Home

Medicare Bulletin - April 2014

1. The Centers for Medicare amp Medicaid Services CMS has issued a revision to the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number MM8465 Revised Related Change Request CR CR 8465 Related CR Release Date February 26 2014 Effective Date December 3 2013 Related CR Transmittal R13530TN Implementation Date March 3 2014 Note This article was revised on February 27 2014 to reflect a revised CR that provides additional information to providers suppliers and clearinghouses about how claims will be submitted for testing page 2 in bold The transmittal number CR release date and link to the CR were also changed All other information remains the same This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at oO http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 PN m Z mr O PN lt Ro O Hs U gt AD a gt T1 Provider Types Affected This MLN Matters article is intended for Medicare providers and suppliers submitting cl
2. The Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles htm MLN Matters Number MM8445 Related Change Request CR CR 8445 Related CR Release Date February 7 2014 Effective Date For Admissions occurring Related CR Transmittal R2877CP on or after October 1 2013 Implementation Date April 7 2014 Provider Types Affected This MLN Matters article is intended for providers and suppliers who submit claims to Medicare claims administration contractors MACs for services provided to Medicare beneficiaries This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 aA m Z mr O PN lt Ro O Hs U gt AD a gt 45 Provider Action Needed This article is based on CR 8445 which provides details regarding the implementation of payment policies related to hospital Part B inpatient billing from the final regulation CMS 1599 F Make sure that your billing
3. 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 aA m Z mr O PN lt Ro O Hs U gt AD a gt T5 The four pronged approach includes e CMS internal testing of its claims processing systems e Provider initiated Beta testing tools e Acknowledgement testing and End to end testing Each approach is discussed in more detail below CMS Internal Testing of Its Claims Processing Systems CMS has a very mature and rigorous testing program for its Medicare FFS claims processing systems that supports the implementation of four quarterly releases per year Each release is supported by a three tiered and time sensitive testing methodology Alpha testing is performed by each FFS claims processing system maintainer for 4 weeks e Beta testing is performed by a separate Integration Contractor for 8 weeks and e Acceptance testing is performed by each MAC for 4 weeks to ensure that local coverage requirements are met and the systems are functioning as expected aA m Z mr O PN lt Ro O Hs T gt A a gt CMS began installing and testing system changes to support ICD 10 in 2011 As of October 1 2013 all Medicare FFS claims processing systems were ready for ICD 10 implementation CMS continues to test its CD 10 software changes with each quarterly release Provider Initiated Beta Testing Tools To help you prepare for ICD
4. Address Change for Audit and Reimbursement Correspondence Effective March 31 2014 please send all correspondence for Audit amp Reimbursement to the following address GS Audit and Reimbursement PO Box 20020 Nashville TN 37202 Physical Address for Documents CGS Two Vantage Way Nashville TN 37228 Note Send to the attention of Audit and Reimbursement Prior to this date you may continue to use the existing address for Audit amp Reimbursement which is CGS Audit and Reimbursement 3021 Montvale Drive Springfield IL 62704 This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 40 Financial Information MM8619 Implementation of Health Insurance Portability amp Accountability Act HIPAA Standards and Operating Rules for Health Care Electronic Funds Transfers The Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number
5. TRN TRN01 TRNO2 TRNO3 TRNO4 Segment Terminator data element separator The following table explains this example Mandatory Element Element Name or Optional Data Content TRN Reassociation Trace Number M ASC X12 835 segment identifier This is always TRN TRNO1 Trace Type Code M Trace Type Code is always a 1 TRNO2 Reassociation Information M This data element must contain the EFT trace number TRNO3 Origination Company ID M A unique identifier designating the company initiating the funds transfer This must be a 1 followed by the payer s Tax Identification Number TIN TRNO4 Reference Identification O This data element is required when information beyond the Originating Company Identifier in TRNO3 is necessary for the payee to identify the source of the payment Segment Segment Terminator M The TRN data segment in the addenda record must end with Terminator either a tilde or a backslash This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 44 Additional Information For information on the NACHA Operating Rules that apply to health care payments particularly with regard
6. gt AD a gt If the beneficiary s liability under Part A for the initial claim submitted for inpatient services is greater than the beneficiary s liability under Part B for the inpatient services they received the hospital must refund the beneficiary the difference between the applicable Part A and Part B amounts Conversely if the beneficiary s liability under Part A is less than the beneficiary s liability under Part B for the services they received the beneficiary may face greater cost sharing Summary of Business Requirements for CR 8445 e MACs will ensure that provider submitted medical necessity denial claims contain the Occurrence Span Code M1 and dates on the inpatient claim Hospital part B Inpatient service claims that are billed after a Medical Necessity denial should contain the following data elements A treatment authorization code of A B Rebilling submitted by a provider NOTE Providers submitting an 8371 will be instructed to place the appropriate Prior Authorization code above into Loop 2300 REF02 REFO1 G1 as follows REF G1 A B Rebilling gt For DDE or paper Claims A B Rebilling will be added in FL 63 A condition code W2 attesting that this is a rebilling and no appeal is in process and The original denied inpatient claim CCN DCN ICN number and gt NOTE Providers submitting an 8371 will be instructed to place the DCN in the Billing Notes loop 2300 NTE in
7. Code D at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads MM3881 pdf on the CMS website aA m Z mr O PN lt Ro O Hs T gt A a gt To review the Inpatient Psychiatric Facility Prospective Payment System Fact Sheet that provides detailed information about the background coverage requirements payment rates Fiscal Year FY 2013 updates to the IPF PPS quality reporting and resources visit http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts downloads InpatientPsychFac pdf on the CMS website Hospital Information SE1412 Update to 2014 Hospital Outpatient Clinical Diagnostic Laboratory Test Payment and Billing The Centers for Medicare amp Medicaid Services CMS has issued the following Special Edition Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number SE1412 Related Change Request CR 8572 Related CR Release Date December 27 2013 Effective Date January 1 2014 Related CR Transmittal R2845CP Implementation Date January 6 2014 Provider Types Affected This MLN Matters Special Edition article is intended for Outpatient Prospective Payment System OPPS pr
8. MEDICARE BULLETIN GR 2014 04 APRIL 2014 19 What You Need to Know This article describes upcoming changes to Medicare beneficiary health insurance eligibility inquiry services that CMS will implement in the coming months In April 2013 access to CWF eligibility query functions implemented in the Multi Carrier System MCS and ViPS Medicare System VMS also referred to as PPTN and VPIQ was terminated CMS intends to terminate access to the other CWF eligibility queries implemented in the Fiscal Intermediary Standard System FISS Direct Data Entry DDE often referred to the HIQA HIQH ELGA and ELGH screens and HUQA Change Request 8248 creates the ability for CMS to terminate these queries While termination was originally scheduled for April 2014 CMS is delaying the date CMS will provide at least 90 days advanced notice of the new termination date This will not affect the use of DDE to submit claims or to correct claims and will not impact access to beneficiary eligibility information from Medicare Contractor s Interactive Voice Response IVR units and or Internet portals Background In 2005 CMS began offering HETS in a real time environment to Medicare health care providers suppliers and their billing agents software vendors and clearinghouses HETS is Medicare s Health Care Eligibility Benefit Inquiry and Response electronic transaction ASCX12 270 271 Version 5010 adopted under HIPAA HETS replaces the CWF queries and i
9. TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 62 When a patient is discharged from an acute hospital to a Critical Access Hospital CAH swing bed use Patient discharge status Code 61 Swing beds are not part of the post acute care transfer policy 62 Discharged Transferred to an Inpatient Rehabilitation Facility Including Distinct Part Units of a Hospital Inpatient rehabilitation facilities or designated units are those facilities that meet a specific requirement that 75 of their patients require intensive rehabilitative services for the treatment of certain medical conditions This code should be used when a patient is transferred to a facility or designated unit that meets this qualification 63 Discharged Transferred to Long Term Care Hospitals This code is for hospitals that meet the Medicare criteria for LTCH certification as follows Long term care hospitals are facilities that provide acute inpatient care with an average length of stay of 25 days or greater This code should be used when transferring a patient to along term care hospital If you are not sure whether a facility is a long term care hospital or a short term care hospital you should contact the facility to verify their facility type before assigning a patient discharge status code 64 Discharged Transferred to a Nursing Facility Certified Under Medicaid but not Certified Under Medicare Nursing facilities may elect to certify only a port
10. Updated Payment Rates for Certain HCPCS Codes Effective October 1 2013 through December 1 2013 The payment rates for three HCPCS codes were incorrect in the October 2013 OPPS Pricer The corrected payment rates are listed in Table 6 below and they have been installed in the April 2014 OPPS Pricer effective for services furnished on October 1 2013 through December 31 2013 MACs will adjust claims that were previously processed incorrectly if you bring such claims to the attention of your MAC Table 6 Updated Payment Rates for Certain HCPCS Codes Effective October 1 2013 through December 31 2013 Corrected Minimum HCPCS Code Status Indicator APC Short Descriptor Corrected Payment Rate Unadjusted Copayment A9600 K 0701 Sr89 strontium 1 196 47 239 29 J2323 K 9126 Natalizumab injection 12 99 2 60 Q4127 G 1449 Talymed 13 78 2 76 g Reassignment of Skin Substitute Products that are New for CY 2014 from the Low Cost Group to the High Cost Group In the CY 2014 OPPS ASC final rule CMS finalized a policy to package payment for skin substitute products into the associated skin substitute application procedure You can review the CY 2014 OPPS ASC final rule at http www gpo gov fdsys pkg FR 2013 12 10 pdf 2013 28737 pdf on the Internet For packaging purposes CMS created two groups of application procedures application procedures that use high cost skin substitute products billed usin
11. amp Medicaid Services CMS has issued a revision to the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number MM8582 Revised Related Change Request CR CR 8582 Related CR Release Date February 24 2014 Effective Date April 1 2014 Related CR Transmittal R2884CP Implementation Date April 7 2014 Note This article was revised on February 27 2014 to reflect an updated Change Request CR The CR corrects the date when the Claim Status Category Codes and Claim Status Codes will be posted which is March 1 2014 All other information remains the same Provider Types Affected aA m Z mr O PN lt Ro O Hs T gt AD a gt This MLN Matters article is intended for physicians other providers and suppliers submitting claims to Medicare administrative contractors MACs including durable medical equipment Medicare administrative contractors DME MACs and home health amp hospice MACs for services to Medicare beneficiaries Provider Action Needed This article is based on CR 8582 which informs Medicare contractors about the changes to Claim Status Category Codes and Claim Status Codes Make sure that your billing personnel are aware of these changes Bac
12. pdf and http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads MM8204 pdf on the CMS website Although for payment purposes the single payment amounts replace the fee schedule amounts for mail order DTS KL modifier the fee schedule amounts remain on the DMEPOS fee schedule file as reference data such as for establishing bid limits for future rounds of competitive bidding programs The mail order DTS fee schedule amounts shall be updated annually by the covered item update adjusted for Multi Factor Productivity MFP which results in update of 1 0 percent for CY 2014 The single payment amount public use file for the national mail order competitive bidding program is available at http www dmecompetitivebid com palmetto cbicrd2 nsf DocsCat Single 20 Payment 20Amounts on the Internet CY2014 Fee Schedule Update Factor For CY 2014 the update factor of 1 0 percent is applied to the applicable CY 2013 DMEPOS fee schedule amounts In accordance with the statutory Sections 1834 a 14 and 1886 b 3 B xi II of the Act the DMEPOS fee schedule amounts are to be updated for 2014 by the percentage increase in the consumer price index for all urban consumers United States city average or CPI U for the 12 month period ending with June of 2013 adjusted by the change in the economy wide productivity equal to the 10 year moving average of changes in annual economy wide private non farm
13. 2014 Hospital Outpatient Clinical Diagnostic Laboratory Test Payment and Billing 68 ICD 10 MM8465 Revised International Classification of Diseases 10th Revision ICD 10 Testing with Providers through the Common Edits and Enhancements Module CEM and Common Electronic Data Interchange CEDI 71 MM8602 International Classification of Diseases Tenth Revision ICD 10 Limited End to End Testing with Submitters 73 SE1409 Revised Medicare Fee For Service FFS International Classification of Diseases 10th Edition ICD 10 Testing Approach 15 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 MEDICARE BULLETIN GR 2014 04 APRIL 2014 3 General Information 2014 Provider Contact Center PCC Training and Holiday Closure Schedule Medicare is a continuously changing program and it is important that we provide correct and accurate answers to your questions To better serve the provider community the Centers for Medicare amp Medicaid Services CMS allows the provider contact centers the opportunity to offer training to our customer service representatives CSRs The CGS Part A PCC 1 866 590 6703 will continue to close up to eight hours per month for CSR training and staff development The Interacti
14. CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 RETURN TO VAN lO CONTENTS aA m Z mr O PN lt Ro O Hs T gt A 5j gt 15 Enhancement Topic Details What It Does Changes that Apply to Just One App Open Payments Mobile for Physicians Manage Companies Within Manage Vendors a new data field allows users to assign vendors to companies when added entering new vendor information e Company information is needed for the Reports Statistics functionality to illustrate all payments by company name The updated Frequently Asked Questions at htip www cms gov Regulations and Guidance Legislation National Physician Payment Transparency Program Downloads Mobile App FAQs 5bAugust 2013 5d pdf about the mobile apps contain all the details about these enhancements link to the document above or visit the Apps for Tracking Assistance page on the Open Payments website QR Code Technical Guide Available for Apps Also now available to support use of the Open Payments apps is a how to guide that explains the technical details associated with how to create Quick Response QR codes usable in the apps The Open Payments QR Code Reader How To Guide includes detailed highly technical instructions for creating or importing contact information using a QR code reader and generating a QR code to transfer profile or payment information
15. Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number MM8442 Related Change Request CR CR 8442 Related CR Release Date February 7 2014 Effective Date March 7 2014 Related CR Transmittal R2876CP Implementation Date March 7 2014 Provider Types Affected This MLN Matters article is intended for individual providers or chains submitting claims to Part A Medicare administrative contractors MAC for services to Medicare beneficiaries aA m Z mr O PN lt Ro O Hs T gt AD a gt What You Need To Know CR 8442 removes amends the Medicare Claims Processing Manual to show that provider chains and individual providers are no longer permitted to select the fiscal intermediary of their choice Background CR 8442 from which this article is taken removes certain sections from the Medicare Claims Processing Manual because they contain policy based on the legacy environment during which chains and individual providers were permitted to select the fiscal intermediary of their choice Section 911 of the Medicare Prescription Drug Improvement and Modernization Act of 2003 MMA Public Law 108 173 which you ca
16. DME MACs for services to Medicare beneficiaries Provider Action Needed This article is based on CR 8418 which informs MACs that effective for claims with dates of service on or after May 29 2013 CMS extends coverage of the oral antiemetic three drug regimen of oral aprepitant an oral 5HT3 antagonist and oral dexamethasone to beneficiaries who are receiving certain anticancer chemotherapeutic agents Make sure that your billing personnel are aware of these changes This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 21 Background Chemotherapy induced emesis is the occurrence of nausea and vomiting during or after anticancer treatment with chemotherapy agents The Social Security Act the Act permits oral drugs to be paid under Part B in very limited circumstances one of which is antiemetic therapy administered immediately before and within 48 hours after anticancer chemotherapy as described in section1861 s 2 of the Act These drugs must fully replace the non self administered drug that would otherwise be covered On April 4 2005 CMS announced a National Coverage Determination NCD for the use of the oral three drug regimen of aprepitant a SHT3 antagon
17. Medicare Medicare Fee for Service Payment HospitalOutpatientPPS on the CMS website Failure to pass these edits will result in claims being returned to the provider No Cost Full Credit and Partial Credit Devices Effective January 1 2014 CMS will no longer recognize the modifier FB Item provided without cost to provider supplier or practitioner or credit received for replaced device or the modifier FC Partial credit received for replaced device which are used to identify a device that is furnished without cost or with a full or partial credit Also effective January 1 2014 for claims with APCs that require implantable devices and have significant device offsets greater than 40 percent the amount of the device credit will be specified in the amount portion for value code FD Credit Received from the Manufacturer for This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 aA m Z mr O PN lt Ro O Hs T gt AD a gt 52 a Replaced Medical Device and will be deducted from the APC payment from the applicable procedure The OPPS payment deduction for the applicable APCs referenced above will be limited to the total amount of
18. Number MM8597 Related Change Request CR CR 8597 Related CR Release Date February 14 2014 Effective Date May 15 2014 E Related CR Transmittal R2878CP Implementation Date May 15 2014 O U0 gt D gt What You Need to Know This article based on CR 8597 provides the removal of language that was erroneously included in CR 8404 and in the Medicare Claims Processing Manual Chapter 30 Sections 50 3 and 50 6 2 It also provides clarified manual instructions regarding home health agency issuance of the Advance Beneficiary Notice of Noncoverage ABN to dual eligible beneficiaries Background The ABN is an Office of Management and Budget OMB approved written notice issued by providers and suppliers for items and services provided under Medicare Part B including hospital outpatient services and care provided under Part A by home health agencies HHAs hospices and religious non medical healthcare institutes only Key Points of CR 8597 e With the exception of Durable Medical Equipment Prosthetic Orthotics amp Supplies DMEPOS suppliers providers and suppliers who are not enrolled in Medicare cannot issue the ABN to beneficiaries DMEPOS suppliers not enrolled as Medicare suppliers are required by statute to provide ABN notification prior to furnishing any items or services to Medicare beneficiaries An example of an approved customization of the ABN which can be used by providers of laboratory services Sam
19. Services CMS 11 MM8531 Revised Calendar Year CY 2014 Quarterly Provider Update 13 Update for Durable Medical Equipment Prosthetics a Orthotics and Supplies DMEPOS Fee Schedule _ 35 SE1402 Updated Mobile Applications Apps for Open Payments 14 FINANCIAL COMMON WORKING FILE Address Change for Audit and Reimbursement Correspondence eee 40 MM8456 Revised Modifying the Daily Common Working File CWF to Medicare MM8619 Implementation of Health Insurance Beneficiary Database MBD File to Include Portability amp Accountability Act HIPAA Standards Diagnosis Codes on the Health Insurance and Operating Rules for Health Care Electronic Portability and Accountability Act Eligibility Funds Transfers oo rererere 41 Transaction System HETS 270 271 Transactions 17 MM8629 Implementation of National MM8620 CWF Editing for Vaccines Automated Clearinghouse Association NACHA Furnished at Hospice Correction 18 Operating Rules for Health Care Electronic eee Funds Transfers EFT 48 SE1249 Revised HIPAA Eligibility Transaction System HETS to Replace Common Working File CWF Medicare Beneficiary Health Insurance Eligibility Queries 19 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 MEDICARE
20. TO of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 49 Hospital Information MM8546 Addition of New Fields and Expansion of Existing Model 1 Discount Percentage Field in the Inpatient Hospital Provider Specific File PSF and Renaming Payment Fields in the Inpatient Prospective Payment System IPPS Pricer Output The Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number MM8546 Related Change Request CR CR 8546 Related CR Release Date February 5 2014 Effective Date July 1 2014 Related CR Transmittal R2870CP Implementation Date July 7 2014 Provider Types Affected This MLN Matters article is intended for providers and suppliers submitting institutional claims to Medicare administrative contractors MACs for services to Medicare beneficiaries Provider Action Needed This article is based on CR 8546 which informs MACs about changes to the PSF The PSF is maintained by MACs to facilitate proper payments to providers Note CR8546 is not im
21. TO of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 80
22. Use Code 51 Hospice medical facility 14 Q What discharge status code should be used when a patient is discharged to a chemical dependency treatment facility that is not part of a hospital A If the chemical dependency treatment facility is not a psychiatric hospital or psychiatric distinct part unit of a hospital and the patient is undergoing inpatient residential treatment use Code 05 discharged transferred to another type of health care institution not defined elsewhere in this code list Note The NUBC has approved the establishment of a new code 70 to take effect April 1 2008 for other types of health care facilities not defined elsewhere in the code list Additional Information If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 aA m Z mr O PN lt Ro O Hs U gt AD a gt 66 Hospital Information SE1401 Point of Origin for Admission or Visit Code Formerly Source of Admission Code for Inpatient Psychiatric Facilities IPFs The Centers for Medicare a
23. but believe you should talk with the myCGS Provider Administrator for your agency organization and they can update your security How do I use the Forms tab to submit a redetermination request To submit a redetermination request click on the Forms tab to access the Secure Forms page In the Go To page field select the Secure Forms option You have O unread message s and O alerts to Go To page Select Form x Secure Forms Welcome to secure forms You can now submit forms to CGS Administrators securely through myCGS You may attach up to five POF attachments to each form Each attachment can be up to 5M6 in size The forms and attachments are automatically entered into our workflow This makes form processing more efficient and cost effective aA m Z mr O PN lt Ro O Hs gt A a gt To begin please select an answer to the questions from the drop down selections below Based upon the answer given for each of the questions the available form s will appear at the bottom of this box At this time only Appeals forms are available Select a Topic Appeals Select a Type First level appeal on a Medicare Claim To verify you are within timely filing requirements for this Appeal please use our Appeals Calculator Is your appeal late over 120 days for a redetermination or over 365 days for a reopening No zj Redetermination 1 Level Appeal EA J15 A 1000 Currently
24. by OPPS hospitals on a 013X Type of Bill TOB Hospital Outpatient As per the OPPS final rule CMS created very limited exceptions to the packaging policy and instructed hospitals to use the 014X TOB Hospital Non Patient to obtain separate payment only in the following circumstances 1 Non patient referred specimen 2 A hospital collects specimen and furnishes only the outpatient labs on a given date of service or 3 A hospital conducts outpatient lab tests that are clinically unrelated to other hospital outpatient services furnished the same day Unrelated means the laboratory test is ordered by a different practitioner than the practitioner who ordered the other hospital outpatient services for a different diagnosis aA m Z mr O PN lt Ro O Hs T gt AD a gt In accordance with Medicare manual instructions CMS assumed that a hospital functions as an independent laboratory in these circumstances Therefore hospitals could use the 014x bill used for non patients In the absence of public comments indicating otherwise CMS believed this was an appropriate use of the 014x TOB Since publication of the final rule and the January release of CR 8572 some hospitals expressed concern that submitting a 014x TOB in this manner may violate the Health Insurance Portability and Accountability Act The National Uniform Billing Committee NUBC definition approved in 2005 for the 014x TOB for billing of l
25. code should not be used for home health services provided by a DME supplier or e Home IV provider for home IV services 07 Left Against Medical Advice or Discontinued Care The important thing to remember about this patient discharge status code is that it is to be used when a patient leaves against medical advice or the care is discontinued According to the NUBC discontinued services may include e Patients who leave before triage or are triaged and leave without being seen by a physician or This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 60 e Patients who move without notice and the home health agency is unable to complete the plan of care 08 Reserved for National Assignment This patient discharge status code is reserved for national assignment 09 Admitted as an Inpatient to this Hospital This code is for use only on Medicare outpatient claims and it applies only to those Medicare outpatient services that begin greater than three days prior to an admission 10 19 Reserved for National Assignment These patient discharge status codes are reserved for national assignment 20 Expired This code is used only when the patient dies 2
26. delusional features F03 90 Unspecified dementia without behavioral disturbance 290 21 Senile dementia with depressive features 290 3 Senile dementia with delirium F03 90 Unspecified dementia without behavioral disturbance F03 90 Unspecified dementia without behavioral disturbance 290 40 Vascular dementia uncomplicated F01 50 Vascular dementia without behavioral disturbance 290 41 Vascular dementia with delirium 290 42 Vascular dementia with delusions F01 51 Vascular dementia with behavioral disturbance F01 51 Vascular dementia with behavioral disturbance 290 43 Vascular dementia with depressed mood F01 51 Vascular dementia with behavioral disturbance 294 10 Dementia in conditions classified elsewhere without behavioral disturbance 294 11 Dementia in conditions classified elsewhere with behavioral disturbance F02 80 Dementia in other diseases classified elsewhere without behavioral disturbance F02 81 Dementia in other diseases classified elsewhere with behavioral disturbance 294 20 Dementia unspecified without behavioral disturbance F03 90 Unspecified dementia without behavioral disturbance 294 21 Dementia unspecified with behavioral disturbance F03 91 Unspecified dementia with behavioral disturbance 331 11 Pick s Disease G31 01 Pick s disease 331 19 Other Frontotemporal dementia G31 09 Other frontotemporal dementia 331 6 Corticobasal degeneration G31 85 Cortic
27. for services provided to Medicare beneficiaries Provider Action Needed This article is based on CR 8653 which describes changes to and billing instructions for various payment policies implemented in the April 2014 OPPS update The April 2014 Integrated Outpatient Code Editor I OCE and OPPS Pricer will reflect the Healthcare Common Procedure Coding System HCPCS Ambulatory Payment Classification APC HCPCS Modifier and Revenue Code additions changes and deletions identified in CR 8653 Be sure your billing staff are aware of these changes Background CR 8653 describes changes to and billing instructions for various payment policies implemented in the April 2014 OPPS update The April 2014 I OCE and OPPS Pricer will reflect the HCPCS APC HCPCS Modifier Status Indicators SIs and Revenue Code additions changes and deletions identified CR 8653 The April 2014 revisions to I OCE data files instructions and specifications are provided in the April 2014 I OCE CR 8658 Upon release of CR 8658 a related MLN Matters article can be found at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads MM8658 pdf on the CMS website The key changes in the April 2014 update to the hospital OPPS are summarized in the following sections Changes to Device Edits for April 2014 The most current list of device edits can be found under Device and Procedure Edits at http www cms gov
28. gt Note This article was revised on March 7 2014 to reflect a revised Change Request CR The revise CR changes the effective and implementation dates All other information remains the same Provider Types Affected This MLN Matters article is intended for physicians providers and suppliers submitting claims to Medicare administrative contractors MACs including home health amp hospice HH amp H MACs and durable medical equipment Medicare administrative contractors DME MACs for services to Medicare beneficiaries Provider Action Needed This article is based on CR 8456 which informs Medicare contractors about changes to the Medicare Beneficiary Database MBD File to include Diagnosis Codes on the Health Insurance Portability and Accountability Act Eligibility Transaction System HETS 270 271 transactions The HETS 271 response transaction will include as much Medicare Secondary Payer MSP information as possible to assist providers physicians and suppliers to identify which diagnosis codes are relevant to given MSP no fault liability and workers compensation cases The diagnosis codes that the provider community will access via the HETS 270 271 process will assist providers physicians and other suppliers to better determine when Medicare is the secondary payer in association with their patients current liability no fault or workers compensation incidents that may prompt beneficiaries to seek
29. if occurrence code 32 indicating a signed ABN is on file or occurrence code 32 with modifier GA is present NCDs are binding on all MACs and contractors with the Federal government that review and or adjudicate claims determinations and or decisions quality improvement organizations qualified independent contractors the Medicare appeals council and administrative law judges ALJs An NCD that expands coverage is also binding on a Medicare advantage organization In addition an ALJ may not review an NCD See the Social Security Act Section 1869 f 1 A i at http www ssa gov OP_Home ssact title18 1869 htm on the Internet Additional Information The official instruction CR 8525 was issued to your MACs regarding this change via two transmittals The first is the transmittal that updates the NCD Manual and it is available at may be viewed at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R161NCD pdf on the CMS website The second transmittal updates the Medicare Claims Processing Manual and it is at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R2872CP pdf on the CMS website If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider su
30. modifiers These are published every month Just search ona keyword s and you will find articles that contained those word s Then just click on one of the related article numbers and it will open that document Give it a try General Information Quarterly Provider Update The Quarterly Provider Update is a comprehensive resource published by the Centers for Medicare amp Medicaid Services CMS on the first business day of each quarter It is a listing of all nonregulatory changes to Medicare including transmittals manual changes and any other instructions that could affect providers Regulations and instructions published in the previous quarter are also included in the update The purpose of the Quarterly Provider Update is to Inform providers about new developments in the Medicare program e Assist providers in understanding CMS programs and complying with Medicare regulations and instructions This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 aA m Z mr O PN lt Ro O Hs T gt A a gt 13 e Ensure that providers have time to react and prepare for new requirements Announce new or changing Medicare requirements on a
31. of four data elements Health Insurance Claim Number HICN Medicare Beneficiary s Date of Birth Medicare Beneficiary s Full Last Name including Suffix if applicable and Medicare Beneficiary s Full First Name The Date of Birth and First Name are optional but at least one must be present This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 20 Does HETS return the same eligibility information that is currently provided by the CWF eligibility queries Changes are currently underway in HETS to return psychiatric information to authorized providers and to return Hospice period information in the same format as CWF When these changes are made HETS will return all of the information provided by the CWF eligibility queries that is needed to process Medicare claims These changes will be in place before the termination date for the FISS DDE CWF query access HETS returns additional information that CWF does not return For example HETS returns e Part D plan number address and enrollment dates and e Medicare Advantage Organization name address website and phone number The HETS 270 271 Companion Guide provides specific details about the eligibility infor
32. on the development of new OTS orthotic codes can be found at http www cms gov Medicare Medicare Fee for Service Payment DMEPOSFeeSched OTS Orthotics htm on the CMS website Neurostimulator Devices HCPCS codes L8685 L8686 L8687 and L8688 are not included on the 2014 DMEPOS fee schedule file They were removed from the file to reflect the change in the coverage indicators for these codes to invalid for Medicare I effective January 1 2014 However code L8679 Implantable Neurostimulator Pulse Generator Any Type is added to the HCPCS and DMEPOS fee schedule file effective January 1 2014 for billing Medicare claims previously submitted under L8685 L8686 L8687 and L8688 The fee schedule amounts for code L8679 are based on the established Medicare fee schedule amounts for all types of pulse generators under the previous HCPCS code E0756 Implantable Neurostimulator Pulse Generator which was discontinued effective 12 31 2005 The payment amount is based on the explosion of code E0756 into four codes for different types of neurostimulator pulse generator systems which were not materially utilized in the Medicare program As such payment for code L8679 will revert back to the fee schedule amounts previously established for code E0756 This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at http
33. or more procedures assigned to APCs subject to the adjustment are reported with value code FD the OPPS Pricer will apportion the device credit to the applicable line on the claim for each procedure assigned to an APC subject to the adjustment When value code FD is reported on a claim where multiple APCs would be subject to the adjustment the OPPS Pricer apportions the device credit to each of those lines The percentage of the device credit apportioned to each applicable line is based on the percentage that the unadjusted payment of each applicable line represents relative to the total unadjusted payment for all applicable lines This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 53 Note The tables of APCs and devices to which the offset reductions apply and the full and partial offset amounts are available at http www cms gov Medicare Medicare Fee for Service Payment HospitalOutpatientPPS index html on the CMS website New Services New services listed in Table 1 below are assigned for payment under the OPPS effective April 1 2014 Table 1 New Services Payable under OPPS Effective April 1 2014 Effective Minimum Unad
34. order to make changes to the amounts more efficient CMS is adding the estimated per claim UCP amount to the PSF The Medicare EHR Incentive Program provides incentive payments for eligible acute care inpatient hospitals that are meaningful users of certified EHR technology Eligible acute care inpatient hospitals are defined as subsection d hospitals which are generally hospitals that are paid under the IPPS and are located in one of the 50 states This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 aA m Z mr O PN lt Ro O Hs T gt Bu a gt 50 or the District of Columbia Hospitals that are not meaningful users of certified EHR technology will be subject to payment adjustments beginning in FY 2015 Model 1 of the Bundled Payments for Care Improvement BPCl initiative provides a discounted payment to Model 1 participating hospitals for the acute care hospital stay The discount will be phased in over the performance period of 3 years To accommodate the 0 5 discount for months 7 to 12 the Model 1 discount percentage field in the PSF must be expanded SUMMARY OF CR8546 CHANGES The inpatient PSF will be expanded to include 3
35. patient s claim Attachments must be in a PDF format and at least one attachment is required This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 5 How do know if my Redetermination request was successfully received Once all required information is entered simply click the Submit button to submit your redetermination request to CGS You will receive a message in your myCGS inbox You can access the message by either clicking on the Messages tab or clicking the link displayed in the Message bar ces name Cims emia atity rnd oo Forms Spar Admin User Provider You have 3 unread message s and O alerts Go To page Select Form MESSAGE INBOX ARCHIVED MESSAGES Click on the subject inks to view messages Bold links indicate new unread messages elete Selected In Message inbox No items found 1 aA m Z mr O PN lt Ro O Hs gt A a gt myCGS will confirm receipt of your redetermination request by indicating Secure Form Received Once a tracking number has been assigned to your redetermination request myCGS will show Secure Form Confirmation along with the Submission ID number so you can continue to monitor
36. predictable schedule and e Communicate the specific days that CMS business will be published in the Federal Register To receive notification when regulations and program instructions are added throughout the quarter go to https Awww cms gov Regulations and Guidance Regulations and Policies QuarterlyProviderUpdates CMS Quarterly Provider Updates Email Updates htm to sign up for the Quarterly Provider Update electronic mailing list We encourage you to bookmark the Quarterly Provider Update website at https www cms gov Regulations and Guidance Regulations and Policies QuarterlyProviderUpdates index html and visit it often for this valuable information If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 General Information SE1402 Updated Mobile Applications Apps for Open Payments aA m Z mr O PN lt Ro O Hs T gt A a gt The Centers for Medicare amp Medicaid Services CMS has issued the following Special Edition Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number SE1402 Related Change Request CR N A Related CR Release Date N A Ef
37. procurement process It is vital that the Centers for Medicare amp Medicaid Services CMS ensure the smooth transition of workload in order to guarantee minimal disruption to the provider community The last day that Recovery Auditors will send ADRs and Semi Automated Notification Letters to providers is February 21 2014 CGS will process therapy claims in accordance with established guidelines For further information refer to the following resources e CMS MLN Matters article MM8407 Therapy Cap Values for Calendar Year CY 2014 http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads MM8407 pdf e CMS Therapy Services Web page http www cms gov Medicare Billing TherapyServices index html Remittance Advice Information MM8485 Reporting Principal and Interest Amounts When Refunding Previously Recouped Money on the Remittance Advice RA aA m Z mr O PN lt Ro O Hs T gt AD a gt The Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at htto www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles htm MLN Matters Number MM8485 Related Change Request CR CR 8485 Related CR Release Date February 6 2014 Effe
38. provider based clinic for an outpatient cataract surgery that is scheduled in two weeks with the ophthalmologist On the same day while at the hospital the beneficiary goes to the hospital lab to have blood drawn for long term psychiatric medication monitoring by order of a community psychiatrist In this situation the hospital can use the new modifier to bill Medicare for separate payment under the CLFS of the lab test to monitor the This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at oO S http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENT MEDICARE BULLETIN GR 2014 04 APRIL 2014 70 patient s psychiatric medication level However any lab tests run by the hospital lab that day upon the order of the ophthalmologist or another physician in the ophthalmologist s group practice in preparation for the cataract surgery cannot be billed for separate payment 3 The beneficiary in example 2 goes to the hospital lab to have blood drawn for long term psychiatric medication monitoring by order of a community psychiatrist and has no other hospital services that day The hospital can use the new modifier to bill Medicare for separate payment under the CLFS of the lab test to monitor the patient s psychiatric medication level 4 The beneficiary in example 2 has the
39. services of this system Users of this system must adhere to CMS information security polices standards and procedures Your usage of this system may be monitored recorded and audited Your use of this information system established your consent to any and al monitoring and recording of your activities Unauthorized user is prohibited and subject to criminal and cvil penakbes Refer to the Terms of Use CGS is pleased to offer you claim status Claims e remits Remittance beneficiary eligibility Eligibility and Financial Tools online just click on the items in the grey navigation bar to access the features of Online Provider Services What is the Forms tab in myCGS The Forms tab in myCGS allows users the ability to submit a redetermination request 1st appeal level using the myCGS portal Additional features via the Forms tab will be available in the near future This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 4 What do I need to know about using the Forms tab Only those myCGS users who have been assigned rights by their Provider Administrator will have access to the Forms tab If you do not have access to the Forms tab
40. services that were furnished and would have been reasonable and necessary if the beneficiary had been treated as a hospital outpatient rather than admitted to the hospital as an inpatient except for those services that specifically require an outpatient status provided the beneficiary is enrolled in Medicare Part B and provided the allowed timeframe for submitting claims is not expired The policy applies to all hospitals and critical access hospitals CAHs participating in Medicare including those paid under a prospective payment system or alternative payment methodology such as State cost control systems and to emergency hospitals services furnished by nonparticipating hospitals In this document and in CR 8445 the term hospital includes all hospitals and CAHs regardless of payment methodology unless otherwise specified This policy applies when a hospital determines under Medicare s utilization review requirements that a beneficiary should have received hospital outpatient rather than hospital inpatient services and the beneficiary has already been discharged from the hospital commonly referred to as hospital self audit If the hospital already submitted a claim to Medicare for payment under Part A the hospital must cancel its Part A claim prior to submitting a claim for payment of Part B services Whether or not the hospital has submitted a claim to Part A for payment Medicare requires the hospital to submit a no pay Part A cl
41. shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 aA m Z mr O PN lt Ro O Hs U gt A a gt 42 Additional Information The official instruction CR 8619 issued to your MAC regarding this change is available at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R13510TN pdf on the CMS website If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 Financial Information MM8629 Implementation of National Automated Clearinghouse Association NACHA Operating Rules for Health Care Electronic Funds Transfers EFT The Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html aA m Z mr O PN lt Ro O Hs T gt AD a gt MLN Matters Number MM8629 Related Change Request CR CR 8629 Related CR Release Date February 2
42. staffs are aware of these changes Background CMS issued the Fiscal Year FY 2014 Inpatient Prospective Payment System IPPS Long Term Care Hospital LTCH Final Rule CMS 1599 F CMS 1455 F on August 19 2013 in which CMS finalized a policy to provide additional payment under Medicare Part B for hospital inpatient services when a hospital inpatient admission is determined not reasonable and necessary for payment under Medicare Part A and the beneficiary should have been treated as a hospital outpatient You can find the CMS FY 2014 IPPS LTCH Final Rule Home Page at http www cms gov Medicare Medicare Fee for Service Payment AcutelnpatientPPS FY2014 IPPS Final Rule Home Page html on the CMS website CR 8445 provides claims processing guidance related to the implementation of this policy for all hospitals and critical access hospitals CAHs CR 8445 contains related revisions to the Medicare Claims Processing Manual Pub 100 04 and CMS will issue companion revisions to the Medicare Benefit Policy Manual Pub 100 02 in a separate release aA m Z mr O PN lt Ro O Hs U gt AD a gt Payment of Part B Inpatient Services When Medicare Part A payment cannot be made because an inpatient admission is found to be not reasonable and necessary and the beneficiary should have been treated as a hospital outpatient rather than a hospital inpatient Medicare will allow payment under Part B of all hospital
43. strategy Pl claim is present in history using the following e CARC B5 Coverage program guidelines were not met or were exceeded e RARC N640 Exceeds number frequency approved allowed within time period e Group Code PR assigning financial liability to the beneficiary if a claim is received with a GA modifier indicating a signed ABN is on file e Group Code CO assigning financial liability to the provider if a claim is received with a GZ modifier indicating no signed ABN is on file Note Providers should refer to Attachment A of CR8468 for appropriate oncologic diagnosis codes Please refer to MM6632 issued on October 16 2009 available at htip www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads MM6632 pdf on the CMS website and MM7148 issued September 24 2010 available at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads MM7148 pdf on the CMS website for previous information on this coverage Additional Information The official instruction CR 8468 was issued to your MAC via two transmittals The first transmittal updates the National Coverage Determinations Manual and it is available at http www cms hhs gov Regulations and Guidance Guidance Transmittals Downloads R162NCD pdf on the CMS website The second transmittal is at http www cms hhs gov This newsletter should be shared with
44. the device offset when the FD value code appears on a claim The offset amounts for the above referenced APCs along with the offsets for other APCs are available under the Annual Policy Files link on the left column at http Awww cms gov HospitalOutpatientPPS on the CMS OPPS website CMS is updating the Medicare Claims Processing Manual Chapter 4 Sections 61 3 1 through 61 3 4 and adding Sections 61 3 5 through 61 3 6 to Chapter 4 of that manual to reflect these changes to the reporting guidelines for no cost full credit and partial credit devices and these revised and added sections are included as an attachment to CR 8653 Those added sections are as follows 61 3 5 Reporting and Charging Requirements When a Device is Furnished Without Cost to the Hospital or When the Hospital Receives a Full or Partial Credit for the Replacement Device Beginning January 1 2014 Effective January 1 2014 when a hospital furnishes a new replacement device received without cost or with a credit of 50 percent or more of the cost of a new replacement from a manufacturer due to warranty recall or field action the hospital must report the amount of the device credit in the amount portion for value code FD Credit Received from the Manufacturer for a Replaced Medical Device Also effective January 1 2014 hospitals must report one of the following condition codes when the value code FD is present on the claim aA m Z mr O P
45. the format NTE ADD ABREBILL12345678901234 This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 48 gt For DDE or paper Claims Providers will be instructed to use the word ABREBILL plus the denied inpatient DCN CCN ICN will be added to the Remarks field form locator 80 on the claim using the following format ABREBILL12345678901234 e NOTE The numeric string above 12345678901234 is meant to represent original claim DCN ICN numbers from the inpatient denial MACs will Return to Provider a TOB 121 A B Rebilling claim that does not have a medical denied 11x claim in history that matches the DCN in remarks MACs will dismiss redetermination requests of Part A 11x claims if the provider has previously billed a 121 A B rebilling claim However contractors will accept appeal requests of A B rebilled 121 claims Medicare will not allow observation services Revenue Code 762 and outpatient visits Revenue Codes 45x and 51x to be billed on the A B rebilling 121 TOB claim This includes G0738 G0739 99201 99215 99281 99285 G0380 G0384 and G0463 Additionally Medicare s claims processing systems will set edits to prevent payment on Type of Bill
46. the only level of appeal that can be submitted via the myCGS portal is the first level of appeal the redetermination To determine if your appeal request is still timely click on the Appeals Calculator link If your appeal is untimely you cannot submit your redetermination request via the myCGS portal Click on the Redetermination 1st Level Appeal link to access the online Redetermination Form What information do need to submit a redetermination request using myCGS The myCGS Redetermination Form is separated into sections Beneficiary Information Provider Information and Attachments Basic information such as the beneficiary s claim number HICN dates of service being appealed the Document Control Number DCN of the claim being appealed and an explanation about why you are appealing the claim It is also important to indicate whether your appeal request is related to an overpayment such as the Comprehensive Error Rate Testing CERT program a recovery audit RA findings or a Zone Program Integrity Contractor ZPIC review Fields that contain a red asterisk indicate that information is required myCGS also allows documentation supporting the appeal request to be attached directly to the redetermination request This eliminates the need to copy and mail documentation with your appeal request myCGS will accommodate up to 5 attachments of 5 MB each which should accommodate all medical documentation required for a
47. therapy would have been reasonable and necessary as hospital outpatient services and provided the beneficiary has Part B entitlement the services can be billed using Type of Bill 012x All payment and billing requirements for outpatient therapy including therapy caps functional reporting and other instructions in this chapter apply to these claims Additional Information The official instruction CR 8556 issued to your MAC regarding this change may be viewed at http Awww cms gov Regulations and Guidance Guidance Transmittals Downloads R2868CP pdf on the CMS website If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 aA m Z mr O PN lt Ro O Hs U gt A a gt Helpful Information Contact Information for CGS Part A To contact a CGS Customer Service Representative call the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 For additional contact information please access the Kentucky amp Ohio Part A Contact Information Web page at hitp www cgsmedicare com parta help contact_info htm for information about the myCGS Web portal the Interactive Voice Response IVR system as well as telephone numbers fax numbers and mailing addresses for other CGS departments This newsletter should be shared with all health care practitioners and managerial members RETURN
48. to other user s devices A m Z O PN am Ro O 1 U gt A a gt Additional Information If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 To review The Open Payments Mobile Application Quick Response QR Code Reader Documentation A How To Guide to Create Java Script Object Notation JSON QR Code referenced in this SE1402 see http www cms gov Regulations and Guidance Legislation National Physician Payment Transparency Program Downloads Open Payments QR Code Reader How To Guide 5bDecember 2013 5d pdf on the CMS website To review the series of SE articles leading up to SE1402 see the following 1 MLN Matters SE1303 Information on the National Physician Payment Transparency Program Open Payments is available at htip www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads SE1303 pdf on the CMS website 2 MLN Matters SE1329 Mobile Apps for the Open Payments program Physician Payments Sunshine Act is available at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads SE1329 pdf on the CMS website 3 MLN Matters SE1330 Open Payments An Overview for Physicians and Teaching Hospitals may be found at http www cms gov Outreach and Education Medicare Learning Network MLN MLNM
49. to requirements for originators see hiips healthcare nacha org healthcarerules The official instruction CR 8629 issued to your MAC regarding this change may be viewed at http Awww cms gov Regulations and Guidance Guidance Transmittals Downloads R13490TN pdf on the CMS website If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 2 Hospital Information MM8273 Rescinded Common Working File CWF and Fiscal Intermediary Standard System FISS Informational Unsolicited Response IUR or Denial of Inpatient Services Related to a Hospice Terminal Diagnosis The Centers for Medicare amp Medicaid Services CMS has rescinded the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number MM8273 Rescinded Related Change Request CR CR 8273 Related CR Release Date November 7 2013 Effective Date April 1 2014 Related CR Transmittal R13120TN Implementation Date April 7 2014 Note This article was rescinded on February 20 2014 as the related CR8273 was rescinded Hospital Information MM8445 Implementing the Part B Inpatient Payment Policies from CMS 1599 F
50. website If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 aA m Z mr O PN lt Ro O Hs T gt AD a gt 51 Hospital Information MM8653 April 2014 Update of the Hospital Outpatient Prospective Payment System OPPS The Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number MM8653 Related Change Request CR CR 8653 Related CR Release Date February 28 2014 Effective Date April 1 2014 Related CR Transmittal R2894CP Implementation Date April 7 2014 Provider Types Affected This MLN Matters article is intended for providers and suppliers who submit claims to Part A Medicare administrative contractors A MACs and home health and hospice HH amp H MACs
51. www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 A m Z mr O PN lt Ro O Hs U gt AD 5j gt oT Diabetic Testing Supplies The fee schedule amounts for non mail order diabetic testing supplies without KL modifier for codes A4233 A4234 A4235 A4236 A4253 A4256 A4258 A4259 are not updated by the covered item update for CY 2014 In accordance with Section 636 a of the American Taxpayer Relief Act of 2012 the fee schedule amounts for these codes were adjusted in CY 2013 so that they are equal to the single payment amounts for mail order Diabetic Testing Supplies DTS established in implementing the national mail order Competitive Bidding Program CBP under Section 1847 of the Act The non mail order payment amounts on the fee schedule file will be updated each time the single payment amounts are updated which can happen no less often than every three years as CBP contracts are recompeted The national CBP for mail order diabetic supplies is effective July 1 2013 to June 30 2016 The program instructions reviewing these changes are Transmittal 2709 Change Request CR 8325 dated May 17 2013 and Transmittal 2661 Change Request CR 8204 dated February 22 2013 You may review the MLN Matters Articles for these CRs at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads MM8325
52. your redetermination request For more information about the Forms tab and submitting redeterminations using myCGS go to Chapter 6 Messaging Forms Tab of the myCGS User Manual http www cgsmedicare com mycgs manual html and select the appropriate link for your line of business Part B or Home Health amp Hospice General Information MLN Connects Provider e News The MLN Connects Provider e News contains a week s worth of Medicare related messages issued by the Centers of Medicare amp Medicaid Services CMS These messages ensure planned coordinated messages are delivered timely about Medicare related topics The following provides access to the weekly messages Please share with appropriate staff If you wish to receive the ListServ directly from CMS please contact CMS at LearnResource L cms hhs gov e February 20 2014 http go usa gov Bfxh e February 27 2014 htip go usa gov BJwz e March 6 2014 hitp go usa gov KgZY e March 13 2014 http go usa gov K83W This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 6 General Information MM8442 Update to Pub 100 04 Claims Processing Manual Chapter One The
53. 0 Hospice home should be used if the patient went to his her own home or an alternative setting that is the patient s home such as a nursing facility and will receive in home hospice services General Inpatient Care Patient discharge status code 51 Hospice medical facility should be used if the patient went to an inpatient facility that is qualified and the patient is to receive the general inpatient hospice level of care Inpatient Respite Patient discharge status code 51 Hospice medical facility should be used if the patient went to a facility that is qualified and the patient is receiving hospice inpatient respite level of care Unless a patient has already been admitted to accepted by a hospice level of care can not be determined Therefore it is recommended that if a patient is going home or to an institutional setting with a hospice referral only without having already been accepted for hospice care by a hospice organization the patient discharge status code should simply reflect the site to which the patient was discharged not hospice i e 01 home or self care or 04 an intermediate care nursing facility assuming it is not a Medicare SNF admission aA m Z mr O PN lt Ro O Hs T gt AD a gt Additional Guidance on Use of Patient discharge status Code 50 or 51 e Patient discharge status Code 50 should be used if the patient went to his her own home or an alternative set
54. 1 2014 Effective Date July 1 2014 Related CR Transmittal R13490TN Implementation Date July 7 2014 Provider Types Affected This MLN Matters article is intended for physicians other providers and suppliers submitting claims to Medicare administrative contractors MACs including home health amp hospice MACs HH amp H MACs and durable medical equipment Medicare administrative contractors DME MACs for services to Medicare beneficiaries What You Need to Know This article is based on CR 8629 which informs MACs that they must comply with NACHA Operating Rules that are applicable to initiators of health care payments CR 8629 requires MACs to modify or change data elements currently inputted into payment information that is transmitted through the ACH EFT Network with electronic health care payments The overarching goal of the requirements of CR 8629 are to assure that providers receiving health care payments via EFT will receive a trace number that facilitates automatic reassociation of the EFT health care payment with its associated remittance advice Physicians other providers and suppliers should be aware that consequently the payment information that a provider receives or that is transmitted from a provider s financial institution regarding the health care EFT payment may change as per these requirements Specifically the Company Entry Description and the TRN Segment that is reported or transmitted to a provider fr
55. 1 29 Reserved for National Assignment These patient discharge status codes are reserved for national assignment aA m Z mr O PN lt Ro O Hs T gt AD a gt 30 Still Patient or Expected to Return for Outpatient Services This code is used when the patient is still within the same facility and is typically used when billing for leave of absence days or interim bills It can be used for both inpatient or outpatient claims It is used for inpatient claims when billing for leave of absence days or interim billing i e the length of stay is longer than 60 days On outpatient claims the primary method to identify that the patient is still receiving care is the bill type frequency code e g Frequency Code 3 Interim Continuing Claim 31 39 Reserved for National Assignment These patient discharge status codes are reserved for national assignment Hospice Patient discharge status Codes Hospice Claims Only TOBs 81X amp 82X The following patient discharge status codes should only be used when submitting hospice claims e 40 Expired at Home This code is for use only on Medicare and TRICARE claims for hospice care e 41 Expired in a Medical Facility such as a Hospital Skilled Nursing Facility SNF Intermediate Care Facility ICF or Free standing Hospice and e 42 Expired Place Unknown This code is for use only on Medicare and TRICARE claims for hospice care 43 Discharged Transfer
56. 10 CMS recommends that you leverage the variety of Beta versions of its software that include ICD 10 codes as well as National Coverage Determination NCD code crosswalks to test the readiness of your own systems The following testing tools are available for download NCDs converted from International Classification of Diseases 9th Edition ICD 9 to ICD 10 located at http www cms gov Medicare Coverage CoverageGenInfo ICD10 html The ICD 10 Medicare Severity Diagnosis Related Groups MS DRGs conversion project along with payment logic and software replicating the current MS DRGs which used the General Equivalence Mappings to convert ICD 9 codes to International Classification of Diseases 10th Edition Clinical Modification ICD 10 CM codes located at http cms hhs gov Medicare Coding ICD10 ICD 10 MS DRG Conversion Project html on the CMS website On this Web page you can also find current versions of the ICD 10 CM MS DRG Grouper Medicare Code Editor available from National Technical Information Service and MS DRG Definitions Manual that will allow you to analyze any payment impact from the conversion of the MS DRGs from ICD 9 CM to ICD 10 CM codes and to compare the same version in both ICD 9 CM and ICD 10 CM and A pilot version of the October 2013 Integrated Outpatient Code Editor IOCE that utilizes ICD 10 CM located at hitp www cms gov Medicare Coding OutpatientCodeEdit Downloads ICD 10 IOCE Code Lists pdf on the C
57. 12x for claims containing the revenue codes listed as follows 010x 011x 012x 013x 014x 015x 016x 017x 018x 019x 020x 021x 022x 023x 024x 029x 0390 0399 045x 050x 051x 052x 054x 055x 056x 057x 058x 059x 060x 0630 0631 0632 0633 0637 064x 065x 066x 067x 068x 072x 0762 082x 083x 084x 085x 088x 089x 0905 0906 0907 0912 0913 093x 0941 0943 0944 0945 0946 0947 0948 095x 0960 0961 0962 0963 0964 0969 097x 098x 099x 100x 210x 310x aA m Z mr O PN lt Ro O Hs T gt A a gt In the case of Revenue Code 0964 this is used by hospitals that have a CRNA exception Additional Information The official instruction CR 8445 issued to your MAC regarding this change may be viewed at http Awww cms gov Regulations and Guidance Guidance Transmittals Downloads R2877CP pdf on the CMS website If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 You can review the FY 2014 IPPS LTCH Final Rule CMS 1599 F CMS 1455 F displayed in the Federal Register Vol 78 No 160 dated August 19 2013 at http www gpo gov fdsys pkg FR 2013 08 19 pdf 2013 18956 pdf on the CMS website This newsletter should be shared with all health care practitioners and managerial members RETURN
58. 15 Mitomycin ophthalmic 0 2 mg or HCPCS code J3490 unclassified drugs for the topical application of mitomycin during or following ophthalmic surgery J7315 may be reported only if the hospital uses mitomycin with the trade name Mitosol Any other topical mitomycin should be reported with J3490 Hospital outpatient departments are not permitted to bill HCPCS code J9280 Injection mitomycin 5 mg for the topical application of mitomycin New HCPCS Code Effective April 1 2014 One new HCPCS code has been created for reporting services supplies and accessories used in the home under the Medicare intravenous immune globulin IVIG demonstration This code is listed in Table 8 below and it is effective for services furnished on or after April 1 2014 Table 8 New HCPCS Codes Effective April 1 2014 Status Indicator HCPCS Code Long Descriptor Short Descriptor Effective 4 1 14 Q2052 Services supplies and accessories used in the home under the Ivig demo N Medicare intravenous immune globulin ivig demonstration services supplies Changes to OPPS Pricer Logic Effective January 1 2014 for claims with APCs which require implantable devices and have significant device offsets greater than 40 percent a device offset cap will be applied to the applicable procedure line based on the credit amount listed in the FD Credit Received from the Manufacturer for a Replaced Medical Device value code The cr
59. 7 2013 the Centers for Medicare amp Medicaid Services CMS will only allow coverage for PET AB imaging one PET AB scan per patient through coverage with evidence development CED to 1 develop better treatments or prevention strategies for Alzheimer s Disease AD or as a strategy to identify subpopulations at risk for developing AD or 2 resolve clinically difficult differential diagnoses e g frontotemporal dementia FTD versus AD where the use of PET AB imaging appears to improve health outcomes when the patient is enrolled in an approved clinical study under CED Background After careful consideration effective for claims with dates of service on or after September 27 2013 CMS believes that the evidence is insufficient to conclude that PET AB imaging improves health outcomes for Medicare beneficiaries with dementia or neurodegenerative disease However there is sufficient evidence that the use of PET AB imaging could be promising in certain scenarios Therefore Medicare will only allow coverage for PET AB imaging one PET AB scan per patient through CED to 1 Develop better treatments or prevention strategies for AD or as a strategy to identify subpopulations at risk for developing AD or 2 Resolve clinically difficult differential diagnoses e g FTD versus AD where the use of PET AB imaging appears to improve health outcomes when the patient is enrolled in an approved clinical study under CED Health outc
60. ACs will return an acknowledgment to the submitter a 277A that confirms whether the submitted test claims were accepted or rejected For more information about acknowledgement testing refer to the information on your MAC s website Note from CGS For more information about the ICD 10 testing week refer to the ICD 10 CM PCS Web page at http www cgsmedicare com parta claims ICD 10 html on the CGS website CMS plans to offer a second week of acknowledgement testing in early May 2014 aA m Z mr O PN lt Ro O Hs T gt AD a gt End to End Testing In late July 2014 CMS will offer end to end testing to a small sample group of providers End to end testing includes the submission of test claims to CMS with ICD 10 codes and the provider s receipt of a Remittance Advice RA that explains the adjudication of the claims The goal of this testing is to demonstrate that e Providers or submitters are able to successfully submit claims containing ICD 10 codes to the Medicare FFS claims systems e CMS software changes made to support ICD 10 result in appropriately adjudicated claims based on the pricing data used for testing purposes and Accurate RAs are produced The sample will be selected from providers suppliers and other submitters who volunteer to participate Information about the volunteer registration will be available in March 2014 Over 500 volunteer submitters will be selected na
61. APC payment to SI K Paid under OPPS separate APC payment Effective January 1 2014 the status indicator for HCPCS code Q0181 Unspecified oral dosage form FDA approved prescription anti emetic for use as will change from SI E not paid by Medicare when submitted on outpatient claims any outpatient bill type to SI N Paid under OPPS payment is packaged into payment for other services Therefore there is no separate APC payment These codes are listed in Table 3 below along with the effective date for the revised status indicator Table 3 Drugs and Biologicals with Revised Status Indicators HCPCS Code Long Descriptor APC Status Indicator Effective Date A9545 lodine 131 tositumomab therapeutic per treatment dose E 4 1 2014 J1446 Injection TBO Filgrastim 5 micrograms 1477 K 1 1 2014 J7178 Injection human fibrinogen concentrate 1 mg 1478 K 1 1 2014 Q0181 Unspecified oral dosage form FDA approved prescription N 1 1 2014 anti emetic for use as d Updated Payment Rate for Q4127 Effective April 1 2013 through June 30 2013 The payment rate for Q4127 was incorrect in the April 2013 OPPS Pricer The corrected payment rate is listed in Table 4 below and it has been installed in the April 2014 OPPS Pricer effective for services furnished on April 1 2013 through June 30 2013 MACs will adjust claims that were previously processed incorrectly if you bring such claims to the a
62. APRIL 2014 gt WWW CGSMEDICARE COM Medicare Bulletin Jurisdiction 15 Reaching Out to the Medicare Community CELERIAN GROUP COMPANY 2014 Copyright CGS Administrators LLC AN m L C O AN lt Ro O O T D gt AU gt Medicare Bulletin Jurisdiction 15 GENERAL INFORMATION COVERAGE 2014 Provider Contact Center PCC Training MM8418 Aprepitant for Chemotherapy and Holiday Closure Schedule ooo eee 4 Induced Emesis 21 Introducing the myCGS Web Portal MM8468 Fluorodeoxyglucose FDG Positron Submitting Redeterminations through Forms Tab 4 Emission Tomography PET for Solid Tumors 24 MLN Connects Provider e News a 6 MM8525 National Coverage Determination NCD for Single Chamber and Dual Chamber Permanent lhl el aa Cardiac Pacemakers 26 Claims Processing Manual Chapter One 7 MM8526 Medicare National Coverage MM8506 Pub 100 03 Chapter 1 Determination NCD for Beta Amyloid Positron Language only Update ooo eects 8 Emission Tomography PET in Dementia and MM8582 Revised Claim Status Category Neurodegenerative Disease 30 and Claim Status Codes Update oe 9 MM8597 Correction CR Advance Beneficiary MM8611 Healthcare Provider Taxonomy Notice of Noncoverage ABN Form CMS R 131 33 Codes HPTC Update April 2014 10 FEE SCHEDULE News Flash Messages from the Centers for Medicare amp Medicaid
63. BULLETIN GR 2014 04 APRIL 2014 V LYVd OIHO 8 AMONLNA Medi Bulleti A edicare Bulletin A J risdicthon 15 4 O HOSPITAL MEDICAL REVIEW Zz MM8273 Rescinded Common Working Immediate Suspension of Edits for Recovery Audit fo File CWF and Fiscal Intermediary Standard Prepayment Reviews Including Outpatient Therapy 77 System FISS Informational Unsolicited I Response IUR or Denial of Inpatient Services REMITTANCE Related to a Hospice Terminal Diagnosis 45 MM8445 Implementing the Part B Inpatient MM8485 Reporting Principal and Interest Amounts U Payment Policies from CMS 1599 F 45 When Refunding Previously Recouped Money on gt the Remittance Advice RA oo ec eeeeeeeeeeeeees 78 A MM8546 Addition of New Fields and Expansion of Existing Model 1 Discount Percentage Field in the Inpatient Hospital Provider Specific THERAPY gt File PSF and Renaming Payment Fields in the Inpatient Prospective Payment MM8556 Therapy Modifier Consistency Edits 19 System IPPS Pricer Output 50 MM8653 April 2014 Update of the Hospital HELPFUL INFORMATION Outpatient Prospective Payment System OPPS 52 Contact Information for CGS Part A a 80 SE0801 Revised Clarification of Patient Discharge Status Codes and Hospital Transfer Policies 58 E1401 Point of Origin for Admission or Visit Code Formerly Source of Admission Code for Inpatient Psychiatric Facilities IPFs oo 67 SE1412 Update to
64. BULLETIN GR 2014 04 APRIL 2014 22 must be billed with the following not otherwise classified NOC code effective April 1 2014 in the IOCE update Q0181 Unspecified oral dosage form FDA approved prescription antiemetic for use as a complete therapeutic substitute for a IV antiemetic at the time of chemotherapy treatment not to exceed a 48 hour dosage regimen This NOC code must also be accompanied with a diagnosis code of an encounter for antineoplastic chemotherapy ICD9 10 codes V58 11 Z51 11 This coverage policy applies only to the oral forms of the three drug regimen as a full replacement for their intravenous equivalents All other indications or combinations for the use of oral aprepitant are non covered under Medicare Part B but may be considered under Medicare Part D For claims with dates of service on or after May 29 2013 MACs will adjust claims processed before CR8418 was implemented if you bring those claims to the attention of your MAC Effective for claims with dates of service on or after May 29 2013 MACS will deny lines for oral aprepitant J8501 or NOC code Q0181 if an encounter for antineoplastic chemotherapy identified by ICD 9 10 codes V58 11 Z51 11 is not present The denied lines will reflect the following messages on the remittance advice aA m Z mr O PN lt Ro O Hs U gt A a gt e Claim Adjustment Reason Code 96 Non covered Charge s e Remittance Advice Remarks
65. Code RARC M100 We do not pay for an oral anti emetic drug that is not administered for use immediately before at or within 48 hours of administration of a covered chemotherapy and e RARC N386 This decision was based on a National Coverage Determination NCD An NCD provides a coverage determination as to whether a particular item or service is covered A copy of this policy is available at www cms gov mcd search asp If you do not have Web access you may contact the contractor to request a copy of the NCD Additional Information The official instruction CR 8418 was issued to your MAC via three transmittals The first updates the Medicare Benefit Policy Manual and that is available at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R180BP pdf on the CMS website The second updates the Medicare Claims Processing Manual and is available at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R2883CP pdf and the third updates the Medicare National Coverage Determinations Manual and it is available at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R163NCD pdf on the CMS website If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 This newsletter should be shared with all health care practitioners and managerial members RETURN T
66. EDICARE BULLETIN GR 2014 04 APRIL 2014 aA m Z mr O PN lt Ro O Hs U gt AD a gt 28 426 10 Atrioventricular block unspecified 144 30 Unspecified atrioventricular block 426 4 Right bundle branch block 145 10 Unspecified right bundle branch block 145 19 Other right bundle branch block 427 0 Paroxysmal supraventricular tachycardia 147 1 Supraventricular tachycardia In addition be aware of the following e MACs will deny claims for implanted dual chamber for one of the following CPT codes 33206 33207 or 33208 and contains at least one of the following ICD 9 CM ICD 10 CM diagnosis codes even if submitted with at least one of the acceptable diagnosis codes listed above 426 11 144 0 427 89 149 8 ROO 1 427 31 148 1 148 2 148 91 780 2 R55 427 32 48 2 148 3 148 4 or 148 91 MACs will use the following messages when denying claims for implanted permanent cardiac pacemakers single chamber or dual chamber containing one of the following HCPCS and or CPT codes C1785 C1786 C2619 C2620 33206 33207 or 33208 and at least one diagnosis code from the list of ICD 9 ICD 10 diagnosis codes above CARC 96 Non covered charge s e RARC N569 Not covered when performed for the reported diagnosis e Group Code CO contractual obligation if claim received with GZ modifier indicating no signed Advance Beneficiary Notice ABN is on file or Group Code PR Patient Responsibility
67. Hospice and Home Health Claims TOBs 32X 33X 34X 81X and 82X It is important to select the correct patient discharge status code and in cases in which two or more patient discharge status codes apply you should code the highest level of care known Omitting a code or submitting a claim with an incorrect code is a claim billing error and could result in your claim being rejected or your claim being cancelled and payment being taken back Applying the correct code will help assure that you receive prompt and correct payment PN m Z mr O PN lt Ro O Hs T gt AD a gt Identifying the appropriate Patient discharge status Code can sometimes be confusing so be sure to read the Frequently Asked Questions FAQ Section at the end of this article for further guidance Patient discharge status Codes and Their Appropriate Use The following describes patient discharge status codes and provides details regarding their appropriate use 01 Discharge to Home or Self Care Routine Discharge This code includes discharge to home jail or law enforcement home on oxygen if DME only any other DME only group home foster care and other residential care arrangements outpatient programs such as partial hospitalization or outpatient chemical dependency programs assisted living facilities that are not state designated 02 Discharged Transferred to a Short term General Hospital for Inpatient Care This patient discharge
68. MM8619 Related Change Request CR CR 8619 Related CR Release Date February 21 2014 Effective Date July 1 2014 Related CR Transmittal R13510TN Implementation Date July 7 2014 Provider Types Affected aA m Z mr O PN lt Ro O Hs T gt AD a gt This MLN Matters article is intended for physicians providers and suppliers submitting claims to Medicare administrative contractors MACs including durable medical equipment Medicare administrative contractors DME MACs and home health and hospice HH amp H MACs for services to Medicare beneficiaries What You Need to Know This article is based on CR 8619 which informs Medicare contractors that Section 1104 of the Affordable Care Act mandates the adoption of a standard for the Health Care Electronic Funds Transfers EFT HIPAA transaction and operating rules for the Health Care EFT and Remittance Advice Transaction The main intent of these standards and operating rules is to assure health plans transmit a trace number that allows providers to re associate the EFT health care payment with its associate electronic remittance advice Make sure that your billing staffs are aware of these changes Note that CR 8619 requires MACs to modify or change data elements currently inputted into payment information that is transmitted through the ACH EFT Network with electronic health care payments Physicians other providers and suppliers should be aware that cons
69. MS website The final version of the IOCE that utilizes ICD 10 CM is scheduled for release in August 2014 Crosswalks for Local Coverage Determinations LCDs will be available in April 2014 If you will not be able to complete the necessary systems changes to submit claims with ICD 10 codes by October 1 2014 you should investigate downloading the free billing software that CMS offers from their MACs The software has been updated to This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 76 support ICD 10 codes and requires an internet connection This billing software only works for submitting fee for service claims to Medicare Alternatively many MACs offer provider internet portals and some MACs offer a subset of these portals that you can register for to ensure that you have the flexibility to submit professional claims this way as a contingency Acknowledgement Testing CMS will offer CD 10 acknowledgement testing from March 3 7 2014 This testing will allow all providers billing companies and clearinghouses the opportunity to determine whether CMS will be able to accept their claims with ICD 10 codes While test claims will not be adjudicated the M
70. N lt Ro He T gt AD 5j gt This MLN Matters article is intended for physicians other providers and suppliers submitting claims to Medicare claims administration contractors fiscal intermediaries Fls carriers A B Medicare administrative contractors A B MACs regional home health intermediaries RHHIs home health and hospices MACs HHH MACs and durable medical equipment MACs DME MACs for services provided to Medicare beneficiaries Provider Action Needed CR 8611 from which this article is taken instructs Medicare contractors to obtain the most recent HPTC set and use it to update their internal HPTC tables and or reference files Background The Health Insurance Portability and Accountability Act of 1996 HIPAA requires that covered entities use the standards adopted under this law for electronically transmitting certain health care transactions including health care claims The standards include implementation guides which dictate when and how data must be sent including specifying the code sets which must be used Both the current Accredited Standards Committee ASC X 12 837 institutional and professional Technical Report Type 3 TR3s require that the National Uniform Claim Committee NUCC HPTC set be used to identify provider specialty information on a health care claim However the standards do not mandate the reporting of provider specialty information via a HPTC be on every claim nor for eve
71. N lt Ro O Hs T gt AD a gt 49 Product Replacement within Product Lifecycle Replacement of a product earlier than the anticipated lifecycle due to an indication that the product is not functioning properly e 50 Product Replacement for Known Recall of a Product Manufacturer or FDA has identified the product for recall and therefore replacement 61 3 6 Medicare Payment Adjustment Beginning January 1 2014 Rev 1657 Issued 12 31 08 Effective 01 01 14 Implementation 01 05 09 Effective January 1 2014 Medicare payment is reduced by the amount of the device credit for specified procedure codes reported with value code FD The payment deduction is limited to the full device offset when the FD value code appears on a claim Payment is only reduced for procedure codes that map to the APCs on the list of APCs subject to the adjustment that are reported with value code FD and that are present on claims with specified device HCPCS codes The OPPS Pricer deducts the lesser of the device credit or the full unadjusted device offset amount from the Medicare payment for a procedure code in an APC subject to the adjustment when billed with value code FD on the claim This deduction is made from the Medicare payment after the multiple procedure discounting and terminated procedure discounting factors are applied units of service are accounted for and after the APC payment has been wage adjusted When two
72. NUBC Frequently Asked Questions FAQs and Answers 1 Q A patient is discharged from our facility disposition code 01 and is to go to a doctor s appointment the same day The patient is then admitted to another hospital after seeing the doctor What disposition code is appropriate 01 or 02 A Based on the information the hospital had at discharge the patient was discharged to home 01 If your facility was unaware of the planned admission at the second facility it is likely that you will have to modify adjust your previously submitted claim to indicate a disposition code 02 which reflects where the patient was later admitted on the same date 2 Q Ifa facility discharges a patient to a personal care home which is similar to assisted living facilities are they most appropriately coded as 01 or 04 A If the personal care home is the person s place of residence even temporarily use Code 01 discharged to home or self care This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 aA m Z mr O PN lt Ro O Hs T gt AD a gt 64 3 Q What discharge status code should be used when a patient is sent to another acute care facility for
73. O of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 23 Coverage Information MM8468 Fluorodeoxyglucose FDG Positron Emission Tomography PET for Solid Tumors The Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number MM8468 Related Change Request CR CR 8468 Related CR Release Date February 6 2014 Effective Date June 11 2013 Related CR Transmittal R2873CP R162NCD Implementation Date March 7 2014 Non shared System Edits July 7 2014 Shared System Edits Provider Types Affected This MLN Matters article is intended for physicians providers and suppliers submitting claims to Medicare A B administrative contractors MACs for services to Medicare beneficiaries aA m Z mr O PN lt Ro O Hs T gt AD a gt What You Need to Know This article is based on CR 8468 which advises you that effective for claims with dates of service on and after June 11 2013 CMS will cover three Flourodeoxyglucose Positron Emission Tomo
74. TURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 Y General Information Provider Types Affected This MLN Matters article is intended for physicians providers and suppliers submitting claims to A B Medicare administrative contractors A B MACs hospice and home health HH amp H MACs and durable medical equipment MACs DME MACs for services provided to Medicare beneficiaries A MM8506 Pub 100 03 m Chapter 1 Language only Update zj The Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on A the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN lt MLNMattersArticles 2014 MLN Matters Articles html Qo MLN Matters Number MM8506 Related Change Request CR CR 8506 e Related CR Release Date February 5 2014 Effective Date October 1 2014 I Related CR Transmittal R159NCD Implementation Date October 1 2014 O U0 gt D gt Provider Action Needed CMS issued CR 8506 as an informational alert to providers that language only changes updates to the Medicare National Coverage Determinations NCD Manual Pub 100 03 were made The changes w
75. The update process for the DMEPOS fee schedule is located in the Medicare Claims Processing Manual Chapter 23 Section 60 which is available at http www cms gov Regulations and Guidance Guidance Manuals downloads clm104c23 pdf on the CMS website Payment on a fee schedule basis is required for Durable Medical Equipment DME prosthetic devices orthotics prosthetics and surgical dressings by Section1834 a h and i of the Social Security Act the Act Also payment on a fee schedule basis is a regulatory requirement at 42 CFR Section 414 102 for Parenteral and Enteral Nutrition PEN and splints casts and certain intraocular lenses Fee Schedule Files The DMEPOS fee schedule file will also be available for providers and suppliers as well as State Medicaid Agencies managed care organizations and other interested parties at http www cms gov Medicare Medicare Fee for Service Payment DMEPOSFeeSched on the CMS website Healthcare Common Procedure Coding System HCPCS Codes Added Deleted The following new codes are effective January 1 2014 e A7047 in the inexpensive routinely purchased IN payment category e E0766 in the frequently serviced FS payment category and E1352 This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Co
76. Transmittals Downloads R2871CP pdf on the CMS website If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 32 Coverage Information Provider Types Affected This MLN Matters article is intended for physicians providers including home health agencies and suppliers that submit claims to Medicare administrative contractors MACs including home health amp hospice Medicare administrative contractors HH amp H MACs and durable medical equipment Medicare administrative contractors DME MACs for services to Medicare beneficiaries A MM8597 Correction CR Advance Beneficiary y Notice of Noncoverage ABN Form CMS R 131 z l The Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on A the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN lt MLNMattersArticles 2014 MLN Matters Articles html Ro MLN Matters
77. URN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 39 cannot occur more than once per beneficiary regardless of the combination of oxygen concentrator equipment and or transfilling equipment used by the beneficiary for any 6 month period Per 42 CFR 414 210 5 iii the 2010 maintenance and servicing fee for certain oxygen equipment was based on 10 percent of the average price of an oxygen concentrator For CY 2011 and subsequent years the maintenance and servicing fee is adjusted by the covered item update for DME as set forth in Section1834 a 14 of the Act Thus the 2013 maintenance and servicing fee is adjusted by the 1 percent MFP adjusted covered item update factor to yield a CY 2014 maintenance and servicing fee of 68 73 for oxygen concentrators and transfilling equipment Additional Information The official instruction CR 8531 issued to your MAC regarding this change may be viewed at http Awww cms gov Regulations and Guidance Guidance Transmittals Downloads R2836CP pdf on the CMS website If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 aA m Z mr O PN lt Ro O Hs T gt A a gt Financial Information
78. V 23 18 21 66 40 12 Z DC 14 55 21 66 29 43 NY 26 79 21 68 29 43 DE 26 79 21 66 29 43 OH 14 55 21 66 29 43 C FL 14 55 21 68 29 43 OK 14 55 21 68 29 43 Q GA 14 55 21 68 29 43 OR 14 55 21 66 42 32 lt HI 17 99 31 22 36 73 PA 15 62 22 30 29 43 Ro IA 14 55 21 66 35 23 PR 14 55 21 68 29 43 ID 14 55 21 66 29 43 RI 17 34 22 32 29 43 IL 14 55 21 66 29 43 SC 14 55 21 68 29 43 aE IN 14 55 21 66 29 43 SD 16 26 21 66 39 35 e KS 14 55 21 66 36 73 TN 14 55 21 68 29 43 KY 14 55 27 16 37 64 TX 14 55 21 68 29 43 E LA 14 55 21 68 29 43 UT 14 59 21 66 45 83 PU MA 24 30 21 66 29 43 VA 14 55 21 66 29 43 4 MD 14 55 21 66 29 43 VI 14 55 21 68 29 43 gt ME 24 30 21 66 29 43 VT 15 62 21 66 29 43 MI 14 55 21 66 29 43 WA 23 18 31 77 37 74 MN 14 55 21 66 29 43 WI 14 55 21 66 29 43 MO 14 55 21 66 29 43 WV 14 55 21 66 29 43 MS 14 55 21 68 29 43 WY 20 28 28 89 41 04 MT 14 55 21 66 36 73 2014 National Monthly Payment Amounts for Stationary Oxygen Equipment CR8531 implements the 2014 national monthly payment amount for stationary oxygen equipment HCPCS codes E0424 E0439 E1390 and E1391 effective for claims with dates of service on or after January 1 2014 As required by statute the payment amount must be adjusted on an annual basis as necessary to ensure budget neutrality of the new payment class for Oxygen Generating Portable Equipment OGPE The updated 2014 monthly payment amount of 178 24 includes the 1 percent update factor for th
79. aboratory services provided to Non Patients means referred specimen where the patient is not present at the hospital To alleviate this concern for CY 2014 a new modifier will be used on the 013X TOB instead of the 014X TOB when non referred lab tests are eligible for separate payment under the CLFS for exceptions 2 and 3 listed above The 014x will only be used for non patient meaning referred laboratory specimens exception 1 above and will not include this new modifier The new modifier will be effective for claims received on or after July 1 2014 and retroactive for dates of service on or after January 1 2014 Please note that CMS views this new modifier as an immediate solution to hospitals concern for CY 2014 and that we may evaluate better means to bill for laboratory services next year Additionally to alleviate concerns on what hospitals can do in the interim period until the new modifier is implemented on July 1 2014 CMS at the request of the NUBC will continue to allow providers to utilize the 014x TOB during this interim period when a hospital seeks separate payment under any of the three exceptions listed above as per the CY 2014 OPPS final rule This will allow time for providers to make necessary system adjustments without having to hold claims until the July implementation It will continue to be the hospital s responsibility to determine when laboratory tests qualify to receive separate payment Star
80. aim indicating that the provider is liable under section 1879 of the Social Security Act for the cost of the Part A services The hospital may then submit an inpatient claim for payment under Part B for all services that would have been reasonable and necessary if the beneficiary had been treated as a hospital outpatient rather than admitted as a hospital inpatient except where those services specifically require an outpatient status Those services that specifically require an outpatient status includes those that are by definition provided to hospital outpatients and not inpatients including e Hospital outpatient visits emergency department and clinic visits e Observation services This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 46 e Diabetes Self Management Training Services Hospitals may not bill for inpatient routine services in a hospital Inpatient routine services generally are those services included by the provider in a daily service charge sometimes referred to as the room and board charge Payable and non payable services are further described in the update of the Medicare Claims Processing Manual Chapter 4 Part B Hospital I
81. aims to Medicare contractors A B Medicare administrative contractors A B MACs home health and hospice MACs HHH MACs and the durable medical equipment MACs DME MACs for services to Medicare beneficiaries What Providers Need to Know This article is based on CR 8465 which announces plans for front end ICD 10 testing between MACs and their trading partners For dates of service of October 1 2014 and after providers are required to submit ICD 10 codes on their claims MACs must provide the opportunity for providers and suppliers to submit test claims through the CEM or the CEDI on the designated testing days e Test claims with ICD 10 codes must be submitted with current dates of service i e October 1 2013 through March 3 2014 since testing does not support future dated claims Test claims will receive the 277CA or 999 acknowledgement as appropriate to confirm that the claim was accepted or rejected in the system aA m Z mr O PN lt Ro O Hs T gt AD a gt Testing will not confirm claim payment or produce remittance advice e MACs and CEDI will be staffed to handle increased call volume during this week Make sure that your billing staff is aware of these upcoming ICD 10 testing periods Background CMS is in the process of implementing ICD 10 All covered entities have to be fully compliant on October 1 2014 CR 8465 instructs all Medicare MACs and the DME MACs CEDI contractor to i
82. all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 25 Regulations and Guidance Guidance Transmittals Downloads R2873CP pdf and that transmittal updates the Medicare Claims Processing Manual If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 Coverage Information MM8525 National Coverage Determination NCD for Single Chamber and Dual Chamber Permanent Cardiac Pacemakers The Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number MM8525 Related Change Request CR CR 8525 Related CR Release Date February 7 2014 Effective Date August 13 2013 Related CR Transmittal R161NCD and Implementation Date July 7 2014 R2872CP aA m Z mr O PN lt Ro O Hs U gt AD a gt Provider Types Affected This MLN Matters article is intended for physicians othe
83. an outpatient procedure later in the day This occurs when we do not have the equipment to perform the procedure and the intention is that the patient will not be returning to our facility after the procedure A Since this is a discharge to outpatient treatment and it is expected that the patient will go home afterward use discharge status 01 discharged to home or self care 4 Q We have a Home Health Agency with DME Often we find the orders reads Home with Walker We do not see a physician order for home health care nor has there been an assessment documented by the receiving home health nurse The nursing discharges instructions check home Is the Patient discharge status Code still 06 A No Home with Walker does not imply a discharge to home under care of organized home health service organization in anticipation of covered skilled care Accordingly Code 01 discharged to home or self care routine discharge would be appropriate 5 Q What is the difference between residential care and assisted living care A In terms of patient discharge status codes there is no difference Discharges to residential care and private non state designated supported assisted living facilities are coded alike 01 6 Q An established nursing home patient i e the nursing home is their permanent residence is transferred to an acute setting Upon discharge they are sent back to the same nursing home with a hospice referral o
84. are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 78 Step by step instructions on how refunds with interest on previously recouped money are handled including step s required by providers as well as an example of reporting for the new Refund PLB Codes are found in Attachment 1 to this CR Additional Information The official instruction CR 8485 issued to your MAC regarding this change is available at http www cms hhs gov Regulations and Guidance Guidance Transmittals Downloads R1342OTN pdf on the CMS website If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 Therapy Information MM8556 Therapy Modifier Consistency Edits The Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number MM8556 Related Change Request CR CR 8556 Related CR Release Date February 6 2014 Effective Date July 1 2014 Related CR Transmittal R2868CP Implementation Date July 7 2014 What You Sho
85. ata segment that is included on the electronic remittance advice Healthcare providers will use the data within the addenda record to match the payment to the electronic remittance advice which is sent to the provider separate from the payment As a result specific addenda formatting requirements must be followed for healthcare EFT payments The TRN data segment must contain the following data elements separated by an asterisk Example TRN 1 12345 1512345678 9999999 TRN TRNO1 TRNO2 TRNO3 TRNO4 Segment Terminator data element separator TRNO1 Trace Type Code Trace Type Code is always a 1 Mandatory Element Element Name or Optional Data Content TRN Re association Trace Number M ASC X12 835 segment identifier This is always TRN M TRNO2 Re association Information M This data element must contain the EFT trace number M TRNO3 Origination Company ID A unique identifier designating the company initiating the funds transfer This must be a 1 followed by the payer s Tax Identification Number TIN TRNO4 Reference Identification O This data element is required when information beyond the Originating Company Identifier in TRNO3 is necessary for the payee to identify the source of the payment Segment Segment Terminator M The TRN data segment in the addenda record must end with Terminator either a tilde or a backslash This newsletter should be
86. attersArticles downloads SE1330 pdf on the CMS website This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 16 Common Working File Information MM8456 Revised Modifying the Daily Common Working File CWF to Medicare Beneficiary Database MBD File to Include Diagnosis Codes on the Health Insurance Portability and Accountability Act Eligibility Transaction System HETS 270 271 Transactions The Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning Network MLN Matters article on February 11 2014 A revision to this article was then issued on March 7 2014 The following reflects the revised article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number MM8456 Revised Related Change Request CR CR 8456 Related CR Release Date March 6 2014 Effective Date October 1 2014 Related CR Transmittal R13560TN Implementation Date October 6 2014 aA m Z mr O PN lt Ro O Hs T gt Bu a
87. bf1fe559cc9dfdf amp tpl ecfrbrowse Title42 42cfr419_main_02 tpl on the Internet Other Circumstances When Part A Payment Cannot Be Made CMS notes that there are no changes to the policies for billing Part B under other circumstances when Part A payment cannot be made For example when beneficiaries treated as hospital inpatients are either not entitled to Part A at all or are entitled to Part A but have exhausted their Part A benefits hospitals may only bill for a limited set of ancillary Part B inpatient services Some of these services are typically packaged for payment under the OPPS and the primary service into which they are packaged is not payable In these circumstances CMS will provide separate payment for the ancillary Part B inpatient service For example hospitals should continue to use HCPCS code C9899 created by CMS to obtain separate payment under this provision for certain implantable prosthetic devices which replace all or part of an internal body organ and do not have pass through payment status However CMS revised the Medicare Claims Processing Manual Ch 4 Sec 240 to specify that this code should not be used when billing Part B following a reasonable and necessary Part A denial because the primary service the implantation surgery is a payable Part B inpatient service and payment of the device is packaged with the surgery Payment of Part B Services in the Payment Window for Outpatient Services Treated as Inpatien
88. business Multi Factor Productivity MFP The MFP adjustment is 0 8 percent and the CPI U percentage increase is 1 8 percent Thus the 1 8 percentage increase in the CPI U is reduced by the 0 8 percentage increase in the MFP resulting in a net increase of 1 0 percent for the update factor 2014 Update to the Labor Payment Rates The 2014 fees for HCPCS labor payment codes K0739 L4205 and L7520 are increased 1 8 percent effective for claims with dates of service from January 1 2014 through December 31 2014 and those rates are as follows STATE K0739 L4205 L7520 STATE K0739 L4205 L7520 AK 27 40 31 22 36 73 NC 14 55 21 68 29 43 AL 14 55 21 68 29 43 ND 18 13 31 16 36 73 AR 14 55 21 68 29 43 NE 14 55 21 66 41 04 AZ 17 99 21 66 36 21 NH 15 62 21 66 29 43 CA 22 32 35 59 41 48 NJ 19 63 21 66 29 43 This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 aA m Z mr O PN lt Ro O Hs T gt A a gt 38 STATE K0739 L4205 L7520 STATE K0739 L4205 L7520 x CO 14 55 21 68 29 43 NM 14 55 21 68 29 43 m CT 24 30 22 16 29 43 N
89. cific Centers for Medicare amp Medicaid Services CMS Activities Educational Tool ICN 906983 downloadable at http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads ContractorEntityGuide ICN906983 pdf Revised Medical Privacy of Protected Health Information Fact Sheet ICN 006942 Downloadable only at http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads SE0726FactSheet pdf REVISED Quick Reference Information Medicare Immunization Billing Educational Tool ICN 006799 downloadable at htip www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads gr_immun_bill pdf REVISED General Equivalence Mappings Frequently Asked Questions Booklet ICN 901743 hard copy only at http Awww cms gov Medicare Coding ICD10 Downloads GEMs CrosswalksBasicFAQ pdf NEW Medicare Quarterly Provider Compliance Newsletter Volume 4 Issue 2 Educational Tool ICN 908994 downloadable at htip cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads MedQtrlyComp Newsletter ICN908994 pdf RELEASED Transitional Care Management Services Fact Sheet ICN 908628 Hard Copy only at http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads Transitional Care Management Services Fact Sheet ICN908628 pdf Revised Inpatient Rehabilitation Facility Prospect
90. cription style tear pads that allow you to give a customized flu shot reminder to patients at high risk for complications from the flu On the CDC order form under Programs select Immunizations and Vaccines Influenza Flu for a list of flu related resources Are you ready to transition to ICD 10 on October 1 2014 In this MLN Connects video at http www youtube com watch v kCV6aFIA Sc amp feature youtu be on ICD 10 Coding Basics Sue Bowman from the American Health Information Management Association AHIMA provides a basic introduction to ICD 10 coding including Similarities and differences CD 10 code structure and Coding process and examples To receive notification of upcoming MLN Connects videos and calls and the latest Medicare program information on ICD 10 subscribe to the weekly MLN Connects Provider eNews at https public dc2 govdelivery com accounts USCMS subscriber new pop t amp topic_id USCMS_7819 MLN Matters Articles Index Have you ever tried to search MLN Matters articles for information regarding a certain issue but you did not know what year it was published To assist you next time in your search try the CMS article indexes that are published at http www cms gov outreach and education medicare learning network min MLNMattersArticles on the CMS website These indexes resemble the index in the back of a book and contain keywords found in the articles including HCPCS codes and
91. ctive Date July 1 2014 Related CR Transmittal R13420TN Implementation Date July 7 2014 Provider Types Affected This MLN Matters article is intended for physicians and other providers submitting claims to Medicare administrative contractors MACs including home health amp hospice HH amp H MACs for services to Medicare beneficiaries Provider Action Needed This article is based on CR 8485 which informs MACs about changes necessary to create a new process that insures refunded principal and associated interest amounts can be reported separately on remittance advices and that claim identifiers are used to identify the appropriate claim for which those amounts apply Make sure that your billing staffs are aware of these changes Background CMS was advised that the current practice of reporting principal and interest amounts for all related claims on the Remittance Advice RA as one lump sum amount was creating problems for the provider community since it was not conducive to the proper posting of payments CR 8485 instructs the MACs on how to report refunded principal and interest amounts separately and how to use claim identifiers to indicate the appropriate claim for those amounts Providers should see these changes appear on RAs created after CR 8485 is implemented on July 7 2014 This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters
92. d with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 72 e Providers and suppliers participating during the testing week will receive electronic acknowledgement confirming that the submitted test claims were accepted or rejected On or before March 18 2014 your contractor will report the following to CMS Number of trading partners conducting testing during the testing week Percent of trading partners that conducted testing during the testing week versus number of trading partners supported by contract Percent of test claims accepted versus rejected Report of any significant issues found during testing Additional Information The official instruction CR 8465 issued to your MAC regarding this change may be viewed at http Awww cms gov Regulations and Guidance Guidance Transmittals Downloads R13530TN pdf on the CMS website If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 aA m Z mr O PN lt Ro O Hs T gt AD a gt ICD 10 Information MM8602 International Classification of Diseases Tenth Revision ICD 10 Limited End to End Testing w
93. e 2014 DMEPOS fee schedule Please note that when updating the stationary oxygen equipment fees corresponding updates are made to the fee schedule amounts for HCPCS codes E1405 and E1406 for oxygen and water vapor enriching systems Since 1989 the fees for codes E1405 and E1406 have been established based on a combination of the Medicare payment amounts for stationary oxygen equipment and nebulizer codes E0585 and E0570 respectively 2014 Maintenance and Servicing Payment Amount for Certain Oxygen Equipment CR 8531 also updates the 2014 payment amount for maintenance and servicing for certain oxygen equipment You can read more about payment for claims for maintenance and servicing for oxygen equipment in MLN Matters Articles MM6792 at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads MM6792 pdf and MM6990 at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads MM6990 pdf on the CMS website To summarize payment for maintenance and servicing of certain oxygen equipment can occur every 6 months beginning 6 months after the end of the 36th month of continuous use or end of the supplier s or manufacturer s warranty whichever is later for either HCPCS code E1390 E1391 E0433 or K0738 billed with the MS modifier Payment This newsletter should be shared with all health care practitioners and managerial members RET
94. e testing The forms for this information must be completed and returned to the MAC CEDI by May 2 2014 If these forms are not returned by May 2 the tester may lose the opportunity to test CEDI will instruct suppliers to submit claims with ICD 10 codes with Dates of Service DOS 10 1 2014 through 10 15 2014 They may also submit claims with ICD 9 codes with DOS before 10 1 2014 MACs will instruct testers to submit test claims with ICD 10 codes with DOS on or after 10 1 2014 They may also submit test claims with ICD 9 codes with DOS before 10 1 2014 MACs and CEDI will be prepared to support increased call volume from testers during the testing window and up to 2 weeks following the receipt of the Electronic Remittance Advices ERAs from testing MACs and CEDI will provide information to This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 aA m Z mr O PN lt Ro O Hs T gt AD a gt 74 the testers on who to contact for testing questions There may be separate contacts for front end questions and remittance questions e MACs will post an announcement about the testing to their websites Additional Information The official instruc
95. ed in case a physician or vendor has multiple occurrences of the same payment The only data field that needs to be re entered is the date Vendors Physicians sorted alphabetically In Manage Vendors Physicians vendors or physicians are now listed alphabetically The prior app version listed vendors and physicians in the order in which they were entered Email print QR code added A Share button is available to email or print a QR code that is generated within the app for sharing at a later time Payment QR code warning added After a payment QR code is scanned a red warning message appears to remind the user to manually add the vendor or physician name to the payment data conveyed in the QR code Additional data elements added in Add Payment gt Travel amp Lodging When nature of payment in Add Payment is Travel amp Lodging the following additional data elements can be entered city state and country of travel note that these new data elements are required for reporting purposes but remember the apps are not used for reporting data only for tracking it Tablet support e Both apps are optimized for viewing on tablet devices This newsletter should be shared with all health care practitioners and managerial members of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright
96. edit amount in value code FD which reduces the post wage adjusted APC line payment for the applicable procedure will be capped by the device offset amount for that APC The offset amounts for the above referenced APCs along with the offsets for other APCs is available under the Annual Policy Files link on the left column at http www cms gov Medicare Medicare Fee for Service Payment HospitalOutpatientPPS index htm on the CMS OPPS website Coverage Determinations The fact that a drug device procedure or service is assigned a HCPCS code anda payment rate under the OPPS does not imply coverage by the Medicare program but indicates only how the product procedure or service may be paid if covered by the program MACs determine whether a drug device procedure or other service meets all program requirements for coverage For example MACs determine that it is reasonable This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 A m Z Cc O PN lt Ro O I gt Bu oe gt 5 and necessary to treat the beneficiary s condition and whether it is excluded from payment Additional Information The official instruction CR 8653 i
97. eneficiaries Health care providers are encouraged to get a flu vaccine to help protect themselves from the flu and to keep from spreading it to their family co workers and patients Note The flu vaccine is not a Part D covered drug For more information visit MLN Matters Article MM8433 Influenza Vaccine Payment Allowances Annual Update for 2013 2014 Season hitp www cms gov Outreach and This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 12 Education Medicare Learning Network MLN MLNMattersArticles Downloads MM8433 pdf MLN Matters Article SE1336 2013 2014 Influenza Flu Resources for Health Care Professionals http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads SE1336 pdf HealthMap Vaccine Finder htip vaccine healthmap org a free online service where users can search for locations offering flu and other adult vaccines While some providers may offer flu vaccines those that don t can help their patients locate flu vaccines within their local community Free Resources http www cdc gov flu ireeresources can be downloaded from the CDC website including pres
98. ength of stay for the DRG Under Medicare s Post Acute Care Transfer policy 42 CFR 412 4 a discharge of a hospital inpatient is considered to be a post acute care transfer when the patient s discharge is assigned to one of the qualifying diagnosis related groups DRGs and the discharge is made under any of the following circumstances To a hospital or distinct part hospital unit excluded from the inpatient prospective payment system IPPS includes Inpatient Rehabilitation Facilities Long Term Care Hospitals psychiatric hospitals cancer hospitals and children s hospitals To a skilled nursing facility not swing beds and To home under a written plan of care for the provision of home health services from a home health agency and those services begin within 3 days after the date of discharge Note A list of the FY2008 DRGs is available in Table 5 of the IPPS final rule for 2008 That table is available at http www cms gov Medicare Medicare Fee for Service Payment AcutelnpatientPPS Acute Inpatient Files for Download Items CMS1247844 html on the CMS website Based on the above the IPPS Post Acute Care Transfer Policy applies to claims coded with Patient discharge status Codes 03 05 06 62 63 and 65 Inpatient Rehabilitation Facilities IRFs 42 CFR 412 624 f The following Patient discharge status Codes are applicable under the IRF Transfer Policy for IRF PPS 02 03 61 62 63 and 64
99. equently the payment information that a provider receives or that is transmitted from a provider s financial institution regarding the health care EFT payment may change as per these requirements Specifically the Company Entry Description and the TRN Segment that is reported or transmitted to a provider from its financial institution may change in terms of content or length Providers are urged to contact their financial institutions directly in order to understand the form in which payment information will be transmitted or reported on a per payment basis as a result of CR 8619 We suggest that providers should subsequently take steps to assure that the payment information that is changed as a result of related CR 8629 see the related article at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads MM8629 pdf can be accommodated by your accounting processes and systems This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at oO http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 41 Background The regulation adopting the Health Care EFT standards is available at https www federalregister gov articles 2012 01 10 2012 132 administrative simplification adoption of s
100. ere made to comply with 1 Conversion from ICD 9 to ICD 10 Conversion from ASC X12 Version 4010 to Version 5010 Conversion of former contractor types to MACs and POS Other miscellaneous editorial and formatting updates provided for better clarity correctness and consistency Note The edits made to the NCD Manual are technical editorial only and in no way alter existing NCD policies Background These edits to Pub 100 03 are part of a CMS wide initiative to update its manuals and bring them in line with recently released instructions regarding the above noted subject matter Additional Information The official instruction CR 8506 issued to your MAC regarding this change may be viewed at http Awww cms gov Regulations and Guidance Guidance Transmittals downloads R159NCD pdf on the CMS website If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 8 General Information MM8582 Revised Claim Status Category and Claim Status Codes Update The Centers for Medicare
101. erred to the same hospital s inpatient psychiatric Distinct Part Unit DPU Under the Medicare PPS the Centers for Medicare amp Medicaid Services CMS makes an additional payment to an IPF or a DPU for the first day of a beneficiary s stay to account for emergency department costs if the IPF has a qualifying emergency department However CMS does not make this payment if the beneficiary was discharged from an acute care stay and transferred to its own hospital based IPF since payment for the emergency department services are included in the Medicare payment for the acute care stay The Point of Origin for Admission or Visit Code D prevents this overpayment The correct Point of Origin for Admission or Visit code formerly Source of Admission must be applied to prevent incorrect payments Case Studies Example 1 On January 10 2010 an 85 year old female is admitted through the Emergency Room for a one day stay in an acute care inpatient hospital setting On January 11 2010 the patient is admitted to the inpatient psychiatric unit of the same facility The claim for this admission was submitted with Point of Origin for Admission or Visit Code 1 Physician Referral Resolution Because the January 11th admission was a transfer from the same facility the Point of Origin for Admission or Visit Code should be coded D The incorrect Source of Admission Code resulted in an overpayment of 105 06 Example 2 On Januar
102. fective Date N A Related CR Transmittal N A Implementation Date N A Provider Types Affected This MLN Matters Special Edition SE is intended for physicians providers and suppliers submitting claims to Medicare administrative contractors MACs for services to Medicare beneficiaries What You Need to Know CMS is issuing this article to alert the provider community of updates to the mobile applications apps Open Payments Mobile for Industry and Open Payments Mobile for Physicians implemented as a result of user feedback to CMS See the Background and Key Points sections of this article for details Also a part of SE1402 is new technical documentation The Open Payments QR Code Reader How To Guide Included are the technical instructions for creating or importing contact information using a QR code reader and generating a QR code to transfer profile or payment information to other user devices Background In July 2013 CMS released two mobile apps Open Payments Mobile for Industry and Open Payments Mobile for Physicians Below are enhancements to the original Open Payments mobile apps The changes to the apps include the following Streamlining the menu on the Welcome screen e Adding the ability to export all profile data associated with a payment into CSV format and This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier s
103. for this service go to htip www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts downloads What_Is_MLNMatters pdf and start receiving updates immediately Products from the Medicare Learning Network MLN NEW Information on the National Physician Payment Transparency Program Open Payments Podcast ICN 908961 downloadable only at htip www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts MLN Multimedia Items ICN908961 Podcast html NEW Vaccine Payments Under Medicare Part D Fact Sheet ICN 908764 downloadable and hard copy at hittp www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads Vaccines Part D Factsheet ICN908764 pdf NEW Hospice Related Services Part B Podcast ICN 908995 downloadable only at http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts MLN Multimedia Items ICN908995 podcast html This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 aA m Z mr O PN lt Ro O Hs U gt A a gt 11 REVISED Contractor Entities At A Glance Who May Contact You About Spe
104. from an acute inpatient hospital to a rehab unit in a SNF 9 Q What is the appropriate patient discharge status code for a patient transferred from an acute care hospital to a nursing facility for a non skilled custodial residential level of care For example The patient is discharged to a facility that is only certified with skilled beds but the patient does not qualify for a skilled level of care This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 aA m Z mr O PN lt Ro O Hs U gt AD a gt 65 The Medicare certified nursing facility is licensed for both skilled and intermediate care beds and the patient is transferred to intermediate care The patient resides at a Medicare certified SNF but only receives non skilled services A Code 04 discharged transferred to an intermediate care facility ICF would be the appropriate patient status discharge code for all of the examples above 10 Q If a patient is discharged from a hospital based Transitional Care Unit i e skilled nursing unit to the acute hospital under Observation Status what is the Discharge Status for the TCU claim A Use Code 05 discharged transferred to ano
105. g Current Procedural Terminology CPT codes 15271 15278 and application procedures that use low cost skin substitute products billed using HCPCS codes C5271 C5278 Assignment of skin substitute products to the high cost or low cost groups depended upon a comparison of the July 2013 payment rate for the skin substitute product to 32 which is the weighted average payment per unit for all skin substitute products using the skin substitute utilization from the CY 2012 claims data and the July 2013 payment rate for each product Skin substitute products with a July 2013 payment rate that was above 32 per square centimeter are paid through the high cost group and those with a July 2013 payment rate that was at or below 32 per square centimeter are paid through the low cost group for CY 2014 As a reminder for CY 2015 CMS will follow the usual policy with regard to the specific quarterly ASP data sets used for proposed and final rule making in that CMS will use April 2014 ASP data to establish the proposed rule low high cost threshold and CMS will use July 2014 ASP data to establish the final low high cost threshold for CY 2015 CMS also finalized a policy that for any new skin substitute products approved for payment during CY 2014 CMS will use the 32 per square centimeter threshold to determine mapping to the high or low cost skin substitute group Any new skin substitute products without pricing information were assigned to the low cost cate
106. gory until pricing This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at o http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 A m Z Cc O PN lt Ro O I gt Bu gt 56 information becomes available There were nine new skin substitute products that were effective January 1 2014 and that were assigned to the low cost payment group because pricing information was not available for these products at the time of the January 2014 update There is now pricing information available for three of these nine products Table 7 below shows the 3 new products and their low high cost status based on the comparison of the price per square centimeter for each product to the 32 square centimeter threshold for CY 2014 Table 7 Updated Payment Rates for Certain HCPCS Codes Effective April 1 2014 HCPCS Code Long Descriptor Status Indicator Low High Cost Status Q4143 Repriza Per Square Centimeter N Low Q4147 Architect Extracellular Matrix Per Square Centimeter N High Q4148 Neox 1k Per Square Centimeter N High h Billing Guidance for the Topical Application of Mitomycin During or Following Ophthalmic Surgery Hospital outpatient departments should only bill HCPCS code J73
107. graphy FDG PET scans without the Coverage with Evidence Development CED requirement when used to guide subsequent management of anti tumor treatment strategy after completion of initial anti cancer therapy for the same cancer diagnosis Coverage of any additional FDG PET scans that is beyond three used to guide subsequent management of anti tumor treatment strategy after completion of initial anti cancer therapy for the same diagnosis will be determined by the local MACs Make sure that your billing staffs are aware of these changes Background CMS was asked to reconsider Section 220 6 of the National Coverage Determinations NCD Manual to end the prospective data collection requirements across all oncologic indications of FDG PET in the context of this document The term FDG PET includes PET Computed Tomography CT and PET Magnetic Resonance MRI CMS is revising the NCD Manual Section 220 6 17 to reflect that CMS has ended the CED requirement for 18 Fluorodeoxyglucose FDG PET and PET CT and PET MRI for all oncologic indications contained in Section 220 6 17 of the NCD Manual This removes the current requirement for prospective data collection by the National Oncologic PET Registry NOPR for oncologic indications for FDG HCPCS A9552 only Effective for services performed on or after June 11 2013 The CED requirement has ended and modifier Q0 Q1 along with condition code 30 institutional claims only or V70 7 both i
108. h all health care practitioners and managerial members of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 A m Z PN am Ro O I U gt A J gt 31 e Remittance Advice Remark Code RARC N517 Resubmit a new claim with the requested information e RARC N519 Invalid combination of HCPCS modifiers For claims with dates of service on or after September 27 2013 Medicare will deny reject claims for more than one PET AB scan HCPCS code A9586 or A9599 in a patient s lifetime MACs will line item deny claims for PET AB HCPCS code A9586 or A9599 where a previous PET AB HCPCS code A9586 or A9599 is paid in history using the following messages e CARC 149 Lifetime benefit maximum has been reached for his service benefit category e RARC N587 Policy benefits have been exhausted e Group Code PR assigning financial liability to the beneficiary if a claim is received with occurrence code 32 indicating a signed ABN is on file or occurrence code 32 is present with modifier GA e Group Code CO assigning financial liability to the provider if a claim is received with a GZ modifier indicating no signed ABN is on file aA m Z mr O PN lt Ro O Hs T gt A a gt Note that MACs will not automatically adjust claims processed p
109. iate chamber s of the heart The surgeon then makes a small pocket in the pad of the flesh under the skin on the upper portion of the chest wall to hold the power source The pocket is then closed with stitches On August 13 2013 CMS issued a National Coverage Determination NCD In this NCD CMS concluded that implanted permanent cardiac pacemakers single chamber This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 26 or dual chamber are reasonable and necessary for the treatment of non reversible symptomatic bradycardia due to sinus node dysfunction and second and or third degree atrioventricular block Symptoms of bradycardia are symptoms that can be directly attributable to a heart rate less than 60 beats per minute for example syncope seizures congestive heart failure dizziness or confusion The following indications are covered for implanted permanent single chamber or dual chamber cardiac pacemakers 1 Documented non reversible symptomatic bradycardia due to sinus node dysfunction 2 Documented non reversible symptomatic bradycardia due to second degree and or third degree atrioventricular block The following indications are non covered f
110. ices delivered under an outpatient physical therapy plan of care When information on a claim is clearly self contradictory as in this example the claim should be returned to the provider for correction The business requirements in CR 8556 create edits to do this effective for dates of service July 1 2014 and after This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 aA m Z mr O PN lt Ro O Hs T gt AD a gt 19 In addition CR 8556 updates Medicare Claims Processing Manual Chapter 5 Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation Facility CORF Services to reflect recent payment regulations The Fiscal Year FY 2014 inpatient hospital final rule contained a policy regarding rebilling of Part B services when an inpatient stay is denied as not reasonable and necessary This policy is now included in Section 40 8 of Chapter 5 of the Medicare Claims Processing Manual Specifically it states that if a beneficiary receives therapy services during an inpatient hospital stay which was denied because the stay was not medically necessary the therapy services may be rebilled under Medicare Part B coverage If the
111. ient discharge status Code 61 67 69 Reserved for National Assignment These patient discharge status codes are reserved for national assignment This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 aA m Z mr O PN lt Ro O Hs U gt AD a gt 63 NEW PATIENT DISCHARGE STATUS CODE 70 Per NUBC Effective April 1 2008 70 Discharged transferred to another Type of Health Care Institution not Defined Elsewhere in this Code List New patient discharge status code 70 was created in order for providers to be able to indicate discharges transfers to another type of health care institution not defined elsewhere in the code list This code is effective for use by providers for discharges to dates on or after April 1 2008 See Code 05 71 99 Reserved for National Assignment These patient discharge status codes are reserved for national assignment Patient Discharge Status Codes Affected by the Hospital Transfer Policies for Inpatient PPS and IRF PPS The IPPS Acute to Acute Transfer policy applies to transfers coded with patient discharge status code 02 and applies to ALL DRGs and when the length of stay is less than the average l
112. ier on or after July 1 2014 to receive packaged payment under the OPPS Hospitals are not required to reprocess any previously submitted claims O The table below summarizes the billing discussed above A lt Claims with Dates of Service Claims with Dates of Service on or after January 1 2014 and on or after January 1 2014 Ro Condition received Prior to July 1 2014 Received on or after July 1 2014 1 Non patient referred specimen TOB 14x TOB 14x without the new modifier JE 2 A hospital collects specimen and furnishes only TOB 14x TOB 13x and the new modifier the outpatient labs on a given date of service effective January 1 2014 3 A hospital conducts outpatient lab tests that TOB 14x TOB 13x and the new modifier U are clinically unrelated to other hospital outpatient effective January 1 2014 gt services furnished the same day D gt Sole Community Hospitals SCHs SCHs are paid under the OPPS Therefore the new OPPS packaging policies apply to SCHs as to other OPPS hospitals for laboratory and other services furnished on or after January 1 2014 However SCHs with qualified laboratories continue to be eligible for the 62 percent CLFS payment amount described in the Medicare Claims Processing Manual Pub 100 04 Chapter 16 Section 40 3 when they furnish outpatient lab tests that are separately payable under exceptions 2 or 3 listed above The 014X TOB does not provide differential CLFS payment
113. igned ABN is on file or e Group Code PR assigning financial liability to the beneficiary if a claim is received with a GA modifier indicating a signed ABN is on file NOTE For clarification purposes as an example each different cancer dx is allowed 1 initial treatment strategy PI modifier PET scan and 3 subsequent treatment strategy PS modifier PET scans without the KX modifier The 4th PET scan and beyond for the same cancer dx will always require the KX modifier If a different cancer dx is reported that cancer dx will allow the same scenario as above 1 initial 3 subsequent no KX modifier required 4 or more for same dx requires a KX modifier aA m Z mr O PN lt Ro O Hs U gt A a gt Note The only exception to the above frequency is with dx 185 0 prostate cancer which is non covered for initial treatment strategy Therefore all P1 modifiers for 185 0 would be denied and PS modifiers would follow the same frequency as all other cancer dx codes For claims with dates of service on or after July 7 2014 contractors shall deny subsequent treatment strategy PS claims for oncologic FDG PET scans when no initial treatment strategy Pl claim is present in history when appropriate CWF will begin counting at this point The prostate cancer exception above applies MACs shall deny subsequent treatment strategy PS claims for oncologic FDG PET scan claims when no initial treatment
114. ion of their beds under Medicare and some nursing facilities choose to certify all of their beds under Medicare Still others elect not to certify any of their beds under Medicare When a patient is transferred to a nursing facility that has no Medicare certified beds this code should be used If any beds at the facility are Medicare certified then the provider should use either Patient discharge status Code 03 or 04 depending on e The level of care the patient is receiving and e Whether the bed is Medicare certified or not 65 Discharged Transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital This code should be used when a patient is transferred to an inpatient psychiatric unit or inpatient psychiatric designated unit Note This code should not be used when a patient is transferred to an inpatient psychiatric unit of a federal hospital e g Veterans Administration Hospitals In this case see Patient discharge status Code 43 66 Discharged Transferred to a Critical Access Hospital CAH Patient discharge status Code 66 is used to identify a transfer to a critical access hospital CAH for inpatient care Providers will need to establish a process for identifying whether a hospital is paid under the prospective payment system PPS or whether the facility is designated as a CAH Note Discharges or transfers to a critical access hospital CAH swing bed should still be coded with Pat
115. iopharmaceuticals a Drugs and Biologicals with Payments Based on Average Sales Price ASP Effective April 1 2014 In the Calendar Year CY 2014 OPPS ASC final rule with comment period CMS stated that payments for drugs and biologicals based on ASPs will be updated on a quarterly basis as later quarter ASP submissions become available You can review the CY 2014 OPPS ASC final rule at http www gpo gov fdsys pkg FR 2013 12 10 pdf 2013 28737 pdf on the Internet In cases where adjustments to payment rates are necessary based on the most recent ASP submissions CMS will incorporate changes to the payment rates in the April 2014 release of the OPPS Pricer The updated payment rates effective April 1 2014 will be included in the April 2014 update of the OPPS Addendum A and Addendum B which will be posted at http www cms gov Medicare Medicare Fee for Service Payment HospitalOutpatientPPS Addendum A and Addendum B Updates html on the CMS website b Drugs and Biologicals with OPPS Pass Through Status Effective April 1 2014 Two drugs and biologicals have been granted OPPS pass through status effective April 1 2014 These items along with their descriptors and APC assignments are identified in Table 2 below This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cg
116. is the same Provider Types Affected Providers billing Medicare fiscal intermediaries Fls or Part A B Medicare Administrative Contractors A B MACs Provider Action Needed STOP Impact to You This Special Edition article is based on information from CMS regulations and transmittals and the National Uniform Billing Committee NUBC Official UB 04 Data Specifications Manual 2008 Version 2 00 July 2007 Section Form Locator 17 Patient Discharge Status Effective Date March 1 2007 copyrighted by the American Hospital Association AHA NUBC UB 04 Version 2 00 Clarifications and Errata as of 8 22 07 It provides clarifications and instructions on determining the correct patient discharge status code to use when completing your claims IMPORTANT The NUBC is responsible for the maintenance and dissemination of guidance for the UB 04 code set The CMS has provided a subset of information below for Medicare participating providers For greater detail providers should visit http www nubc org in order to purchase a UB 04 manual CAUTION What You Need to Know A patient discharge status code is a two digit code that identifies where the patient is at the conclusion of a health care facility encounter or at the end time of a billing cycle This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from
117. ist and dexamethasone for patients who are receiving certain highly emetogenic chemotherapeutic agents On May 29 2013 CMS announced an update to that NCD to cover the use of the oral antiemetic three drug combination of oral aprepitant J8501 an oral 5HT3 antagonist Q0166 Q0179 Q0180 and oral dexamethasone J8540 for patients receiving highly and moderately emetogenic chemotherapy As a result effective for services on or after May 29 2013 the following anticancer chemotherapeutic agents have been added to the list of anticancer chemotherapeutic agents for which the use of the oral antiemetic 3 drug combination of oral aprepitant an oral 5HT3 antagonist and oral dexamethasone is deemed reasonable and necessary e Alemtuzumab J9010 e Daunorubicin J9150 J9151 e Azacitidine J9025 e Idarubicin J9211 e Bendamustine J9033 e lfosfamide J9208 e Carboplatin J9045 e irinotecan J9206 and e Clofarabine J9027 e Oxaliplatin J9263 e Cytarabine J9098 J9100 J9110 Please note the entire list includes the 11 new codes listed above and the 9 existing anticancer chemotherapeutic agents listed below e Carmustine J9050 e Mechlorethamine J9230 e Cisplatin J9060 J9062 e Streptozocin J9320 e Cyclophosphamide J8530 J9070 J9080 e Doxorubicin J9000 J9001 J9090 J9091 J9092 J9093 J9094 J9095 J9002 Q2048 Q2049 J9096 J9097 lt Epirubicin J9178 and e Dacarbazine J9130 J9140 l
118. ith Submitters The Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number MM8602 Related Change Request CR CR 8602 Related CR Release Date February 21 2014 Effective Date July 7 2014 Related CR Transmittal R13520TN Implementation Date July 7 2014 Provider Types Affected This MLN Matters article is intended for physicians other providers and suppliers who submit claims to Medicare claims administration contractors durable medical equipment Medicare administrative contractors DME MACs A B Medicare administrative contractors A B MACs and or home health and hospices HH amp H MACs for services provided to Medicare beneficiaries What You Need to Know This article is based on CR 8602 which instructs providers and clearinghouses on how to volunteer to be chosen for ICD 10 End to End testing with Medicare in July 2014 Potential testers must complete the volunteer form on the MAC website by March 24 2014 Background The International Classification of Disease Tenth Revision ICD 10 must be implemented by October 1 2014 While system changes to implement this project have been completed and tested i
119. itted with the KX modifier 426 0 144 2 426 13 144 1 746 86 Q24 6 426 12 144 1 427 81 149 5 or The following diagnosis codes can be covered at contractor discretion if submitted with at least one of the CPT codes and at least one of the diagnosis codes listed above along with the KX modifier 426 10 Atrioventricular block unspecified 144 30 Unspecified atrioventricular block 426 4 Right bundle branch block 145 10 Unspecified right bundle branch block 145 19 Other right bundle branch block 427 0 Paroxysmal supraventricular tachycardia 147 1 Supraventricular tachycardia Contractors will return claim lines if the KX modifier is not present using the following message Claim Adjustment Reason Code CARC 4 The procedure code is inconsistent with the modifier used or a required modifier is missing Remittance Advice Remarks Code RARC N517 Resubmit a new claim with the requested information Effective for claims with dates of service on or after August 13 2013 MACs will pay outpatient institutional claims for implanted permanent cardiac pacemakers single chamber or dual chamber codes C1785 C1786 C2619 or C2620 provided the claim contains the KX modifier and contains at least one of the CPT codes 33206 33207 or 33208 AND one of the following ICD 9_CM ICD 10 CM diagnostic codes 426 0 144 2 426 13 144 1 746 86 Q24 6 426 12 144 1 427 81 149 5 or MACs will return outpatient institutiona
120. ive Payment System Fact Sheet ICN 006847 downloadable at http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads InpatRehabPaymtfctsht09 508 pdf Revised End Stage Renal Disease Prospective Payment System Fact Sheet ICN 905143 downloadable format at http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads End Stage _Renal_Disease_Prospective_Payment_System_ICN905143 pdf REVISED Medicare Enrollment and Claim Submission Guidelines Booklet ICN 906764 Downloadable and hard copy at http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads MedicareC laimSubmissionGuidelines ICN906764 pdf Want to stay connected about the latest new and revised Medicare Learning Network MLN products and services Subscribe to the MLN Educational Products electronic mailing list For more information about the MLN and how to register for this service visit http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts downloads MLNProducts_ListServ pdf and start receiving updates immediately aA m Z mr C O PN lt Ro O Hs U gt A a gt Generally Medicare Part B covers one flu vaccination and its administration per flu season for beneficiaries without co pay or deductible Now is the perfect time to vaccinate b
121. justed HCPCS date SI APC Short Descriptor Long descriptor Payment Copayment C9739 4 01 2014 T 0162 Cystoscopy Cystourethroscopy with 2 007 32 401 47 prostatic imp 1 3 insertion of transprostatic implant 1 to 3 implants C9740 4 01 2014 T 1564 Cystoimpl4or Cystourethroscopy with 4 750 00 950 00 more insertion of transprostatic implant 4 or more implants Extended Assessment and Management EAM Composite APC 8009 Effective January 1 2014 CMS will provide payment for all qualifying extended assessment and management encounters through newly created composite APC 8009 Extended Assessment and Management EAM Composite Any clinic visit Level 4 or Level 5 Type A Emergency Department ED visit or Level 5 Type B ED visit furnished by a hospital in conjunction with observation services of eight or more hours will qualify for payment through APC 8009 Effective January 1 2014 CMS will no longer provide payment for extended assessment and management encounters through APCs 8002 Level Extended Assessment and Management Composite and 8003 Level Extended Assessment and Management Composite CMS is updating the Medicare Claims Processing Manual Pub 100 04 Chapter 4 Sections 10 2 1 and 290 5 to reflect these changes to the EAM Composite APC reporting guidelines These updated sections are included as an attachment to CR 8653 Billing for Drugs Biologicals and Rad
122. kground The Health Insurance Portability and Accountability Act HIPAA requires all health care benefit payers to use only Claim Status Category Codes and Claim Status Codes approved by the national Code Maintenance Committee in the X12 276 277 Health Care Claim Status Request and Response format adopted as the standard for national use e g previous HIPAA named versions included 004010X093A1 These codes explain the status of submitted claim s Proprietary codes may not be used in the X12 276 277 to report claim status The National Code Maintenance Committee meets at the beginning of each X12 trimester meeting February June and October and makes decisions about additions modifications and retirement of existing codes The codes sets are available at http www wpc edi com reference codelists healthcare claim status category codes and http www wpc edi com reference codelists healthcare claim status codes on the Internet All code changes approved during the January 2014 committee meeting shall be posted on these sites on or about March 1 2014 Included in the code lists are specific details including the date when a code was added changed or deleted These code changes are to be used in the editing of all X12 276 transactions processed on or after the date of implementation and are to be reflected in X12 277 transactions issued on and after the date of implementation of CR 8582 Additional Information The official ins
123. l claims for implanted permanent cardiac pacemakers that do not meet the preceding requirements The following diagnosis codes can be covered at contractor discretion if submitted with at least one of the CPT codes and diagnosis codes listed above 426 10 Atrioventricular block unspecified 144 30 Unspecified atrioventricular block 426 4 Right bundle branch block 145 10 Unspecified right bundle branch block 145 19 Other right bundle branch block 427 0 Paroxysmal supraventricular tachycardia 147 1 Supraventricular tachycardia Effective for claims with dates of service on or after August 13 2013 MACs will pay inpatient claims for implanted permanent cardiac pacemakers single chamber or dual chamber provided the claim contains one of the following ICD 9 ICD 10 diagnosis AND procedure codes 37 81 0JH604Z OJH634Z OJH804Z 0JH834Z 37 82 0JH605Z OJH635Z OJH805Z O0JH835Z or 37 83 OJH606Z OJH636Z OJH806Z OJH836Z AND 426 0 144 2 426 12 144 1 426 13 144 1 427 81 149 5 or 746 86 Q24 6 The following diagnosis codes can be covered at contractor discretion if submitted with at least one of the CPT codes and diagnosis codes listed above This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS M
124. mation that is returned in the HETS 271 response The guide is available at http www cms gov Research Statistics Data and Systems CMS Information Technology HETSHelp Downloads HETS270271CompanionGuide5010 pdf on the CMS website aA m Z mr O PN lt Ro O Hs T gt AD a gt Additional Information If you use a software vendor or clearinghouse to access Medicare beneficiary health insurance eligibility information you should direct questions to your vendor or clearinghouse If you have any questions about HETS please contact the MCARE Help Desk at 1 866 324 7315 Coverage Information MM8418 Aprepitant for Chemotherapy Induced Emesis The Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number MM8418 Related Change Request CR CR 8418 Related CR Release Date February 21 2014 Effective Date May 29 2013 Related CR Transmittal R180BP R2883CP Implementation Date July 7 2014 and R163NCD Provider Types Affected This MLN Matters article is intended for providers and suppliers submitting claims to Part A Medicare administrative contractors A MACs and or durable medical equipment MACs
125. medical services Please ensure that your billing staffs are aware of these changes Background The HETS 270 271 process is used by providers physicians and other suppliers to receive individual beneficiary eligibility information under the Medicare program including information found on the CWF MSP auxiliary file Although most MSP information from the MSP record is currently included on the HETS 271 response transaction International Classification of Diseases ICD Clinical Modification CM diagnosis codes are not included CMS believes it would be beneficial for CWF to include ICD CM diagnosis codes as derived from MSP no fault liability and workers This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 17 compensation MSP auxiliary records on the interface file that it sends to MBD Through a separate Medicare Advantage Prescription Drug CR CMS will ensure that the MBD table information that is exchanged with HETS will be modified to include ICD diagnosis codes Thereafter the diagnosis codes will be included in the HETS 271 response transaction that CMS makes available to providers physicians and suppliers Since the HETS 271 response transaction ca
126. ments Mobile for Physicians e A number of infrequently used menu options e g Program Information and Change Password moved from the Welcome screen and now appear in a hidden menu To access the menu swipe to the right at the Welcome screen Reports Statistics e Anew Reports Statistics button accessible on the Welcome screen allows the user to create a chart bar and pie showing their transfer of value data sorted by physician within Open Payments Mobile for Industry or vendor within Open Payments Mobile for Physicians e This new chart creation capability will streamline data review CSV exporting e When payment data is exported via CSV format all profile data for the associated vendor physician is included in the CSV file including address phone number etc The prior app version included only vendor physician name in the CSV file This enhancement will simplify the data review process Streamlined Add Payment process The steps to Add Payment are streamlined to allow the user to enter contact information for the vendor or physician while staying within the Add Payment menu The prior app version required the user to first enter contact information for the vendor or physician separately and then go to the Add Payment menu Easy payment duplication A new button available on the View Payment screen allows payment data to be easily duplicat
127. mp Medicaid Services CMS has issued the following Special Edition Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number SE1401 Related Change Request CR N A Related CR Release Date N A Effective Date N A Related CR Transmittal N A Implementation Date N A Provider Types Affected This MLN Matters Special Edition article is intended for inpatient psychiatric facilities IPFs submitting claims to Part A B Medicare administrative contractors A B MACs that involve inpatient transfers within the same facility aA m Z mr O PN lt Ro O Hs T gt AD a gt What You Need to Know Recovery Auditors have conducted reviews of Medicare Prospective Payment System PPS claims for inpatient psychiatric facilities IPF services These reviews have identified a substantial number of overpayments for inpatient psychiatric services directly following an acute care stay within the same facility These errors and overpayments occurred because the Source of Admission Code D was not applied to those claims The Point of Origin for Admission or Visit Code D formerly the Source of Admission Code must be used when a patient is discharged from an acute care stay in a hospital and transf
128. mplement an ICD 10 testing week with trading partners The concept of trading partner testing was originally designed to validate the trading partners ability to meet technical compliance and performance processing standards during the HIPAA 5010 implementation The ICD 10 testing week has been created to generate awareness and interest and to instill confidence in the provider community that CMS and the MACs are ready and prepared for the ICD 10 implementation This testing week will give trading partners access to the MACs and CEDI for testing with real time help desk support The event will be conducted virtually and will be posted on each MAC and the CEDI website as well as the CMS website The testing week will be March 3 through March 7 2014 Testing Week Information e Your MAC will announce and actively promote the testing week via ListServ messages and will post the testing week announcement on their website Your MAC will host a registration site for the testing week or provide an e mail address for the trading partners to provide registration information The registration site or e mail address information will be available and publicized to trading partners at least four weeks prior to the testing week During the testing week EDI help desk support will be available at a minimum from 9 00 a m to 4 00 p m local contractor time with enough support to handle any increased call volume This newsletter should be share
129. n find at http www gpo gov fdsys pkg PLAW 108publ173 pdf PLAW 108publ173 pdf on the internet amended Title XVIII of the Social Security Act the Act to repeal its provider nomination provision and replaced it with the geographic assignment rule This means that a chain or an individual provider can no longer select the fiscal intermediary Fl or MAC of its choice and you should be aware that your MAC will no longer accept your requests for change of intermediary Rather an individual provider will be assigned to the MAC that covers the state in which the provider is located and a chain that meets the criteria set forth at 42 CFR 421 404 may contact CMS and ask to have all eligible downstream providers assigned to the MAC that covers the state in which the chain s home office is located A chain home office wishing to contact CMS to request qualified chain status may send an email to Provider MAC_Assignment_Inquiry cms hhs gov Additional Information The official instruction CR 8442 issued to your MAC regarding this change may be viewed at http Awww cms gov Regulations and Guidance Guidance Transmittals Downloads R2876CP pdf on the CMS website If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 This newsletter should be shared with all health care practitioners and managerial members RE
130. n only accommodate up to 8 diagnosis codes CR 8456 instructs CWF to send up to 25 iterations of diagnosis codes associated with MSP no fault liability and workers compensation records for inclusion on the HETS 271 response transaction Additional Information The official instruction CR 8456 issued to your MAC regarding this change may be viewed at http Awww cms gov Regulations and Guidance Guidance Transmittals Downloads R13560TN pdf on the CMS website If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 aA m Z mr O PN lt Ro O Hs T gt AD a gt Common Working File Information MM8620 CWF Editing for Vaccines Furnished at Hospice Correction The Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number MM8620 Related Change Request CR CR 8620 Related CR Release Date February 6 2014 Effective Date October 1 2013 Related CR Transmittal R13390TN Implementation Date April 7 2014 Provider Types Affected This MLN Matters article is intended as an update for non hospice pro
131. n previous releases the industry has requested the opportunity to test with CMS This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 T3 CR 8602 will allow for a small subset of Medicare claims submitters to test with MACs and the Common Electronic Data Interchange CEDI contractor to demonstrate that CMS systems are ready for the ICD 10 implementation This additional testing effort will further ensure a successful transition to ICD 10 To facilitate this testing CR 8602 requires MACs to do the following e Conduct a limited end to end testing with submitters in July 2014 Test claims will be submitted July 21 25 2014 Each MAC and CEDI with assistance from DME MACs will select 32 submitters to participate in the end to end testing The Railroad Retirement Board RRB contractor will select 16 submitters Testers will be selected randomly from a list of volunteers At least five but not more than ten of the testers will be a clearinghouse and submitters should be a mix of provider types By March 7 2014 the MACs and CEDI will post a volunteer form to their website to collect volunteer information with which to select volunteers The form will provide informati
132. ncluding Inpatient Hospital Part B and OPPS Section 240 which is attached to CR 8445 Part B inpatient services are billed using the 12X TOB For Part B inpatient services furnished by the hospital that are not paid under the OPPS but rather under some other Part B payment mechanism Part B inpatient payment will be made pursuant to the Part B fee schedules or prospectively determined rates for which payment is made for these services when provided to hospital outpatients All hospitals billing Part A services are eligible to bill the Part B inpatient services including Short term acute care hospitals paid e Inpatient Rehabilitation Facilities IRFs under the IPPS and IRF hospital units Hospitals paid under the OPPS e Critical Access Hospitals CAHs e Long Term Care Hospitals LTCHs e Children s hospitals aA m Z mr O PN lt Ro O Hs T gt A a gt e Inpatient Psychiatric Facilities IPFs e Cancer hospitals and and IPF hospital units e Maryland waiver hospitals Hospitals paid under the OPPS continue billing the OPPS for Part B inpatient services Hospitals that are excluded from payment under the OPPS in Title 42 of the Code of Federal Regulations CFR Section 419 20 b are eligible to bill Part B inpatient services under their non OPPS Part B payment methodologies For more information regarding 42 CFR 419 20 b refer to http www ecfr gov cgi bin text idx c ecfr amp SID f0a3c4c0d05 1e60e0
133. new fields and an expansion of the existing Model 1 discount percentage field as follows 1 Add an indicator for hospitals subject to the Hospital Acquired Conditions HAC reduction program for future implementation 2 Add an estimated interim per claim Uncompensated Care Payment amount 3 Add an indicator for hospitals subject to an Electronic Health Records Incentive Program reduction for future implementation 4 Expand the existing 2 byte Model 1 discount percentage field to 3 bytes In order to avoid confusion with the 4 new payment amount fields created in CR 8217 we are renaming them here In addition we are redefining existing filler in the output record PRICER returns to Fiscal Intermediary Standard System FISS to accommodate future policy and or legislative changes that might require system changes The new fields are e PPS EHR PAYMENT ADJUST AMT PIC S9 07 V9 02 e PPS FLX5 PAYMENT PIC 9 07 V9 02 lt PPS FLX6 PAYMENT PIC 9 07 V9 02 e PPS FLX7 PAYMENT PIC S9 07 V9 02 The renamed fields are e From PPS FLX1 PAYMENT to PPS UNCOMP CARE AMOUNT e From PPS FLX2 PAYMENT to PPS BUNDLE ADJUST AMT e From PPS FLX3 PAYMENT to PPS VAL BASED PURCH ADJUST AMT e From PPS FLX4 PAYMENT to PPS READMIS ADJUST AMT Additional Information The official instruction CR 8546 issued to your MAC regarding this change may be viewed at http Awww cms gov Regulations and Guidance Guidance Transmittals downloads R2870CP pdf on the CMS
134. ng assembling or customizing to fit the individual Regulations at 42 CFR 414 402 define the term minimal self adjustment to mean an adjustment that the beneficiary caretaker for the beneficiary or supplier of the device can perform and that does not require the services of a certified orthotist an individual who is certified by the American Board for Certification in Orthotics and Prosthetics Inc or by the Board for Orthotist Prosthetist Certificationor an individual who has specialized training This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 36 As shown in the following table 22 new codes are added to the HCPCS for OTS orthotics In addition as part of the review to determine which HCPCS codes for prefabricated orthotics describe OTS orthotics it was determined that HCPCS codes for prefabricated orthotics describe items that are furnished OTS and items that require expertise in customizing the orthotic to fit the individual patient Therefore it was necessary to explode these codes into two sets of codes One set is the existing codes revised effective January 1 2014 to only describe devices customized to fit a specific patient by an individual with ex
135. nly What patient discharge status code would be appropriate A If the patient has not made a hospice election and has a referral only use Code 01 Discharged to Home 7 Q A patient was discharged to home with home health services Two days later the patient was readmitted to our hospital We were notified by the discharge planner of the patient s readmission and the fact that home health services were not started for the patient and the discharge status code needed to be changed to 01 By the time of the discharge planner s notification we had already submitted the patient s bill with the discharge status code of 06 In this instance what should the correct discharge status code be on this patient A To ensure accurate reimbursement and reporting send a replacement claim with the correct discharge status code 01 8 Q What status code should be used for a patient transferred to a SNF rehabilitation unit This unit is within the SNF Is this considered a transfer to a SNF or to a rehabilitation facility A A rehabilitation unit that is part of a skilled nursing facility is paid under the SNF prospective payment system Moving a patient from one unit to another does not constitute a transfer for billing purposes and should not result in separate claims If a patient is discharged from an acute inpatient hospital to a Medicare certified SNF in anticipation of skilled care use 03 Status code 03 is also used if the patient moves
136. nstitutional and practitioner claims are no longer required e MACs shall pay FDG PET claims for subsequent management identified by CPT codes 78608 78811 78812 78813 78814 78815 or 78816 modifier PS HCPCS A9552 and the same cancer dx code which exceeded 3 FDG PET scans when the KX modifier is included on the claim line e MACs will not search their files to identify claims processed prior to implementation of CR 8468 however they will adjust such claims that you bring to their attention This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 24 MACs will deny subsequent treatment strategy PS claims for FDG PET which exceeded 3 FDG PET scans when a KX modifier is not included on the claim line using the following e Claim Adjustment Reason Code CARC 96 Non covered charge s Refer to the 835 Healthcare Policy Identification Segment loop 2110 Service Payment Information REF if present e Remittance Advice Remarks Code N435 Exceeds number frequency approved allowed within time period without support documentation e Group Code CO assigning financial liability to the provider if a claim is received with a GZ modifier indicating no s
137. obasal degeneration 331 82 Dementia with Lewy Bodies G31 83 Dementia with Lewy bodies 331 83 Mild cognitive impairment so stated G31 84 Mild cognitive impairment so stated 780 93 Memory Loss R41 1 Anterograde amnesia R41 2 Retrograde amnesia R41 3 Other amnesia Amnesia NOS Memory loss NOS V70 7 Examination for normal comparison or control in clinical research Z00 6 Encounter for examination for normal comparison and control in clinical research program Effective for claims with dates of service on or after September 27 2013 MACs will return to provider return as unprocessable claims for PET AB imaging through CED during a Clinical trial not containing the following e Condition code 30 for institutional claims only e Modifier QO and or modifier Q1 as appropriate ICD 9 dx code V70 7 ICD 10 dx code Z00 6 on either the primary secondary position e A PET HCPCS code 78811 or 78814 e Dx codes see list in table above and e AB HCPCS code A9586 or A9599 MACs will return as unprocessable claims for PET AB imaging using the following messages e Claim Adjustment Reason Code CARC 4 the procedure code is inconsistent with the modifier used or a required modifier is missing Note Refer to the 835 Healthcare Policy Identification Segment loop 2110 Service Payment Information REF if present RETURN TO TABLE OF CONTENTS APRIL 2014 This newsletter should be shared wit
138. of service falls within a hospice election e Your MAC will adjust vaccine claims with dates of service on or after October 1 2013 which were previously rejected due to a hospice election if you bring such claims to your MAC s attention Additional Information The official instruction CR 8620 issued to your MAC regarding this change is available at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R1339OTN pdf on the CMS website If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 Common Working File Information SE1249 Revised HIPAA Eligibility Transaction System HETS to Replace Common Working File CWF Medicare Beneficiary Health Insurance Eligibility Queries aA m Z mr O PN lt Ro O Hs T gt AD a gt The Centers for Medicare amp Medicaid Services CMS has issued a revision to the following Special Edition Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at hitp www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2012 MLN Matters Articles htm MLN Matters Number SE1249 Revised Related Change Request CR N A Related CR Release Date N A Effective Date N A Related CR Transmittal N A Implementation Date N A N
139. om its financial institution may change in terms of content or length Providers are urged to contact their financial institutions directly in order to understand the form in which payment information will be transmitted or reported on a per payment basis as a result of CR 8629 We suggest that providers should subsequently take steps to assure that the payment information that is changed as a result of CR 8629 can be accommodated by your accounting processes and systems This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 43 Background In support of Health Insurance Portability amp Accountability Act of 1996 HIPAA Operating Rules for health care EFT and remittance advice transactions adopted by HHS NACHA The Electronic Payments Association has adopted its own operating rules that apply to ACH transactions that are health care payments from health plans to providers NACHA manages the development administration and governance of the ACH Network used by all types of financial networks and represents more than 10 000 financial institutions A new NACHA standard for electronic healthcare claim payments went into effect on September 20 2013 impacting all originat
140. omes may include 1 Avoidance of unnecessary or potentially harmful treatment or tests 2 Improving or slowing the decline of quality of life to include maintenance of independence and cognitive and functional status and 3 Survival Outcomes may be short term e g related to meaningful changes in clinical management or longterm e g related to dementia outcomes This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 30 A list of ICD 9 and corresponding ICD 10 Codes for Beta Amyloid for Dementia and Neurodegenerative Diseases is in the following table ICD 9 Codes Corresponding ICD 10 Codes 290 0 Senile dementia uncomplicated 290 10 Presenile dementia uncomplicated F03 90 Unspecified dementia without behavioral disturbance F03 90 Unspecified dementia without behavioral disturbance 290 11 Presenile dementia with delirium F03 90 Unspecified dementia without behavioral disturbance 290 12 Presenile dementia with delusional features 290 13 Presenile dementia with depressive features F03 90 Unspecified dementia without behavioral disturbance F03 90 Unspecified dementia without behavioral disturbance 290 20 Senile dementia with
141. on to verify that volunteers are ready to test meet the requirements to test and collect needed data about the tester how they submit claims what type of claims will be tested etc Volunteers must submit the completed forms to the MACs and CEDI by March 24 2014 By April 14 2014 the MACs and CEDI for the DME MACs will notify the volunteers that they have been selected to test and provide them with the information needed for the testing such as How to submit test claims for example what test indicators should be set What dates of service may be used for testing How many claims may be submitted for testing Test claims volume is limited to a total of 50 claims for the entire testing week submitted in no more than three files Request for National Provider Identifiers NPIs and Health Insurance Claim Numbers HICNs that will be used in testing no more than 5 NPIs and 10 HICNs per submitter Notice that if more than 50 claims are submitted they may not be processed Notice that claims submitted with NPIs or HICNs not previously submitted for testing likely will not be completed and Notice of potential Protected Health Information PHI on test remittances not submitted and instructions to report PHI found to the MAC MACs and CEDI for the DME MACs will collect information from the selected test volunteers to request the HICNs NPls and Provider Transaction Access Numbers PTANs the testers will use during th
142. or implanted permanent single chamber or dual chamber cardiac pacemakers 1 Reversible causes of bradycardia such as electrolyte abnormalities medications or drugs and hypothermia Asymptomatic first degree atrioventricular block aA m Z mr O PN lt Ro O Hs T gt AD a gt Asymptomatic sinus bradycardia Asymptomatic sino atrial block or asymptomatic sinus arrest Ol oe OS Ineffective atrial contractions e g chronic atrial fibrillation or flutter or giant left atrium without symptomatic bradycardia 6 Asymptomatic second degree atrioventricular block of Mobitz Type I unless the QRS complexes are prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of the His Bundle a component of the electrical conduction system of the heart 7 Syncope of undetermined cause 8 Bradycardia during sleep 9 Right bundle branch block with left axis deviation and other forms of fascicular or bundle branch block without syncope or other symptoms of intermittent atrioventricular block 10 Asymptomatic bradycardia in post myocardial infarction patients about to initiate long term beta blocker drug therapy 11 Frequent or persistent supraventricular tachycardias except where the pacemaker is specifically for the control of tachycardia 12 A clinical condition in which pacing takes place only intermittently and briefly and which is not associated with a rea
143. ors and receivers of EFT used to pay healthcare claims This Healthcare EFT standard stems from the Affordable Care Act which requires that healthcare payers must pay healthcare claim payments electronically using HIPAA standards if requested by the healthcare provider The standard designated for these claim payments is the Healthcare EFT Standard which is a NACHA CCD transaction that includes the ASC X12 835 TRN data segment in the addenda record The Healthcare EFT Standard requires the following Company Entry Description of HCCLAIMPMT to identify the payment as healthcare aA m Z mr O PN lt Ro O Hs T gt AD a gt e Company Name should be the health plan or third party administrator paying the claim e An addenda record must be included with a Record Type Code of 7 and an Addenda Type Code equal to 05 and e Payment Related Information in the addenda record must contain the ASC X12 835 TRN Re association Trace Number data segment that is included on the electronic remittance advice Healthcare providers will utilize the data within the addenda record to match the payment to the electronic remittance advice which is sent to the provider separate from the payment As a result specific addenda formatting requirements must be followed for healthcare EFT payments See Healthcare EFT Standard Format in the Medicare IOM for more information Example TRN 1 12345 1512345678 9999999
144. osen based on State guidance but the HHA is aware that the State sometimes asks for a Medicare claim submission at a later time the HHA must add a statement in the Additional Information box such as Medicaid will pay for these services Sometimes Medicaid asks us to file a claim with Medicare We will file a claim with Medicare if requested by your Medicaid plan aA m Z mr O PN lt Ro O Hs T gt A a gt Additional Information The official instruction CR 8597 issued to your MAC regarding this change may be viewed at http Awww cms gov Regulations and Guidance Guidance Transmittals Downloads R2878CP pdf on the CMS website If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 34 Fee Schedule Information MM8531 Revised Calendar Year CY 2014 Update for Durable Medical Equipment Prosthetics Orthotics and Supplies DMEPOS Fee Schedule The Centers for Medicare amp Medicaid Services CMS has issued a revision to the following Medicare Learning Net
145. ote This article was revised on February 10 2014 to update certain language to reflect the current status of this change see bolded language on page 2 Also clarifications have been made to the last question in the Frequently Asked Questions section on page 3 All other information is unchanged Provider Types Affected This MLN Matters Special Edition Article is intended for health care providers suppliers and their billing agents software vendors and clearinghouses that use Medicare s Common Working File CWF queries to obtain their patient s Medicare health insurance eligibility information from Medicare contractors carriers fiscal intermediaries Fls regional home health intermediaries RHHIs durable medical equipment Medicare administrative contractors DME MACs and or Part A B Medicare administrative contractors A B MACs Provider Action Needed If you currently use CWF queries to obtain Medicare health insurance eligibility information for Medicare fee for service patients you should immediately begin transitioning to the Medicare Health Insurance Portability and Accountability Act HIPAA Eligibility Transaction System HETS This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC
146. our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 58 It belongs in Form Locator 17 on a UB 04 claim form or its electronic equivalent in the HIPAA compliant 837 format GO What You Need to Do See the Background section of this article for more details regarding instructions and clarifications for patient discharge status coding Background This Special Edition article is being provided to help you determine the right discharge status code to use with your claims Assigning the correct patient discharge status code is just as important as any other coding used when filing a claim and the same processes should be applied for patient discharge status codes as with any other coding Choosing the patient discharge status code correctly avoids claim errors and helps you receive payment for your claim sooner A patient discharge status code is a two digit code that identifies where the patient is at the conclusion of a health care facility encounter this could be a visit or an actual inpatient stay or at the time end of a billing cycle the through date of a claim CMS requires patient discharge status codes for e Hospital Inpatient Claims type of bills TOBs 11X and 12X e Skilled Nursing Claims TOBs 18X 21X 22X and 23X e Outpatient Hospital Services TOBs 13X 14X 71X 73X 74X 75X 76X and 85X and e All
147. oviders submitting claims to A B Medicare administrative contractors MACs for outpatient clinical diagnostic laboratory services to Medicare beneficiaries What You Need to Know This article conveys updated requirements for CR 8572 which describes changes to the OPPS to be implemented in the January 2014 update Make sure your billing staff is aware of these changes This guidance updates the operational mechanism OPPS hospitals should use to bill Medicare on or after July 1 2014 for outpatient clinical diagnostic laboratory tests lab tests furnished in CY 2014 that are eligible for separate payment under the Clinical Laboratory Fee Schedule CLFS This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 68 Background In the January 2014 update to the hospital OPPS CR 8572 issued December 27 2013 CMS implemented a new policy under the CY 2014 OPPS final rule providing packaged payment of outpatient lab tests other than molecular pathology under the OPPS rather than separate CLFS payment effective for dates of service on or after January 1 2014 In the Medicare claims system packaged payment would apply to all lab tests other than molecular pathology billed
148. pertise and a second set of new codes describing the OTS items Also as shown in the table that follows for CY 2014 the fee schedule amounts for existing codes will be applied to the corresponding new codes added for the items furnished OTS The cross walking of fee schedule amounts for a single code that is exploded into two codes for distinct complete items is in accordance with the instructions found in the Medicare Claims Processing Manual Chapter 23 Section 60 3 1 which is available at http www cms gov Regulations and Guidance Guidance Manuals downloads clm104c23 pdf on the CMS website Prefabricated Orthotic Codes Split into Two Codes Effective January 1 2014 Fee from Crosswalk to New Off The Shelf and Fee from Crosswalk to New Off The Shelf and Existing Code Revised Custom Fitted Orthotic Codes Existing Code Revised Custom Fitted Orthotic Codes L0454 L0455 and L0454 L1810 L1812 and L1810 L0456 L0457 and L0456 L1832 11833 and L1832 L0466 L0467 and L0466 L1847 L1848 and L1847 L0468 L0469 and L0468 L3807 L3809 and L3807 L0626 L0641 and L0626 L3915 L3916 and L3915 L0627 L0642 and L0627 L3917 L3918 and L3917 L0630 L0643 and L0630 L3923 L3924 and L3923 L0631 L0648 and L0631 L3929 L3930 and L3929 L0633 L0649 and L0633 L4360 L4361 and L4360 L0637 L0650 and L0637 L4386 L4387 and L4386 L0639 L0651 and L0639 L4396 L4397 and L4396 Further information
149. ple Lab ABN is now available for download at http www cms gov Medicare Medicare General Information BNI ABN html When issuing ABNs to dual eligibles or beneficiaries having a secondary insurer HHAs are permitted to direct the beneficiary to select a particular option box on the notice to facilitate coverage by another payer This is an exception to the usual ABN issuance guidelines prohibiting the notifier from selecting one of the options for the beneficiary When a Medicare claim denial is necessary to facilitate payment by Medicaid or a secondary insurer HHAs should instruct beneficiaries to select Option 1 on the ABN HHAs may add a statement in the Additional Information section to help a dual eligible better understand the payment situation such as We will submit a claim for this care with your other insurance or Your Medical Assistance plan will pay for this care HHAs may also use the Additional Information on the ABN to This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 33 include agency specific information on secondary insurance claims or a blank line for the beneficiary to insert secondary insurance information Agencies can pre
150. plementing the Hospital Acquired Condition HAC Reduction Program initiative or the Electronic Health Records EHR Incentive Program but is only preparing the Centers for Medicare amp Medicaid Services CMS systems for the future Specific instructions implementing these programs including manual updates to Addendum A of the Medicare Claims Processing Manual will be issued in the future in the event these policies are finalized Make sure that your billing staffs are aware of these changes Background Section 3008 of the Affordable Care Act establishes a program beginning in FY 2015 for IPPS hospitals to improve patient safety by imposing financial penalties on hospitals that perform poorly with regard to certain HACs HACs are conditions that patients did not have when they were admitted to the hospital but which developed during the hospital stay Under the HAC Reduction Program hospitals that rank in the lowest performing quartile of selected HAC measures will be subject to a reduction of what they would otherwise be paid under the IPPS Section 3133 of the Affordable Care Act provides for an additional payment for a hospital s uncompensated care Each Medicare Disproportionate Share DSH hospital will receive an Uncompensated Care Payment UCP based on its share of uncompensated care as calculated by CMS for Medicare DSH hospitals Currently for FY 2014 the estimated per claim UCP amount is stored in PRICER In
151. pplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 aA m Z mr O PN lt Ro O Hs T gt A a gt 29 Coverage Information MM8526 Medicare National Coverage Determination NCD for Beta Amyloid Positron Emission Tomography PET in Dementia and Neurodegenerative Disease The Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number MM8526 Related Change Request CR CR 8526 Related CR Release Date February 6 2014 Effective Date September 27 2013 Related CR Transmittal 2871CP 160NCD Implementation Date July 7 2014 Provider Types Affected This MLN Matters Article is intended for physicians and other providers who submit claims to Medicare A B Medicare Administrative Contractors A B MACs for services provided to Medicare beneficiaries with dementia or neurodegenerative disease aA m Z mr O PN lt Ro O Hs T gt AD a gt What You Need to Know Effective for claims with dates of service on or after September 2
152. pre surgery exam in the ophthalmologist s free standing physician office The ophthalmologist refers the beneficiary to the hospital lab located across the street for diagnostic lab tests in preparation for the upcoming outpatient surgery The beneficiary has to immediately return to work and chooses to have the lab work done at the hospital 2 days later The hospital can use the new modifier to bill Medicare for separate payment under the CLFS 5 The beneficiary in example 3 goes to the hospital lab the same day to have the pre surgical labs drawn The hospital can use the new modifier to bill Medicare for separate payment under the CLFS As a reminder for claims received on or after July 1 2014 OPPS providers are instructed to submit specimen only services on the 014x TOB OPPS providers are instructed not to use the new modifier on 014x TOB Additional Information To read the article related to CR 8572 go to htip www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads MM8572 pdf on the CMS website If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 ICD 10 Information MM8465 Revised International Classification of Diseases 10th Revision ICD 10 Testing with Providers through the Common Edits and Enhancements Module CEM and Common Electronic Data Interchange CEDI
153. print language in the Additional Information section of the notice Some States have specific rules established regarding HHA completion of liability notices in situations where dual eligibles need to accept liability for Medicare noncovered care that will be covered by Medicaid Medicaid has the authority to make this assertion under Title XIX of the Act where Medicaid is recognized as the payer of last resort meaning other Federal programs like Medicare Title XVIII must pay in accordance with their own policies before Medicaid picks up any remaining charges In the past some States directed HHAs to select the third checkbox on the HHABN to indicate the choice to bill Medicare On the ABN the first check box under the Options section indicates the choice to bill Medicare and is similar to the third checkbox on the outgoing HHABN Note If there has been a State directive to submit a Medicare claim for a denial HHAs must mark the first check box when issuing the ABN HHAs serving dual eligibles should comply with existing HHABN State policy within their jurisdiction as applicable to the ABN unless the State instructs otherwise The appropriate option selection for dual eligibles will vary depending on the State s Medicaid directive If the HHA s State Medicaid office does NOT want a claim filed with Medicare prior to filing a claim with Medicaid the HHA should direct the beneficiary to choose Option 2 When Option 2 is ch
154. pyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 35 The following new codes are in the prosthetics and orthotics PO payment category L5969 L8679 L0455 L0457 L0467 L0469 L0641 L0643 L0648 L0651 L1812 L1833 L1848 L3678 L3809 L3916 L3918 L3924 L3930 L4361 L4387 and L4397 The following code is deleted from the HCPCS effective January 1 2014 and therefore is removed from the DMEPOS fee schedule files L0430 The following codes are deleted from the DMEPOS fee schedule files as of January 1 2014 A4611 A4612 A4613 E0457 E0459 L8685 L8686 L8687 and L8688 For gap filling purposes the 2013 deflation factors by payment category are listed in the following table Factor Category 0 469 Oxygen 0 472 Capped Rental 0 473 Prosthetics and Orthotics 0 600 Surgical Dressings 0 653 Parental and Enteral Nutrition aA m Z mr O PN lt Ro O Hs T gt AD a gt Specific Coding and Pricing Issues As part of this update fee schedules for the following codes will be added to the DMEPOS fee schedule file effective January 1 2014 e A4387 Ostomy Pouch Closed With Barrier Attached With Built In Convexity I Piece Each and L3031 Foot Insert Plate Removable Addition to Lower Extremity Orthotic High Strength Lightweight Material All Hybrid Lamination Prepreg Composite Each CMS is adjusting the fee schedule amo
155. r providers and suppliers who submit claims to Medicare claims administration contractors A B Medicare administrative contractors A B MACs for cardiac pacemaker services provided to Medicare beneficiaries Provider Action Needed This article is based on CR 8525 which allows payment for nationally covered implanted permanent cardiac pacemakers single chamber or dual chamber for the indications outlined in the Medicare National Coverage Determinations Manual Chapter 1 Part 1 Section 20 8 Cardiac Pacemakers and the Medicare Claims Processing Manual Chapter 32 Section 320 Billing Requirements for Cardiac Pacemakers Single and Dual Chamber which were revised by and included as attachments to CR 8525 CR 8525 is effective for claims with dates of service on or after August 13 2013 Make sure that your billing personnel know about these changes Background Permanent cardiac pacemakers refer to a group of self contained battery operated implanted devices that send electrical stimulation to the heart through one or more implanted leads Single chamber pacemakers typically target either the right atrium or right ventricle Dual chamber pacemakers stimulate both the right atrium and the right ventricle The implantation procedure is typically performed under local anesthesia and requires only a brief hospitalization A catheter is inserted into the chest and the pacemaker s leads are threaded through the catheter to the appropr
156. rates for SCHs with qualified laboratories and other OPPS hospitals Qualified SCHs must submit a 013X TOB with the new modifier appended to separately payable outpatient lab services in order to obtain the 62 percent CLFS payment amount provided in current manual instructions CMS recognizes that these providers may wish to cancel or adjust claims that are submitted without the new modifier prior to July 1 2014 and submit a new 013x claim with the appended modifier after July 1 2014 in order to receive corrected reimbursement or for other reasons when the new modifier is implemented in July CMS will be reviewing claims data for CY 2014 for potential inappropriate unbundling of laboratory services under the new OPPS packaging policy As stated in the OPPS final rule CMS does not expect changes in practice patterns under the new policy Hospitals may not establish new scheduling patterns in order to provide laboratory services on separate dates of service from other hospital services for the purpose of receiving separate payment under the CLFS Billing Scenarios for the New Modifier on or after July 1 2014 1 A patient goes to hospital and the hospital only collects the specimen and furnishes only laboratory services on that date of service No other services are rendered on this date of service It is generally appropriate to append the new modifier to the laboratory services See example 2 2 A beneficiary has a pre surgery exam in a
157. red to a Federal Hospital This code applies to discharges and transfers to a government operated health care facility including e Department of Defense hospitals e Veteran s Administration hospitals or e Veteran s Administration nursing facilities This patient discharge status code should be used whenever the destination at discharge is a federal health care facility whether the patient resides there or not The NUBC has also clarified that this code should also be used when a patient is transferred to an inpatient psychiatric unit of a Veterans Administration VA hospital This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 61 44 49 Reserved for National Assignment These patient discharge status codes are reserved for national assignment 50 and 51 Discharged Transferred to a Hospice These two patient discharge status codes are used to identify when a patient is discharged or transferred to hospice care The level of care that will be provided by the hospice upon discharge is essential to determining the proper code to use NUBC clarified the following Hospice Levels of Care e Routine or Continuous Home Care Patient discharge status code 5
158. rior to implementation of CR8526 but they will adjust such claims that you bring to their attention Note Each new beta amyloid radiopharmaceutical will require a separate code Therefore for the interim period HCPCS code A9599 Radiopharmaceutical for beta amyloid positron emission tomography PET imaging diagnostic per study dose shall be used with an effective date of January 1 2014 After a new beta amyloid radiopharmaceutical is approved for a separate individual HCPCS code a subsequent CR will be issued to update this NCD policy Note Contractors should refer to the business requirements in CR8526 well as general clinical trial billing requirements at Pub 100 03 chapter 1 section 310 and Pub 100 04 chapter 32 section 69 See Pub 100 03 NCD Manual chapter 1 section 220 6 20 for the coverage of Beta Amyloid PET in Neurodegenerative Disease and Dementia and Pub 100 04 Claims Processing Manual chapter 13 section 60 12 for claims processing instructions Additional Information The official instruction CR 8526 is in two transmittals issued to your A B MAC The first transmittal updates the National Coverage Determinations Manual and it is available at http Awww cms gov Regulations and Guidance Guidance Transmittals Downloads R160NCD pdf on the CMS website The second transmittal updates the Medicare Claims Processing Manual and it is at http www cms gov Regulations and Guidance Guidance
159. rt B claim s for payment The no pay Part A claim indicates that the provider and not the beneficiary is liable under the Social Security Act Section 1879 see http Awww socialsecurity gov OP_Home ssact title18 1879 htm for the cost of the Part A services Submission of this claim cancels any claim that may have already been submitted by the hospital for payment under Part A When a Medicare review contractor denies a Part A claim for medical necessity the claims system converts the originally submitted 11X claim to a 110 TOB on behalf of the hospital When the hospital and not the beneficiary is liable for the cost of the Part A services pursuant to the limitation on liability provision in Section 1879 of the Social Security Act the beneficiary is not responsible for paying the deductible and coinsurance charges related to the denied Part A claim and the beneficiary s Medicare utilization record is not charged for the services and items furnished The hospital must refund any payments including coinsurance and deductible made by the beneficiary or third party for a denied Part A claim when the provider is held financially liable for that denial see section 1879 b of the Act 42 CFR 411 402 and chapter 30 30 1 2 Beneficiary Determined to Be Without Liability and 30 2 2 Provider Practitioner Supplier is Determined to Be Liable of the Medicare Claims Processing Manual aA m Z mr O PN lt Ro O Hs U
160. ry provider to be identified by specialty The standard implementation guides state that this information is e Required when the payer s adjudication is known to be impacted by the provider taxonomy code and e If not required by this implementation guide do not send Note Medicare does not use HPTCs to adjudicate its claims and would not expect to see these codes on a Medicare claim However currently it validates any HPTC that a provider happens to supply against the NUCC HPTC set The Transactions and Code Sets Final Rule published on August 17 2000 establishes that the maintainer of the code set determines its effective date See htip aspe hhs gov admnsimp final txfin00 htm on the Internet This rule also mandates that covered This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 10 entities must use the nonmedical data code set specified in the standard implementation guide that is valid at the time the transaction is initiated For implementation purposes Medicare generally uses the date the transaction is received for validating a particular nonmedical data code set required in a standard transaction The HTPC set is main
161. s It is also used To designate patients that are discharged transferred to a nursing facility with neither Medicare nor Medicaid certification or aA m Z mr O PN lt Ro O Hs T gt A a gt e For discharges transfers to state designated Assisted Living Facilities 05 Discharged Transferred to Another Type of Health Care Institution Not Defined Elsewhere in This Code List Cancer hospitals excluded from Medicare PPS and children s hospitals are examples of such other types of health care institutions NEW DEFINITION FOR PATIENT DISCHARGE STATUS CODE 05 Effective per NUBC on April 1 2008 05 Discharged Transferred to a Designated Cancer Center or Children s Hospital Usage Note Transfers to non designated cancer hospitals should use Code 02 A list of National Cancer Institute Designated Cancer Centers can be found at hitp cancercenters cancer gov cancer_centers on the Internet 06 Discharged Transferred to Home Under Care of Organized Home Health Service Organization in Anticipation of Covered Skilled Care This code should be reported when a patient is Discharged transferred to home with a written plan of care for home care services tailored to the patient s medical needs whether home attendant nursing aides certified attendants etc Discharged transferred to a foster care facility with home care and e Discharged to home under a home health agency with DME This
162. s to be used for the business of Medicare such as preparing an accurate Medicare claim or determining eligibility for specific services aA m Z mr O PN lt Ro O Hs T gt A a gt Key Points General Information CMS plans to discontinue access to the CWF queries through the shared systems Medicare providers and their agents that currently access the CWF queries through the shared system screens will need to modify their business processes to use HETS to access Medicare beneficiary eligibility information HETS HETS allows Medicare providers and their agents to submit and receive X12N 270 271 eligibility request and response files over a secure connection Many Medicare providers and their agents are already receiving eligibility information from HETS For more information about HETS and how to obtain access to the system refer to the CMS HETS Help Web page at http www cms gov Research Statistics Data and Systems CMS Information Technology HE TSHelp HowtoGetConnectedHETS270271 html on the CMS website Frequently Asked Questions Are Medicare providers that currently use CWF to obtain beneficiary eligibility information required to switch to HETS No but it is recommended Providers may also choose to use a Medicare Contractor s IVR or Internet portal What are the minimum data elements required in order to complete an eligibility search in HETS HETS applies search logic that uses a combination
163. smedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 A m Z mr O PN lt Ro O I O U gt Bu 5 gt 54 Table 2 Drugs and Biologicals with OPPS Pass Through Status Effective April 1 2014 HCPCS Code Short Descriptor Long descriptor APC Status Indicator c9021 Injection obinutuzumab 10 mg Injection obinutuzumab 1476 G Q4121 Theraskin per square centimeter Theraskin 1479 G Note The HCPCS code identified with an indicates that this is a new code effective April 1 2014 c Revised Status Indicator for HCPCS Codes A9545 J1446 J7178 and Q0181 Effective April 1 2014 the status indicator for HCPCS code A9545 lodine I 131 tositumomab therapeutic per treatment dose will change from SI K Paid under OPPS separate APC payment to SI E Not paid by Medicare when submitted on outpatient claims any outpatient bill type Effective January 1 2014 the status indicator for HCPCS code J1446 Injection TBO Filgrastim 5 micrograms will change from SI E not paid by Medicare when submitted on outpatient claims any outpatient bill type to SI K Paid under OPPS separate APC payment Effective January 1 2014 the status indicator for HCPCS code J7178 Injection human fibrinogen concentrate 1 mg will change from SI N Paid under OPPS payment is packaged into payment for other services Therefore there is no separate
164. sonable likelihood that pacing needs will become prolonged MACs will determine coverage under the Social Security Act Section 1862 a 1 A see http www ssa gov OP_Home ssact title18 1862 htm for any other indications for the implantation and use of single chamber or dual chamber cardiac pacemakers that are not specifically addressed in this NCD Note MACs will accept the inclusion of the KX modifier on the claim line s as an attestation by the practitioner and or provider of the service that documentation is on file verifying the patient has non reversible symptomatic bradycardia symptoms of bradycardia are symptoms that can be directly attributable to a heart rate less than 60 beats per minute for example syncope seizures congestive heart failure dizziness or confusion This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 21 Other key notes for billing e MACs will pay professional claims for implanted permanent cardiac pacemakers single chamber or dual chamber provided the claim contains at least one of the CPT codes of 33206 33207 or 33208 AND one of the following ICD 9 CM ICD 10 CM diagnostic codes and only when the claim is subm
165. ssued to your MAC regarding these changes is available at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R2894CP pdf on the CMS website If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 Hospital Information SEO801 Revised Clarification of Patient Discharge Status Codes and Hospital Transfer Policies aA m Z mr O PN lt Ro O Hs T gt AD a gt The Centers for Medicare amp Medicaid Services CMS has issued the following revision to the Special Edition Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2008 MLN Matters Articles html MLN Matters Number SE0801 Revised Related Change Request CR N A Related CR Release Date N A Effective Date N A Related CR Transmittal N A Implementation Date N A Note This article was revised on March 3 2014 to add a reference to SE1411 htip www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads SE1411 pdf SE1411 was released on March 3 2014 and supplements SE0801 by providing information on more recently established patient discharge status codes 69 and 81 95 All other information
166. status code should be used when the patient is discharged or transferred to a short term acute care hospital Discharges or transfers to long term care hospitals should be coded with Patient discharge status Code 63 This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 59 03 Discharged Transferred to a Skilled Nursing Facility SNF with Medicare Certification in Anticipation of Skilled Care This code indicates that the patient is discharged transferred to a Medicare certified nursing facility in anticipation of skilled care For hospitals with an approved swing bed arrangement use Code 61 Swing Bed This code should be used regardless of whether or not the patient has skilled benefit days and regardless of whether the transferring hospital anticipates that this SNF stay will be covered by Medicare For reporting other discharges transfers to nursing facilities see codes 04 and 64 Code 03 should not be used if The patient is admitted to a non Medicare certified area 04 Discharged Transferred to an Intermediate Care Facility ICF Patient discharge status code 04 is typically defined at the state level for specifically designated intermediate care facilitie
167. t Lomustine S0178 PN m Z mr O PN lt Ro O Hs T gt AD a gt CMS also permits the MACs to determine coverage for other all oral three drug antiemesis regimens of aprepitant or any other Food and Drug Administration FDA approved oral NK 1 antagonist in combination with an oral 5HT3 antagonist and oral dexamethasone with the chemotherapeutic agents listed or any other anticancer chemotherapeutic agents that are FDA approved and may in the future be defined as highly or moderately emetogenic CMS is defining highly emetogenic chemotherapy and moderately emetogenic chemotherapy as those anticancer agents so designated in at least two of three guidelines published by the National Comprehensive Cancer Network NCCN American Society of Clinical Oncology ASCO and European Society of Medical Oncology ESMO Multinational Association of Supportive Care in Cancer MASCC The inclusive examples are NCCN plus ASCO NCCN plus ESMO MASCC or ASCO plus ESMO MASCC Until a specific code is assigned to the new drug any new FDA approved oral antiemesis drug oral NK 1 antagonist or oral 5HT3 antagonist as part of the three drug regimen This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE
168. t Services When Payment Cannot Be Made Under Part A Medicare continues the current policy allowing hospitals to bill Part B for services furnished by the hospital that were bundled into the original Part A claim under the 3 day 1 day for non IPPS hospitals payment window prior to the inpatient admission CMS revised the manual to clarify that if these services were furnished by the hospital including referred hospital lab tests they may be billed to Part B CMS is clarifying that This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at oO S http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENT MEDICARE BULLETIN GR 2014 04 APRIL 2014 47 both 13X 85x for CAH and 14X TOB may be submitted for payment of these services subject to the revised manual instructions Timely Filing and Supporting Documentation Timely filing restrictions will apply for the Part B services billed Therefore Part B claims that are filed beyond 12 months from the date of service will be rejected as untimely and will not be paid Hospitals are required to maintain documentation to support the services billed on the Part B claim s Provider and Beneficiary Liability A no pay provider liable Part A claim 110 TOB must be present in the claims history before accepting the Pa
169. taff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 14 e Developing a new function to view reports of payments in bar and pie charts The apps are intended to support reporting under the Open Payments program For more details refer to http www cms gov Regulations and Guidance Legislation National Physician Payment Transparency Program index html on the CMS website For help with the apps contact the CMS helpdesk at OpenPayments cms hhs gov Key Points of SE1402 If you already downloaded the apps you will need to run an update to take advantage of the new app functionality To do so visit either the Google Play app store or iOSApple app store look for your available updates and select the Open Payments apps to download the updates If you have not yet downloaded the apps search for Open Payments in the applicable app store and you ll be prompted to download the newly updated versions In response to user feedback the table below describes the enhancements made to the apps since their initial launch in July 2013 All changes are intuitive and will add elements of ease expected by app users Enhancement Topic Details What It Does Streamlined Welcome screen options Changes that Apply to Both Apps Open Payments Mobile for Industry and Open Pay
170. tained by the NUCC for standardized classification of health care providers and the NUCC updates the code set twice a year with changes effective April 1 and October 1 The HPTC set is available for view or for download from the Washington Publishing Company WPC at hittp www wpc edi com codes on the Internet CR 8611 implements the NUCC HPTC code set that is effective on April 1 2014 and instructs Medicare contractors to obtain the most recent HPTC set and use it to update their internal HPTC tables and or reference files When reviewing the HPTC set online revisions made since the last release can be identified by the color code e New items are green e Modified items are orange and e Inactive items are red Additional Information The official instruction CR 8611 issued to your carriers Fls A B MACs RHHIs HHH MACs and DME MACs regarding this change may be viewed at hitp www cms gov Regulations and Guidance Guidance Transmittals Downloads R2888CP pdf on the CMS website If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 General Information News Flash Messages from the Centers for Medicare amp Medicaid Services CMS e Looking for the latest new and revised MLN Matters articles Subscribe to the MLN Matters electronic mailing list For more information about MLN Matters and how to register
171. tandards for health care electronic funds transfers efts on the Internet The regulation adopting the EFT amp ERA Operating Rules can be found at https www federalregister gov articles 2012 08 10 2012 19557 administrative simplification adoption of operating rules for health care electronic funds transfers h 4 on the Internet A new National Automated Clearinghouse Association NACHA standard for electronic healthcare claim payments went into effect on September 20 2013 impacting all originators and receivers of electronic funds transfers EFT used to pay healthcare claims This Healthcare EFT standard stems from the Affordable Care Act which requires that healthcare payers must pay healthcare claim payments electronically using HIPAA standards if requested by the healthcare provider The standard designated for these claim payments is the Healthcare EFT Standard which is a NACHA CCD transaction that includes the ASC X12 835 TRN data segment in the addenda record The Healthcare EFT Standard requires the following Company Entry Description of HCCLAIMPMT to identify the payment as healthcare Company Name should be the health plan or third party administrator paying the claim e An addenda record must be included with a Record Type Code of 7 and an Addenda Type Code equal to 05 and e Payment Related Information in the addenda record must contain the ASC X12 835 TRN Re association Trace Number d
172. ther type of health care institution not defined elsewhere in this code list 11 Q If a patient is discharged to home for the provision of home health services but the continuing care is either 1 not related to the condition or diagnosis for which the individual received inpatient hospital services or 2 is related but not provided within the post discharge window what is the correct patient status code to use A Code 06 would be the appropriate patient discharge status code In addition the provider should append one of the following condition codes as appropriate to the claim Condition Code 42 Continuing care not related i e condition or diagnosis to inpatient admission or Condition Code 43 Continuing care not provided within prescribed post discharge window 12 Q If a patient is discharged from an acute care hospital and PT OT is arranged to be done in the home by a rehabilitation agency that is not affiliated with the home health care agency that made the arrangements what is the appropriate code to use 01 or 06 A If the therapy services are being provided under the home health benefit e g Medicare Part A use Code 06 if the therapy is provided under the outpatient therapy benefit e g Medicare Part B use Code 01 13 Q If a patient is discharged from acute hospital care but remains at the same hospital under hospice care what status code should be used for the acute stay discharge A
173. ting that is the patient s home such as a nursing facility and will receive in home hospice services Patient discharge status Code 51 should be used when a patient is e Discharged from acute hospital care but remains at the same hospital under hospice care Transferred from an inpatient acute care hospital to a Medicare certified SNF under the following conditions The patient has elected the hospice benefit and will be receiving hospice care under arrangement with a hospice organization the patient is receiving residential care only The patient does not qualify for skilled level of care outside the hospice benefit for conditions unrelated to the terminal illness Admitted from home a private residence to an acute setting Upon discharge the patient is transferred as a new nursing home placement to a designated hospice unit bed 52 60 Reserved for National Assignment These patient discharge status codes are reserved for national assignment 61 Discharged Transferred to a Hospital based Medicare Approved Swing Bed This code is used for reporting patients discharged transferred to a SNF level of care within the hospital s approved swing bed arrangement This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright CGS Administrators LLC
174. ting with claims received July 1 2014 and after when a hospital appends the new modifier to a laboratory service the provider is attesting that exception 2 or 3 listed above is met The requirement for all OPPS services to be submitted on a single 13x claim other than recurring services continues to apply In addition laboratory tests for molecular pathology tests described by CPT codes in the ranges of 81200 through 81383 81400 through 81408 and 81479 are not packaged in the OPPS and do not require the new modifier This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 69 The 014X TOB does not provide differential CLFS payment rates for SCHs with qualified laboratories and other OPPS hospitals See section below for further details Note Under the CY 2014 OPPS final rule it is optional for OPPS hospitals to seek separate payment DS under the CLFS for a given outpatient lab test To minimize administrative burden OPPS hospitals are m not required to distinguish related and unrelated outpatient lab tests and may bill unrelated outpatient Z labs on the 013X TOB prior to July 1 2014 or on the 013X TOB without the new modif
175. tion CR 8602 issued to your MAC regarding this change may be viewed at http Awww cms gov Regulations and Guidance Guidance Transmittals Downloads R1352OTN pdf on the CMS website If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 ICD 10 Information SE1409 Revised Medicare Fee For Service FFS International Classification of Diseases 10th Edition ICD 10 Testing Approach The Centers for Medicare amp Medicaid Services CMS issued the following Special Edition Medicare Learning Network MLN Matters article on February 19 2014 A revision to this article was then issued on February 27 2014 This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles htm MLN Matters Number SE1409 Revised Related Change Request CR N A Related CR Release Date N A Effective Date October 1 2014 Related CR Transmittal N A Implementation Date N A Note This article was revised on February 27 2014 to add information about the second week of acknowledgement testing and to provide more details about end to end testing Provider Types Affected This article is intended for all physicians providers and suppliers submitting claims to Medicare administra
176. tionwide to participate in the end to end testing The small sample group of participants will be selected to represent a broad cross section of provider types claims types and submitter types Additional details about the end to end testing process will be disseminated at a later date in a separate MLN Matters article If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 Medical Review Information Immediate Suspension of Edits for Recovery Audit Prepayment Reviews Including Outpatient Therapy Effective February 28 2014 there are two important changes regarding Recovery Audit Prepayment Reviews including reviews for outpatient therapy CGS and other Medicare Administrative Contractors MACs will No longer issue Additional Documentation Requests ADRs related to Recovery Audit Prepayment Reviews including outpatient therapy and This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 77 e Suspend ALL edits related to Recovery Audit Prepayment Reviews including outpatient therapy These changes are being made based on the current Recovery Audit
177. tive contractors MACs including home health amp hospice MACs HH amp H MACs and durable medical equipment MACs DME MACs for services provided to Medicare beneficiaries Provider Action Needed For dates of service on and after October 1 2014 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 2014 Be sure you are ready This MLN Matters Special Edition article is intended to convey the testing approach that CMS is taking for ICD 10 implementation Background The implementation of International Classification of Diseases 10th Edition ICD 10 represents a significant code set change that impacts the entire health care community As the ICD 10 implementation date of October 1 2014 approaches CMS is taking a comprehensive four pronged approach to preparedness and testing to ensure that CMS as well as the Medicare Fee For Service FFS provider community is ready When you is used in this publication we are referring to the FFS provider community This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com
178. truction CR 8582 issued to your MAC regarding this change may be viewed at http www cms hhs gov Regulations and Guidance Guidance Transmittals Downloads R2884CP pdf on the CMS website This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 9 If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 General Information MM8611 Healthcare Provider Taxonomy Codes HPTC Update April 2014 The Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number MM8611 Related Change Request CR CR 8611 Related CR Release Date February 28 2014 Effective Date April 1 2014 Related CR Transmittal R2888CP Implementation Date July 7 2014 Contractors with the capability to do so will implement April 1 2014 Provider Types Affected A m Z mr O P
179. ttention of your MAC Table 4 Updated Payment Rates for Certain HCPCS Codes Effective April 1 2013 through June 30 2013 Corrected Minimum HCPCS Code Status Indicator APC Short Descriptor Corrected Payment Rate Unadjusted Copayment Q4127 G 1449 Talymed 13 78 2 76 This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at oO S http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENT MEDICARE BULLETIN GR 2014 04 APRIL 2014 A m Z Cc O PN lt Ro O Hs v gt Bu a gt 55 e Updated Payment Rate for Q4127 Effective July 1 2013 through September 30 2013 The payment rate for Q4127 was incorrect in the July 2013 OPPS Pricer The corrected payment rate is listed in Table 5 below and it has been installed in the April 2014 OPPS Pricer effective for services furnished on July 1 2013 through September 30 2013 MACs will adjust claims that were previously processed incorrectly if you bring such claims to the attention of your MAC Table 5 Updated Payment Rates for Certain HCPCS Codes Effective July 1 2013 through September 30 2013 Corrected Minimum HCPCS Code Status Indicator APC Short Descriptor Corrected Payment Rate Unadjusted Copayment Q4127 G 1449 Talymed 13 78 2 76 f
180. uld Know This MLN Matters article is intended for physicians providers and suppliers submitting claims to Medicare administrative contractors MACs for services to Medicare beneficiaries Provider Action Needed This article is based on CR 8556 which creates edits in Original Medicare claims processing systems to ensure that certain always therapy evaluation and reevaluation codes are reported with the correct modifier It also makes several clarifications of details in the Medicare Claims Processing Manual Chapter 5 Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation Facility CORF Services CR 8556 contains no new policy It updates Medicare systems and manuals to better reflect current published policies Make sure that your billing staffs are aware of these updates Background Longstanding Original Medicare billing instructions require reporting of discipline specific outpatient rehabilitation modifiers All claims for therapy service Healthcare Common Procedure Coding System HCPCS codes must report a modifier that indicates the discipline of the plan of care under which the services are provided Through analysis of Original Medicare claims data the CMS has identified cases where claims for discipline specific evaluation codes have reported the modifier corresponding to another discipline For example occupational therapy evaluations have been billed and paid while reporting a GP modifier Serv
181. unts for shoe modification codes A5503 through A5507 as part of this update in order to reflect more current allowed service data Section 1833 0 2 C of the Act required that the payment amounts for shoe modification codes A5503 through A5507 be established in a manner that prevented a net increase in expenditures when substituting these items for therapeutic shoe insert codes A5512 or A5513 To establish the fee schedule amounts for the shoe modification codes the base fees for codes A5512 and A5513 were weighted based on the approximated total allowed services for each code for items furnished during the second quarter of CY2004 For 2014 CMS is updating the weighted average insert fees used to establish the fee schedule amounts for the shoe modification codes with more current allowed service data for each insert code The base fees for A5512 and A5513 will be weighted based on the approximated total allowed services for each code for items furnished during the Calendar Year 2012 The fee schedule amounts for shoe modification codes A5503 through A5507 are being revised to reflect this change effective January 1 2014 Off the Shelf Orthotics Section 1847 a 2 C of the Act mandates implementation of competitive bidding programs throughout the United States for awarding contracts for furnishing Off The Shelf OTS orthotics which require minimal self adjustment for appropriate use and do not require expertise in trimming bending moldi
182. ve Voice Response IVR unit will be available during these scheduled training sessions for automated customer service transactions Listed below are the training closure dates and time for April Date PCC Office Closed April 3 10 17 and 24 2014 PCC Closed 2 30 p m to 4 30 p m ET For your reference access the Kentucky Ohio Part A 2014 Holiday Training Closure Schedule at https www cgsmedicare com parta help holiday_schedule pdf for a complete list of PCC closures aA m Z mr O PN lt Ro O Hs gt A a gt General Information Introducing the myCGS Web Portal Submitting Redeterminations through Forms Tab This article is the third in a series of articles previously published in the CGS Medicare Bulletin to introduce the myCGS Web portal to all providers that submit claims to CGS The information below provides a general overview of the Forms tab in myCGS which allows CGS providers to submit redetermination requests the first appeal level and monitor the status of these requests using the myCGS Web portal ces Home Claims Remittance Eligibility Financial Toots Messages Forms Support User Provider You have 0 unread message s and 0 alerts co Welcome You are accessing a US Government information system The Centers for Medicare amp Medxaid Services CMS maintains ownership and responsibilty for this computer system and has allowed CGS to provide the
183. viders furnishing vaccines to hospice beneficiaries and submitting claims to Medicare Administrative Contractors MACs Provider Action Needed CMS issued CR 8620 to alert providers that any provider may furnish vaccines to hospice beneficiaries Be sure your billing staffs are aware of this change Background When CR 8098 Transmittal 1298 was published effective October 1 2013 it denied claims for vaccines furnished to hospice patients that were provided by anyone other than the patient s hospice provider This was to enforce the statement in the Medicare Claims Processing Manual chapter 18 section 10 2 4 that vaccines may be covered when furnished by the hospice CMS has determined that this enforcement is too restrictive since the manual does not say only when furnished by the hospice CR 8620 removes the changes made to Medicare systems in CR 8098 in order to allow any provider to furnish vaccines to hospice beneficiaries This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 04 APRIL 2014 18 Key Points e Your MAC will allow professional claims for vaccines Influenza PPV and Hepatitis B and vaccine administration containing modifier GW when the date
184. work MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2013 MLN Matters Articles html MLN Matters Number MM8531 Revised Related Change Request CR CR 8531 Related CR Release Date December 13 2013 Effective Date January 1 2014 Related CR Transmittal R2836CP Implementation Date January 6 2014 Note This article was revised on March 6 2014 to provide updates regarding HCPCS codes changes that were effective January 1 2014 The changes are on page 2 bold All other information remains unchanged aA m Z mr O PN lt Ro O Hs T gt AD a gt Provider Types Affected This MLN Matters article is intended for providers and suppliers submitting claims to Medicare administrative contractors MACs for DMEPOS items or services paid under the DMEPOS fee schedule What You Need to Know The CMS issued CR 8531 to advise providers of the Calendar Year CY 2014 annual update for the Medicare DMEPOS fee schedule The instructions include information on the data files update factors and other information related to the update of the DMEPOS fee schedule Make sure your staffs are aware of these updates Background and Key Points of CR 8531 The DMEPOS fee schedules are updated on an annual basis in accordance with statute and regulations
185. y 19 2012 a 63 year old male is admitted through the Emergency Room for a two day stay in an acute care inpatient hospital setting On January 21 2012 This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available at no cost from our website at TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 04 APRIL 2014 67 the patient is admitted to the inpatient psychiatric unit of the same facility The claim for this admission was submitted with Point of Origin for Admission or Visit Code 2 Clinic Referral Resolution Because the January 21st admission was a transfer from the same facility the Point of Origin for Admission or Visit Code should be coded D The incorrect Source of Admission Code resulted in an overpayment of 98 15 Additional Information If you have any questions please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1 866 590 6703 and choose Option 1 For more information about IPFs and use of Point of Origin for Admission or Visit Code D see the MLN Matters article SE1020 at hitp www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads SE1020 pdf on the CMS website MM3881 also provides additional information about Point of Origin for Admission or Visit

Medicare Bulletin - April 2014

Contents

Download Pdf Manuals

Related Search

Related Contents