Signature Requirements
Contents
1. Healthcare Solutions Advanced Beneficiary Notice of Non Coverage and Signature Requirements Presented by Medicare Part B Provider Outreach and Education POE May 2014 Noridian Hoakhcare Solutions LLC TEE nci idian Workshop Protocol WebEx Registration cannot be completed using mobile device Must use desktop or laptop e Entering workshop Attendee lines are muted upon entry CA additional attendee names provider city in Chat not amp Adobe PDF slides emailed to all registered providers e Throughout workshop Questions pertinent to workshop slide addressed Address Q amp Ato all panelists not to host directly All other questions call Part B Provider Contact Center e Workshop conclusion Asking questions aloud Use raise lower hand feature MUTE phones never place on HOLD June 2014 2 No CEU Process e Attend entire workshop Must take short polling survey After closing out of workshop CEU certificate emailed after workshop No later than 5 days after presentation No password needed All providers may use CEU certificate Certificate of Attendance no longer available June 2014 3 DISCLAIMER This information release is the property of Noridian Healthcare Solutions LLC Noridian It may be freely distributed in its entirety but may not be modified sold for profit or used in commercial documents The information is prov2. relatively localized areas with or without Mer I underlying IUL BINE These codes are for 44 noridian List of CPT HCPCS Affected by the Policy Revenue Codes Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service In most instances Revenue Codes are purely advisory unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes 99999 Not Applicable CPT HCPCS Codes Group 1 Paragraph N A Group 1 Codes 10060 Drainage of skin abscess 10061 Drainage of skin abscess 11042 Deb subq tissue 20 sq cm lt 11043 Deb musc fascia 20 sq cm lt 11044 Deb bone 20 sq cm lt 11045 Deb tissue add on 11046 Deb musc fascia add on 11047 Deb bone add on 11055 Trim skin lesion 11056 Trim skin lesions 2 to 4 11057 Trim skin lesions over 4 June 2014 nsiidian ICD 9 Codes that Support Medical Necessity ICD 9 Codes that Support Medical Necessity Group 1 Paragraph These are the only covered ICD 9 CM codes that support medical necessity Note Diagnostic restrictions do not apply to CPT codes 10060 and 10061 For CPT codes 11042 11047 the claim must have at least one of the following diagnosis codes Group
3. Paid under the Clinical Lab Fee Schedule CLFS Signature not required when physicians NPPs request tests using Annotated medical records Documented telephonic requests Electronically ordered requests Request types not considered requisitions February 2014 noiidian Healthcare Solutions Reminders Sign Up For Medicare News e Receive most recent JF Medicar news and information Noridian CMS news Regulation policy updates Bra Payment reimbursement Workshop educational event notices hours of JE availability related every Tuesday and Fry notifications June 2014 ASH Endeavor Sign Up Today Free secure internet website Verify Eligibility Check claim and check status View and print Remittance Advice Full or single claim Reopening Redetermination requests Submit view and track Endeavor Sign Up Today gt EDI registration required Hours of operation nearly 24 7 Exception for maintenance CMS required downtime Information tutorials and user manual e JE https med noridianmedicare com web jeb topics end eavor jsessionid 47398DB81B877707CD2B21A1D23 14C38 e JF https www noridianmedicare com partb claims ende avor index php June 2014 79 Noridian Appreciates Feedback Please complete Foresee Results Website Survey
4. Electronic image of handwritten signature Electronic Statement electronically signed or verified reviewed by followed by practitioner s name and credentials Digital Electronic method of handwritten signature generated by special encrypted software June 2014 Unacceptable Signature Signature stamps Records dictated and transcribed without valid signature Practitioners name typed on report or records Signature on file illegible unrecognizable handwritten signature June 2014 71 Signature not Readable e Have an official signature page with name and signature Send an attestation statement Certify physician s signature February 2014 Signature Attestation noridian EBENEN SIGNATURE ATTESTATION STATEMENT Today s Date Provider Information Billing Provider s Name Billing Provider s NPI Performing Provider s Name Performing Provider s NPI State in which the Provider s health care business is located Beneficiary Information First and Last Name Date of Birth Date of Service Attestation Statement hereby attest that the medical record entry for Provider Name accurately reflects signatures notations that I made in my Date of Service capacity as when I diagnosed treated Provider s Credentials e g M D etc the Medicare beneficiary listed above I do hereby further attest that this information is true accur
5. Reports Clearance Officer Maryland 2174 1850 Form CMS E 131 03 11 Form Approved OMB No 0938 0566 June 2014 i _ Requirements Use Form 5 131 ssue BN each time Before item service rendered www cms hhs gov bni Requirements Identify item service Denial expected otate reason for denial e Only page Type or handwrite e 12 pt Font Black or blue ink ABN Delivery e Hand deliver Must be able to comprehend Dont deliver under duress e Give copy User Customizable Sections e Header Notifier Typed handwritten pre printed label Provider Information C Identification Number Advance Beneficiary Notice of Noncoverage ABN NOTE If Medicare doesnt pay for D below you may have to pay User Customizable Sections B Enter patients name Patient ID optional Never use SS or HIC Advance Beneficiary Notice of Noncoverage ABN NOTE If Medicare doesnt pay for D 1 below you may have to pay sridian Healthcare Solutions A Notifier B Patient Name C Identification Number Item D Complete the blanks WHAT YOU NEED TO DO NOW Read this notice so you can make an informed decisiggs e Ask us any questions that you may have after you Choose an option below about whether to receive Not
6. A B C of the Act excludes payment for the treatment of flat foot conditions the treatment of subluxation of the foot and routine foot care 42 Code of Federal Register 411 15 11 I i Particular services excluded from coverage concerning foot care CMS On Line Manual Publication 100 02 Medicare Benefit Policy Manual Chapter 16 530 states that some foot is covered and some is excluded CMS On Line Manual Publication 100 02 Medicare Benefit Policy Manual Chapter 15 290 clarifies which foot care services are covered and which are excluded from coverage CMS On Line Manual Pub 100 03 Medicare National Coverage Determinations Manual Chapter 1 Part 1 70 2 Consultation services rendered by a podiatrist in a skilled nursing facility are covered if the services are reasonable and necessary and do not come within any of the specific statutory exclusions CMS On Line Manual Pub 100 03 Medicare National Coverage Determinations Manual Chapter 1 Part 1 70 2 1 Addresses services provided for the diagnosis and treatment of diabetic sensory neuropathy with loss of protective sensation LOPS CMS On Line Manual Pub 100 08 Medicare Program Integrity Manual Chapter 3 3 4 1 3 Diagnosis Code Requirements Coverage Guidance Coverage Indications Limitations and or Medical Necessity For Medicare purposes an ulcer does not exist until there is a partial thickness skin loss involving epidermis with or without derm
7. Collagen Crosslinks Any Method 190 20 Blood Glucose Testing 80 190 21 Glycated Hemoglobin Glycated Protei 87 190 22 Thyroid Testing 190 23 Lipids Testing 190 24 Digoxin Therapeutic Drug Assay 190 25 Alpha fetoprotein 190 26 Carcinoembryonic Antigen 190 27 Human Chorionic Gonadotropin 190 28 Tumor Antigen by Immunoassay CA 125 190 29 Tumor Antigen by Immunoassay CA 15 3 CA 27 29 190 30 Tumor Antigen by Immunoassay CA 19 9 190 31 Prostate Specific Antigen 190 32 Gamma Glutamyl Transferase 190 33 Hepatitis Panel Acute Hepatitis Panel 190 34 Fecal Occult Blood Test Jammary 13 Changes Red Fu Associates Ltd January 2013 June 2014 Medicare National Coverage Determinations NCD S e C f C N CMS Coding Policy Manual and Change Report 190 12 Urine Culture Bacterial Information erp Other Names Abbreviations Urine culture Description A bacterial urine culture is a laboratory procedure performed on a urine specimen to establish the probable etiology of a presumed urinary tract infection It is common practice to do a urinalysis priorto a urine culture A urine culture may also be used as partof the evaluation and management of another related condition The procedure includes aerobic agar based isolation of bacteria or other cultivable organisms present and quantitation of types present based on morphologic criteria Isolates deem
8. Provide constructive complimentary feedback noridian Thank you for visiting Noridian Medicare Upon leaving our website you may be selected to take part in a customer satisfaction survey The feedback you provide will help Noridian Medicare enhance its site and serve you better in the future All results are strictly confidential Yes give feedback This survey is conducted by an independent company ForeSee on behalf Noridian Medicare TRUSTe June 2014 80 OU Healthcare Solutions Webinar Workshops 5 27 14 1 00 PM Laboratory Services and CERT Documentation 5 29 14 1 00 PM CCI and MUE Explanation 1004 6 25 14 1 00 PM Transitional Care Management 7 16 14 1 00 PM ACT Ask the Contractor Teleconference Watch for May June and July Webinar and workshop postings Register Now JE https med noridianmedicare com web jeb education training events JF https www noridianmedicare com partb train workshops index html OSA SH nc No Reminder CEU Process Attend entire workshop For AAPC credit add additional names when registering Must take short polling survey After closing out of workshop CEU certificate emailed after workshop e No password needed All providers may use CEU certificate Certificate of Attendance no longer available Healthcare Solutions Questions Thank you
9. Select Active LCDs Active Local Coverage Determinations POLICIES x Determination Providers may access the Local Coverage Determinations LCDs from the CMS Medicare Coverage Database Active LCDs Future LCDs Draft LCDs Retired LCDs Potential LCDs New LCD Request Process LCD Reconsideration Process Open Public Meeting Carrier Advisory Committee CAC National Coverage Determination NCD Medicare Coverage Database Articles Investigational Device Exemptions IDEs California Northern CZ Contractor ID 01112 California Southern 2 Contractor ID 01182 Hawaii and Territories 2 Contractor ID 01212 Nevada 2 Contractor ID 01312 11420 11421 11422 11423 11424 11426 11440 11441 11442 Post Market Studies and Post CA 11443 11444 11446 17000 17003 17004 96567 17308 7309 Market Extension Studies Southern Self Administered Drugs AS GU SADs HI NMI Coverage Topics Outside NV NCDs LCDs L33678 Allergen Immunotherapy CA 95115 95117 95144 95145 95146 95147 95148 95149 95165 Northern 95180 CA Southern AS GU HI NMI NV L33508 Allergy Testing CA 86003 96005 95004 95017 95018 95024 95027 95028 95044 Northern 95052 95056 95060 95065 95070 95071 95076 95079 CA Southern AS Gil LCD Opening Home About CMS Newsroom Center FAQs A
10. 1 Codes SECONDARY DIABETES MELLITUS WITH OTHER SPECIFIED MANIFESTATIONS NOT STATED AS UNCONTROLLED OR UNSPECIFIED 249 81 SECONDARY DIABETES MELLITUS WITH OTHER SPECIFIED MANIFESTATIONS UNCONTROLLED 250 80 DIABETES VVITH OTHER SPECIFIED MANIFESTATIONS TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTHROLLED 250 81 DIABETES VVITH OTHER SPECIFIED MANIFESTATIONS TYPE I JUVENILE TYPE NOT STATED AS UNCONTROLLED 250 82 DIABETES WITH OTHER SPECIFIED MANIFESTATIONS TYPE II OR UNSPECIFIED TYPE UNCONTROLLED 250 83 DIABETES WITH OTHER SPECIFIED MANIFESTATIONS TYPE I JUVENILE TYPE UNCONTROLLED 440 23 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH ULCERATION 440 24 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE 454 0 VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER 454 2 VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER AND INFLAMMATION 459 33 CHRONIC VENOUS HYPERTENSION WITH ULCER AND INFLAMMATION 681 10 UNSPECIFIED CELLULITIS AND ABSCESS OF TOE 681 11 ONYCHIA AND PARONYCHIA OF TOE 6827 CELLULITIS AND ABSCESS OF FOOT EXCEPT 686 8 OTHER SPECIFIED LOCAL INFECTIONS OF SKIN AND SUBCUTANEOUS TISSUE 686 9 UNSPECIFIED LOCAL INFECTION OF SKIN AND SUBCUTANEOUS TISSUE 707 00 PRESSURE ULCER UNSPECIFIED SITE 707 01 PRESSURE ULCER ELBOW 707 02 PRESSURE ULCER UPPER BACK 707 03 PRESSURE ULCER LOWER BACK 707 04 PRESSURE ULCER HIP 707 05 PRESSURE ULCER BUTTOCK 707 06 PRESSURE ULCER ANKLE 707 07 P
11. cannot require us to do this June 2014 11 U idian 4 2 Solutions ABN Information OPTIONS Check only one box We cannot choose box for you L1 OPTION 1 want the D listed above You may ask to be paid now but also want Medicare billed for an official decision on payment which is sent to me on a Medicare Summary Notice MSN understand that if Medicare doesn t pay am responsible for payment but can appeal to Medicare by following the directions on the MSN If Medicare does pay you will refund any payments made to you less co pays or deductibles O OPTION 2 wantthe D _ listed above but do not bill Medicare You may ask to be paid now as am responsible for payment cannot appeal if Medicare is not billed O OPTION 3 1 dont want the D 1 11 listed above understand with this choice am not responsible for payment and cannot appeal to see if Medicare would pay H Additional Information This notice gives our opinion an official Medicare decision If you have other questions on this notice or Medicare billing call 1 800 MEDICARE 1 800 632 422 7 TTY 1 877 486 2048 ing below means that yo have received and understand this notice You also receive a copy Tha aid Paparacck Redaction Act of 1895 no OME contol member for this c collection comceming the Army i dia isch si il e sai Rin pia sc CMS 7300 Security Boakvard
12. with patient Get required and or voluntary signed ABNs noiidian Healthcare Solutions Specialty Specific Requirements ABN Modifiers GA Waiver of liability statement issued as required by payer policy GZ Item or service expected to be denied as not reasonable and necessary June 2014 58 ABN Modifiers GX Notice of liability issued voluntary under payer policy e GY Item or service statutorily excluded does not meet the definition of any Medicare benefit June 2014 59 idian Laboratory Services e Specimen at lab Lab reviews LCD NCD Get ABN if necessary e Specimen sent from office Office review LCD NCD Send signed ABN to lab Lab Tips Medicare may not pay this Prostate opecific Antigen PSA screening lab test performed less than one year ago e Screening pays once per year more frequently need ABN unless diagnostic Physicians forward ABN copy to labs oss Podiatry Examples e Modifier ABN on file LCD requirements for diagnosis not met e Modifier no ABN needed Routine foot care No requirements for coverage Therapy Example e Mandatory ABN that exceed cap not exception Modifier ABN on file The cap has not been met and continuation of service doesn t meet the need for a skilled therapist e M
13. 1 877 486 2048 below means that have received and understand this notice You also receive a copy you bme comment comcamung the Boulevard Aro PRA Reports Clearance Ocar Baltimore LR Form CMS R 131 03 11 Form Approved OMB No 0938 0566 June 2014 27 n oridian Authorized Representative Acting on beneficiary s behalf e No conflict of interest Person indicated by beneficiary e Disinterested 3 party Authorized Representative Legal authorization Beneficiary s best interest at heart spouse parent An adult child An adult sibling A close friend TRASH Beneficiary Refuses to Sign Beneficiary cannot refuse to sign ABN and still demand service item If beneficiary refuses to sign but chooses to have procedure and provider agrees Document beneficiary refusal to sign in patient chart Attesting to witnessing provision and refusal Notifier and office witness both sign ABN annotation IOM Publication 100 04 Chapter 30 Section 40 3 4 6 Electronic Issuance the ABN Patient must be given the option of paper Signature may be capture electronically e Patient must be given a paper signed copy NNI ncridian Repetitive Services e Patient signs original with complete information Time frame covered by ABN Only if no changes IOM P
14. 2014 noiidian Healthcare Solutions ABN Completion Who Uses Medicare Fee For Service Providers Practitioners Suppliers Laboratories and Home Health Agencies in 2013 Given to original Medicare fee for service beneficiaries Notifies the beneficiary that Medicare may not allow for an item or service Maybe a mandatory or voluntary notice Medical Necessity Medical necessity is defined as services that are reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member and are not excluded under another provision of the Medicare Program noiidian Healthcare Solutions ABN Information Notifier B Patient Mame C Identification Mumber Advance Beneficiary Notice of Noncoverage ABN NOTE If Medicare doesn t pay for D 1 1 below you may have to pay Medicare does not pay for everything even some care that you or your health care provider a good reason to think you need We expect Medicare may not pay for the D _ SE ar YOU NEED TO DO NOW Read this notice so you can make an informed decision about vour Ask us any questions that you may have after you finish reading Choose an option below about whether to receive the D 0 000 listed above Note If you choose Option 1 or 2 we may help you to use any other insurance that you might have but Medicare
15. RESSURE ULCER HEEL 707 09 PRESSURE ULCER OTHER SITE 707 10 UNSPECIFIED ULCER OF LOWER LIMB 707 11 ULCER OF THIGH 707 12 ULCER OF CALF 249 80 June 2014 A SSH Make NCDs amp LCD s Accessible Organize NCDs amp LCDs e Educate staff noiidian Healthcare Solutions National Coverage Determinations NCDs National Coverage Determinations e CMS developed Outline coverage criteria http www cms hhs gov mcd indexes a sp clickon index noiidian http www cms gov Medicare Coverage CoverageGenlnfo index html Home About CMS Newsroom Center FAQs Archive Share Help Email 44 Print C MS e O V Learn about your healthcare options Search Centers for Medicare amp Medicaid Services Home gt Medicare gt Medicare Coverage General Information gt Medicare Coverage General Information d Rates Medicare Coverage General Information Compendia 1861 142 Anti Medicare provides coverage for items and services for over 43 million beneficiaries The vast majority of coverage is cancer provided on a lacal level and developed by clinicians at the contractors that pay Medicare claims However in certain Lab NCDs cases Medicare deems it appropriate to develop a National Coverage Determination NCD for an item or service to be applied on a national basis for all Medicare beneficiaries meeting the criteria for coverage
16. This page provides general Erythropoietin Stimulating Agents information on various parts of that NCD process resources of both a general and historical nature and summaries and Policies support documents concerning several miscellaneous NCDs ICD 10 People with Medicare family members and caregivers should visit Medicare gov the Official U S Government Site for People with Medicare for the latest information on Medicare enrollment benefits and other helpful tools Related Links Medicare Coverage Database Medicare Coverage Center Medicare Coverage Determination Process Page last Modified 04 03 2014 8 03 AM Help with File Formats and Plug Ins June 2014 50 Ban idian http www cms gov Medicare Coverag e CoverageGenlnfo LabNCDs html icare National Coverage Manual and Lab NC TDD 410 786 0727 Fu Associates E td June 2014 51 noridian Medicare National Coverage Determinations NCD Table of Contents n 5 Reasons for Denial for All NCD Edits Coding Guidelines for All NCD Edits Additional Coding Guidelines 190 12 Urine Culture Bacterial 190 13 Human Immunodeficiency Virus HIV Testing Prognosis Including Monitoring 18 190 14 Human Immunodeficiency Virus HIV Testing Diagnosis 20 190 15 Blood Counts 28 190 16 Partial Thromboplastin Time PTT 39 190 17 Prothrombin Time PT 50 190 18 Serum Iron Studies 65 190 19
17. ate and complete to the best of my knowledge and I understand that any falsification omission or concealment of material fact may subject me to administrative civil or criminal liability Signature and credentials Provider Initials Note For an attestation statement to be valid it must be signed by the performing provider Electronic signatures Need statement electronically signed by or verified reviewed by followed by provider name credentials Authentication of signing provider must be clearly defined in the records IOM Medicare Program Integrity Manual Publication 100 08 Chapter 3 Section 3 4 1 1 Signature Fact Sheet http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts downloads Sign ature Requirements Fact Sheet IC N905364 pdf CMS Complying with Medicare Signature Requirements fact sheet at CR6698 Signature Requirements noridian Signature Check List e Legible provider name date and credentials e Intent established in signed charts e Legible provider name date and credentials JH e Therapist and overseeing provider e Legible provider name date and credentials e Incident to services both providers of care noted in documentation February 2014 Signature Requirements Paper requisitions must be signed by rendering ordering physician NPP Clearly identified in records Clinical diagnostic laboratory tests
18. ctibles OPTION 2 Iwantthe 0 listed above but do not bill Medicare You may ask to be paid now as am responsible for payment cannot appeal if Medicare is not billed X OPTION 3 don t want the 0 listed above understand with this choice am not responsible for payment and cannot appeal to see if Medicare would pay Item H e Clarification e Additional information Translations e 1 800 MEDICARE am not responsible for payment and H Additional Information This notice gives our opinion not an Medicare decision If you have other questions on this notice or Medicare billing call 1 800 MEDIC ARE 1 800 633 422 7 TTY 1 877 486 2048 Signing below means that you have received and understand this notice You also receive a copy ture Late O 1 5 TER TR TR li sridian Healthcare Solutions A Notifier B Patient Name C Identification Number aa detnr Beneficiary Medicare does not pay for everything even some care that you or your health care up d completes good reason to think you need We expect Medicare may not pay for the WHAT YOU NEED DO NOW Read this notice so you can make an informed decision about your care Ask us any questions that you may have after you finish reading item H nd J Choose an option below about whether to receive the D 1 11 listed above D Note If you choose Option 1 or 2 we may help you to
19. ded services Pay now No Appeals rights OPTIONS Check only one box We cannot choose box for you O OPTION 1 want the D 14 above You may ask to be paid now but also want Medicare billed for an official decision on payment which is sent to me on a Medicare Summary Notice MSN understand that if Medicare doesn t pay am responsible for payment but can appeal to Medicare by following the directions on the MSN If Medicare does pay you will refund any payments made to you less co pays or deductibles X OPTION 2 Iwantthe D listed above but do not bill Medicare You may ask to be paid now as am responsible for payment cannot appeal if Medicare is not billed OPTION dont want the D listed above understand with this choice am not responsible for payment and cannot appeal to see if Medicare would pay not want service e No bills to Medicare e No financial liability G OPTIONS Check only one box We cannot choose a box for you O OPTION 1 want the D 14 above You may ask to be paid now but also want Medicare billed for an official decision on payment which is sent to me on a Medicare Summary Notice MSN understand that if Medicare doesn t pay am responsible for payment but can appeal to Medicare by following the directions on the MSN If Medicare does pay you will refund any payments made to you less co pays or dedu
20. e If you choose Option 1 or 2 we may help that you might have but lbove You may ask to be paid now but I igan payment which is sent to me on a Medicare ledicare doesn t pay I am responsible for glowing the directions on the MSN If Medicare less co pays or deductibles Above but do not bill Medicare You may cannot appeal if Medicare is not billed Enter exact service s that patient understands Summary Notice MSN payment but I can appeal to Medic are This notice gives our opinion not an official Medicare decision If you have other questions on this notice or Medicare billing call 1 800 MEDICARE 1 877 486 2048 the Paperwork Redaction Act of 1995 no of indcemason unless it displays valid OMB control mambar OMB conse mmber for formation is 09 repeating n vee B Se ira needed and comple and moys Se collection If you kxve comments the accuracy of for i this form write to CMS 7500 Security Boulevard Arm Baltimore Maryland 21244 1830 Form CMS R 131 03 11 Form Approved OMB No 0938 0566 June 2014 User Customizable Sections NOTE If Medicare doesnt pay for D below you may have to pay Medicare does not pay for everything even some care that you or your health care provider have good reason ta think you need We exp
21. ect Medicare may not pay for the D Item service Reason for denial Estimated cost June 2014 19 Medicare does pay for the item or service for your condition e more often than which it considers to be experimental or for research use because it is an excluded service from the program 1 A Notifier B Patient Name C Identification Number Advance Beneficiary Notice of Noncoverage ABN NOTE If Medicare doesn t pay for D _ below may have to pay Medicare does not pay for everything even some care that you or your health care provider good reason to think you need We expect Medicare not pay for the D __ E Reason Medicare May Not WHAT YOU NEED TO DO NOW Read this notice so you can make an informed decision about your care estions that you may have after you finish listed above listed above You may ask to be paid now but I cial decision on payment which is sent to me on a Medicare that if Medicare doesn t pay I am responsible for payment but I can appeal to Me does pay you will refund any payrgents made to you less co pays or deductibles OPTION 2 D listed above but do not bill Medicare You may ask to be paid now as am resporfkible for payment cannot appeal if Medicare is not billed listed above understand with this choice j n not an official Medicare decision If you ha
22. ed significant may be subjected to additional identification and susceptibility procedures as requested by the ordering physician The physician s request may be through clearly documented and communicated laboratory protocols HCPCS Codes Alphanumeric CPT9 AMA eDescription Culture bacterial with isolation and presumptive identification of each isolates urine 87186 Susceptibility studies antimicrobial agent microdilution or agar Listed in manual only dilution minimum inhibitory concentration MIC or breakpoint each multi antimicrobial per plate CPT HCPCS codes RM LAM The individual ICD 9 CM codes included in code ranges in the table below can be viewed CMS website under Leb Coda List The link is www cms gov Medicara Coverage CoveragzeGenInfo T aBNCDs html 31i Salmonella septicemia 038 0 038 10 038 11 e C O e S 038 12 038 19 038 2 038 3 038 40 038 44 038 49 038 8 038 9 Septicemia covere eutropenia NCD 190 12 January 13 Changes Red Fu Associates Ltd January 2013 June 2014 53 S f e C C Medicare National Coverage Determinations NCD CMS Information i 6 Coding Policy Manual and Change Report The patient is being evaluated for suspected urosepsis fever of unknown origin or other systemic manifestations of infection but without a known source Signs and symptoms used to define sepsis have been well es
23. ided as is without any expressed or implied warranty While all information in this document is believed to be correct at the time of writing this document is for educational purposes only and does not purport to provide legal advice All models methodologies and guidelines are undergoing continuous improvement and modification by Noridian and CMS The most current edition of the information contained in this release can be found on the Noridian website at and the CMS website at The identification of an organization or product in this information does not imply any form of endorsement CPT codes descriptors and other data only are copyright 2014 American Medical Association All rights reserved Applicable FARS DFARS apply ACRONYM DESCRIPTION ABN LCD MILN NCD CCI CERT CR IOM Advance Beneficiary Notice of Non Coverage Local Coverage Determination Medicare Learning Network National Coverage Determinations Correct Coding Initiative Comprehensive Error Rate Testing Change Request Internet Only Manual idian e ABN form Completion requirements Uses Modifier usage National and Local Coverage Determinations Signature Requirements June 2014 6 Advance before the item or service is provided Beneficiary issued to the beneficiary or representative Notice of Noncoverage written notification that Medicare may not or won t pay for an item or service May
24. is Some authors will define a pre ulcer condition and others even Stage 1 Ulcer e g Wagner 1 where the skin is still intact Such changes do not constitute an ulcer for Medicare payment purposes under this policy Ulcers may develop because of a combination of ischemia infection abscess trauma prolonged pressure repetitive stress edema and loss of sensation Their management includes 1 Overall medical and surgical treatment of the cause 2 Meticulous care of the ulcerated skin and other associated soft tissue with application of medications and dressings and 3 When reasonable and necessary debridement of the necrotic and devitalized tissue The management of a symptomatic hyperkeratosis may involve medical treatment paring or cutting shaving excision or destruction This policy addresses only the paring or cutting approach The other approaches are addressed in the Noridian Skin Lesion Non melanoma Removal LCD This policy does not address treatment of burns or debridement of nails For treatment of burns including debridement refer to the CPT 16000 series For debridement of nails refer to CPT codes 11720 and 11721 When the only service provided is the non surgical cleansing of the ulcer site with or without the application of a surgical dressing the provider should bill this service with the appropriate evaluation and management E M code and not a debridement code s SET codes 1 1042 3 1044 describe
25. odifier no ABN needed he cap has been met and continuation of service doesn t meet the need for a skilled therapist noiidian Healthcare Solutions Resources Resource Links CMS Form and instructions https www cms gov BNI Downloads ABNFormInstructio ns zip ABN FAQ Forms JE https med noridianmedicare com web jeb forms JF https www noridianmedicare com partb forms e CR 6563 Effective 4 1 2010 e CR 7821 Effective 9 24 2012 Medicare Learning Network MLN http www cms gov MLNProducts downloads MLNCa talog pdf June 2014 65 CMS References ABN Www cms hhs gov bni e LCDs http www cms gov medicare coverage database overview and quick search aspx 0 ATA idian CMS References e NCDs http www cms hhs gov mcd index list a sp list type ncd e NCDs Lab http www cms gov Medicare Coverage CoverageGenilnto index htm noiidian Healthcare Solutions Signature Requirements A HD Signature Purpose Clearly identified in the medical records Must be legible with first and last name and credentials Demonstrate services are documented reviewed and authenticated Certifies the medical necessity and reasonableness of the service AID Validity Signature e Handwritten signature Must be legible e Electronic signature Digitized
26. rchive Share Help Email ij Print CMS gov Learn about your healthcare options Search Centers for Medicare amp Medicaid Services OVERVIEW ADVANCED mos REPORTS DownLoaps Page Help lt lt Back to Local Coverage Determinations LCDs for Noridian Healthcare Solutions LLC 01182 Local Coverage Determination LCD Treatment of Ulcers amp Symptomatic Hyperkeratoses L33496 Select the Print Record Add to Basket or Email Record buttons to print the record to add it to your basket or to email the record Add to Basket Need PDF Email Record Section Navigation Select Section z Expand All Collapse All Contractor Information Contractor Name Contract Number Contract Type Noridian Healthcare Solutions LLC 01182 MAC Back to Top June 2014 43 June 2014 Coverage Indications and Limitations CMS National Coverage Policy Title XVIII of the Social Security Act 1862 a 1 A Allows coverage and payment only for those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member Title XVIII of the Social Security Act 1833 e Prohibits Medicare payment for any claim which lacks the necessary information to process the claim Title XVIII of the Social Security Act 1862 a 13
27. refore not covered by Medicare The U S Preventive Services Task Force has concluded that screening for asymptomatic bacteriuria outside of the narrow indication for pregnant women is generally not indicated There are insufficient data to recommend screening in ambulatory elderly patients including those with diabetes Testing may be clinically indicated on other grounds including likelihood of recurrence or potential adverse effects of antibiotics but is considered screening in the absence of clinical or laboratory evidence of infection ICD 9 CM Codes That Do Not Support Medical Necessity Any ICD 9 CM code not listed in either of the ICD 9 CM covered or non covered sections Documentation Requirements Appropriate HCPCS CPT code s must be used as described e H Sources of Information O C U O N Bal FB Cerra amp Hp ene ra anfa t Chest 10131644 1655 3998 press Cumitech 2B Laboratory Diagnosis of Urinary Tract Infections Kunin CM 1994 Urinary tract infections in females Clip Infect Dis 18 1 12 NCD 190 12 January 13 Changes Red Fu Associates Ltd January 2013 June 2014 oridian Frequency Utilization Head policy thoroughly Check Limitations Utilizations WP ncridian Covered Preventive Services and the ABN Frequency parameters apply Become familiar with coverage e Communicate
28. tablished Atest of cure is generally notindicated an uncomplicated infection However it may be indicated if the patient is being evaluated for response to therapy and there is a complicating co existing urinary abnormality including structural or functional abnormalities calculi foreign bodies or ureteral renal stents or there is clinical or laboratory evidence of failure to respond as described in Indications 1 and 2 In surgical procedures involving major manipulations of the genitourinary tract preoperative examinationto detect occult infection may be indicated in selected cases for example prior to renal transplantation manipulation or removal of kidney stones or transurethral surgery of the bladder or prostate Urine culture may be indicated to detect occult infection in renal transplant recipients on immunosuppressive therapy Limitations 1 eindications 2 eLimitations CPT 87086 may be used one time per encounter Colony count restrictions on coverage of CPT 87088 do not apply as they may be highly variable according to syndrome or other clinical circumstances for example antecedent therapy collection time and degree of hydration CPT 87088 87184 and 87186 may be used multiple times in association with or independent of 87086 as urinary tract infections may be polymicrobial Testing for asymptomatic bacteriuria as part of a prenatal evaluation may be medically appropriate butis considered screening and the
29. thcare Solutions Local and National Coverage Determinations LCDs amp NCDs Local Coverage Determinations e Contractor developed Outline coverage criteria ncridian Healthcare Solutions JE Part B Browse Browse Fees amp News by Topic by Specialty A A JE Part B Policies POLICIES gt Local Coverage Determination LCD National Coverage Determination NCD Medicare Coverage Database Articles Investigational Device Exemptions IDEs Post Market Studies and Post Market Extension Studies Self Administered Drugs SADs Coverage Topics Outside NCDs LCDs June 2014 noridian Policies Provider Portal Endeavor Login Contact Us Help CERT amp Reviews Education amp Enrollment Outreach CERT MR Recovery Training Events Enroll Changes Downloadable Auditor Materials Revalidation Forms and Links Policies LCDs and NCDs A Local Coverage Determination LCD is a decision by a Medicare Administrative Contractor MAC whether to cover a particular service on a MAC wide basis The LCDs are located on the CMS website in a Medicare Coverage Database MCD How to Use The Medicare Coverage Database CZ National Coverage Determinations NCDs are developed by CMS to describe the circumstances for Medicare coverage nationwide for a specific medical service procedure or device Last Updated Sep 15 2013 41 noridian
30. u need We expect WHAT YOU NEED TO DO NOW Read this notice so you can make an informed decision about your e Ask us any questions that you may have after you finish reading Choose an option below about whether to receive the D listed above Note If you choose Option 1 or 2 we may help you to use any other insurance that you might have but Medicare cannot require us to do this OPTIONS Check only one box We cannot choose a box for you OPTION 1 want the D ________ listed above You may ask to be paid now but 1 also want Medicare billed for an official decision on payment which is sent to me on a Medicare Summary Notice MSN understand that if Medicare doesn t pay am responsible for payment but I can appeal to Medicare by following the directions on the MSN If Medicare does pay you will refund any payments made to you less co pays or deductibles OPTION 2 wantthe D listed above but do not bill Medicare You may ask to be paid now as am responsible for payment I cannot appeal if Medicare is not billed OPTION 3 dont want the D ________ listed above understand with this choice am not responsible for payment and I cannot appeal to see if Medicare would pay H Additional Information This notice gives our opinion not an official Medicare decision If you have other questions on this notice or Medicare billing call 1 800 MEDIC ARE 1 800 633 4227 TTY
31. ublication 100 04 Chapter 30 50 14 3 Repetitive Services e Patient may sign date reverse side every Visit Not a CMS requirement Medicare doesn t take a stand either way e Valid up to one year e If new triggering event with changes need new ABN ABN Retention Five years from service Unless State requires longer retention Required to keep ABN Beneficiary declined care Refused to choose an option Refused to sign notice Beneficiary s Financial Liability Can collect usual and customary charge Both assigned non assigned claims Not limited to Medicare allowed amounts Return funds if provider liable Return funds is subsequently paid IOM 100 4 Chapter 30 850 13 Financial Responsibility Cannot issue ABN To shift financial liability to patient when full payment is made through bundled payments E g National Correct Coding Initiative NCCI When patient would not be financially liable for payments because Medicare made full payment poridian Healthcare Solutions June 2014 AH Categorical Exclusions IOM 100 4 Chapter 30 20 1 1 Routine physicals amp some screening tests Most shots vaccinations Routine eye care Hearing aids and exams Cosmetic surgery Dental care and dentures Orthopedic shoes and foot supports Services by immediate relatives OO C noiidian Heal
32. use any other insurance that you might have but Medicare cannot require us to do this G OPTIONS Check only one box We cannot choose a box for you Date OPTION 1 want the D __________ listed above You may ask to paid now but 1 also want Medicare billed for an official decision on payment which is sent to me on a Medicare Summary Notice MSN understand that if Medicare doesn t pay I am responsible for payment but I can appeal to Medicare by following the directions on the MSN If Medicare e does pay you will refund any payments made to you less co pays or deductibles e OPTION 2 wantthe D listed above but do not bill Medicare You may 1 ask to be paid now as am responsible for payment I cannot appeal if Medicare is not billed OPTION 3 dont want the D 11 1 listed above understand with this choice am not responsible for payment and cannot appeal to see if Medicare would pay H Additional Information E of fe estimate nd ae era you bw accuracy Boulevard Arm PRA Reports Clearance Officer Bano Mami June 2014 aridian A Notifier B Patient Name C Identification Number Advance Beneficiary Notice of Noncoverage ABN NOTE Medicare doesn t pay for D below you may have to pay Medicare does not pay for everything even some care that you or your health care provider have good reason to think yo
33. ve other questions on g call 1 800 MEDICARE 1 800 633 4227 TTY 1 877 486 2048 response i gt you comment for this form write to CMS 7500 Security conceming or suggestions for improving plene Form CMS R 131 03 11 Form Approved OMB No 0938 0566 June 2014 oiidian Healthcare Solutions Beneficiary completes Option 1 2 or 3 21 TE Option 1 e Want service Bill Medicare for decision Medical Necessity denial anticipated e Pay now or later Appeals available OPTIONS Check only one box We cannot choose box for you X OPTION 1 want the D listed above You may ask to be paid now but also want Medicare billed for an official decision on payment which is sent to me on a Medicare Summary Notice MSN understand that if Medicare doesn t pay am responsible for payment but can appeal to Medicare by following the directions on the MSN If Medicare does pay you will refund any payments made to you less co pays or deductibles OPTION 2 Iwantthe D _ above but do not bill Medicare You may ask to be paid now as am responsible for payment cannot appeal if Medicare is not billed O OPTION 3 dont want the D listed above understand with this choice am not responsible for payment and cannot appeal to see if Medicare would pay 2 Want service Dont bill Medicare Exclu
Download Pdf Manuals
Related Search