warning messages will result in claim
rejections as “unprocessable.”
• Act now: monitor your RAs to identify claims with remark codes N264 or N265.
o Contact the ordering/referring provider, as necessary, to obtain valid and complete information.
o Verify that the ordering/referring provider is listed in PECOS and is of a specialty permitted to
order/refer by downloading the Medicare Ordering and Referring File from the CMS website.
Note: this report is updated weekly, so check often.
o On your claim, enter the ordering/referring provider’s name exactly as it appears in the
provider’s record in PECOS. Do not include titles like “Dr.”
• Claims with missing, incomplete, or invalid ordering/referring provider information will be rejected as
unprocessable with remark codes MA130, CO-16, and N264 or N265.
For more information:
• Read CMS MLN Matters article SE1305 to learn more about the edits for ordering/referring providers.
• Internet-based PECOS
PAX6 Gene Sequencing: Coding and Claim Submission Guidelines
PAX6 is most frequently associated with PAX6-associated aniridia and WAGR syndrome (predisposition to
Wilms tumor, Aniridia, genitourinary anomalies and mental retardation). Because FISH probes are reported
to detect 100% of the WAGR syndrome cases, FISH probes represent the gold standard for patient diagnosis.
Although PAX6 sequencing will identify the underlying genetic mutation leading to the development of aniridia
in approximately 50% of individuals with sporadic disease, the remaining 50% will have negative test results.
Therefore, CGS has determined PAX6 gene sequencing does not support the required clinical utility for the
established Medicare benefit category and is a statutorily excluded test.
The following PAX6 gene sequencing test has been identified as non-covered:
Test
PAX6 Gene Sequencing and Deletion/Duplication
however, you may choose to submit claims (e.g., at the patient’s request). Claims for PAX6 gene sequencing
tests must include:
• The name of the test (PAX6):
Reference:
statutorily excluded services: CMS Beneficiary Notices Initiative webpage – Fee-For-Service (FFS)
ABN
- page 73 -
May 2013
Pervenio Lung RS Assay: Coding and Claim Submission Guidelines
CGS has determined that there is insufficient evidence to support the required clinical utility for Pervenio Lung
RS, an assay formerly known as Pinpoint Dx Lung, as an established Medicare benefit category. Therefore,
Pervenio lung RS assays are statutorily excluded services.
however, you may choose to submit claims (e.g., at the patient’s request). Claims for Pervenio lung RS assays
must include:
• CPT code 84999 – unlisted chemistry procedure
• The appropriate ICD-9-CM code(s)The name of the assay (Pervenio):
Reference:
statutorily excluded services: CMS Beneficiary Notices Initiative webpage – Fee-For-Service (FFS)
ABN
PreDx Diabetes Risk Score (DRS): Coding and Claim Submission
Guidelines
CGS has determined that there is insufficient evidence to support the required clinical utility for PreDx®
Diabetes Risk Score (DRS), developed by Tethys Bioscience, Inc. as an established Medicare benefit category.
Therefore, the PreDx® Diabetes Risk Score (DRS) is a statutorily excluded service. Health care providers are not required to submit claims to Medicare for statutorily non-covered services;
however, you may choose to submit claims (e.g., at the patient’s request). Claims for PreDx Diabetes risk Score
(DRS) tests must include:
• CPT code 84999 – unlisted chemistry procedure
• The appropriate ICD-9-CM code(s)The name of the test (PreDx DRS):
Reference:
Reduced Services (CPT Modifier 52) and Discontinued Procedures
(CPT modifier 53): Coding, Documenting, and Payment
As CGS reviews services submitted with CPT modifiers 52 (reduced service) and 53 (discontinued procedure),
we have identified helpful information about how payments are calculated when these modifiers are submitted
as well as submitting them appropriately and ensuring that you have proper supporting documentation.
May 2013
- page 74 -
CPT Modifier 52: Reduced Services
• This modifier is used to report a service or procedure that is partially reduced or eliminated at the physician’s
election.
• Submit CPT modifier 52 with the code for the reduced procedure.
• Do not submit CPT modifier 52 to report an elective cancellation of a procedure before anesthesia induction
and/or surgical preparation in the operating suite. You may not submit CPT modifier 52 if the procedure is
discontinued after administration of anesthesia.
• Do not submit CPT modifier 52 with Evaluation & Management (E/M) services.
Guidelines for claim submission and documentation:
• Submit the reason for the reduced service in the electronic documentation field (or, if you are approved
to submit paper claims, in Item 19).
• Check the CPT code requirements. For example, many ophthalmology codes are unilateral AND/OR
bilateral. Submitting CPT modifier 52 with one of these codes will result in an incorrect payment.
• Make sure you are submitting the correct modifier. If a procedure is a failed operative procedure
or a reduced operative procedure after induction of anesthesia and after the start of the operative
procedure, there are more appropriate modifiers to indicate cancelled or discontinued procedures.
o Ambulatory Surgery Centers (ASCs): refer to CPT modifiers 73 and 74.
o Physician claims for services performed in ASCs: refer to CPT modifier 53.
Payment:
• Payment for radiology services, including mammograms, will be reduced by 50%.
• Payment for surgical services will be reduced based on documentation of amount of service performed
and reason for reduced service. Please note: CGS may request additional documentation for surgical
service claims, such as an operative report.
• Payment for timed codes will be prorated based on the length of time for actual service, with a base
payment of 25% of the fee schedule amount.
CPT Modifier 53: Discontinued Procedures
• Submit CPT modifier 53 with surgical codes or medical diagnostic codes when the procedure is discontinued
because of extenuating circumstances.
• This modifier is used to report services or procedure when the services or procedure is discontinued after
anesthesia is administered to the patient.
• Do not submit CPT modifier 53 to report an elective cancellation of a procedure prior to the patient’s
anesthesia induction and/or surgical preparation in the operating suite.
• Do not submit CPT modifier 53 when a laparoscopic or endoscopic procedure is converted to an open
procedure.
Guidelines for claim submission and documentation:
• Submit the length/amount of procedure completed and reason for discontinuing service in the
electronic documentation field (or, if you are approved to submit paper claims, in Item 19).
Payment:
• Payment for discontinued procedures is based on percentage of service completed. Please note: CGS
may request additional documentation for these claims.
References:
• CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12:
o CPT modifier 52 cannot be submitted with E/M services: section 30.6.1.B
o How payment is calculated: sections 20.4.6 and 40.4
o Other information required for services submitted with CPT modifier 52: section 40.2.A.10
o CPT modifier 53 and incomplete colonoscopies: section 30.1.B
• CPT modifier 53 and incomplete screening colonoscopies: CMS Medicare Claims Processing Manual
(Pub. 100-04), chapter 18, section 60.2.A2
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May 2013
Revised: MM7260 - Modification to CWF, FISS, MCS and VMS to
Return Submitted Information When There is a CWF Name and HIC
Number Mismatch
News Flash:
REVISED product from the Medicare Learning Network® (MLN)
• “CMS Website Wheel,” Educational Tool, ICN 006212, Hard Copy.
Note: This article was revised on March 15, 2013, to reflect a revised Change Request (CR). The revised CR
restores the Common Working File (CWF) entitlement validation criterion (in bold below) used prior to the
implementation of CR 7260 (October 1, 2012). The implementation date for CR 7260 was changed to April 1,
2013.The Transmittal Number, CR release date, and web address of the CR also changed. All other information
remains the same.
This MLN Matters® Article is intended all physicians, providers, and suppliers submitting claims to Medicare
contractors (fiscal intermediaries (FIs), Regional Home Health Intermediaries (RHHIs), carriers, A/B Medicare
Administrative Contractors (MACs) and Durable Medical Equipment MACs or DME MACs) for Medicare
beneficiaries.
If Medicare systems reject a claim when there is a mismatch of the Health Insurance Claim Number
(HICN) with the beneficiary’s personal characteristics (such as name, sex or date of birth), your Medicare
contractor will return the claim to you as unprocessable with the identifying beneficiary information from the
submitted claim as follows
• Your contractor will return to provider (RTP) Part A claims.
• Your contractor will return as unprocessable Part B claims. Your contractor will use Reason Code 140
(Patient/Insured health identification number and name do not match).
When returning these claims as unprocessable, your contractor will utilize remittance advice codes MA130 and
MA61. Also, based on CR 7260, you will receive the beneficiary name information you originally submitted when
the claim is returned rather than the beneficiary data associated with the potentially incorrectly entered HICN.
Previously, Medicare returned the name of the beneficiary that is associated with that HICN within its files.
If an adjustment claim is received where the beneficiary’s name does not match the submitted HICN, your
contractor will suspend the claim and, upon their review, either correct, develop, or delete the adjustment, as
appropriate.
All providers should ensure that their billing staffs are aware of these changes.
The official instruction, CR 7260 issued to your FI, A/B MAC, and DME/MAC regarding this change may be
viewed at http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2670CP.pdf on
the Centers for Medicare & Medicaid Services (CMS) website.
If you have any questions, please contact your carrier, A/B MAC, or DME MAC at their toll-free number, which
May 2013
- page 76 -
REVISED: MM7441 - Magnetic Resonance Imaging (MRI) in Medicare
Beneficiaries with Food and Drug Administration (FDA)-Approved
Implanted Permanent Pacemakers (PMs) for Use in the MRI Environment
News Flash – All providers and suppliers who enrolled in the Medicare program prior to March 25,
2011, will have their enrollment revalidated under new risk screening criteria required by the Affordable Care
Act (Section 6401a). Do NOT send in revalidated enrollment forms until you are notified to do so by your
Medicare Administrative Contractor. You will receive a notice to revalidate between now and March
2013. For more information about provider revalidation, review MLN Matters® Special Edition Article SE1126,
which can be found at http://www.cms.gov/Outreach-and-Education/Medicare-Learning- Network-MLN/
MLNMattersArticles/downloads/SE1126.pdf on the Centers for Medicare & Medicaid Services (CMS) website.
Note: This article was revised on March 22, 2013, to add a reference to article SE1239 at http://www.cms.gov/
Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/SE1239.pdf on
the CMS website. SE1239 announces the revised ICD-10 implementation date of October 1, 2014. All other
information is the same.
Physicians, providers, and suppliers who bill Medicare contractors (Fiscal Intermediaries (FI), Carriers, or A/B
Medicare Administrative Contractors (A/B MAC)) for providing Magnetic Resonance Imaging (MRI) services to
Medicare beneficiaries are affected.
This article, based on Change Request (CR) 7441, informs you that Medicare believes that the evidence
is adequate to conclude that MRIs improve health outcomes for Medicare beneficiaries with implanted
Pacemakers (PMs) when the PMs are used according to the Food and Drug Administration (FDA)-approved
labeling for use in an MRI environment. Effective for services on or after July 7,
2011, Medicare will allow coverage of MRIs for beneficiaries with implanted PMs when the PMs are used
according to the FDA-approved labeling for use in an MRI environment.
Effective for claims with dates of service on or after July 7, 2011, you should include the following information
on MRI claims for beneficiaries with implanted PMs that are FDA-approved for use in an MRI environment:
•
•
•
Appropriate MRI code;
KX modifier; and
ICD-9 code V45.01 (cardiac pacemaker).
Inclusion of the KX modifier on the claim line(s) means that the provider attests that documentation is on file
verifying that FDA-approved labeling requirements are met. For such claims without the KX modifier, Medicare
will deny MRI line items using the following remittance advice messages:
•
•
Group Code of CO (contractual obligation); and
Claim Adjustment Reason Code (CARC) 188 (This product/procedure is only covered when used
according to FDA recommendations.).
As described previously in the MLN Matters® article MM7296 (http://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7296.pdf ), Medicare posted a separate
decision on February 24, 2011, that allows coverage of MRIs for beneficiaries with implanted PMs or implantable
cardioverter defibrillators (ICDs) for use in an MRI environment in a Medicare-approved clinical study. This
policy is effective for claims with dates of service on and after February 24, 2011. Providers should follow the
instructions issued in the MM7296 article and the additional instructions referenced below.
- page 77 -
May 2013
The following information should be included on MRI claims for beneficiaries with implanted PMs or ICDs for
use in an MRI environment in a Medicare-approved clinical study:
•
•
•
•
•
Appropriate MRI code;
Q0 modifier;
ICD-9 code V70.7 - Examination of participant in clinical trial (institutional claims only);
Condition code 30 (institutional claims only); and
ICD-9 code V45.02 (automatic cardiac defibrillator) or CPT code V45.01 (cardiac pacemaker).
MRI claims for beneficiaries with implanted PMs or ICDs for use in an MRI environment in a Medicare-approved
clinical study that do not include all the line items listed above will be denied using the following remittance
messages:
•
•
•
Group Code of CO;
CARC B5 (Coverage/program guidelines were not met or were exceeded); and
Remittance Advice Remarks Code (RARC) N386 (This decision was based on a National Coverage
Determination (NCD). An NCD provides a coverage determination as to whether a particular item
or service is covered. A copy of this policy is available at http://www.cms.gov/medicare-coveragedatabase/overview-and-quick-search.aspx on the CMS website. If you do not have web access, you may
contact the contractor to request a copy of the NCD).
Providers are reminded that ICD-10 implementation occurs on October 1, 2013. At that time the ICD-9 codes
mentioned above will be replaced by the appropriate ICD10 codes, which are:
•
•
•
ICD-10 - Z006 - Encounter for examination for normal comparison and control in clinical research
program;
ICD-10- Z950 - Presence of cardiac pacemaker; and
ICD-10- Z95810 - Presence of automatic implantable cardiac defibrillator.
Medicare payment for these services is as follows:
• Professional claims (practitioners and suppliers) - based on the Medicare Physician Fee Schedule
(MPFS).
• Inpatient (Type of Bill (TOB) 11x) - Prospective payment system (PPS), based on the diagnosis-related
group.
• Hospital outpatient departments (TOB 13x) - Outpatient PPS, based on the ambulatory payment
classification.
• Rural Health Clinics (RHCs)/Federally Qualified Health Centers (FQHCs) (TOB
• 71x/77x) - All-inclusive rate, professional component only, based on the visit furnished to the RHC/
FQHC beneficiary to receive the MRI. The technical component is outside the scope of the RHC/FQHC
benefit. Therefore the provider of the technical service bills their carrier or A/B MAC on the ANSI X12N
• 837P or hardcopy Form CMS-1500 and payment is made under the MPFS.
• Critical Access Hospitals (CAHs) (85x) - For CAHs that elected the optional method of payment for
outpatient services, the payment for technical services would be the same as the CAHs that did
not elect the optional method, which is reasonable cost. The FI or A/B MAC pays the professional
component at 115% of the MPFS.
Medicare will not adjust claims automatically that were processed prior to implementation of CR7441. However,
they will adjust such claims that you bring to the attention of your Medicare contractor.
Please be sure that your staffs are aware of these changes.
To view the article, MM7296, “Magnetic Resonance Imaging (MRI) in Medicare Beneficiaries with Implanted
Permanent Pacemakers (PMs) or Implantable Cardioverter Defibrillators (ICDs),” visit http://www.cms.gov/
Outreach-and- Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/MM7296.pdf on
the CMS website.
May 2013
- page 78 -
The official instruction, CR 7441, was issued to your FI, carrier, or A/B MAC regarding this change in two
transmittals. The first modified the National Coverage Determinations Manual and is at http://www.cms.gov/
Regulations-and- Guidance/Guidance/Transmittals/downloads/R135NCD.pdf on the CMS website.
The second updates the Medicare Claims Processing Manual and is at http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/downloads/R2307CP.pdf on the CMS website.
If you have any questions, please contact your FI, carrier, or A/B MAC at their toll-free number, which may
be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/providercompliance-interactive-map/index.html on the CMS website.
For current information on the new ICD-10 implementation date of October 1, 2014, see article SE1239 at http://
www.cms.gov/Outreach-and-Education/Medicare- Learning-Network-MLN/MLNMattersArticles/Downloads/
SE1239.pdf on the CMS website.
Revised: MM7492 - Medicare Fee-For-Service (FFS) Claims Processing
Guidance for Implementing International Classification of Diseases,
10th Edition (ICD-10)
News Flash – The new publication titled “Providing the Annual Wellness Visit” is now available in downloadable
format from the Medicare Learning Network® at http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNProducts/Downloads/AnnualWellnessVisit-ICN907786.pdf on the Centers for
Medicare & Medicaid Services (CMS) website. This brochure is designed to provide education on the Annual
Wellness Visit, providing Personalized Prevention Plan Services, at no cost to the beneficiary, so beneficiaries can
work with their physicians to develop and update their personalized prevention plan.
Note: This article was revised on March 27, 2013, to add a reference to article MM8207 (http://www.cms.gov/
Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM8207.pdf ) to
alert DMEPOS providers and suppliers of modifications being made to the claims processing systems to report
the appropriate NCD/LCD captured during claims processing based on their associations with either ICD-9 or
ICD-10 diagnosis codes, the claim line service date, and the and the ICD-10 diagnosis code effective date. This
article was previously revised on March 21, 2013, to add a reference to article SE1239 at http://www.cms.
gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/SE1239.pdf
on the CMS website. SE1239 announces the revised ICD-10 implementation date of October 1, 2014. All
other information remains unchanged.
This article is for all physicians, providers, and suppliers submitting claims to Medicare contractors (carriers,
Fiscal Intermediaries (FIs) and/or Part A/B Medicare Administrative Contractors (MACs), Regional Home Health
Intermediaries (RHHIs), and Durable Medical Equipment MACs (DME MACs)) for services provided to
For dates of service on and after October 1, 2013, entities covered under the Health Insurance Portability and
Accountability Act (HIPAA) are required to use the ICD-10 code sets in standard transactions adopted under
HIPAA. The HIPAA standard health care claim transactions are among those for which ICD-10 codes must be
used for dates of service on and after October 1, 2013. Make sure your billing and coding
staffs are aware of these changes.
Key Points of CR7492
• General Reporting of ICD-10
- page 79 -
May 2013
As with ICD-9 codes today, providers and suppliers are still required to report all characters of a valid ICD-10
code on claims. ICD-10 diagnosis codes have different rules regarding specificity and providers/suppliers are
required to submit the most specific diagnosis codes based upon the information that is available at the time.
Please refer to http://www.cms.gov/Medicare/Coding/ICD10/index.html for more information on the format
of ICD-10 codes. In addition, ICD-10 Procedure Codes (PCs) will only be utilized by inpatient hospital claims as is
currently the case with ICD-9 procedure codes.
• General Claims Submissions Information
ICD-9 codes will no longer be accepted on claims (including electronic and paper) with FROM dates of service (on
professional and supplier claims) or dates of discharge/through dates (on institutional claims) on or after October 1,
2013. Institutional claims containing ICD-9 codes for services on or after October 1, 2013, will be Returned to Provider
(RTP). Likewise, professional and supplier claims containing ICD-9 codes for dates of services on or after October 1, 2013,
will also be returned as unprocessable. You will be required to re-submit these claims with the appropriate ICD-10 code.
A claim cannot contain both ICD-9 codes and ICD-10 codes. Medicare will RTP/return as unprocessable all claims that
are billed with both ICD-9 and ICD-10 diagnosis codes on the same claim. For dates of service prior to October 1, 2013,
submit claims with the appropriate ICD-9 diagnosis code. For dates of service on or after October 1, 2013, submit with
the appropriate ICD-10 diagnosis code. Likewise, Medicare will also RTP/return as unprocessable all claims that are billed
with both ICD-9 and ICD-10 procedure codes on the same claim. For claims with dates of service prior to October 1,
2013, submit with the appropriate ICD-9 procedure code. For claims with dates of service on or after October 1, 2013,
submit with the appropriate ICD-10 procedure code. Remember that ICD-10 codes may only be used for services
provided on or after October 1, 2013. Institutional claims containing ICD-10 codes for services prior to October 1, 2013,
will be Returned to Provider (RTP). Likewise, professional and supplier claims containing ICD-10 codes for services prior
to October 1, 2013, will be returned as unprocessable. Please submit these claims with the appropriate ICD-9 code.
• Claims that Span the ICD-10 Implementation Date
The Centers for Medicare & Medicaid Services (CMS) has identified potential claims processing issues for
institutional, professional, and supplier claims that span the implementation date; that is, where ICD-9 codes
are effective for the portion of the services that were rendered on September 30, 2013, and earlier and where
ICD-10 codes are effective for the portion of the services that were rendered October 1, 2013, and later. In some
cases, depending upon the policies associated with those services, there cannot be a break in service or time
(i.e., anesthesia) although the new ICD-10 code set must be used effective October 1, 2013. The following tables
provide further guidance to providers for claims that span the periods where ICD-9 and ICD-10 codes may both
be applicable.
Table A – Institutional Providers
Bill
Facility Type/Services
Type(s)
11X
12X
13X
Claims Processing Requirement
Use FROM or
THROUGH Date
Inpatient Hospitals (incl. TERFHA
If the hospital claim has a discharge and/or
THROUGH
hospitals, Prospective Payment
through date on or after 10/1/13, then the
System (PPS) hospitals, Long Term entire claim is billed using ICD-10.
Care Hospitals (LTCHs), Critical Access
Hospitals (CAHs)
Inpatient Part B Hospital
Split Claims - Require providers split the claim FROM
Services
so all ICD-9 codes remain on one claim with
Dates of Service (DOS) through 9/30/2013 and
all ICD-10 codes placed on the other claim with
DOS beginning 10/1/2013 and later.
Outpatient Hospital
May 2013
- page 80 -
14X
Non-patient Laboratory
Services
18X
Swing Beds
If the [Swing bed or SNF] claim has a discharge THROUGH
and/or through date on or after 10/1/13, then
the entire claim is billed using ICD-10.
21X
Skilled Nursing (Inpatient Part A)
If the [Swing bed or SNF] claim has a discharge THROUGH
and/or through date on or after 10/1/13, then
the entire claim is billed using ICD-10.
22X
Skilled Nursing Facilities
(Inpatient Part B)
23X
Skilled Nursing Facilities
(Outpatient)
32X
Home Health (Inpatient Part B)
3X2
Home Health – Request for
Anticipated Payment (RAPs)*
Allow HHAs to use the payment group code
THROUGH
derived from ICD-9 codes on claims which
span 10/1/2013, but require those claims to be
submitted using ICD-10 codes.
* NOTE - RAPs can report either an ICD-9 code *See Note
or an ICD-10 code based on the one (1) date
reported. Since these dates will be equal to
each other, there is no requirement needed.
The corresponding final claim, however, will
need to use an ICD-10 code if the HH episode
spans beyond 10/1/2013.
34X
Home Health – (Outpatient )
71X
Rural Health Clinics
72X
End Stage Renal Disease
(ESRD)
73X
Federally Qualified Health
Clinics (prior to 4/1/10)
Split Claims - Require providers split the claim so
all ICD-9 codes remain on one claim with Dates
of Service (DOS) through 9/30/2013 and all ICD10 codes placed on theo ther claim with DOS
beginning 10/1/2013 and later.
N/A – Always ICD-9 code set.
FROM
N/A
- page 81 -
May 2013
Bill
Type(s)
74X
75X
76X
77X
81X
82X
83X
85X
Facility Type/Services Claims Processing Requirement
Use FROM or
THROUGH Date
Split Claims - Require providers split the claim so all
ICD-9 codes remain on one claim with Dates of Service
Outpatient Therapy
(DOS) through 9/30/2013 and all ICD-10 codes placed FROM
on the other claim with DOS beginning 10/1/2013 and
later.
Comprehensive
Outpatient
Rehab facilities
later.
Community Mental
Health
Clinics
later.
Federally Qualified
Health
Clinics (effective 4/4/10) on the other claim with DOS beginning 10/1/2013 and
later.
Hospice- Hospital
later.
Hospice – Non hospital (DOS) through 9/30/2013 and all ICD-10 codes placed FROM
later.
Hospice – Hospital
N/A
N/A
Based
Critical Access Hospital (DOS) through 9/30/2013 and all ICD-10 codes placed FROM
later.
Table B - Special Outpatient Claims Processing Circumstances
Scenario
Use FROM or THROUGH
Date
3-day /1-day Payment Since all outpatient services (with a few exceptions) are
THROUGH
Window
required to be bundled on the inpatient bill if rendered within
three (3) days of an inpatient stay; if the inpatient hospital
discharge is on or after 10/1/2013, the claim must be billed
with ICD-10 for those bundled outpatientm services.
May 2013
- page 82 -
Table C – Professional Claims
Type of Claim
Use FROM or
THROUGH Date
All anesthesia claims
Anesthesia procedures that begin on 9/30/13 but end on
10/1/13 are to be billed with ICD-9 diagnosis codes and use
9/30/13 as both the FROM and THROUGH date.
FROM
Table D –Supplier Claims
Use FROM or
THROUGH/TO Date
Supplier Type
DMEPOS
Billing for certain items or supplies (such as capped rentals or
monthly supplies) may span the ICD-10 compliance date of
FROM
10/1/13 (i.e., the FROM date of service occurs prior to 10/1/13
and the TO date of service occurs after 10/1/13).
The official instruction, CR7492 issued to your carrier, FI, RHHI, or MAC regarding this change may be viewed at http://
www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R950OTN.pdf on the CMS website.
See article MM7818, available at http://www.cms.gov/outreach-and-education/medicare-learning- networkmln/mlnmattersarticles/downloads/MM7818.pdf, for information on the creation and updating of hard-coded
Medicare shared system edits that contain ICD-9 diagnosis codes with comparable ICD-10 diagnosis codes and
the operational changes needed to implement the conversion.
If you have any questions, please contact your carrier, FI, RHHI, or MAC at their toll-free number, which may
For current information on the new ICD-10 implementation date of October 1, 2014, see article SE1239
at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/
Downloads/SE1239.pdf on the CMS website.
Revised: MM8010 - Update To Publication 100-04, Claims Processing
Instructions For Chapter 12, Non-Physician Practitioners (NPPs)
News Flash – In September 2012, the Centers for Medicare & Medicaid Services (CMS) announced the availability of
a new electronic mailing list for those who refer Medicare beneficiaries for Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS). Referral agents play a critical role in providing information and services to
Medicare beneficiaries. To ensure you give Medicare patients the most current DMEPOS Competitive Bidding Program
information, CMS strongly encourages you to review the information sent from this new electronic mailing list. In
addition, please share the information you receive from the mailing list and the link to the “mailing list for referral
agents” subscriber webpage with others who refer Medicare beneficiaries for DMEPOS. Thank you for signing up!
Note: This article was revised on February 11, 2013, to reflect a revised CR8010 issued on February 7.
The CR was modified to clarify that modifiers AH and AJ are not being eliminated, but will no longer
be required to be submitted. The article was adjusted accordingly. In addition, the CR release date,
Transmittal number, and the Web address for accessing the CR have been revised. All other information
remains the same.
- page 83 -
May 2013
This MLN Matters® Article affects Non-Physician Practitioners (NPPs), i.e., Physicians Assistants (PAs), Nurse
Practitioners (NPs), Clinical Nurse Specialists (CNSs), Clinical Psychologists (CPs), and Clinical Social Workers
(CSWs) submitting claims to Medicare contractors (carriers and A/B Medicare Administrative Contractors
(MACs)) for services to Medicare beneficiaries.
Change Request (CR) 8010 deletes and/or corrects obsolete and erroneous billing information in Chapter 12 of
the “Medicare Claims Processing Manual” as it relates Claims Processing Instructions for PAs, NPs, CNSs, CPs, and
CSWs. Make sure that your billing staffs are aware of these changes.
Background
Key manual revisions/updates conveyed in CR8010 are as follows:
•
NPP assistant-at-surgery services should be billed with the “AS” modifier only.
•
The health professional shortage area (HPSA) payment modifiers, “QB” and “QU” have been eliminated
because they are no longer valid.
•
The “AH” modifier for CPs and the “AJ” modifier for CSWs will no longer need to be submitted because
they are no longer necessary for identification purposes.
•
The correct payment amount for the professional services of PAs, NPs and CNSs is 80 percent of the
lesser of the actual charge or, 85 percent of what a physician is paid under the Medicare Physician Fee
Schedule (MPFS).
•
Additionally, the correct payment amount for assistant-at-surgery services furnished by PAs, NPs and
CNSs is 80 percent of the lesser of the actual charge or, 85 percent of 16 percent of what a physician is
paid under the MPFS for surgical services.
•
Procedures billed with the assistant-at-surgery physician modifiers -80, -81, -82, or the AS modifier for
physician assistants, nurse practitioners and clinical nurse specialists, are subject to the assistant-atsurgery policy. Accordingly, Medicare will pay claims for procedures with these modifiers only if the
services of an assistant-at-surgery are authorized.
•
Medicare’s policies on billing patients in excess of the Medicare allowed amount apply to assistant-atsurgery services.
•
When a PA, NP, or CNS furnishes services to a patient during a global surgical period, Medicare
contractors shall determine the level of PA, NP, or CNS involvement in furnishing part of the surgeon’s
global surgical package consistent with their current practice for processing such claims.
•
Billing requirements and adjudication of claims requirements for global surgeries are under chapter 12,
sections 40.2 and 40.4 of the “Medicare Claims Processing Manual.”
•
PAs must have their own “nonphysician practitioner” national provider identification (NPI) number. This
NPI is used for identification purposes only when billing for PA services, because only an appropriate PA
employer or a provider/supplier for whom the PA furnishes services as an independent contractor can
bill for PA services.
•
Specialty code 97 applies for PAs enrolled in Medicare. NPs enrolling in Medicare use specialty code 50
and CNSs use specialty code 89.
The official instruction, CR8010 issued to your carrier and A/B MAC regarding this change may be viewed at
http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2656CP.pdf on the CMS
website.
May 2013
- page 84 -
News Flash - Flu Season is Here- According to the Centers for Disease Control and Prevention, flu activity is
beginning to increase and further increases are expected in the coming weeks and months. Now is the time to
protect against flu before activity increases in the community. About 5 to 20 percent of the population gets the
flu each year and more than 200,000 people are hospitalized because of flu-related complications. Make each
office visit an opportunity to talk with your patients about the importance of getting an annual flu vaccination
and a pneumococcal vaccination according to the recommended schedule. This message also serves as a
reminder for you to get your seasonal flu vaccination to protect yourself, your family, and your patients.
Remember – the Influenza and pneumococcal vaccines and their administration fees are covered Part B
benefits. Influenza and pneumococcal vaccines are NOT Part D-covered drugs.
CMS has posted the 2012-2013 Seasonal Influenza Vaccines Pricing list. You may also refer to the MLN
Matters® Article #MM8047, “Influenza Vaccine Payment Allowances - Annual Update for 2012-2013 Season.”
Please visit the CMS Medicare Learning Network® Preventive Services Educational Products and CMS
Immunizations web pages for more information on coverage and billing of the flu and pneumococcal vaccines
and their administration fees.
While some providers may offer the flu vaccine, those who don’t can help their patients locate a vaccine
provider within their local community. The HealthMap Vaccine Finder is a free, online service where users can
find nearby locations offering flu vaccines.
Revised: MM8127 - Manual Updates to Clarify Inpatient
Rehabilitation Facility (IRF) Claims Processing
News Flash – In September 2012, the Centers for Medicare & Medicaid Services (CMS) announced the
availability of a new electronic mailing list for those who refer Medicare beneficiaries for Durable Medical
Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). Referral agents play a critical role in providing
information and services to Medicare beneficiaries. To ensure you give Medicare patients the most current
DMEPOS Competitive Bidding Program information, CMS strongly encourages you to review the information
sent from this new electronic mailing list. In addition, please share the information you receive from the mailing
list and the link to the “mailing list for referral agents” subscriber webpage with others who refer Medicare
beneficiaries for DMEPOS. Thank you for signing up!
Note: This article was revised on March 18, 2013, to reflect a revised Change Request (CR) that corrects
formatting in the CR. The Transmittal Number, CR release date, and web address of the CR also changed. All
other information remains the same.
This MLN Matters® Article is intended for physicians and providers (including Inpatient Rehabilitation Facilities
(IRFs)) submitting claims to Medicare contractors (Fiscal Intermediaries (FIs), carriers, and A/B Medicare
Administrative Contractors (MACs)) for inpatient rehabilitation services to Medicare beneficiaries.
Change Request (CR) 8127, from which this article is taken, updates the “Medicare Claims Processing Manual,” Chapter
3 (Inpatient Hospital Billing), to clarify key components of Inpatient Rehabilitation Facility (IRF) claims processing. These
changes are intended only to clarify the existing policies and there are no system or policy changes.
- page 85 -
May 2013
Background
The changes that CR8127 makes to the manual are clarifications of existing policy. The entire manual revision is
attached to CR8127. Key manual changes of interest to IRFs are summarized as follows:
Medicare IRF Classification Requirements
A facility paid under the IRF Prospective Payment System (PPS) is always subject to verification that it continues
to meet the criteria for exclusion from the Inpatient PPS (IPPS). Your FI or MAC provides the Centers for Medicare
& Medicaid Services (CMS) Regional Office (RO) with data for determining the classification status of each
facility and the RO reviews the IRF’s classification status each year. A determination that a facility either is or is
not classified as an IRF takes effect only at the start of a facility’s cost reporting period and applies to that entire
cost reporting period. If a facility fails to meet the criteria necessary to be paid under the IRF PPS, but meets the
criteria to be paid under the IPPS, it may be paid under the IPPS.
If a patient is admitted to a facility that is being paid under the IRF PPS, but is discharged from the facility when
it is no longer being paid under the IRF PPS, then payment to the facility will be made from the applicable
payment system that is in effect for the facility at the time the patient is discharged.
For cost reporting periods beginning on or after July 1, 2005, the IRF must have served an inpatient population
of whom at least 60 percent required intensive rehabilitative services for treatment of one or more of the
medical conditions specified in the revised manual Section 140.1.1C. See CR8127 for a list of these criteria.
Additional Criteria for Inpatient Rehabilitation Units
Inpatient rehabilitation units must also meet additional criteria to be paid under the IRF PPS. These criteria are
detailed in Section 140.1.2 of the revised manual, as attached to CR8127.
Verification Process Used to Determine if IRF Meets Classification Criteria
For cost reporting periods beginning on or after July 1, 2005, the compliance threshold that must be met is 60
percent. Thus, for all compliance review periods beginning on or after January 1, 2013 (except in the case of new
IRFs), the compliance review period will be one continuous 12-month time period beginning 4 months before
the start of a cost reporting period and ending 4 months before the beginning of the next cost reporting period.
For complete details of the verification process, see the revised Section 140.1.3 of the manual, which is attached
to CR8127.
New IRFs
An IRF hospital or IRF unit is considered new if it has not been paid under the IRF PPS for at least 5 calendar
years. A new IRF will be considered new from the point that it first participates in Medicare as an IRF until the
end of its first full 12-month cost reporting period.
A new IRF must provide written certification that the inpatient population it intends to serve will meet the
certification requirements. The written certification is effective for the first full 12-month cost reporting period
that occurs after the IRF begins being paid under the IRF PPS, and for any cost reporting period of not less than
1 month and not more than 11 months occurring between the date the IRF begins being paid under the IRF PPS
and the start of the IRF’s first full 12-month cost reporting period.
Changes in the Status of an IRF Unit
For purposes of payment under the IRF PPS, the status of an IRF unit may be changed from not excluded from
the IPPS to excluded from the IPPS only at the start of a cost reporting period. If an IRF unit is added to a hospital
after the start of a cost reporting period, it cannot be excluded from the IPPS before the start of the hospital’s
next cost reporting period.
The status of an IRF unit may be changed from excluded from the IPPS to not excluded from the IPPS at any time
during a cost reporting period, but only if the hospital notifies the FI/MAC and the RO in writing of the change
at least 30 days before the date of the change. In addition, the hospital must maintain the information needed
to accurately determine which costs are and are not attributable to the IRF unit. A change in the status of a
unit from excluded to not excluded that is made during a cost reporting period must remain in effect for the
remainder of that cost reporting period.
May 2013
- page 86 -
New IRF Beds
Any IRF beds that are added to an existing IRF must meet all applicable State Certificates of Need and State
licensure laws. New IRF beds may be added one time at any time during a cost reporting period and will be
considered new for the rest of that cost reporting period. A full 12-month cost reporting period must elapse
between the delicensing or decertification of IRF beds in an IRF hospital or IRF unit and the addition of new IRF
beds to that IRF hospital or IRF unit. Before an IRF can add new beds, it must receive written approval from the
appropriate CMS RO, so that the CMS RO can verify that a full 12-month cost reporting period has elapsed since
the IRF has had beds delicensed or decertified.
Change of Ownership or Leasing
If an IRF hospital (or a hospital that has an IRF unit) undergoes a change of ownership or leasing, as defined in
42 CFR 489.18, the IRF (or IRF unit of a hospital) retains its excluded status and will continue to be paid under
the IRF PPS before and after the change of ownership or leasing if the new owner(s) of the IRF hospital (or the
hospital with an IRF unit) accept assignment of the previous owners’ Medicare provider agreement and the IRF
continues to meet all of the requirements for payment under the IRF PPS. Note that an IRF’s payment status
under the IRF PPS is a Medicare classification status, which cannot be separated from its host hospital and
therefore cannot be purchased outside of the purchase of its host hospital.
If the new owner(s) do not accept assignment of the previous owners’ Medicare provider agreement, the IRF
is considered to be voluntarily terminated and the new owner(s) may re-apply to the Medicare program to
operate a new IRF, under the requirements for new IRFs.
Mergers
If an IRF hospital (or a hospital with an IRF unit) merges with another hospital and the owner(s) of the merged
hospital accept assignment of the IRF hospital’s provider agreement (or the provider agreement of the hospital
with the IRF unit), then the IRF hospital or IRF unit retains its excluded status and will continue to be paid under
the IRF PPS before and after the merger, as long as the IRF hospital or IRF unit continues to meet all of the
requirements for payment under the IRF PPS. Note that an IRF’s payment status under the IRF PPS is a Medicare
classification status, which cannot be separated from its host hospital and therefore cannot be merged with
another entity outside of the merger with its host hospital.
If the owner(s) of the merged hospital do not accept assignment of the IRF hospital’s provider agreement
(or the provider agreement of the hospital with the IRF unit), then the IRF hospital or IRF unit is considered
voluntarily terminated and the owner(s) of the merged hospital may re-apply to the Medicare program to
operate a new IRF under the requirements for new IRFs.
Full Time Equivalent (FTE) Resident Cap
Effective for cost reporting periods beginning on or after October 1, 2011, the IRF FTE resident caps may be
temporarily adjusted to reflect interns and residents added because of another IRF’s closure or the closure of
another IRF’s residency training program. An IRF is only eligible for the temporary cap adjustment if training
the additional interns and residents would cause the IRF to exceed its FTE resident cap. In addition, an IRF that
closes a medical residency training program must agree to temporarily reduce its FTE cap before other IRFs can
receive temporary adjustments to their caps for training the IRF’s interns and residents. IRFs may qualify for the
temporary cap adjustment for cost reporting periods beginning on or after October 1, 2011, if they are already
training interns and residents displaced by IRF closures or residency training program closures that occurred
prior to October 1, 2011.
Outliers
The Social Security Act provides the Secretary of Health and Human Services with the authority to make payments
in addition to the basic IRF prospective payments for cases incurring extraordinarily high cost. A case qualifies
for outlier payment if the estimated cost of the case exceeds the adjusted outlier threshold. CMS calculates the
adjusted outlier threshold by adding the IRF PPS payment for the case (that is, the Case-Mix Group (CMG) payment
adjusted by all of the relevant facility-level adjustments) and the adjusted threshold amount (also adjusted by all
of the relevant facility-level adjustments). Then, CMS calculates the estimated cost of the case by multiplying the
IRF’s overall Cost-to-Charge Ratio (CCR) by the Medicare allowable covered charge. If the estimated cost of the
case is higher than the adjusted outlier threshold, CMS makes an outlier payment for the case equal to 80 percent
of the difference between the estimated cost of the case and the outlier threshold.
- page 87 -
May 2013
The adjusted threshold amount and upper threshold CCR are set forth annually in the IRF PPS notices published
in the Federal Register.
The official instruction, CR8127 issued to your FI, carrier, or A/B MAC regarding this change may be viewed
at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2673CP.pdf on the
CMS website. As mentioned above, you can find the updated “Medicare Claims Processing Manual,” Chapter 3
(Inpatient Hospital Billing) as an attachment to this CR.
News Flash - Flu Season is Here - Flu season is here but it is not too late to protect your patients against the
flu. The Centers for Disease Control and Prevention (CDC) recommends that everyone 6 months of age
and older get a yearly flu vaccine. As the occurrence of the flu continues to be reported around the country,
remember, every office visit is an opportunity to check your patients’ vaccination status and encourage a
yearly flu vaccine for those that have not yet taken action to protect themselves and their loved ones from the
flu. Vaccination is especially important for those at high risk for flu-related complications (please refer to the
People at High Risk web page). Additionally, research shows that a strong provider recommendation for yearly
flu vaccination increases a patient’s willingness to get vaccinated themselves.
Getting vaccinated is just as important for health care personnel, like you, for many reasons. You can get sick with
the flu and spread it to your family, colleagues and patients without knowing or having symptoms. Be an example
by getting your flu vaccine and know that you’re helping to reduce the spread of flu in your community.
Note: The influenza and pneumococcal vaccines and their administration fees are covered Part B benefits.
Influenza and pneumococcal vaccines are NOT Part D-covered drugs.
• CMS has posted the 2012-2013 Seasonal Influenza Vaccines Pricing list. You may also refer to the MLN
Matters® Article MM8047, “Influenza Vaccine Payment Allowances - Annual Update for 2012-2013 Season.”
• Please visit the CMS Medicare Learning Network® Preventive Services Educational Products and CMS
Immunizations web pages for more information on coverage and billing of the flu and pneumococcal
vaccines and their administration fees.
• While some providers may offer the flu vaccine, those who don’t can help their patients locate a vaccine
provider within their local community. The HealthMap Vaccine Finder is a free, online service where users
can find nearby locations offering flu vaccines.
• The CDC website offers a variety of provider resources for the 2012-2013 flu season.
Revised: MM8147 - Quarterly Update to Correct Coding Initiative
(CCI) Edits, Version 19.1, Effective April 1, 2013
News Flash –
NEW products from the Medicare Learning Network® (MLN)
• “Screening Pelvic Examinations,” Booklet, ICN 907792, Downloadable only.
Note: This article was revised on March 13, 2013, to update website information. The transmittal release date,
transmittal number and web address for the transmittal was also changed.. All other information remains the same.
This MLN Matters® Article is intended for physicians submitting claims to Medicare Carriers and/or A/B Medicare
Administrative Contractors (A/B MACs) for services provided to Medicare beneficiaries.
May 2013
- page 88 -
This article is based on Change Request (CR) 8147 which provides a reminder for physicians to take note of
the quarterly updates to Correct Coding Initiative (CCI) edits. The last quarterly release of the edit module was
issued in January 2013.
Background
The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (CCI) to
promote national correct coding methodologies and to control improper coding that leads to inappropriate
payment in Part B claims.
The coding policies developed are based on coding conventions defined in the:
• American Medical Association’s (AMA’s) “Current Procedural Terminology (CPT) Manual;”
• National and local policies and edits;
• Coding guidelines developed by national societies;
• Analysis of standard medical and surgical practice; and by
• Review of current coding practice.
The latest package of CCI edits, Version 19.1, is effective April 1, 2013, and includes all previous versions and
updates from January 1, 1996, to the present. It will be organized in two tables:
• Column I/Column 2 Correct Coding Edits, and
• Mutually Exclusive Code (MEC) Edits.
Additional information about the CCI, including the current CCI and Mutually Exclusive Code (MEC) edits, is
available at http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html on the CMS website.
The CCI and MEC file formats are defined in the “Medicare Claims Processing Manual,” (Chapter 23, Section
20.9) which is available at http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/
clm104c23.pdf on the CMS website.
The official instruction, CR 8147, issued to your carrier or and A/B MAC regarding this change may be viewed at
http://www.cms.hhs.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2669CP.pdf on the
CMS website.
Revised: MM8169 - April Update to the CY 2013 Medicare Physician
Fee Schedule Database (MPFSDB)
News Flash –
New product from the Medicare Learning Network® (MLN)
• “The Medicare Fee-For-Service Recovery Audit Program Process,” Educational Tool, ICN 908524,
downloadable
Note: This article was revised on March 26, 2013, to reflect a revised CR8169 issued on March 26, 2013.
In this article, the CR transmittal number, CR release date, and the Web address for accessing the CR are
revised. All other information remains the same.
This MLN Matters® Article is intended for physicians and other providers who submit claims to Medicare
contractors (carriers, Fiscal Intermediaries (FI), A/B Medicare Administrative Contractors (A/B MAC), and/
- page 89 -
May 2013
or Regional Home Health Intermediaries (RHHI)) for services that are paid under the Medicare Physician Fee
Schedule (MPFS).
What You Need To Know
This article is based on Change Request (CR) 8169 and instructs Medicare contractors to download and
implement a new Medicare Physician Fee Schedule Data Base (MPFSDB), effective January 1, 2013.
Background
Section 1848 (c) (4) of the Social Security Act (see http://www.ssa.gov/OP_Home/ssact/title18/1848.htm)
authorizes the U.S. Secretary of Health and Human Services (HHS) to establish ancillary policies necessary to
implement relative values for physicians’ services.
CR 8169, from which this article is taken announces that the Medicare Physician Fee Schedule Data Base
(MPFSDB) has been updated effective January 1, 2013; and new payment files have been created in order to
reflect appropriate payment policy in line with the CY 2013 (Medicare Physician Fee Schedule (MPFS) Final
Rule, published in the Federal Register on November 16, 2012, as modified by the Final Rule Correction Notice,
published in the Federal Register on January 2, 2013, and relevant statutory changes applicable January 1, 2013.
The summary of changes in the April 2013 update consists of the following (all other indicators remain the
same):
•
0309T Global Indicator is being corrected to “ZZZ” (add-on). This change is effective January 1, 2013.
•
For 36222 – 36228, their Bilateral Indicators are being corrected to “1” = 150% payment adjustment
applies if billed with modifier 50. This change is effective January 1, 2013.
•
90785 Global Indicator is being corrected to “ZZZ” (add-on). This change is effective January 1, 2013.
•
The codes in the following table are having their short descriptors corrected or adjusted as shown
below. These changes are effective January 1, 2013.
HCPCS Code
Old Short Description
Revised Short Description
19301
31648
31649
31651
87631
95907
95908
95909
95910
95911
95912
95913
95907-26
95908-26
95909-26
95910-26
95911-26
95912-26
95913-26
95907-TC
Partical mastectomy
Bronchial valve addl insert
Bronchial valve remov init
Bronchial valve remov addl
Resp virus 3-11 targets
Motor&/sens 1-2 nrv cndj tst
Motor&sens 7-8 nrv cndj test
Motor&sen 9-10 nrv cndj test
Motor&sen 11-12 nrv cnd test
Motor&sens 13/> nrv cnd test
Partial mastectomy
Bronchial valve remov init
Bronchial valve remov addl
Bronchial valve addl insert
Resp virus 3-5 targets
Nvr cndj tst 1-2 studies
Nrv cndj tst 3-4 studies
Nrv cndj test 7-8 studies
Nrv cndj test 13/> studies
May 2013
- page 90 -
HCPCS Code
Old Short Description
Revised Short Description
95912-26
95913-26
95907-TC
95908-TC
95909-TC
95910-TC
95911-TC
95912-TC
95913-TC
0195T
0196T
0206T
Arthrod presac interbody
Arthrod presac interbody eac
Pptr dbs alys car elec dta
Prescrl fuse w/o instr L5/S1
Prescrl fuse w/o instr L4/L5
Cptr dbs alys car elec dta
90700
Dtap vaccine > 7 yrs im
Dtap vaccine < 7 yrs im
90702
Dt vaccine > 7 yrs im
Dt vaccine < 7 yrs im
•
G9157 will become an active code with a Procstat of “A” and a PC/TC indicator of “2” = Professional
component only. Payment amounts are being included. All other indicators remain the same. This
change is effective January 1, 2013.
•
33961 Global Indicator is being corrected to “XXX”. This change is effective January 1, 2013.
•
The TC components of the following Nerve Conduction Test: 95907, 95908, 95909, 95910, 95911,
95912, and 95913, are having their Physician Supervision Of Diagnostic Procedures Indicators adjusted
to “7A” = “Supervision standards for level 77 apply; in addition, the PT with ABPTS certification may
personally supervise another PT, but only the PT with ABPTS certification may bill.”
•
(“77” = “Procedure must be performed by a PT with ABPTS certification (TC & PC) or by a PT without
certification under general supervision of a physician (TC only; PC always physician)”). These changes
are effective January 1, 2013.
•
81161 is being added to the fee schedule with a Procstat of “X” = Statutory exclusion. This change is
effective January 1, 2013.
•
Q0507, Q0508, Q0509 are being added to the fee schedule with Procstat indicators of “E” = Excluded
from physician fee schedule by regulation. These codes are effective April 1, 2013.
•
The Procstat indicator of 3750F, 4142F, 6150F, 3517F is changing to “M” effective April 1, 2013.
•
The Procstat indicator of G8559, G8560, G8561, G8562, G8563, G8564, G8565, G8566, G8567, G8568,
Q0505 is changing to “I” effective April 1, 2013.
•
For 23000, 32997, 32998, their Bilateral Indicators are being corrected to “1” = 150% payment
adjustment applies if billed with modifier 50. These changes are effective April 1, 2013.
The official instruction, CR 8169, issued to your carrier, FI, A/B MAC, or RHHI regarding this change may be
viewed at http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R2677CP.pdf
on the CMS website.
If you have any questions, please contact your carrier, FI, A/B MAC, or RHHI at their toll-free number, which
may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring- Programs/providercompliance-interactive-map/index.html on the CMS website.
- page 91 -
May 2013
News Flash - Flu Season Isn’t Over – Continue to Recommend Vaccination - While each flu season is different, flu
activity typically peaks in February. Yet, even in February, the flu vaccine is still the best defense against the flu. The
CDC recommends yearly flu vaccination for everyone 6 months of age and older; and although anyone can get the
flu, adults 65 years and older are at greater risk for serious flu-related complications that can lead to hospitalization
and death. Every office visit is an opportunity to check your patients’ vaccination status and encourage flu
vaccination when appropriate. And getting vaccinated is just as important for health care personnel who can get sick
with the flu and spread it to family, colleagues and patients. Be an example by getting your flu vaccine and know that
you’re helping to reduce the spread of flu in your community. Note: influenza vaccines and their administration fees
are covered Part B benefits. Influenza vaccines are NOT Part D-covered drugs. For More Information:
•
•
•
•
•
2012-2013 Seasonal Influenza Vaccines Pricing.
MLN Matters® Article MM8047, “Influenza Vaccine Payment Allowances - Annual Update for 20122013 Season.”
CMS Medicare Learning Network® 2012-2013 Seasonal Influenza Virus Educational Products and
Resources and CMS Immunizations web pages for information on coverage and billing.
HealthMap Vaccine Finder – a free, online service where users can find nearby locations offering flu
vaccines as well as other vaccines for adults.
The CDC’s website offers a variety of provider resources for the 2012-2013 flu season.
Revised: MM8197 - International Classification of Diseases (ICD)10 Conversion from ICD-9 and Related Code Infrastructure of the
Medicare Shared Systems as They Relate to CMS National Coverage
Determinations (NCDs)
News Flash REVISED products from the Medicare Learning Network® (MLN)
“Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services”, Fact Sheet, ICN
904084, Downloadable
MLN Matters® Number: MM8197
Revised
Related Change Request (CR) #: CR 8197
Related CR Release Date: March15, Effective Date: Please note that the implementation date is
2013
prior to the effective date in order to be prepared to meet the
timeline to implement the new ICD-10 diagnosis codes on
October 1, 2014. The shared systems began implementation of
the necessary changes to the NCDs in the January 2013 systems
release with CR7818, followed by CR8109 in the April 2013
release, and finishing up with this CR split between the July
2013 and October 2013 releases (analysis and design/
implementation).
Related CR Transmittal #:
R1199OTN
Implementation Date: July 1, 2013
Note: This article was revised on March 26, 2013, to add further information on accessing the
spreadsheets attached to CR 8197. All other information remains the same.
This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to
Medicare contractors (carriers, Fiscal Intermediaries (FIs), Medicare Administrative Contractors (A/B MACs),
May 2013
- page 92 -
and Durable Medical Equipment Medicare Administrative Contractors, (DME MACs) for services to Medicare
beneficiaries.
Change Request (CR) 8197, from which this article is taken, creates and updates National Coverage
Determination (NCD) hard-coded shared system edits that contain International Classification of Diseases (ICD)9 diagnosis codes with the comparable ICD-10 diagnosis codes, along with all related coding infrastructure
such as procedure codes, Healthcare Common Procedure Coding System/Current Procedural Terminology
(HCPCS/CPT) codes, messages, frequency edits, Place of Service/Type of Bill (POS/TOB), provider specialties, etc.
The requirements it describes reflect the operational changes that are necessary to implement the conversion of
the Medicare shared system coding from ICD-9 to ICD-10 specific to 30 NCDs that are attachments to CR8197.
In order to be prepared to meet the timeline to implement the new ICD-10 diagnosis codes on October
1, 2014, the shared systems began implementation of the necessary changes to the NCDs in the January 2013,
quarterly release with CR7818, followed by CR8109 in the April 2013, quarterly release and culminates with this
CR split between the July 2013, and October 2013, quarterly releases.
See the Background and Additional Information Sections of this article for further details regarding these
changes, and be sure that you are ready for ICD-10 implementation by October 1, 2014.
Background
As announced in CMS-40-F, 45 CFR Part 162 [CMS–0040–F] RIN 0938–AQ13, “Administrative Simplification:
Adoption of a Standard for a Unique Health Plan Identifier; Addition to the National Provider Identifier
Requirements, and a Change to the Compliance Date for the International Classification of Diseases, 10th
Edition (ICD–10–CM and ICD–10–PCS) Medical Data Code Sets” (September 5, 2012), effective October 1, 2014,
all Medicare claims submissions will convert from the 9th Edition (ICD-9) to the 10th Edition (ICD-10).
(You can find this document at http://www.gpo.gov/fdsys/pkg/FR-2012-09-05 on pages 54663-54720.)
All Health Insurance Portability and Accountability Act (HIPAA)-covered entities must adhere to the conversion,
which will require business and systems changes throughout the health care industry. In accordance, per the
ICD-10 Final Rule, published in the January 16, 2009, Federal Register, (see http://www.gpo.gov/fdsys/pkg/FR2009-01-16/pdf/E9-740.pdf ). The Secretary of the Department of Health and Human Services adopts the ICD10-CM and ICD-10-PCS code sets for use in appropriate HIPAA standard transactions (including those submitted
in both electronic and paper formats) effective October 1, 2014.
General Information Found in Spreadsheets in the Attachments
Thirty spreadsheets are attached to CR8197 indicating certain affected ICD-9 codes and their corresponding
ICD-10 codes as they relate to their respective NCDs, in addition to the rest of the coding infrastructure specific
to each NCD. To access the attachments, go to the downloads section at http://www.cms.gov/Regulationsand-Guidance/Guidance/Transmittals/2013-Transmittals- Items/R1199OTN.html on the CMS website.
Each spreadsheet contains the following information:
• NCD Number/Title;
•
Internet-Only Manual (IOM) searchable link related to the NCD; and
•
Medicare Coverage Database (MCD) searchable link related to the NCD.
Within each spreadsheet, there are three tabs:
•
ICD Diagnosis;
•
ICD; and,
•
Rule Description.
- page 93 -
May 2013
Spreadsheets attached to CR8197 explain the following NCDs:
20.4
20.7
20.16
20.30
20.31
20.31.1
20.31.2
40.1
40.7
50.3
100.14
110.4
110.8.1
150.10
180.1
190.1
190.3
Implantable Automatic Defibrillator
Percutaneous Transluminal Angioplasty
Cardiac Output Monitoring by Thoracic Electrical Bioimpedance
Microvolt T-Wave Alternans
Intensive Cardiac Rehabilitation Programs
The Pritikin Program
Ornish Program for Reversing Heart Disease
Diabetes Outpatient Self-Management Training
Outpatient Intravenous Insulin Treatment
Cochlear Implantation
Surgery for Diabetes
Extracorporeal Photopheresis
Stem Cell Transplantation
Lumbar Artificial Disc Replacement
Medical Nutrition Therapy
Histocompatibility Testing
Cytogenetic Studies
190.5
190.8
190.11
210.2
210.4
210.4.1
210.7
210.10
220.4
220.6.16
220.6.19
260.1
260.9
Sweat Test
Lymphocyte Mitogen Response Assays
Home Prothrombin Time/International Normalized Ratio Monitoring for Anticoagulation Management
Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer
Smoking and Tobacco-Use Cessation Counseling
Counseling to Prevent Tobacco Use
Screening for the Human Immunodeficiency Virus Infection
Screening for Sexually Transmitted Infections and High-Intensity Behavioral Counseling to Prevent STIs
Mammograms
FDG PET for Infection and Inflammation
Positron Emission Tomography (NaF-18) to Identify Bone Metastasis of Cancer
Adult Liver Transplantation
Heart Transplants
Should your contractor deny claims associated with the NCDs addressed by CR8197, they will use:
•
•
•
Group Code PR (Patient Responsibility) assigning financial responsibility to the beneficiary (if a claim is
received with a GA modifier indicating a signed Advance Beneficiary Notice of Noncoverage (ABN) is on file).
Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim is
received with a GZ modifier indicating no signed ABN is on file).
Claim Adjustment Reason Code (CARC) 50: These services are non-covered services because this is not
deemed a “medical necessity” by the payer; and
Additionally, where appropriate and not specifically indicated in the various attached spreadsheets, they will use:
•
Remittance Advice Remark Code (RARC) N386: This decision was based on a National Coverage
Determination (NCD). An NCD provides a coverage determination as to whether a particular item
or service is covered. A copy of this policy is available at http://www.cms.gov/medicare-coveragedatabase/overview-and-quick-search.aspx on the CMS website.
Additionally, NCD 190.11 includes a change to CR6313 dated 1/8/09, and is also a change to the spreadsheet
attached to CR8109/TR1162.
Likewise, NCD 110.4 includes a change to CR7806/TR2551 correction dated 9/24/12 that removed 996.88 from
CR7806 dated 8/3/12, and a change to the spreadsheet attached to CR7818 dated 9/14/12.
The official instruction, CR8197 issued to your carrier, FI, A/B MAC, or DME MAC regarding this change may be
May 2013
- page 94 -
viewed at http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R1199OTN.pdf
on the CMS website.
You will find spreadsheets that contain all affected ICD-9 codes and their corresponding ICD-10 codes as
they relate to their respective NCDs, in addition to the rest of the coding infrastructure specific to each NCD
as attachments to this CR. To access those spreadsheets, visit the downloads section at http://www.cms.gov/
Regulations-and-Guidance/Guidance/Transmittals/2013-Transmittals- Items/R1199OTN.html on the CMS website.
If you have any questions, please contact your carrier, FI, A/B MAC, or DME MAC at their toll-free number, which
Revised: SE0711 - Reminder - Medicare Now Provides Coverage for
Eligible Medicare Beneficiaries of a One-Time Ultrasound Screening
for Abdominal Aortic Aneurysms (AAA) When Referred for this
Screening as a Result of the Initial Preventive Physical Examination
(“Welcome to Medicare” Physical Exam)
Note: This article was updated on March 8, 2013, to update statements regarding the coinsurance and
deductible payments for AAA and the IPPE. There is no coinsurance or Part B deductible for AAA screening
or the IPPE. For updated information regarding payment for preventive care services under the Affordable
Care Act, please go to http://www.cms.gov/outreach-and-education/medicare-learningnetwork-mln/
mlnmattersarticles/downloads/MM7012.pdf on the CMS website. All other information remains unchanged.
All Medicare fee-for-service (FFS) physicians, providers, suppliers, and other health care professionals, who
furnish or provide referrals for and/or file claims for the initial preventive physical examination (IPPE) and the
ultrasound screening for abdominal aortic aneurysms (AAA).
This article conveys no new policy information. This article is for informational purposes only and serves
as a reminder that Medicare provides coverage of a one-time initial preventive physical examination and a onetime preventive ultrasound screening for abdominal aortic aneurysms subject to certain coverage, frequency,
and payment limitations. The Centers for Medicare & Medicaid Services (CMS) needs your help to get the word
out and to encourage eligible beneficiaries to take full advantage of these benefits and all preventive services
and screenings covered by Medicare.
Background
In January 2005, the Medicare program expanded the number of preventive services available to Medicare
beneficiaries, as a result of Section 611 of the Medicare Prescription Drug, Improvement, and Modernization Act
(MMA) of 2003, to include coverage under Medicare Part B of a one-time IPPE, also referred to as the “Welcome
to Medicare” physical exam, for all Medicare beneficiaries whose Medicare Part B effective date began on or
after January 1, 2005.
On January 1, 2007, Medicare further expanded the number of preventive benefits, as provided for in Section 5112
of the Deficit Reduction Act (DRA) of 2005, to include coverage under Medicare Part B of a one-time preventive
ultrasound screening for the early detection of abdominal aortic aneurysms (AAA) for at risk beneficiaries as part
of the IPPE. Both benefits (the IPPE and AAA) are subject to certain eligibility and other limitations.
The information in this Special Edition MLN Matters article reminds health care professionals that Medicare now
pays for these benefits as well as a broad range of other preventive services and screenings. CMS needs your
help to ensure that patients new to Medicare receive their “Welcome to Medicare” physical exam within the first
six months of their effective date in Medicare Part B and those beneficiaries at risk for AAA receive a referral for
the preventive ultrasound screening as part of their “Welcome to Medicare” physical exam.
- page 95 -
May 2013
Benefit Coverage Summary
The Initial Preventive Physical Examination (“Welcome to Medicare” Physical Exam)
Effective for dates of service on or after January 1, 2005: Medicare beneficiaries whose Medicare Part B effective
date is on or after January 1, 2005, are covered for a one-time IPPE visit. The IPPE must be received by the
beneficiary within the first six months of their Medicare Part B effective date. The IPPE is a preventive evaluation
and management (E/M) service that includes the following seven components:
1. A review of an individual’s medical and social history with attention to modifiable risk factors,
2. A review of an individual’s potential (risk factors) for depression,
3. A review of the individual’s functional ability and level of safety,
4. An examination to include an individual’s height, weight, blood pressure measurement, and visual acuity screen,
5. Performance of an electrocardiogram (EKG) and interpretation of the EKG,
6. Education, counseling, and referral based on the results of the review and evaluation services described in
the previous five elements, and
7. Education, counseling, and referral (including a brief written plan such as a checklist provided to the
individual for obtaining the appropriate screenings and other preventive services that are covered as separate
Medicare Part B benefits).
Important reminders about the IPPE:
1. The IPPE is a unique benefit available only for beneficiaries new to the Medicare Program and must be
received within the first six months of the effective date of their Medicare Part B coverage.
2. This exam is a preventive physical exam and not a “routine physical checkup” that some seniors may receive
every year or two from their physician or other qualified non-physician practitioner. Medicare does
The Part B deductible and coinsurance/copayment no longer apply to the IPPE benefit. (See note above)
Note: The deductible does not apply for an IPPE provided in a Federally Qualified Health Center (FQHC). Only
the coinsurance/copayment applies.
Other preventive services and screenings covered under Medicare Part B include: Adult immunizations (flu,
pneumococcal, and hepatitis B), bone mass measurements, cardiovascular screening, diabetes screening,
glaucoma screening, screening mammograms, screening Pap test and pelvic exam, colorectal and prostate
cancer screenings, diabetes self-management training, medical nutrition therapy for beneficiaries diagnosed
with diabetes or renal disease, and smoking and tobacco-use cessation counseling. Benefits are subject to
certain eligibility and other limitations.
NOTE: The IPPE/”Welcome to Medicare” physical exam does not include any clinical laboratory tests. The
physician, qualified non-physician practitioner, or hospital may also provide and bill separately for the
preventive services and screenings that are currently covered and paid for by Medicare Part B. (See the
Additional Information section below for links to MLN Matters articles MM3771 and MM3638, which provide
detailed coverage criteria and billing information about the IPPE benefit.)
Preventive Ultrasound Screening for Abdominal Aortic Aneurysms (AAA)
Effective for dates of service on or after January 1, 2007, Medicare will pay for a one-time preventive ultrasound
screening for AAA for beneficiaries who are at risk (has a family history of AAA or is a man age 65 to 75 who
has smoked at least 100 cigarettes in his lifetime). Eligible beneficiaries must receive a referral for the screening
as a result of their “Welcome to Medicare” physical exam. There is no Part B deductible or coinsurance/
copayment applied to this benefit.
May 2013
- page 96 -
IMPORTANT NOTE: Only Medicare beneficiaries who receive a referral from their physician or other qualified nonphysician practitioner for the preventive ultrasound screening, as part of their “Welcome to Medicare” physical
exam, will be covered for the AAA benefit. (See the Additional Information section below for a link to MLN Matters
article MM5235, which provides detailed coverage criteria and billing information about the AAA benefit.)
For more information about Medicare’s coverage criteria and billing procedures for the AAA and
IPPE benefits, refer to the following MLN Matters articles:
• MM5235 (2006), Implementation of a One-Time Only Ultrasound Screening for Abdominal Aortic
Aneurysms (AAA), Resulting from a Referral from an Initial Preventive Physical Examination, http://
www.cms.gov/outreach-and-education/medicare-learning-networkmln/mlnmattersarticles/
downloads/MM5235.pdf
• MM3771 (2005), MMA – Clarification for Outpatient Prospective Payment system (OPPS) Hospitals
Billing the Initial Preventive Physical Exam (IPPE), http://www.cms.gov/outreach- and-education/
medicare-learning-networkmln/mlnmattersarticles/downloads/MM3771.pdf
• MM3638 (2004), MMA – Initial Preventive Physical Examination, http://www.cms.gov/outreach-and-education/
medicare-learning-networkmln/mlnmattersarticles/downloads/MM3638.pdf on the CMS website.
• CMS has also developed a variety of educational products and resources to help health care
professionals and their staff, become familiar with coverage, coding, billing, and reimbursement for all
preventive services covered by Medicare.
• The MLN Preventive Services Educational Products Web Page ~ provides descriptions and ordering
information for all provider specific educational products related to preventive services. The web
page is located at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNProducts/index.html on the CMS website.
• The CMS website provides information for preventive service covered by Medicare is at
• http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/index.html on the CMS website..
For products to share with your Medicare patients, visit http://www.medicare.gov/ on the Internet.
REVISED: SE1029 - 5010 Requirement for Ambulance Suppliers
News Flash – Health care providers, health plans, clearinghouses and vendors should be finished with their
internal testing of the Version 5010 HIPAA electronic health care transaction standards by the first recommended
deadline for internal testing, December 31, 2010, and be ready to start testing with their external partners,
beginning in January 2011, just about four months away. Please visit http://www.cms.gov/Medicare/Coding/
ICD10/index.html for the latest news and sign up NOW for Version 5010 and ICD-10 e-mail updates!
Note This article was revised on March 22, 2013, to add a reference to article SE1239 at http://www.cms.gov/
Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/SE1239.pdf on
the CMS website. SE1239 announces the revised ICD-10 implementation date of October 1, 2014. All other
information remains unchanged.
This article is intended for ambulance suppliers submitting claims in the 5010 837P (Professional) electronic
claim format beginning January 1, 2011, to Medicare Carriers or Part A/B Medicare Administrative Contractors
(A/B MAC) for services rendered to Medicare beneficiaries.
The Centers for Medicare & Medicaid Services (CMS) has decided upon early adoption of version 5010 of the
837P electronic claim format and will implement it on January 1, 2011. If you are an ambulance supplier who
plans early adoption of the new standard, this Special Edition article tells you how to submit your claims
electronically in light of the new 837P, version 5010 diagnosis code reporting requirement.
Effective for claims submitted in the version 5010 837P electronic claim format on and after January 1, 2011,
ambulance suppliers will have three options for complying with the new diagnosis reporting requirement.
- page 97 -
May 2013
•
•
•
•
Option 1: Suppliers may choose a code or codes from the Medical Conditions List provided by CMS
that corresponds to the condition of the beneficiary at the time of pickup and report the code(s) in the
diagnosis field on the claim. The Medical Conditions List and instructions for using this list can be found
in the Medicare Claims Processing Manual, Chapter
15, Section 40, “Medical Conditions List and Instructions,” available at http://www.cms.gov/Regulationsand- Guidance/Guidance/Manuals/downloads/clm104c15.pdf on the CMS website. The codes in the
medical conditions list are taken from the International Classification of Diseases, 9th revision, Clinical
Modification (ICD-9CM) diagnosis code set. Suppliers must continue to accurately maintain transport
records to support any data reported on the claim.
Option 2: Suppliers may report an ICD-9 (or ICD-10 when appropriate) diagnosis code that is provided
to them by the treating physician or other practitioner.
Option 3: Suppliers may report ICD-9 diagnosis code 799.9 (unspecified illness).
Note: Effective October 1, 2013, the new ICD-10 diagnosis code set will be implemented, thus making the ICD-9
code set obsolete.
• Suppliers choosing Options 1 or 3 will be given further guidance upon implementation of the new
code set.
• Suppliers choosing Option 2 should ensure that they are provided with the appropriate ICD-10
diagnosis code for dates of service on and after October 1, 2013.
If you choose to submit claims in the version 5010 837P electronic claim format on and after January 1, 2011,
you must comply with the requirement to include a diagnosis code. CMS will not be capable of accepting
claims submitted under the 5010 version of the 837P that do not comply with this requirement. You may
continue to use the 4010A1 version of the 837P until December 31, 2011.
Background
The Administrative Simplification Compliance Act (ASCA) and its implementing regulation require that all
initial claims for payment under Medicare be submitted electronically as of October 16, 2003, unless one of the
statutory or regulatory exceptions applies. Electronic claim submissions are required to be in compliance with
the claim standards adopted for national use under the Health Insurance Portability and Accountability Act of
1996. Ambulance suppliers currently use the American National Standards Institute (ANSI) 837P (professional),
version 4010A1 to submit claims for payment.
The 4010A1 version of the 837P electronic claim does not require submission of a diagnosis code from the ICD-9CM
code set in Loop 2300, Segment HI. Additionally, CMS does not currently require ambulance suppliers to submit a
diagnosis code on claims for payment. However, the 5010 version of the 837P, which becomes effective on January
1, 2012, requires that a diagnosis code be present on all 837P electronic claims, including ambulance claims.
at http://www.cms.gov/Research-Statistics-Data- and-Systems/Monitoring-Programs/provider-complianceinteractive- map/index.html on the CMS website.
Also see SE1106 (http://www.cms.gov/Outreach-and-Education/Medicare- Learning-Network-MLN/
MLNMattersArticles/downloads/SE1106.pdf ) for important reminders about the implementation of HIPAA
5010 and D.O., including Fee-For-Service implementation schedule and readiness assessments. Another related
article is SE1138, which is at http://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network- MLN/
MLNMattersArticles/downloads/SE1138.pdf on the CMS website.
You may want to review MM7489 (http://www.cms.gov/Outreach-and- Education/Medicare-LearningNetwork- MLN/MLNMattersArticles/downloads/MM7489.pdf) which alerts ambulance suppliers that Medicare
contractors will begin supplying denial notices for billing secondary insurance for those HCPCS codes that
identify Medicare statutorily excluded ambulance transportation services, effective January 1, 2012.
For current information on the new ICD-10 implementation date of October 1,
2014, see article SE1239 at http://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network- MLN/
MLNMattersArticles/Downloads/SE1239.pdf on the CMS website.
May 2013
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SE1305 - Full Implementation of Edits on the Ordering/Referring
Providers in Medicare Part B, DME, and Part A Home Health Agency
(HHA) Claims (Change Requests 6417, 6421, 6696, and 6856)
News Flash – In September 2012, the Centers for Medicare & Medicaid Services (CMS) announced the
availability of a new electronic mailing list for those who refer Medicare beneficiaries for Durable Medical
Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). Referral agents play a critical role in providing
information and services to Medicare beneficiaries. To ensure you give Medicare patients the most current
DMEPOS Competitive Bidding Program information, CMS strongly encourages you to review the information
sent from this new electronic mailing list. In addition, please share the information you receive from the mailing
list and the link to the “mailing list for referral agents” subscriber webpage with others who refer Medicare
beneficiaries for DMEPOS. Thank you for signing up!
Note: This Special Edition MLN Matters® Article is a consolidation and update of prior articles SE1011, SE1201,
SE1208, and SE1221. Effective May 1, 2013, the Centers for Medicare & Medicaid Services (CMS) will turn on the
Phase 2 denial edits. This means that Medicare will deny claims for services or supplies that require an ordering/
referring provider to be identified and that provider is not identified, is not in Medicare’s enrollment records, or
is not of a specialty type that may order/refer the service/item being billed.
This MLN Matters® Special Edition Article is intended for:
•
•
•
•
•
Physicians and non-physician practitioners (including interns, residents, fellows, and those who are
employed by the Department of Veterans Affairs (DVA), the Department of Defense (DoD), or
the Public Health Service (PHS)) who order or refer items or services for Medicare beneficiaries,
Part B providers and suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
(DMEPOS) who submit claims to carriers, Part A/B Medicare Administrative Contractors (MACs), and
DME MACs for items or services that they furnished as the result of an order or a referral, and
Part A Home Health Agency (HHA) services who submit claims to Regional Home Health Intermediaries
(RHHIs), Fiscal Intermediaries (FIs, who still maintain an HHA workload), and Part A/B MACs.
Optometrists may only order and refer DMEPOS products/services and laboratory and X-Ray services
payable under Medicare Part B.
If you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment
record, you need to submit an enrollment application to Medicare. You can do this using the Internet-based
Provider Enrollment, Chain, and Ownership System (PECOS) or by completing the paper enrollment application
(CMS-855O). Review the background and additional information below and make sure that your billing staff is
aware of these updates.
What Providers Need to Know
Phase 1: Informational messaging: Began October 5, 2009, to alert the billing provider that the identification
of the ordering/referring provider is missing, incomplete, or invalid, or that the ordering/referring provider is
not eligible to order or refer. The informational message on an adjustment claim that did not pass the edits
indicated the claim/service lacked information that was needed for adjudication. Phase 2: Effective May
1, 2013, CMS will turn on the edits to deny Part B, DME, and Part A HHA claims that fail the ordering/
referring provider edits. Physicians and
others who are eligible to order and refer items or services need to establish their Medicare enrollment record
and must be of a specialty that is eligible to order and refer.
All enrollment applications, including those submitted over the Internet, require verification of the information
reported. Sometimes, Medicare enrollment contractors may request additional information in order to process
the enrollment application.
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May 2013
Waiting too long to begin this process could mean that your enrollment application may not be processed prior
to the May 1, 2013 implementation date of the ordering/referring Phase 2 provider edits.
Background
The Affordable Care Act, Section 6405, “Physicians Who Order Items or Services are Required to be Medicare
Enrolled Physicians or Eligible Professionals,” requires physicians or other eligible professionals to be enrolled
in the Medicare Program to order or refer items or services for Medicare beneficiaries. Some physicians or other
eligible professionals do not and will not send claims to a Medicare contractor for the services they furnish and
therefore may not be enrolled in the Medicare program. Also, effective January 1, 1992, a physician or supplier
that bills Medicare for a service or item must show the name and unique identifier of the attending physician
on the claim if that service or item was the result of an order or referral. Effective May 23, 2008, the unique
identifier was determined to be the National Provider Identifier (NPI). The Centers for Medicare & Medicaid
Services (CMS) has implemented edits on ordering and referring providers when they are required to be
identified in Part B, DME, and Part A HHA claims from Medicare providers or suppliers who furnished items or
services as a result of orders or referrals.
Below are examples of some of these types of claims:
• Claims from laboratories for ordered tests;
•
•
Claims from imaging centers for ordered imaging procedures; and
Claims from suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) for
ordered DMEPOS.
Only physicians and certain types of non-physician practitioners are eligible to order or refer items or services
for Medicare beneficiaries. They are as follows:
•
•
•
•
•
•
•
•
Physicians (doctor of medicine or osteopathy, doctor of dental medicine, doctor of dental surgery,
doctor of podiatric medicine, doctor of optometry, optometrists may only order and refer DMEPOS
products/services and laboratory and X-Ray services payable under Medicare Part B.)
Physician Assistants,
Clinical Nurse Specialists,
Nurse Practitioners,
Clinical Psychologists,
Interns, Residents, and Fellows,
Certified Nurse Midwives, and
Clinical Social Workers.
CMS emphasizes that generally Medicare will only reimburse for specific items or services when those items or
services are ordered or referred by providers or suppliers authorized by Medicare statute and regulation to do
so. Claims that a billing provider or supplier submits in which the ordering/referring provider or supplier is not
authorized by statute and regulation will be denied as a non-covered
service. The denial will be based on the fact that neither statute nor regulation allows coverage of certain
services when ordered or referred by the identified supplier or provider specialty.
CMS would like to highlight the following limitations:
•
•
•
•
Chiropractors are not eligible to order or refer supplies or services for Medicare beneficiaries.
All services ordered or referred by a chiropractor will be denied.
Home Health Agency (HHA) services may only be ordered or referred by a Doctor of Medicine (M.D.),
Doctor of Osteopathy (D.O.), or Doctor of Podiatric Medicine (DPM). Claims for HHA services ordered by
any other practitioner specialty will be denied.
Optometrists may only order and refer DMEPOS products/services, and laboratory and X-Ray services
payable under Medicare Part B.
May 2013
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Questions and Answers Relating to the Edits
1. What are the ordering and referring edits?
The edits will determine if the Ordering/Referring Provider (when required to be identified in Part B, DME, and
Part A HHA claims) (1) has a current Medicare enrollment record and contains a valid National Provider Identifier
(NPI) (the name and NPI must match), and (2) is of a provider type that is eligible to order or refer for Medicare
beneficiaries (see list above).
2. Why did Medicare implement these edits?
These edits help protect Medicare beneficiaries and the integrity of the Medicare program.
3. How and when will these edits be implemented?
These edits were implemented in two phases:
Phase 1 -Informational messaging: Began October 5, 2009, to alert the billing provider that the identification
of the ordering/referring provider is missing, incomplete, or invalid, or that the ordering/referring provider is
not eligible to order or refer. The informational message on an adjustment claim that did not pass the edits
indicated the claim/service lacked information that
was needed for adjudication. The informational messages used are identified below:
For Part B providers and suppliers who submit claims to carriers:
N264
Missing/incomplete/invalid ordering provider name
N265
Missing/incomplete/invalid ordering provider primary identifier
For adjusted claims, the Claims Adjustment Reason Code (CARC) code 16 (Claim/service lacks information which
is needed for adjudication.) is used.
DME suppliers who submit claims to carriers (applicable to 5010 edits):
N544
Alert: Although this was paid, you have billed with a referring/ordering provider that does not
match our system record. Unless, corrected, this will not be paid in the future For Part A HHA providers who
order and refer, the claims system initially processed the claim and added the following remark message:
N272
Missing/incomplete/invalid other payer attending provider identifier
For adjusted claims the CARC code 16 and/or the RARC code N272 was used.
CMS has taken actions to reduce the number of informational messages.
In December 2009, CMS added the NPIs to more than 200,000 PECOS enrollment records of physicians and nonphysician practitioners who are eligible to order and refer but who had not updated their PECOS enrollment
records with their NPIs.1
On January 28, 2010, CMS made available to the public, via the Downloads section of the “Ordering Referring
Report” page on the Medicare provider/supplier enrollment website, a file containing the NPIs and the names
of physicians and non-physician practitioners who have current enrollment records in PECOS and are of a type/
specialty that is eligible to order and refer. The file, called the Ordering Referring Report, lists, in alphabetical
order based on last name, the NPI and the name (last name, first name) of the physician or non-physician
practitioner. To keep the available information up to date, CMS will replace the Report on a weekly basis. At
any given time, only one Report (the most current) will be available for downloading. To learn more about
the Report and to download it, go to http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/
MedicareProviderSupEnroll/index.html; click on “Ordering & Referring Information” (on the left). Information
about the Report will be displayed.
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May 2013
Phase 2: Effective May 1, 2013, CMS will turn on the Phase 2 edits. In Phase 2, if the ordering/referring
provider does not pass the edits, the claim will be denied. This means that the billing provider will not be paid
for the items or services that were furnished based on the order or referral. Below are the denial edits for Part B
providers and suppliers who submit claims to carriers and/or MACs, including DME MACs:
254D
Referring/Ordering Provider Not Allowed To Refer
255D
Referring/Ordering Provider Mismatch
289D
Referring/Ordering Provider NPI Required
CARC code 16 and/or the RARC code N264 and N265 shall be used for denied or adjusted claims.
1 NPIs were added only when the matching criteria verified the NPI.
Below are the denial edits for Part A HHA providers who submit claims:
37236
• The statement “From” date on the claim is on or after the date the phase 2 edits are turned on
• The type of bill is ‘32’ or ‘33’
This reason
code will
• Covered charges or provider reimbursement is greater than
assign when: zero but the attending physician NPI on the claim is not present in the eligible attending
physician file from PECOS or the attending physician NPI on the claim is present in the eligible
attending physician files from PECOS but the name does not match the NPI record in the
eligible attending physician files from EPCOS or the specialty code is not a valid eligible code
37237
• The statement “From” date on the claim is on or after the date the phase 2 edits are turned on
• The type of bill is ‘32’ or ‘33’
This reason
code will
• The type of bill frequency code is ‘7’ or ‘F-P’
assign when:
• Covered charges or provider reimbursement is greater than
zero but the attending physician NPI on the claim is not present in the eligible attending
physician file from PECOS or the attending physician NPI on the claims is present in the eligible
attending physician files from PECOS but the name does not
match the NPI record in the eligible attending physician files
from PECOS or the specialty code is not a valid eligible code
Effect of Edits on Providers
I order and refer. How will I know if I need to take any sort of action with respect to these two edits?
In order for the claim from the billing provider (the provider who furnished the item or service) to be paid by
Medicare for furnishing the item or service that you ordered or referred, you, the ordering/referring provider,
need to ensure that:
a. You have a current Medicare enrollment record.
• If you are not sure you are enrolled in Medicare, you may:
i. Check the Ordering Referring Report and if you are on that report, you have a current enrollment record in
Medicare and it contains your NPI;
ii. Contact your designated Medicare enrollment contractor and ask if you have an enrollment record in
Medicare and it contains the NPI; or
iii. Use Internet-based PECOS to look for your Medicare enrollment record (if no record is displayed, you do
not have an enrollment record in Medicare).
May 2013
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iv. If you choose iii, please read the information on the Medicare provider/supplier enrollment web page
about Internet-based PECOS before you begin.
b. If you do not have an enrollment record in Medicare.
•
You need to submit either an electronic application through the use of internet-based PECOS or a
paper enrollment application to Medicare.
i. For paper applications - fill it out, sign and date it, and mail it, along with any required supporting paper
documentation, to your designated Medicare enrollment contractor.
ii. For electronic applications – complete the online submittal process and either e-sign or mail a printed,
signed, and dated Certification Statement and digitally submit any required supporting paper documentation
to your designated Medicare enrollment contractor.
iii. In either case, the designated enrollment contractor cannot begin working on your application
until it has received the signed and dated Certification Statement.
iv. If you will be using Internet-based PECOS, please visit the Medicare provider/supplier enrollment web
page to learn more about the web-based system before you attempt to use it. Go to http://www.cms.gov/
Medicare/Provider-Enrollment-and- Certification/MedicareProviderSupEnroll/index.html, click on “Internetbased PECOS” on the left-hand side, and read the information that has been posted there. Download and
read the documents in the Downloads Section on that page that relate to physicians and non- physician
practitioners. A link to Internet-based PECOS is included on that web page.
v. If you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment
record, you need to submit an enrollment application to Medicare. You can do this using Internet-based PECOS
or by completing the paper enrollment application (CMS-855O). Enrollment applications are available via
internet-based PECOS or .pdf for downloading from the CMS forms page (http://www.cms.gov/Medicare/CMSForms/CMS- Forms/index.html).
c. You are an opt-out physician and would like to order and refer services. What should you do?
If you are a physician who has opted out of Medicare, you may order items or services for Medicare
beneficiaries by submitting an opt-out affidavit to a Medicare contractor within your specific jurisdiction.
Your opt-out information must be current (an affidavit must be completed every 2 years, and the NPI is
required on the affidavit).
d. You are of a type/specialty that can order or refer items or services for Medicare beneficiaries.
When you enrolled in Medicare, you indicated your Medicare specialty. Any physician specialty (Chiropractors
are excluded) and only the non-physician practitioner specialties listed above in this article are eligible to order
or refer in the Medicare program.
e. I bill Medicare for items and services that were ordered or referred. How can I be sure that my claims
for these items and services will pass the Ordering/Referring Provider edits?
• You need to ensure that the physicians and non-physician practitioners from whom you accept orders
and referrals have current Medicare enrollment records and are of a type/specialty that is eligible
to order or refer in the Medicare program. If you are not sure that the physician or non- physician
practitioner who is ordering or referring items or services meets those criteria, it is recommended that
you check the Ordering Referring Report described earlier in this article.
• Ensure you are correctly spelling the Ordering/Referring Provider’s name.
• If you furnished items or services from an order or referral from someone on the Ordering
• Referring Report, your claim should pass the Ordering/Referring Provider edits.
• The Ordering Referring Report will be replaced weekly to ensure it is current. It is possible that you
may receive an order or a referral from a physician or non-physician practitioner who is not listed in the
Ordering Referring Report but who may be listed on the next Report.
f. Make sure your claims are properly completed.
•
•
•
Do not use “nicknames” on the claim, as their use could cause the claim to fail the edits.
Do not enter a credential (e.g., “Dr.”) in a name field.
On paper claims (CMS-1500), in item 17, you should enter the Ordering/Referring Provider’s first name
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May 2013
•
•
first, and last name second (e.g., John Smith).
Ensure that the name and the NPI you enter for the Ordering/Referring Provider belong to a physician
or non-physician practitioner and not to an organization, such as a group practice that employs the
physician or non-physician practitioner who generated the order or referral.
Make sure that the qualifier in the electronic claim (X12N 837P 4010A1) 2310A NM102 loop is a 1
(person). Organizations (qualifier 2) cannot order and refer.
If there are additional questions about the informational messages, Billing Providers should contact their local
carrier, A/B MAC, or DME MAC.
Billing Providers should be aware that claims that are denied because they failed the Ordering/Referring
Provider would not expose the Medicare beneficiary to liability. Therefore, an Advance Beneficiary Notice is
not appropriate.
g. What if my claim is denied inappropriately?
If your claim did not initially pass the Ordering/Referring provider edits, you may file an appeal through the
standard claims appeals process.
Additional Guidance
1. Terminology: Part B claims use the term “ordering/referring provider” to denote the person who ordered,
referred, or certified an item or service reported in that claim. The final rule uses technically correct terms: 1)
a provider “orders” non-physician items or services for the beneficiary, such as DMEPOS, clinical laboratory
services, or imaging services and 2) a provider “certifies” home health services to a beneficiary. The terms
“ordered” “referred” and “certified” are often used interchangeably within the health care industry. Since it would
be cumbersome to be technically correct, CMS will continue to use the term “ordered/referred” in materials
directed to a broad provider audience.
2. Orders or referrals by interns or residents: The IFC mandated that all interns and residents who order
and refer specify the name and NPI of a teaching physician (i.e., the name and NPI of the teaching physician
would have been required on the claim for service(s)). The final rule states that State-licensed residents may
enroll to order and/or refer and may be listed on claims. Claims for covered items and services from un-licensed
interns and residents must still specify the name and NPI of the teaching physician. However, if States provide
provisional licenses or otherwise permit
residents to order and refer services, CMS will allow interns and residents to enroll to order and refer, consistent
with State law.
3. Orders or referrals by physicians and non-physician practitioners who are of a type/specialty that
is eligible to order and refer who work for the Department of Veterans Affairs (DVA), the Public Health
Service (PHS), or the Department of Defense(DoD)/Tricare: These physicians and non-physician practitioners
will need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.
They may do so by filling out the paper CMS-855O or they may use Internet-based PECOS. They will not be
submitting claims to Medicare for services they furnish to Medicare beneficiaries.
4. Orders or referrals by dentists: Most dental services are not covered by Medicare; therefore, most
dentists do not enroll in Medicare. Dentists are a specialty that is eligible to order and refer items or services for
Medicare beneficiaries (e.g., to send specimens to a laboratory for testing). To do so, they must be enrolled in
Medicare. They may enroll by filling out the paper CMS-855O or they may use Internet-based PECOS. They will
not be submitting claims to Medicare for services they furnish to Medicare beneficiaries.
For more information about the Medicare enrollment process, visit http://www.cms.gov/Medicare/ProviderEnrollment-and- Certification/MedicareProviderSupEnroll/index.html or contact the designated Medicare
contractor for your State. Medicare provider enrollment contact information for each State can be found at
http://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/MedicareProviderSupEnroll/downloads/
Contact_list.pdf on the CMS website.
The Medicare Learning Network® (MLN) fact sheet titled, “Medicare Enrollment Guidelines for Ordering/
May 2013
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Referring Provider,” is available at http://www.cms.gov/Outreach-and- Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/MedEnroll_OrderReferProv_factSheet_ICN906223.pdf on the CMS website.
Note: You must obtain a National Provider Identifier (NPI) prior to enrolling in Medicare. Your NPI is a required
field on your enrollment application. Applying for the NPI is a separate process from
Medicare enrollment. To obtain an NPI, you may apply online at https://nppes.cms.hhs.gov/NPPES/Welcome.do
on the CMS website. For more information about NPI enumeration, visit http://www.cms.gov/Regulations-andGuidance/HIPAA-Administrative- Simplification/NationalProvIdentStand/index.html on the CMS website.
MLN Matters® Article MM7097, “Eligible Physicians and Non-Physician Practitioners Who Need to Enroll
in the Medicare Program for the Sole Purpose of Ordering and Referring Items and Services for Medicare
Beneficiaries,“ is available at http://www.cms.gov/Outreach-and-Education/Medicare- Learning-Network-MLN/
MLNMattersArticles/Downloads/MM7097.pdf on the CMS website.
MLN Matters® Article MM6417, “Expansion of the Current Scope of Editing for Ordering/Referring Providers
for Claims Processed by Medicare Carriers and Part B Medicare Administrative Contractors (MACs),” is available
at http://www.cms.gov/Outreach-and-Education/Medicare-Learning- Network-MLN/MLNMattersArticles/
Downloads/MM6417.pdf on the CMS website.
MLN Matters® Article MM6421, “Expansion of the Current Scope of Editing for Ordering/Referring Providers for Durable
Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers’ Claims Processed by Durable Medical
Equipment Medicare Administrative Contractors (DME MACs),” is available at http://www.cms.gov/Outreach-andEducation/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM6421.pdf on the CMS website;
MLN Matters® Article MM6129, “New Requirement for Ordering/Referring Information on Ambulatory Surgical
Center (ASC) Claims for Diagnostic Services,” is available at http://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM6129.pdf on the CMS website.
MLN Matters Article, MM6856, “Expansion of the Current Scope for Attending Physician Providers for freestanding and provider-based Home Health Agency (HHA) Claims processed by Medicare Regional Home Health
Intermediaries (RHHIs), is available at http://www.cms.gov/Outreach-and- Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/downloads/MM6856.pdf on the CMS website.
If you have questions, please contact your Medicare Carrier, Part A/B MAC, or DME MAC, at their toll- free
numbers, which may be found at http://www.cms.gov/Research-Statistics-Data-and- Systems/MonitoringPrograms/provider-compliance-interactive-map/index.html on the CMS website.
SE1308 - Physician Delegation of Tasks in Skilled Nursing Facilities
(SNFs) and Nursing Facilities (NFs)
News Flash –
Effective May 1, 2013, CMS will instruct contractors to turn on Phase 2 denial edits on the following claims to check
for a valid individual National Provider Identifier (NPI) and to deny the claim when this information is missing:
• Medicare Part B laboratory and imaging claims and Durable Medical Equipment, Orthotics, and
Supplies (DMEPOS) claims that require an ordering or referring physician/non-physician provider; and
• Part A Home Health Agency (HHA) claims that require an attending physician provider.
See MLN Matters® Article SE1305 for more information.
This MLN Matters® Article Special Edition (SE) is intended for physicians, non-physician practitioners (NPPs) and
providers who bill for services related to beneficiaries in Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs).
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May 2013
The Centers for Medicare & Medicaid Services (CMS) is publishing this article to provide clarification of Federal
guidance regarding Section 3108 of the Affordable Care Act (ACA), related to physician delegation of certain
tasks in SNFs and NFs to NPPs (NPPs are formerly “physician extenders”) such as nurse practitioners (NPs),
physician assistants (PAs), or clinical nurse specialists (CNSs).
This article addresses the authority of NPs, PAs, or CNSs to perform certain tasks such as conducting physician
visits and writing orders, and to sign certifications and re-certifications.
Background
CMS is clarifying the regulatory differences concerning physician delegation of tasks in SNFs and NFs. The
distinction in policies between these two settings (SNFs and NFs) is based in statute and regulation. Improper
application of these regulations may affect a facility’s compliance and payment to providers.
The key to accurate application is to identify:
1. In which setting, SNF or NF, the physician services are being provided;
2. Whether the task must be performed personally by the physician; and
3. Whether or not the NPP is employed by the facility.
The “setting” is determined by whether the visit to a patient in a certified bed is:
1. To a resident whose care is paid for by Medicare Part A in a SNF; or
2. To a resident whose care is paid for by Medicaid in a NF.
Key Points
The requirements for long-term care facilities, specified in 42 CFR section 483.40(e)(2), provide that, “A physician
may not delegate a task when the regulations specify that the physician must perform it personally, or when
the delegation is prohibited under State law or by the facility’s own policies.” The following bullets outline when
and which tasks may be delegated:
Physician Required and other Medically Necessary Visits during a SNF Stay:
•
A required physician visit includes the initial comprehensive visit in a SNF and every alternate required
visit thereafter. (See 42 CFR 483.40(c)(4).) The initial comprehensive visit in a SNF is the initial visit
during which:
o The physician completes a thorough assessment; and
o Develops a plan of care and writes or verifies admitting orders for the resident.
•
The initial comprehensive visit must occur no later than 30 days after a resident’s admission into the
SNF. The physician may not delegate the initial comprehensive visit in a SNF.
•
NPPs may perform other medically necessary visits prior to and after the physician’s initial
comprehensive visit.
•
Once the physician has completed the initial comprehensive visit in the SNF, the physician may then
delegate alternate visits to a PA, NP, or CNS who is licensed as such by the State and performing within
the scope of practice in that State. These alternate visits, as well as medically necessary visits, may be
performed and signed by the NPP (physician co-signature is not required).
May 2013
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Certifications/Re-certifications in SNFs:
•
42 CFR 424.20(e)(2) (which reflects the requirements of section 1814 (a)(2) of the Social Security
Act (Act)) states that NPs and CNSs who are not employed by the facility and who are working in
collaboration with a physician may sign the required initial certification and re- certifications of a
beneficiary’s need for SNF level of care.
•
Effective with services furnished on or after January 1, 2011, physician assistants who are not employed
by the facility are authorized to perform the required initial certification and periodic re-certifications of
a beneficiary’s need for a SNF level of care.
Performance of Physician Tasks in NFs:
•
Similar to a SNF, the initial comprehensive visit in a NF is the initial visit during which:
o The physician completes a thorough assessment; and
o Develops a plan of care and writes or verifies admitting orders for the resident.
•
The initial comprehensive visit must occur no later than 30 days after admission.
Note: At the option of the State, any required physician task in a NF (including tasks which the regulations
specify must be performed personally by the physician) may also be satisfied when performed by a NP, CNS, or
PA who is not an employee of the facility but who is working in collaboration with a physician.
In other words, NPPs that have a direct relationship with a physician and who are not employed by the facility
may perform the initial comprehensive visit, any other required physician visit, and other medically necessary
visits for a resident of a NF as the State allows. NPPs may also perform other medically necessary visits prior to
and after the physician initial comprehensive visit.
Medically necessary visits performed by NPs, CNSs, and PAs employed by the facility may not take the place
of the physician required visits, nor may the visit count towards meeting the required physician visit schedule
prescribed at 42 CFR 483.40(c)(1). However:
•
At the option of the State, NPs, PAs, and CNSs who are employees of the facility, while not permitted to
perform visits required under the schedule prescribed at 42 CFR 483.40(c)(1), are permitted to perform
other medically necessary visits and write orders based on these visits.
o For example, if a resident complains of a headache, the NP, CNS, or PA employed by the NF may
assess the resident and write orders to address the condition;
o The physician is not required, other than by State law as applicable, to verify and sign orders
written by NPPs who are employed by the facility for other medically necessary visits; and
o These medically necessary visits performed by NPs, CNSs, and PAs employed by the facility may
not take the place of the physician required visits, nor may the visit count towards meeting the
required physician visit schedule prescribed at 42 CFR 483.40(c)(1).
NPs, PAs and CNSs must collaborate with a physician:
• In contrast to the initial SNF visit, NPPs may provide initial NF visits and other required visits under 42
CFR 483.40(c)(3) and (f ) if the State permits it;
• Required physician tasks, such as verifying and signing orders in an NF, may be delegated to a PA, NP, or
CNS who is not an employee of the facility, but who is working in collaboration with a physician; and
• Orders written by an NPP who is employed by the NF and are written during visits that are not required
visits, and are therefore “other medically necessary visits,” do not require physician co-signature except
as mandated by State law.
CMS is issuing this clarification because, where a NPP is permitted to perform a medically necessary visit, the
NPP is likewise permitted to write applicable orders during that visit. The Federal requirements restricting NPPs
who are employed by the NF from performing a required visit, do not apply to other medically necessary visits.
Thus, this guidance clarifies when an NPP employed by a NF may write orders without a countersignature unless
State law requires it.
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May 2013
Note: The following regulatory language is included for reference purposes:
Section 483.40(f ) Performance of Physician Tasks in NFs: At the option of the State, any required physician task
in a NF (including tasks which the regulations specify must be performed personally by the physician) may also
be satisfied when performed by a nurse practitioner, clinical nurse specialist, or physician assistant who is not an
employee of the facility but who is working in collaboration with a physician.
Dually-Certified Facilities (SNF/NFs)
In a facility where beds are dually–certified under Medicare and Medicaid, the facility must determine how the
particular resident stay is being paid.
•
For residents in a Part A Medicare stay, the NPP must follow the guidelines for services in a SNF.
•
For residents in a Medicaid stay, the NPP must follow the provisions outlined for care in NFs.
•
In a dually-certified nursing home, any required physician task for a Medicaid beneficiary in a Medicaid
stay, at the option of the State, may be performed by a NPP who is not an employee of the facility but
who is working in collaboration with a physician.
•
In a dually-certified nursing home and at the option of a physician, required physician visits for a
Medicare beneficiary in a Part A Medicare stay may be alternated between personal visits by the
physician and visits by a NPP after the physician makes the initial first visit.
The following table summarizes the requirements for NPPs to perform visits, sign orders, and sign certifications
and re-certifications, when this function is permitted under the scope of practice for the State.
Authority for NPPs to Perform Visits, Sign Orders and Sign Certifications/Re-certifications When
Permitted by the State*
Initial
Comprehensive
Visit /Orders
Other Required
Visits^
Other Medically
Necessary Visits &
Orders+
Certification/
Recertification
May not perform/
May not sign
May perform
alternate visits
May perform and
sign
May not sign
May not perform/
May not sign
May perform
alternate visits
May perform and
sign
May sign subject to
State requirements
PA, NP & CNS
employed by the
facility
May not perform/
May not sign
May not perform
May perform and
sign
Not applicable ±
PA, NP & CNS not a
facility employee
May perform/ May
sign
May perform
May perform and
sign
Not applicable ±
SNFs
PA, NP & CNS
employed by the
facility
PA, NP & CNS not a
facility employee
NFs
*This reflects clinical practice guidelines
^Other required visits are the required monthly visits.
+Medically necessary visits may be performed prior to the initial comprehensive visit.
± This requirement relates specifically to coverage of a Part A Medicare stay, which can take place only in a
Medicare-certified SNF.
To review 42 CFR 483.40, go to http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol5/pdf/CFR2011-title42-vol5-sec483-40.pdf on the Internet.
May 2013
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To review 42 CFR 424.20 go to http://www.gpo.gov/fdsys/pkg/CFR-2009-title42-vol3/pdf/CFR-2009-title42-vol3sec424-20.pdf on the Internet.
To review the memorandum that is the basis for this article and discusses physician delegation of
tasks in SNFs and NFs go to http://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/
SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-15-.pdf on the CMS website.
To review the Section 3108 of the Affordable Care Act (page 300), Permitting Physician Assistants To
Order Post-Hospital Extended Care Services, go to: http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/
BILLS-111hr3590enr.pdf on the Internet
Subsequent Nursing Facility Care (CPT Codes 99307-99310): Claim
Submission and Documentation
Medicare will pay for federally mandated visits that monitor and evaluate residents at least once every 30 days
for the first 90 days after admission and at least once every 60 days thereafter. Submit CPT codes 99307-99310
(Subsequent Nursing Facility Care, per day) in the following circumstances:
o Federally mandated physician visits and other medically necessary visits
o Medically necessary Evaluation & Management (E/M)services, even if they are provided prior to the
initial visit by the physician
o Medically complex care in a Skilled Nursing Facility (SNF) upon discharge from an acute care visit, even
if the visits are provided prior to the physician’s initial visit
Submitting claims for visits in SNFs and nursing facilities (NFs):
o Consultation codes may not be submitted on Medicare claims.
o Submit the most appropriate visit code that represents the service provided.
o In all cases, documentation in the patient’s medical record must support the medical necessity for
services submitted (including the level of E/M service).
o Submit claims for the first E/M service for a Medicare beneficiary in a SNF or NF during the patient’s
facility stay, even if that service is provided prior to the federally mandated visit, with the most
appropriate E/M code that reflects the services the practitioner furnished. This includes:
o Initial nursing facility care codes (CPT codes 99304-99306)
o Subsequent nursing facility care code (CPT codes 99307-99310), when documentation and
medical necessity do not meet the requirements for submitting an initial nursing facility care code
Medical Necessity, Level of Service, Time, and Signatures
Medicare allows only the medically necessary portion of the visit. Even if a complete note is generated, only the
necessary services for the condition of the patient at the time of the visit can be considered to determine the
level of the E/M code.
1. Check your documentation: is the level of service supported?
a. CPT code 99307 requires at least 2 of these 3 components: problem focused interval history,
problem focused exam, straightforward medical decision making
b. CPT code 99308 requires at least 2 of these 3 key components: expanded problem focused
interval history, problem focused exam, medical decision making of low complexity
c. CPT code 99309 requires at least 2 of these 3 components: detailed interval history, detailed
exam, medical decision making of moderate complexity
d. CPT code 99310 requires at least 2 of these 3 components: comprehensive interval history,
comprehensive exam, high complexity medical decision-making
2. If you are selecting the CPT code for an E/M service based on time, document the time spent on
counseling and/or coordination of care in the patient’s medical record. In order to select an E/M code
based on time, the visit must consist predominantly of counseling and/or coordination of care.
3. All documentation must be signed by the person providing the service.
Reference:
o Additional documentation tips are available in CGS Medical Review Checklists:
o Part B Ohio: http://www.cgsmedicare.com/ohb/coverage/mr/Checklists.html
- page 109 -
May 2013
o
o
o
o
o Part B Kentucky: http://www.cgsmedicare.com/kyb/coverage/mr/Checklists.html
“Medical necessity” as the basis for Medicare coverage: Social Security Act, section 1862(a)(1)(A)
CMS E/M Documentation Guidelines
CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12, section 30.6.1.B
CMS MLN Matters article MM7405, “Clarification of Evaluation and Management (E/M) Payment
Policy”
Transitional Care Management (TCM): Guidance
CMS has developed several Frequently Asked Questions (and answers) regarding transitional care management
(TCM) codes (CPT codes 99495 and 99496). These codes are used to report physician or qualifying nonpractitioner care management services for patients following discharge from a hospital, Skilled Nursing Facility
(SNF), or Community Mental Health Center (CMHC) stay, outpatient observation, or partial hospitalization.
Please refer to these CMS FAQs for guidance regarding these and other specific topics:
•
•
•
•
•
•
•
•
•
Reporting the correct Date of Service (DOS)
Reporting the correct Place of Service (POS)
Incident-to billing
Services provided in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
Readmission
Claims from multiple providers
Applicability to teaching settings under the primary care exception rule
Separate payment for additional services
Definition of a “business day”
UGT1A1 Gene Analysis: Coding and Claim Submission Guidelines
CGS has determined UGT1A1 gene analysis has insufficient evidence to support the required clinical utility for
the established Medicare benefit category. Therefore, UGT1A1 gene analysis is a statutorily excluded test. The following UGT1A1 gene analysis tests have been identified as non-covered:
Test
UGT1A1 Gene Analysis
UGT1A1 PROMOTER GENOTYPING
UGT1A1 (CAMPTOSAR/IRINOTECAN) GENOTYPE
UGT1A1 Gene Polymorphism
UDP Glucuronosyltransferase 1A1 (UGT1A1) Genotyping
UDP-Glucuronosyl Transferase 1A1 TA Repeat Genotype, UGT1A1
UDP-Glucuronosyl Transferase 1A1 (UGT1A1) Gene, Known Mutation
UDP-Glucuronosyl Transferase 1A1 (UGT1A1), Full Gene Sequencing, Hyperbilirubinemia
UDP-Glucuronosyl Transferase 1A1 (UGT1A1), Full Gene Sequencing, Irinotecan Hypersensitivity
UGT1A1 Gene Polymorphism
however, you may choose to submit claims (e.g., at the patient’s request). Claims for UGT1A1 gene analysis test
must include:
• The name of the test (UGT1A1 gene analysis):
May 2013
- page 110 -
Reference:
Vysis Kit by Abbott: Coding and Claim Submission Guidelines
CGS has determined the FDA-approved Vysis ALK Break Apart FISH Probe Kit by Abbot meets the reasonable
and necessary criteria for Medicare reimbursement. Vysis, a molecular diagnostic test designed to detect
rearrangements of the anaplastic lymphoma kinase (ALK) gene in non-small-cell lung cancer (NSCLC)
(adenocarcinoma), identifies patients eligible for treatment with XALKORI® (crizotinib). XALKORI® is indicated for
the treatment of patients with locally advanced or metastatic NSCLC that is ALK-positive as detected by an FDAapproved test.
Claims for Vysis Kit by Abbott tests must include:
• One of the following CPT codes :
CPT Code
88367
88368
•
•
•
Units
2
2
At least one of the following appropriate ICD-9-CM code(s):
o 162.2 – Malignant neoplasm of trachea, bronchus, and lung; main bronchus
o 162.3 – Malignant neoplasm of trachea, bronchus, and lung; upper lobe, bronchus or lung
o 162.4 – Malignant neoplasm of trachea, bronchus, and lung; middle lobe, bronchus or lung
o 162.5 – Malignant neoplasm of trachea, bronchus, and lung; lower lobe, bronchus or lung
o 162.8 – Malignant neoplasm of trachea, bronchus, and lung; other parts of bronchus or lung
o 162.9 – Malignant neoplasm of trachea, bronchus, and lung; bronchus and lung, unspecified
The name of the test (Vysis):
If this test is done based on an ICD-9-CM code other than the ones listed in this article, you may ask the
patient to sign an Advance Beneficiary Notice of Noncoverage (ABN). In these situations, if the patient
has signed an ABN, submit HCPCS modifier GA with the appropriate CPT code.
Reference:
• Guidance on issuing Advance Beneficiary Notices of Noncoverage (ABNs): CMS Beneficiary Notices
Initiative webpage – Fee-For-Service (FFS) ABN
Additional Information:
• To submit the professional component (PC) of this test, a pathologist must read and interpret the raw
data. According to the CMS National Correct Coding Initiative (NCCI) Manual, chapter 10, version
16.3, physicians may not report the professional component provided by a technician or scientist. The
pathologist must submit a separate claim for this service.
Note: This CGS coverage determination and coding guideline ONLY applies to the UNMODIFIED Vysis Kit by
Abbot for patients with NSCLC.
- page 111 -
May 2013
Join the
CGS ListServ
By joining the CGS electronic mailing list, you can
get immediate updates on Medicare information,
including:
Medicare publications
Important updates
Workshops
Medical Review information
To join the ListServ follow this link:
https://www.cgsmedicare.com/medicare_
dynamic/ls/001.asp
- page 112 -
May 2013
Overpayment Refunds
Personal provider checks sent to us for any reason should be sent to the following address (if
you are submitting a refund due to Medicare Secondary Payer, include “MSP” on the envelope or
correspondence):
Kentucky and Ohio Providers
CGS – J15 Part B Kentucky and Ohio
PO Box 957065
St. Louis, MO 63195-7065
Personal provider checks should never be sent to our Nashville operations as this will create
processing delays. For example, in situations where you have received a letter of notification regarding
a Medicare overpayment, these delays can result in payment offset and/or interest accrual.
Checks issued by CGS that need to be returned to us should be sent to the following address:
Kentucky and Ohio Providers
CGS – J15 Part B Kentucky and Ohio
PO Box 957065
St. Louis, MO 63195-7065
Medicare Bulletin
. . . a service of CGS
Two Vantage Way
Nashville, TN 37228
The CGS website (www.cgsmedicare.com) provides formal notification for all notices developed
and distributed by CGS, including the Part B Medicare Bulletin. Providers/suppliers are obligated and
responsible for remaining updated on current Medicare issues and legislation as it is posted to the
website.
Please note that for LCDs listed on the website, the start of the notice period may be different than
the date it is posted to the website. Please abide by the notice period dates on the document, not
the posting date.
A quarterly CD-ROM, which includes the Medicare Bulletin and other additional resources, is mailed
to the same location as Medicare checks. Provider groups will receive one copy of the CD-ROM.
Each individual provider in that group will not receive their own copy for his/her individual provider
identification number (PIN).
May 2013
- page 113 -
OHIO
OH Insert, page 114
May 2013
This newsletter should be shared with all health care practitioners and managerial
members of the provider/supplier staff. Newsletters issued after January 1997 are
available at no cost from our Web site at www.cgsmedicare.com.

OHIO Part B Medicare Bulletin

Transcription

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