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Medicare Bulletin - July 2014 Edition

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1. The services reported without the HCPCS code will receive an encounter visit payment Payment will be based on the all inclusive rate and the coinsurance and deductible will be applied The qualified preventive service will not receive payment as payment is made under the all inclusive rate for the services reported on the first revenue line Coinsurance and deductible are not applicable to the service line with the preventive service Exceptions If the only service provided is a preventive service such as the IPPE or Annual Wellness Visit AWV report only one line with the appropriate site of service revenue code 052X and the preventive service HCPCS code The services will be paid based on the all inclusive rate Coinsurance and deductible are not applicable NOTE An additional visit may be paid for IPPE when billed with another qualified encounter visit as outlined with CR 6445 see the related MLN Matters article MM6445 at hitp www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads MM6445 pdf on the CMS website aA m Z mr O PN lt Ro O Hs T gt A a gt RHCs are not required to report separate revenue lines for influenza virus or pneumococcal pneumonia vaccines on the 71x claims as the cost for these services are not included in the encounter Costs for the influenza virus or pneumococcal pneumonia vaccines are included in
2. In order to reflect appropriate payment policy as included in the CY 2014 MPFS Final Rule the MPFSDB has been updated with April changes and those necessitated by Protecting Access to Medicare Act of 2014 which the President signed on April 1 2014 This law extends the 0 5 update through December 31 2014 Since the Act extends the MPFSDB policies to all of CY 2014 the April update payment files that were previously created to be effective from January 1 2014 to March 31 2014 can now be used by MACs to be effective from January 1 2014 to December 31 2014 Note Medicare contractors will not search their files to either retract payment for claims already paid or to retroactively pay claims However contractors will adjust claims brought to their attention CR 8664 Summary of Changes The summary of changes for the April 2014 update consists of the following 1 Short Description Corrections for HCPCS codes G0416 G0419 HCPCS Code Old Short Description Revised 2014 Short Description G0416 Sat biopsy prostate 1 20 spc Biopsy prostate 10 20 spc G0417 Sat biopsy prostate 21 40 Biopsy prostate 21 40 G0418 Sat biopsy prostate 41 60 Biopsy prostate 41 60 G0419 Sat biopsy prostate gt 60 Biopsy prostate gt 60 2 Adjust the Facility and Non Facility PE RVUs for HCPCS code 77293 Global and 77293 TC via CMS update files nee Non Facility Facility HC
3. N A 0362T Exposure behavioral follow up assessment includes physician or other qualified health care professional direction with interpretation and report administered by physician or other qualified health care professional with the assistance of one or more technicians first 30 minutes of technician s time face to face with the patient 0632 0363T Exposure behavioral follow up assessment includes physician or other qualified health care professional direction with interpretation and report administered by physician or other qualified health care professional with the assistance of one or more technicians each additional 30 minutes of technician s time face to face with the patient List separately in addition to code for primary procedure N A 0364T Adaptive behavior treatment by protocol administered by technician face to face with one patient first 30 minutes of technician time 0322 0365T Adaptive behavior treatment by protocol administered by technician face to face with one patient each additional 30 minutes of technician time List separately in addition to code for primary procedure N A 0366T Group adaptive behavior treatment by protocol administered by technician face to face with two or more patients first 30 minutes of technician time 0325 0367T Group adaptive behavior treatment by protocol administered by technician face to face with two or more patients e
4. 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 07 JULY 2014 aA m Z mr O PN lt Ro O Hs T gt AD a gt 30 coding must be provided for preventive services recommended by the United States Preventive Services Task Force USPSTF with a grade of A or B The Affordable Care Act also waives the deductible for planned colorectal cancer screening tests that become diagnostic Background Historically RHCs and FQHCs billing instructions have been the same However effective January 1 2011 the billing requirements will be different for each of these facilities types As outlined in CR 7208 transmittal 2122 RHCs are only required to submit detailed HCPCS codes for preventive services with a United States Preventive Services Task Force USPSTF grade of A or B in order to waive coinsurance and deductible As outlined in CR 7038 see the related MLN Matters article MM7038 at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads MM7038 pdf on the CMS website FQHCs are required to submit detailed HCPCS code s for all services rendered during the encounter As outlined in CR 8743 see the related MLN
5. includes 0348T X 0261 cervical thoracic and lumbosacral when performed 0349T Radiologic examination radiostereometric analysis RSA upper X 0261 extremity ies includes shoulder elbow and wrist when performed Radiologic examination radiostereometric analysis RSA lower 0350T extremity ies includes hip proximal femur knee and ankle when X 0261 performed Optical coherence tomography of breast or axillary lymph node excised 0351T rae fee N N A tissue each specimen real time intraoperative Optical coherence tomography of breast or axillary lymph node excised 0352T eri B N A tissue each specimen interpretation and report real time or referred 0353T Optical coherence tomography of breast surgical cavity real time N N A intraoperative 0354T Optical coherence tomography of breast surgical cavity interpretation and B N A report real time or referred 0355T Gastrointestinal tract imaging intraluminal e g capsule endoscopy colon T 0142 with interpretation and report Insertion of drug eluting implant including punctal dilation and implant Caset removal when performed into lacrimal canaliculus each Be 0358T Bioelectrical impedance analysis whole body composition assessment Qt 0340 supine position with interpretation and report This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff Newsletters are available a
6. Hs T gt AD a gt CGS is aware that some providers are attempting to use the eOffset feature to submit a voluntary refund However the eOffset function does not support voluntary refunds To make a voluntary refund follow the instructions provided on the Overpayment webpage and use the appropriate Voluntary Refund form available on the CGS website e Part A http www cgsmedicare com parta overpay index html e Part B Ohio http www cgsmedicare com ohb forms overpayment html e Part B Kentucky http www cgsmedicare com kyb forms overpayment html e Home Health amp Hospice http www cgsmedicare com hhh financial Overpay html Note Part A providers including home health and hospices are strongly encouraged to electronically adjust claims to correct overpayments rather than submit a refund via the Voluntary Refund Request form If you have additional questions about using the eOffset feature please contact the CGS EDI Department using the appropriate number below e Part A 1 866 590 6703 Option 2 e Part B Kentucky and Ohio 1 866 276 9558 Option 2 e Home Health amp Hospice 1 877 299 4500 Option 2 You may also refer to the eOffset Job Aid located at http www cgsmedicare com pdf eOffsetsJobAid pdf aA m Z mr O PN lt Ro O Hs T gt A a gt Administration Medicare Learning Network A Valuable Educational Resource The Medicare Learn
7. 31 2014 Your MAC will adjust any claims incorrectly processed if you bring those claims to the attention of your MAC Table 6 Updated Payment Rates for Certain HCPCS Codes Effective January 1 2014 through March 31 2014 Corrected Corrected Minimum HCPCS Code Status Indicator APC Short Descriptor Payment Rate Unadjusted Copayment J0775 K 1340 Collagenase clost hist inj 38 49 7 70 Operational Change to Billing Lab Tests for Separate Payment As delineated in MLN Matters Special Edition Article SE 1412 issued on March 5 2014 see http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads SE1412 pdf effective July 1 2014 OPPS hospitals should begin using modifier L1 on type of bill TOB 13X when seeking separate payment for outpatient lab tests under the Clinical Laboratory Fee Schedule CLFS in the following circumstances 1 A hospital collects specimen and furnishes only the outpatient labs on a given date of service 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 07 JULY 2014 aA m Z mr O PN lt Ro O Hs U gt Bu 5j gt 40 2 A hospital con
8. Base each of the questions the available form s will appear at the bottom of this box At this ti available Select a Topic Appeals gt Select a Type First level appeal on a Medicare Claim x To verify you are within timely filing requirements for this Appeal please use our Appeals Calculator Step 4 Select Yes if the redetermination request is timely Is your appeal late over 120 days for a redetermination or over 365 days for a reopening No x Redetermination 1 Level Appeal EA J15 HHH 1000 A m Z mr O PN lt Ro O I gt A a gt 4 Once you have determined that your request is timely select Yes from the drop down menu If your appeal is untimely you cannot submit your redetermination request via the myCGS portal 5 Click on the Redetermination 1st Level Appeal link to access the online Redetermination Form Select a Type First level appeal on a Medicare Claim gt Step 5 To verify you are within timely filing requirements fi Click to access the online Redetermination Form Is your appeal late over 120 days for a redeterming Redetermination 1 Level Appeal EA J15 HHH 1000 6 The myCGS Redetermination 1st Level Appeal form will appear There are four sections 1 Beneficiary Information 2 Provider Information 3 Claims Information and 4 Attachments Complete the required fields which are marked with a red ast
9. Calendar ee a ee Year CY 2014 Medicare Physician Fee Schedule TS ee a Database MPFSDB 20 Code Editor I OCE Specifications Version 15 2 6 MM8773 July Update to the Calendar News Fipsh Ness og gt Tomine Denies Year CY 2014 Medicare Physician Fee for Medicare amp Medicaid Services CMS T Schedule Database MPFSDB 24 Provider Contact Center Reminders a 8 Quarterly Provider Update 9 FQHC RHC Stay Informed and Join the CGS MM8743 Implementation of a Prospective ListServ Notification OMER sosar 9 Payment System PPS for Federally Qualified Submit Your Redetermination Requests Health Centers FQHCs 26 Hnraughr the myCGS Web POM anainn Painii 0 1039 Revised Rural Health Clinics RHCs and Federally Qualified Health Centers FQHCs Billing Guide 30 Medi HOSPITAL Le r MM8776 July 2014 Update of the Hospital n e t Outpatient Prospective Payment System OPPS 36 ICD 10 Official CMS Information for Medicare Fee For Service Providers 4 MM8691 ICD 10 Conversion Coding Infrastructure http wwwiems gov MLNGeninfo Revisions ICD 9 Updates to National Coverage Determinations NCDs Maintenance CR 42 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 BULLET
10. Medicare intravenous immune globulin IVIG demonstration will change 1 From SI N Paid under OPPS payment is packaged into payment for other services Therefore there is no separate APC payment 2 To SI E Not paid by Medicare when submitted on outpatient claims any outpatient bill type e Updated Payment Rates for Certain HCPCS Codes Effective October 1 2013 through December 31 2013 The payment rate for one HCPCS code was incorrect in the October 2013 OPPS Pricer The corrected payment rate is listed in Table 5 below and it has been installed in the July 2014 OPPS Pricer effective for services furnished on October 1 2013 through December 31 2013 Your MAC will adjust any claims incorrectly processed if you bring those claims to the attention of your MAC Table 5 Updated Payment Rates for Certain HCPCS Codes Effective October 1 2013 through December 31 2013 Corrected Corrected Minimum HCPCS Code Status Indicator APC Short Descriptor Payment Rate Unadjusted Copayment J2788 K 9023 Rho d immune globulin 50 mcg 25 15 5 03 f Updated Payment Rates for Certain HCPCS Codes Effective January 1 2014 through March 31 2014 The payment rate for one HCPCS code was incorrect in the January 2014 OPPS Pricer The corrected payment rate is listed below in Table 6 and it has been installed in the July 2014 OPPS Pricer effective for services furnished on January 1 2014 through March
11. 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 07 JULY 2014 43
12. Web page at http www cgsmedicare com mycgs manual htm for additional information about the messages received in myCGS A m Z Cc O PN lt Ro He T gt AD a gt Claims MM8401 Revised Mandatory Reporting of an 8 Digit Clinical Trial Number on Claims The Centers for Medicare amp Medicaid Services CMS revised the following Medicare Learning Network MLN Matters article on May 15 2014 The article was revised again on June 9 2014 This MLN Matters article and other CMS articles can be found on the CMS website at htip www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number MM8401 Revised Related Change Request CR CR 8401 Related CR Release Date May 13 2014 Effective Date January 1 2014 Related CR Transmittal R2955CP Implementation Date January 6 2014 Note This article was revised on May 15 2014 to reflect the revised CR 8401 issued on May 13 The article has been revised to delete information regarding entry of the clinical trial number on institutional paper or Direct Data Entry DDE claim UB 04 Also the transmittal number the CR release date and the Web address for accessing the CR are revised All other information remains the same Note This article was revised on June 9 2104 to emphasize that coding CT in front of the clinical trial number applies ONLY to paper cl
13. Z mr O PN lt Ro O Hs T gt AD a gt 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 MM8739 Revised Fluorodeoxyglucose FDG Positron Emission Tomography PET for Solid Tumors This Change Request CR rescinds and fully replaces MM 8468 dated February 6 2014 The Centers for Medicare amp Medicaid Services CMS has revised 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 MM8739 Revised Implementation Date May 19 2014 MAC Related CR Release Date May 28 2014 Non Shared System Edits July 7 2014 Related CR Transmittal R2932CP R168NCD CWF development testing FISS requirement Related Change Request CR CR 8739 development October 6 2014 CWF FISS Effective Date June 11 2013 MCS Shared System Edits Note This article was revised on May 30 2014 to reflect the revised CR8739 issued on May 28 In the article the CR release date transmittal number and the Web address for accessing the CR are revised All other information remains the same Provider Types Affected This MLN Matters article is intended f
14. amp Medicaid Services CMS does allow PCCs up to 10 business days to research and return your call This information can be found in the CMS Medicare Contractor Beneficiary and Provider Communications Manual Pub 100 09 Chapter 6 Section 60 2 5 htip www cms gov Regulations and Guidance Guidance Manuals Downloads com109c06 pdf As a reminder CGS offers the Interactive Voice Response IVR Unit and the myCGS Web portal for eligibility claim status information 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 07 JULY 2014 8 e IVR User Guide http www cgsmedicare com parta cs cgs_j15_parta_ivr_user guide pdf e myCGS http www cgsmedicare com parta myCGS index html Administration 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 Updat
15. base Make sure that your billing staffs are aware of this requirement Background CR 5790 Transmittal 310 dated January 18 2008 titled Requirements for Including an 8 Digit Clinical Trial Number on Claims is available at hitp www cms gov Regulations and Guidance Guidance Transmittals Downloads R310O0TN pdf on the CMS website The MLN Matters Article for CR 5790 is available at hitp www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads MM5790 pdf on the CMS website This number is listed prominently on each specific study s page and is always preceded by the letters NCT CMS uses this number to identify all items and services provided to beneficiaries during their participation in a clinical trial clinical study or registry Furthermore this identifier permits CMS to better track Medicare payments ensure that the information gained from the research is used to inform coverage decisions and make certain that the research focuses on issues of importance to the Medicare population Suppliers may verify the validity of a trial study registry by consulting CMS s clinical trials registry website at http Awww cms gov Medicare Medicare General Information MedicareApprovedFacilitie index html on the CMS website For institutional claims that are submitted on the electronic claim 8371 the 8 digit number should be placed in Loop 2300 REF02 REFO1 P4 when a c
16. cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 07 RETURN TO TABLE OF CONTENTS JULY 2014 A m Z O PN am Ro I T gt A J gt 22 Physician Supervision of Px HCPCS Diagnostic Procedures Effective m Code Phys Diag Supv Date Z tc Mri brain stem w dye Phys Diag Supv 70552 TC Correction TC 02 01 01 2014 c ye Mri brain stem w o amp widye Phys Diag 70553 TC Supv Correction TC 02 01 01 2014 5 7o141 1 _ Mri neck spine w o dye Phys Diag Supv o4 o1o12014 lt Correction TC Ro k Mri neck spine w dye Phys Diag Supv 72142 TC Correction TC 02 01 01 2014 72146 TC Mri chest spine w o dye Phys Diag Supv 01 01 01 2014 aE Correction TC O f Mri chest spine w dye Phys Diag Supv 72147 TC Correction TC 02 01 01 2014 3 f Mri lumbar spine w o dye Phys Diag 72148 TC Supv Correction TC 01 01 01 2014 ar 72149 TC Mri lumbar spine w dye Phys Diag Supv 02 01 01 2014 Correction TC gt f Mri neck spine w o amp w dye Phys Diag 72156 TC Supv Correction TC 02 01 01 2014 Mri chest spine w o amp w dye Phys Diag 72157 TC Supv 02 01 01 2014 Correction TC Mri lumbar spine w o amp w dye Phys Diag 72158 TC Supv 02 01 01 2014 Correction TC Ct angiograph pelv w o amp w dye Phys 72191 TC Diag Supv Correction TC 02 01 01 2014 Ct angio abd amp pelv w o am
17. current FQHC interim per visit payment rate methodology Basic FQHC Billing Requirements For dates of service on or after January 1 2011 all valid UB04 revenue codes except the following may be used to report the additional services that are needed for data collection and analysis purposes only e 002x 024x 029x 045x 054x 056x 060x 065x 067x 072x 080x 088x 093x or 096x 310x Medicare will make one payment at the all inclusive rate for each date of service that contains a valid HCPCS code for professional services when one of the following revenue codes is present PN m Z mr O PN lt Ro O Hs T gt A a gt Revenue Code Definition 0521 Clinic visit by member to RHC FQHC 0522 Home visit by RHC FQHC practitioner Visit by RHC FQHC practitioner to a member in a covered Part A stay at a Skilled 0524 i Nursing Facility SNF 0525 Visit by RHC FQHC practitioner to a member in a SNF not in a covered Part A stay or NF or ICF MR or other residential facility RHC FQHC Visiting Nurse Service s to a member s home when in a Home Health 0527 Shortage Area 0528 Visit by RHC FQHC practitioner to other non RHC FQHC site e g scene of accident Payments for Encounter Visits Medicare will make an additional encounter payment at the all inclusive rate on the same claim when e Effective January 1 2011 two services lines are submitted with a 052X revenue code and one li
18. most current list of device edits is available under Device and Procedure Edits at http www cms gov Medicare Medicare Fee for Service Payment HospitalOutpatientPPS on the CMS website Failure to pass these edits will result in the claim being returned to the provider New Brachytherapy Source Payment The Social Security Act Section 1833 t 2 H see hitp www socialsecurity gov OP_Home ssaci title18 1833 htm mandates the creation of additional groups of covered outpatient department OPD services that classify devices of brachytherapy consisting 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 07 JULY 2014 36 of a seed or seeds or radioactive source brachytherapy sources separately from other services or groups of services The additional groups must reflect the number isotope and radioactive intensity of the brachytherapy sources furnished Cesium 131 chloride solution is a new brachytherapy source The HCPCS code assigned to this source as well as payment rate under OPPS are listed in Table 1 below Table 1 New Brachytherapy Source Code Effective July 1 2014 Effective Minimum Unadjusted HCPCS date SI APC Short Descriptor L
19. necessary to implement relative values for physicians services In order to reflect appropriate payment policy based on current law and the Calendar Year CY 2014 Medicare Physician Fee Schedule MPFS Final Rule the MPFS Database MPFSDB has been updated using the 0 5 percent update conversion factor effective January 1 2014 to December 31 2014 Payment files were issued to MACs based upon the CY 2014 MPFS Final Rule published in the Federal Register on December 10 2013 which is available at http www cms gov Medicare Medicare Fee for Service Payment PhysicianFeeSched PFS Federal Regulation Notices Items CMS 1600 FC html and as modified by section 101 of the Pathway for SGR Reform Act of 2013 passed on December 18 2013 and further modified by section 101 of the Protecting Access to Medicare Act of 2014 on April 1 2014 for MPFS rates to be effective January 1 2014 to December 31 2014 The summary of Healthcare Common Procedure Coding System HCPCS Code additions for the July 2014 update are shown in the following table HCPCS Short Descriptor Procedure Status Q9970 Inj Ferric Carboxymaltos 1mg E Q9974 Morphine epidural intratheca E 0144 Inj Propofol 10mg 1034 Art pancreas system 1035 Art pancreas inv disp sensor This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provider supplier staff N
20. plan are paid by the MA organization at the rate that is specified in their contract If the MA contract rate is less than the Medicare PPS rate Medicare will pay the FQHC the difference less any cost sharing amounts owed by the beneficiary The supplemental payment is only paid if the contracted rate is less than the fully adjusted PPS rate To facilitate accurate payment claims for MA supplemental payments under the FQHC PPS must include the specific payment codes that correspond to the appropriate PPS rates and the detailed HCPCS coding required for all FQHC PPS claims Additional Information The official instruction CR 8743 issued to your MAC regarding this change is available at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R1383OTN 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 FQHC RHC SE1039 Revised Rural Health Clinics RHCs and Federally Qualified Health Centers FQHCs Billing Guide The Centers for Medicare amp Medicaid Services CMS has revised 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 govw Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2010 MLN Matters Articles html MLN Matte
21. services furnished to a beneficiary on the same day when a medically necessary face to face FQHC visit is furnished to a Medicare beneficiary Medicare will allow for an additional payment when an illness or injury occurs subsequent to the initial visit or when a mental health visit is furnished on the same day as a medical visit The PPS rate will be adjusted when a FQHC furnishes care to a patient who is new to the FQHC or to a beneficiary receiving an initial preventive physical examination IPPE or an annual wellness visit AWV CMS is establishing specific payment codes to be used under the FQHC PPS based on descriptions of services that will correspond to the appropriate PPS rates The PPS rates will also be adjusted to account for geographic differences in the cost of inputs by applying FQHC geographic adjustment factors FQHC GAFs In calculating the total payment amount the FQHC GAF will be based on the locality of the site where the services are furnished For FQHC organizations with multiple sites the FQHC GAF may vary depending on the location of the FQHC delivery site Complete details of the FQHC PPS are available in MLN Matters article MM8743 which is available at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads mm8743 pdf on the CMS website Additional Information Additional information on vaccines can be found in the Medicare Claims Processing Manual
22. the cost report and no line items are billed Coinsurance and deductible do not apply to either of these vaccines The hepatitis B vaccine is included in the encounter rate The charges of the vaccine and its administration shall be carved out of the office visit and reported on a separate line as outlined in the above example An encounter cannot be billed if vaccine administration is the only service the RHC provides For additional information on incident to services please see the Medicare Benefit Policy Manual Chapter 13 Section 60 at http www cms gov Regulations and Guidance Guidance Manuals downloads bp102c13 pdf on the CMS website RHCs do not receive any reimbursement on TOBs 71x for the technical component of services provided by clinics This is because the technical component of services are not within the scope of Medicare covered RHC services The associated technical component of services furnished by the clinic center are billed on other types of claims that are subject to strict editing to enforce statutory frequency limits FQHCs 77X TOBs The Affordable Care Act Section 10501 i 3 A amended the Social Security Act Section 1834 see http www ssa gov OP_Home ssact title18 1834 htm by adding a new subsection o titled Development and Implementation of Prospective Payment System This subsection provides the statutory framework for development and implementation of a Prospective Payment Syste
23. 2 1 OPT 80 3 Photosensitive Drugs 80 3 1 Verteporfin 100 1 Bariatric Surgery 110 8 1 Stem Cell Transplants 110 4 Extracorpreal Photopheresis 110 10 IV Iron Therapy 150 3 Bone Mineral Density 160 18 VNS 160 24 Deep Brain Stimulation 160 27 TENS for CLBP 180 1 MNT 190 1 Histocompatibility Testing 190 8 Lymphocyte Mitogen Response Assay 190 11 Home PT INR 210 1 PSA Screening Tests 210 2 Screening Pap Pelvic Exams 210 3 Colorectal Cancer Screens 210 10 Screening for STIs 250 4 Treatment for AKs 250 3 IVIG for Autoimmune Blistering Disease 250 5 Dermal Injections for Facial LDS 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 07 JULY 2014 aA m Z mr O PN lt Ro O Hs T gt AD a gt 42 Background The purpose of CR 8691 is to both create and update NCD editing both hard coded shared system edits as well as local MAC edits that contain either ICD 9 diagnosis procedure codes or ICD 10 diagnosis procedure codes or both plus all associated coding infrastructure such as HCPCS CPT codes reason remark codes frequency edits Place of Service POS Type of Bill TOB provider specialties etc The requirements described in CR 8691 reflect the op
24. 2013 Medicare will accept and pay for FDG PET oncologic claims billed to inform initial treatment strategy or subsequent treatment strategy for suspected or biopsy proven solid tumors for all oncologic conditions without requiring the following QO modifier Investigational clinical service provided in a clinical research study that is in an approved Clinical research study institutional claims only e Q1 modifier routine clinical service provided in a clinical research study that is in an approved clinical research study institutional claims only e V70 7 Examination of participant in clinical research or e Condition code 30 institutional claims only Effective for dates of service on or after June 11 2013 MACs will use the following messages when denying claims in excess of three for PET FDG scans for subsequent treatment strategy when the KX modifier is not included identified by CPT codes 78608 78811 78812 78813 78814 78815 or 78816 modifier PS HCPCS A9552 and the same cancer diagnosis code e Claim Adjustment Reason Code CARC 96 Non Covered Charge s Note Refer to the 835 Healthcare Policy Identification Segment loop 2110 Service Payment Information REF if present e Remittance Advice Remarks Code RARC N435 Exceeds number frequency approved allowed within time period without support documentation This newsletter should be shared with all health care practitioners and managerial members R
25. 4 A m Z Cc O PN lt Ro O I 4 gt AD 5j gt 38 Table 2 27 Category Ill CPT Codes Implemented as of July 1 2014 CY 2014 July 2014 OPPS July 2014 CPT Code CY 2014 Long Descriptor Status Indicator OPPS APC Exposure adaptive behavior treatment with protocol modification requiring 0373T two or more technicians for severe maladaptive behavior s first 60 minutes S 0323 of technicians time face to face with patient 0374T Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe maladaptive behavior s each additional 30 minutes of technicians time face to face with patient List separately in Zz N A addition to code for primary procedure Billing for Drugs Biologicals and Radiopharmaceuticals a Drugs and Biologicals with Payments Based on Average Sales Price ASP Effective July 1 2014 In the 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 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 July 2014 release of the OPPS Pricer The updated payment rates effective July 1 2014 will be included in the July 2014 update of the OPPS Addendum A and Ad
26. 66 G0467 G0468 G0469 or G0470 that corresponds to the type of visit FQHC specific payment specific codes G0466 G0467 and G0468 must be reported under revenue code 052X or under revenue code 0519 NOTE Revenue code 0519 is only used for Medicare Advantage MA Supplemental claims FQHC specific payment codes G0469 and G0470 must be reported under revenue code 0900 or 0519 FQHCs must continue to report detailed HCPCS coding on the claim to describe all services that occurred during the encounter All service lines must be reported with their associated charges Payment for a FQHC encounter requires a medically necessary face to face visit Each FQHC specific payment code G0466 G0470 must have a corresponding service line with a HCPCS code that describes the qualifying visit See Attachment A of CR 8743 for a list of qualifying visits that correspond to the specific payment codes NOTE A link to CR 8743 is available in the Additional Information section at the end of this article When submitting a claim for a mental health visit furnished on the same day as a medical visit FQHCs must report a specific payment code for a medical visit G0466 G0467 or G0468 and a specific payment code for a mental health visit G0470 and each specific payment code must be accompanied by a service line with a qualifying visit This newsletter should be shared with all health care practitioners and managerial members RETURN TO of the provi
27. Chapter 1 section 10 at http www cms gov Regulations and Guidance Guidance Manuals downloads clm104c01 pdf on the CMS website and additional coverage requirements for the pneumococcal vaccine hepatitis B vaccine and influenza 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 07 JULY 2014 35 virus vaccine can be found in the Medicare Benefit Policy Manual Chapter 15 at http www cms gov Regulations and Guidance Guidance Manuals downloads bp102c15 pdf on the CMS website Hospital MM8776 July 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 MM8776 Related Change Request CR CR 8776 Related CR Release Date May 23 2014 Effective Date July 1 2014 Related CR Transmittal R2971CP Implementation Date July 7 2014 aA m Z mr O PN lt Ro O Hs T
28. E OF CONTENTS MEDICARE BULLETIN GR 2014 07 JULY 2014 17 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 CGS Administrators LLC Coverage Related CR Transmittal R167NCD and R2959CP Implementation Date October 6 2014 Provider Types Affected This MLN Matters article is intended for providers submitting claims to Medicare administrative contractors MACs for services furnished to Medicare beneficiaries A MM8757 Percutaneous Image guided y Lumbar Decompression PILD for Lumbar Spinal Stenosis LSS A The Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning lt lt 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 Ro MLNMattersArticles 2014 MLN Matters Articles html MLN Matters Number MM8757 Related Change Request CR CR 8757 aE Related CR Release Date May 16 2014 Effective Date January 9 2014 v gt D gt Provider Action Needed Effective for claims with dates of service on and after January 9 2014 Medicare will only allow coverage with evidence development CED for percutaneous image guided lumbar decomp
29. ETURN 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 07 JULY 2014 aA m Z mr O PN lt Ro O Hs T gt AD a gt 16 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 x e Group Code CO assigning financial liability to the provider if a claim is received with Zz a GZ modifier indicating no signed ABN is on file MACs will not search their files to adjust claims processed prior to implementation of CR 8739 However if you have such claims and bring them to the attention of your MAC the lt MAC will adjust such claims if appropriate lt Synopsis of Coverage of FDG PET for Oncologic Conditions Ro Effective for claims with dates of service on and after June 11 2013 the chart below O summarizes national FDG PET coverage for oncologic conditions T Initial Treatment Strategy Subsequent Treatment Strategy O FDG PET for Cancers formerly diagnosis amp formerly restaging amp monitoring Tumor Type staging response to treatment U Colorectal Cover Cover gt Esophagus Cover Cover A lea ane Ma Cover Cover z not thyroid CNS gt Lymphoma Cover Cover Non small cell
30. IN GR 2014 07 JULY 2014 2 Administration 2014 Provider Contact Center PCC Training 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 1 866 590 703 will be closed for CSR training and staff development as indicated below The Interactive 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 July Date PCC Office Closed Friday July 4 2014 Holiday CGS office closed Thursday July 10 2014 PCC Closed 9 00 a m 11 00 a m ET Thursday July 24 2014 PCC Closed 9 00 a m 11 00 a m ET For your reference access the Kentucky Ohio Part A 2014 Holiday Training Closure Schedule at http www cgsmedicare com parta cs holiday_schedule pdf for a complete list of PCC closures Administration Contact Information for CGS Medicare 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 pa
31. Injection ferric carboxymaltose 1 mg 9441 G Q9974 Injection Morphine Sulfate Preservative Free For N A N Epidural Or Intrathecal Use 10 mg HCPCS code C9441 Injection ferric carboxymaltose 1 mg will be deleted and replaced with HCPCS code Q9970 effective July 1 2014 HCPCS code J2275 Injection morphine sulfate preservative free sterile solution per 10 mg and will be replaced with HCPCS code Q9974 effective July 1 2014 The SI for HCPCS code J2275 will change to E Not Payable by Medicare effective July 1 2014 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 07 JULY 2014 A m Z O PN am Ro O ce U gt Bu 5j gt 39 d Revised Sls for HCPCS Codes J2271 and Q2052 Effective July 1 2014 the SI for HCPCS code J2271 Injection morphine sulfate 100mg will change 1 From SI N Paid under OPPS payment is packaged into payment for other services Therefore there is no separate APC payment 2 To SI E Not paid by Medicare when submitted on outpatient claims any outpatient bill type Effective April 1 2014 the SI for HCPCS code Q2052 Services supplies and accessories used in the home under the
32. JULY 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 U gt AU gt Medi Bulleti 3 edicare Bulletin A aoe Z J risdichon 15 4 C ADMINISTRATION CLAIMS Zz 2014 Provider Contact Center PCC Training 3 MM8401 Revised Mandatory Reporting Ro Contact Information for CGS Medicare PartA 3 of an 8 Digit Clinical Trial Number on Claims 13 e eOffset Using myCGSs COV E R AG E T Clarification of Valid Requests ooo eee 3 Medicare Learning Network MM8739 Revised Fluorodeoxyglucose FDG U0 A Valuable Educational Resource 4 Positron Emission Tomography PET for Solid gt MLN Connects Providere News 4 Tumors This Change Request CR rescinds and D full MM 8468 dated F 2014 1 MM8456 Rescinded Modifying the Ui ai nee a 6 2014 3 Daily Common Working File CWF to Medicare MM8757 Percutaneous Image guided gt Beneficiary Database MBD File to Include Lumbar Decompression PILD for Lumbar Diagnosis Codes on the Health Insurance Spinal Stenosis LSS ooo ceeeeeeeeeeeee 18 Portability and Accountability Act Eligibility Transaction System HETS 270 271 Transactions 5 FEE SCHEDULE MM8684 Claim Status Category and Claim Status Codes Update 5 MM8664 Revised April Update to the
33. LLC MEDICARE BULLETIN GR 2014 07 JULY 2014 aA m Z mr O PN lt Ro O Hs T gt A a gt 25 have paid under the Medicare program if the demonstration projects under this section were not implemented The costs of this demonstration were higher than expected and CMS has been recovering costs by deducting 2 percent from payments for chiropractic services Since CMS has determined that the costs are fully recovered the July update eliminates the 2 percent reduction for CPT codes 98940 98941 and 98942 that was utilized for the first half of CY 2014 effective July 1 2014 Additional Information The official instruction CR 8773 issued to your MAC regarding this change may be viewed at http Awww cms gov Regulations and Guidance Guidance Transmittals Downloads R2974CP 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 FQHC RHC MM8 743 Implementation of a Prospective Payment System PPS for Federally Qualified Health Centers FQHCs 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 http www cms gov Outreach and Education Med
34. Matters article MM8743 at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads MM8743 pdf on the CMS website and effective for cost reporting periods beginning on or after October 1 2014 FQHCs are required to implement a prospective payment system PPS FQHCs will remain under the all inclusive rate AIR system until their first cost reporting period beginning on or after October 1 2014 Listed below is a summary of the billing requirements for each facility that you need to know when submitting claims for either RHCs or FQHCs aA m Z mr O PN lt Ro O Hs T gt A a gt RHCs 71X Types of Bills TOBs The professional components of preventive services are part of the overall encounter and for TOB 71x these services have always been billed on revenue lines with the appropriate site of service revenue code in the 052x series In previous requirements HCPCS codes have only been required to report certain preventive services subject to frequency limits Effective for dates of service on or after January 1 2011 coinsurance and deductible are waived for the IPPE the annual wellness visit and other Medicare covered preventive services recommended by the USPSTF with a grade of A or B Detailed HCPCS coding is required to ensure that coinsurance and deductible are not applied to these preventive services Payment for the professional component of allowab
35. 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 07 JULY 2014 4 Administration MM8456 Rescinded 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 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 MM8456 Rescinded Related Change Request CR CR 8456 Related CR Release Date May 16 2014 Effective Date October 1 2014 Related CR Transmittal R1386OTN Implementation Date October 6 2014 aA m Z mr O PN lt Ro O Hs U gt Bu a gt Note This article was rescinded on May 20 2014 as a result of a revision to CR 8456 issued on May 16 The CR revision eliminated the need for provider education As a result this article is rescinded Administration MM8684 Claim Status Category and Claim Status Codes Update The Centers fo
36. OPPS provider not paid under the OPPS and for claims for limited services when provided in a home health agency HHA not under the Home Health Prospective Payment System HH PPS or claims for services to a hospice patient for the treatment of a non terminal illness Provider Action Needed This article is based on CR 8764 which informs MACs about the changes to the I OCE instructions and specifications for the I OCE that is used under the OPPS and Non OPPS for hospital outpatient departments community mental health centers all non OPPS providers and for limited services when provided in a HHA not under the HH PPS 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 07 JULY 2014 6 or to a hospice patient for the treatment of a non terminal illness Make sure your billing staffs are aware of these changes Background This instruction informs the MACs that the I OCE is being updated for July 1 2014 The I OCE routes all institutional outpatient claims which includes non OPPS hospital claims through a single integrated OCE which eliminates the need to update install and maintain two separate OCE software packages on a quarterly basis The full list of I OCE specificatio
37. PCS Mod Status Description PE RVUs PE RVUs Global 77293 A repran monen Tagg NA 722 Jan 1 to March 31 2014 mgmt simul 77293 TC A Pee piraon motong Te NA ZZZ Jan 1 to March 31 2014 mgmt simul Respirator motion Correction April 1 2014 RVU 71293 A ii i simul 10 72 NA ZZZ change effective January 1 to 9 December 31 2014 Respiratormotion Correction April 1 2014 RVU 77293 WTC A fa ss Ci 9 92 NA ZZZ change effective January 1 to 9 December 31 2014 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 07 JULY 2014 aA m Z mr O PN lt Ro O Hs U gt AD a gt 21 3 HCPCS code G9361 will be added to your Medicare contractor s systems HCPCS Code G9361 Procedure Status M Short Descriptor Doc comm risk calc Effective Date 01 01 2014 Work RVU 0 Full Non Facility PE RVU 0 Full Non Facility NA Indicator blank Full Facility PE RVU 0 Full Facility NA Indicator blank Malpractice RVU 0 Multiple Procedure Indicator 9 Bilateral Surgery Indicator 9 Assistant Surgery Indicator 9 Co Surgery Indicator 9 Team Surgery Indicator 9 PC TC 9 Site of Service 9 Global
38. Surgery XXX Pre 0 00 Intra 0 00 Post 0 00 Physician Supervision Diagnostic Indicator 09 Diagnostic Family Imaging Indicator 99 Non Facility PE used for OPPS Payment Amount 0 00 Facility PE used for OPPS Payment Amount 0 00 MP Used for OPPS Payment Amount 0 00 Type of Service 9 Long Descriptor Medical indication for induction Documentation of reason s for elective delivery or early induction e g hemorrhage and placental complications hypertension preeclampsia and eclampsia rupture of membranes premature prolonged maternal conditions complicating pregnancy delivery fetal conditions complicating pregnancy delivery malposition and malpresentation of fetus late pregnancy prior uterine surgery or participation in clinical trial 4 Correct the Physician Supervision of Diagnostic Procedures indicator for the TC s of the following codes effective January 1 2014 Physician Supervision of HCPCS Diagnostic Procedures Effective Code Phys Diag Supv Date Ct head brain w o dye Phys Diag Supv 70450 TC Correction TC 01 01 01 2014 te Cthead brain w dye Phys Diag Supv 70460 TC Correction TC 02 01 01 2014 Mri brain stem w o dye Phys Diag Supv 70551 TC Correction TC 01 01 01 2014 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
39. ach additional 30 minutes of technician time List separately in addition to code for primary procedure N A 0368T Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional with one patient first 30 minutes of patient face to face time 0322 0369T Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional with one patient each additional 30 minutes of patient face to face time List separately in addition to code for primary procedure N A 0370T Family adaptive behavior treatment guidance administered by physician or other qualified health care professional without the patient present 0324 0371T Multiple family group adaptive behavior treatment guidance administered by physician or other qualified health care professional without the patient present 0324 0372T Adaptive behavior treatment social skills group administered by physician or other qualified health care professional face to face with multiple patients 0325 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 CGS Administrators LLC MEDICARE BULLETIN GR 2014 07 RETURN TO TABLE OF CONTENTS JULY 201
40. ail notification service that provides you with prompt notification of Medicare news including policy benefits claims submission claims processing and educational events Subscribing for this service means that you will receive information as soon as itis available and plays a critical role in ensuring you are up do date on all Medicare information Consider the following benefits to joining the CGS ListServ Notification Service e It s free There is no cost to subscribe or to receive information e You only need a valid e mail address to subscribe 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 07 JULY 2014 9 e Multiple people e mail addresses from your facility can subscribe We recommend that all staff clinical billing and administrative who interacts with Medicare topics register individually This will help to facilitate the internal distribution of critical information and eliminates delay in getting the necessary information to the proper staff members To subscribe to the CGS ListServ Notification Service go to hitp www cgsmedicare com medicare_dynamic ls 001 asp and complete the required information Administration Submit Your Redetermination Reques
41. aims The CT is not to be coded on electronic claims All other information remains the same Provider Types Affected This MLN Matters article is intended for physicians providers and suppliers submitting claims to Medicare contractors fiscal intermediaries Fls carriers durable medical equipment DME Medicare administrative contractors MACs and A B MACs for items and services provided in clinical trials to Medicare beneficiaries Provider Action Needed This article is based on CR 8401 which informs you that effective January 1 2014 it will be mandatory to report a clinical trial number on claims for items and services provided in clinical trials that are qualified for coverage as specified in the Medicare National 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 07 JULY 2014 13 Coverage Determination NCD Manual Section 310 1 The clinical trial number to be reported is the same number that has been reported voluntarily since the implementation of CR 5790 dated January 18 2008 That is the number assigned by the National Library of Medicine NLM htip clinicaltrials gov website when a new study appears in the NLM Clinical Trials data
42. and attachments are correct This ensures the signature requirement for all redetermination requests has been met If the information was entered correctly and all desired attachments were included click OK to submit the Redetermination form and all attachments 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 07 JULY 2014 12 If any information needs to be corrected or if any attachments need to be added or deleted click Cancel to return to the form Attachment 4 rose canis Name 01 07 2014 Is this information correct Please review your informatio Required Field attachments carefully If they are correct please submit If not press Cancel Step 11 Click OK to submit Step 11 Click Cancel to correct information or add or remove attachments EA J15 HHH 1000 es outs By clicking on the Ok button you are signing the authorized to submit the information eee Cel ee near Chews 12 Once submitted a message will display in your myCGS inbox with the Subject indicating Secure Form Received Refer to the Messages Tab instructions found on the myCGS User Manual
43. ble Medical Equipment DME laboratory services excluding 36415 ambulance services hospital based services group services and non face to face services will be rejected Diabetes Self Management Training DSMT and Medical Nutrition Therapy MNT services are subject to the frequency edits described in Pub 100 04 Chapter 18 and should not be reported on the same day aA m Z mr O PN lt Ro O Hs U gt AD a gt FQHCs must report HCPCS codes for influenza and pneumococcal vaccines and their administration on a FQHC claim and these HCPCS codes will be considered informational only MACs shall continue to pay for the influenza and pneumococcal vaccines through the cost report Please refer to the examples in Attachment B of CR8743 for additional billing guidance Medicare Payment The total payment amount for a FQHC visit shall be the lesser of the FQHC s reported charge for the FQHC payment code or the fully adjusted FQHC PPS rate for the specific payment code Under the FQHC PPS MACs shall generally pay 80 percent of the lesser of the FQHC s charge for the FQHC payment code or the corresponding FQHC PPS rate Coinsurance will generally be 20 percent of the lesser of the actual charge or the FQHC PPS rate Medicare waives coinsurance for certain preventive services For FQHC claims that consist solely of preventive services that are exempt from beneficiary coinsurance MACs shall pay 100 percent of the less
44. ce with corrected information if warranted and c Group Code Contractual Obligation CO e MACs will return the professional PILD claim as unprocessable if it does not contain the required clinical trial diagnosis code V70 7 ICD 9 or Z00 6 ICD 10 in either the primary secondary positions using a CARC B22 This payment is adjusted based on the diagnosis b RARC M76 Missing incomplete invalid diagnosis or condition c RARC N704 Alert You may not appeal this decision but can resubmit this claim service with corrected information if warranted and d Group Code Contractual Obligation CO e MACs will return the professional PILD claim as unprocessable when billed without Modifier QO using a CARC 4 The procedure code is inconsistent with the modifier used or a required modifier is missing b RARC N657 This should be billed with the appropriate code for these 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 http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 07 JULY 2014 19 c RARC N704 Your claim contains incomplete and or invalid information and no appeal rights are afforded because the claim is unprocessable Please submit a new claim with the comple
45. cial instruction CR 8684 issued to your MAC regarding this change is available at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R2967CP pdf on the CMS website aA m Z mr O PN lt Ro O Hs T gt AD a gt 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 Administration MM8 764 July 2014 Integrated Outpatient Code Editor I OCE Specifications Version 15 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 html MLN Matters Number MM8764 Related Change Request CR CR 8764 Related CR Release Date May 16 2014 Effective Date July 1 2014 Related CR Transmittal R2957CP 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 the home health and hospice MACs for outpatient services provided to Medicare beneficiaries and paid under the Outpatient Prospective Payment System OPPS and for outpatient claims from any non
46. dendum B which will be posted at http Awww cms gov Medicare Medicare Fee for Service Payment HospitalOutpatientPPS Addendum A and Addendum B Updates html on the CMS website Drugs and Biologicals with OPPS Pass Through Status Effective July 1 2014 Three drugs and biologicals have been granted OPPS pass through status effective July 1 2014 These items along with their descriptors and APC assignments are identified below in Table 3 Table 3 Drugs and Biologicals with OPPS Pass Through Status Effective July 1 2014 HCPCS Code Long Descriptor APC Status Indicator c9022 Injection elosulfase alfa 1mg 1480 G C9134 Factor XIII antihemophilic factor recombinant Tretten per 10 i u 1481 G J1446 Injection tbo filgrastim 5 micrograms 1447 G Note The HCPCS codes identified with an indicate that these are new codes effective July 1 2014 New HCPCS Codes Effective July 1 2014 for Certain Drugs and Biologicals Two new HCPCS codes have been created for reporting certain drugs and biologicals other than new pass through drugs and biological listed in Table 4 in the hospital outpatient setting for July 1 2014 These codes are listed below in Table 4 and they are effective for services furnished on or after July 1 2014 Table 4 New HCPCS Codes for Certain Drugs and Biologicals Effective July 1 2014 HCPCS Code Long Descriptor APC Status Indicator Effective 7 1 14 Q9970
47. der 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 07 JULY 2014 aA m Z mr O PN lt Ro O Hs T gt AD a gt 28 When submitting a claim for a subsequent illness or injury FQHCs must report the appropriate specific payment code G0467 for a medical visit or G0470 for a mental health visit with modifier 59 Modifier 59 is the FQHC s attestation that the patient subsequent to the first visit suffers an illness or injury that requires additional diagnosis or treatment on the same day Modifier 59 should only be used when reporting unrelated services that occurred at separate times during the day e g the patient had left the FQHC and returned later in the day for an unscheduled visit for a condition that was not present during the first visit NOTE A qualifying visit is still required when reporting modifier 59 with G0467 or G0470 FQHCs must report all services that occurred on the same day on one claim FQHC may submit claims that span multiple days of service However FQHCs transitioning to the PPS must submit separate claims for services subject to the PPS and services paid based on the AIR MACs shall reject claims with multiple dates of service that include both PPS and non PPS dates as determined based on the individual FQHC s cost reporting period Dura
48. ducts 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 Hospitals should no longer use TOB 14X in these circumstances CMS is providing related updates to the Medicare Claims Processing Manual Publication 100 04 Chapter 2 Section 90 and Chapter 16 Sections 30 3 40 3 and 40 3 1 which are included as an attachment to CR 8766 Clarification of Payment for Certain Hospital Part B Inpatient Labs As recently provided in CR 8445 Transmittal 2877 published on February 7 2014 see http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads MM8445 pdf on the CMS website and CR 8666 Transmittal 182 published on March 21 2014 see hitp www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads MM8666 pdf on the CMS website hospitals may only bill for a limited set of Part B inpatient services when beneficiaries who have Part B coverage are treated as hospital inpatients and aA m Z mr O PN lt Ro O Hs T gt A a gt 1 They are not eligible for or entitled to coverage under Part A or 2 They are entitled to Part A but have exhausted their Part A benefits CMS is clarifyin
49. e PPS FQHCs are required to report separate revenue lines for influenza virus or pneumococcal pneumonia vaccines PPV on the 77x claims The charges of these vaccines and the administration shall be carved out of the office visit and reported on a separate line as outlined in example A The cost for these services will continue to be reimbursed through cost reporting Coinsurance and deductible do not apply to either of these vaccines Hepatitis B vaccine is included in the encounter rate The charges for the vaccine and its administration will be carved out of the office visit and reported on a separate line as outlined in example A An encounter cannot be billed if vaccine administration is the only service the FQHC provides For additional information on incident to services please see Chapter 13 Section 60 of the Medicare Benefit Policy Manual at htip www cms gov Regulations and Guidance Guidance Manuals downloads bp102c13 pdf on the CMS website Laboratory and technical components should continue to be billed as non FQHC services 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 CGS Administrators LLC RETURN TO TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 07 JULY 2014 34 Summary of Differences The chart below displays a list of ele
50. e 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 aA m Z mr O PN lt Ro O Hs U gt A a gt e Ensure that providers have time to react and prepare for new requirements e Announce new or changing Medicare requirements on a 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 www 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 Administration Stay Informed and Join the CGS ListServ Notification Service The CGS ListServ Notification Service is the primary means used by CGS to communicate with Kentucky and Ohio Medicare Part A providers This is a free em
51. earch 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 2015 GEMs Reimbursement Mappings and ICD 10 Files Now Available The 2015 General Equivalence Mappings GEMs Reimbursement Mappings ICD 10 CM files and ICD 10 PCS files are now available on the 2015 ICD 10 CM and GEMs Web page at http www cms gov Medicare Coding ICD10 2015 ICD 10 CM and GEMs htm and 2015 ICD 10 PCS and GEMs Web page at hiip www cms gov Medicare Coding ICD10 2015 ICD 10 PCS and GEMs html The mappings can be used to convert policies from ICD 9 CM to ICD 10 codes The GEMs provide both forward ICD 9 CM to ICD 10 and backward ICD 10 to ICD 9 CM mappings There are no new revised or deleted ICD 10 CM or ICD 10 PCS codes aA m Z mr O PN lt Ro O Hs U gt A a gt Administration Provider Contact Center Reminders Your questions are important to us and CGS s Provider Contact Centers PCCs strive to provide the most accurate and consistent information to our provider community There may be times when we receive a question that requires additional research before an accurate response can be provided by the Customer Service Representative Please be advised that every effort is taken to research your questions and to return your call as soon as possible However the Centers for Medicare
52. ect that CMS has ended the coverage with evidence development CED requirement for 2 F18 fluoro 2 deoxy D glucose FDG PET 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 Healthcare Common Procedure Coding System HCPCS Code A9552 only Note For clarification purposes as an example each different cancer diagnosis is allowed one 1 initial treatment strategy Pl modifier FDG PET Scan and three 3 subsequent treatment strategy PS modifier FDG PET Scans without the KX modifier The fourth FDG PET Scan and beyond for subsequent treatment strategy for the same cancer diagnosis will always require the KX modifier If a different cancer diagnosis is reported whether reported with a PI modifier or a PS modifier that cancer diagnosis will begin a new count for subsequent treatment strategy for that beneficiary A beneficiary s file may or may not contain a claim for initial treatment strategy with a PI modifier The existence or non existence of an initial treatment strategy claim has no bearing on the frequency count of the subsequent treatment strategy PS claims Providers may refer to Attachment 1 of CR 8739 for a list of appropriate diagnosis codes Effective for claims with dates of service on or after June 11
53. er of the provider s charge for the FQHC payment code or the FQHC PPS rate and no beneficiary coinsurance would be assessed For FQHC claims that include a mix of preventive and non preventive services MACs shall use the lesser of the provider s charge for the specific FQHC payment code or the corresponding FQHC PPS rate to determine the total payment amount To determine the amount of Medicare payment and the amount of coinsurance that should be waived MACs shall use the FQHC s reported line item charges and subtract the dollar value of the FQHC s reported line item charge for the preventive services from the full payment amount See the Medicare Claims Processing Manual Pub 100 04 chapter 18 section 1 2 for a table of preventive services that are exempt from beneficiary coinsurance That manual chapter is available at http www cms gov Regulations and Guidance Guidance Manuals Downloads clm104c18 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 07 JULY 2014 29 Claims for Medicare Advantage MA Supplemental Payments FQHCs that have a written contract with a MA organization that furnishes care to beneficiaries covered by the MA
54. erational changes that are necessary to implement the conversion of the Medicare systems from ICD 9 to ICD 10 specific to the 29 NCD spreadsheets attached to CR8691 Additional Information The official instruction CR 8691 issued to your MAC regarding this change is available at http www cms hhs gov Regulations and Guidance Guidance Transmittals Downloads R13880TN pdf on the CMS website Note that there are 29 spreadsheets attached to CR 8691 and those spreadsheets relate to 9 NCDs and provide pertinent policy coding information necessary to implement ICD 10 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 MM7818 is available for review at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads MM7818 pdf on the CMS website MM8109 is available for review at hitp www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads MM8109 pdf on the CMS website aA m Z mr O PN lt Ro O Hs U gt A a gt MMB8197 is available for review at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads MM8197 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
55. ere made to this article The CR release date and the Web address for accessing the CR are revised 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 TABLE OF CONTENTS http www cgsmedicare com 2014 Copyright CGS Administrators LLC MEDICARE BULLETIN GR 2014 07 JULY 2014 20 Provider Types Affected This MLN Matters article is intended for physicians other providers and suppliers who submit claims to Medicare claims administration contractors carriers fiscal intermediaries Fls A B Medicare administrative contractors MACs home health and hospices HH amp Hs MACs and or regional HH intermediaries RHHIs for services provided to Medicare beneficiaries Provider Action Needed This article is based on CR 8664 which amends the payment files that were issued to Medicare contractors based upon the CY 2014 MPFS Final Rule and passage of the Protecting Access to Medicare Act of 2014 which the President signed on April 1 2014 Make sure that your billing staffs are aware of these changes Background The Social Security Act Section 1848 c 4 see hitp www ssa gov OP_Home ssact title18 1848 htm on the Internet authorizes CMS to establish ancillary policies necessary to implement relative values for physicians services
56. erisk Refer to the Forms Tab instructions found on the myCGS User Manual Web page at http www cgsmedicare com mycgs manual htm for additional information 7 Once all the information is entered click Validate myCGS will validate the information entered If information is missing or invalid a message will display indicating the information that must be corrected If information entered is complete and correct the message Your entries have been validated Please attached the required documents input your name and click Submit will display 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 07 JULY 2014 11 Claims Information Service Date From Service Date To Date of Initial Determination Claim DCN i ices DENSI SIN ES Remove Clear All Is there an Overpayment Appeal Cyes No Step 7 Reasons Rationale Click to validate the haracters left information entered Validate NOTE The Attachments section of the Redetermination form allows you to attach documentation e g medical records notes orders etc you would like CGS to consider when processing your redete
57. ewsletters 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 07 JULY 2014 24 HCPCS Short Descriptor Procedure Status 1036 Art pancreas ext transmitter 1037 Art pancreas ext receiver 0347T Ins bone device for rsa C 0348T Rsa spine exam C 0349T Rsa upper extr exam C 0350T Rsa lower extr exam C 0351T Intraop oct brst node spec C 0352T Oct brst node i amp r per spec C 0353T Intraop oct breast cavity C 0354T Oct breast surg cavity i amp r C 0355T Gi tract capsule endoscopy C 0356T Insrt drug device for iop C 0358T Bia whole body C 0359T Behavioral id assessment C 0360T Observ behav assessment C 0361T Observ behav assess addl C 0362T Expose behav assessment C 0363T Expose behav assess addl C 0364T Behavior treatment C 0365T Behavior treatment addl C 0366T Group behavior treatment C 0367T Group behav treatment addl C 0368T Behavior treatment modified C 0369T Behav treatment modify addl C 0370T Fam behav treatment guidance C 0371T Mult fam behav treat guide C 0372T Social skills training group C 0373T Exposure behavior treatment C 0374T Expose behav treatment addl C All the additional codes listed in the above table are effective as of July 1 2014 For full details on the above codes including on descriptors place of
58. f bill TOB 13X or 85X and for professional claims billed with a place of service POS 22 outpatient or 24 ambulatory surgical center Medicare will allow CED for PILD procedure code 0275T for LSS ICD 9 diagnosis range 724 01 724 03 or ICD 10 diagnosis range M48 05 M48 07 only when billed with a Diagnosis code ICD 9 V70 7 ICD 10 Z00 6 and condition code 30 either in the primary or secondary positions and b Modifier Q0 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 07 JULY 2014 18 c An 8 digit clinical trial number listed at hitp www cms gov Medicare Coverage Coverage with Evidence Development PILD html on the CMS CED website e On or after January 9 2014 effective for hospital outpatient procedures on type of bill TOB 13X or 85X your MAC will reject claims for PILD procedure code 0275T for LSS ICD 9 diagnosis range 724 01 724 03 or ICD 10 diagnosis range M48 05 M48 07 when billed without a Diagnosis code ICD 9 V70 7 ICD 10 Z00 6 in either the primary secondary positions b Modifier QO condition code 30 institutional claims only and c An 8 digit clinical trial number listed on the CMS website When rejecting these claims the
59. g its general payment policy that for hospitals paid under the OPPS these Part B inpatient services are separately payable under Part B and are excluded from OPPS packaging if the primary service with which the service would otherwise be bundled is not a payable Part B inpatient service CMS has adjusted its claims processing logic to make separate payment for Laboratory services paid under the CLFS pursuant to this policy that would otherwise be OPPS packaged beginning in 2014 Hospitals should consult their MAC for reprocessing of any 12X TOB claims with dates of service on or after January 1 2014 that were denied and should be paid under this policy Coverage Determinations The fact that a drug device procedure or service is assigned a HCPCS code and a 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 Medicare contractors determine that it is reasonable and necessary to treat the beneficiary s condition and whether it is excluded from payment Additional Information The official instruction CR 8776 issued to your MAC regarding this change is available at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R2971CP pdf on the CMS website If you have an
60. ge at http www cgsmedicare com parta cs index 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 Administration eOffset Using myCGS Clarification of Valid Requests In May CGS announced a new feature in the myCGS Web Portal eOffset This feature allows registered users to submit electronic authorizations to offset from pending overpayments that are owed to CGS This option allows providers to request an immediate offset each time a demanded overpayment is received or authorize a permanent request for all future demanded overpayments To use the eOffset function for an immediate offset the provider must have received an overpayment demand letter from CGS The letter will include a number in the upper right corner of the letter An eOffset may be requested by using this number or the account receivable AR number located on the attachment to the demand letter MEDICARE CENTERS FOR MEDICARE amp MEDICAID SERVICES Ese e a 2988808 l 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 07 JULY 2014 aA m Z mr O PN lt Ro O
61. gt A a gt Provider Types Affected This MLN Matters article is intended for providers and suppliers who submit claims to Medicare administrative contractors MACs including home health and hospice MACs for services provided to Medicare beneficiaries Provider Action Needed This article is based on CR 8776 which describes changes to and billing instructions for various payment policies implemented in the July 2014 Outpatient Prospective Payment System OPPS update Make sure your billing staffs are aware of these changes Background CR 8776 describes changes to and billing instructions for various payment policies implemented in the July 2014 OPPS update The July 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 Status Indicator SI and Revenue Code additions changes and deletions identified in CR 8776 The July 2014 revisions to I OCE data files instructions and specifications are provided in the forthcoming CR 8764 The MLN Matters article related to CR 8764 is available at http Avwww cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads MM8764 pdf on the CMS website Key changes to and billing instructions for various payment policies implemented in the July 2014 OPPS update are as follows Changes to Device Edits for July 2014 The
62. icare Learning Network MLN MLNMattersArticles 2014 MLN Matters Articles htm MLN Matters Number MM8743 Related Change Request CR CR 8743 Related CR Release Date May 9 2014 Effective Date October 1 2014 Related CR Transmittal R13830TN Implementation Date October 6 2014 Provider Types Affected This MLN Matters article is intended for federally qualified health centers FQHCs submitting claims to Part A Medicare administrative contractors A MACs for services furnished to Medicare beneficiaries Provider Action Needed STOP Impact to You CMS is establishing a Federally Qualified Health Center FQHC Prospective Payment System PPS with specific payment codes that FQHCs must use in order to ensure payment CAUTION What You Need to Know CR 8743 from which this article is taken implements the FQHC PPS effective for cost reporting periods beginning on or after October 1 2014 This article does not apply to any FQHC claims that are not subject to the PPS FQHCs will remain under the all inclusive rate AIR system until their first cost reporting period beginning on or after October 1 2014 GO What You Need to Do Make sure your billing staffs are aware of these new coding requirements Background Except for services that are paid at 100 percent of costs Medicare currently pays FQHCs 80 percent of their AIR MACs reconcile costs and visits at year end through cost report settlement Th
63. ing Network MLN offered by the Centers for Medicare amp Medicaid Services CMS includes a variety of educational resources for health care providers Access Web based training courses national provider conference calls materials from past conference calls MLN articles and much more To stay informed about all of the CMS MLN products refer to http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads MailingLists FactSheet pdf and subscribe to the CMS electronic mailing lists Learn more about what the CMS MLN offers at http www cms gov Outreach and Education Medicare Learning Network MLN MLNGenInfo index html on the CMS website Administration MLN Connects Provider e News The MLN Connects Provider e News contains a weeks 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 May 22 2014 http go cms gov 1jVHzTn e May 29 2014 hitp go usa gov 8PgC e June 5 2014 http go cms gov S8OnGR e June 12 2014 http go usa gov 8ugz This newsletter should be shared with all health care practitioners and managerial members RETURN T
64. initial preventive physical examination IPPE or an annual wellness visit AWV CMS is establishing specific payment codes to be used under the FQHC PPS based on descriptions of services that will correspond to the appropriate PPS rates aA m Z mr O PN lt Ro O Hs T gt AD a gt The PPS rates will also be adjusted to account for geographic differences in the cost of inputs by applying FQHC geographic adjustment factors FQHC GAFs In calculating the total payment amount the FQHC GAF will be based on the locality of the site where the services are furnished For FQHC organizations with multiple sites the FQHC GAF may vary depending on the location of the FQHC delivery site From October 1 2014 through December 31 2015 the FQHC PPS base payment rate is 158 85 Updates to the FQHC PPS base payment rate and the FQHC GAF will be made available through program instruction The FQHC PPS rates will be calculated as follows Base payment rate x FQHC GAF PPS rate If the patient is new to the FQHC or the FQHC is furnishing an IPPE initial AWV or subsequent AWV the PPS rate will be adjusted by 1 3416 This is a composite adjustment factor and would only be applied once per day The PPS rate in this case would be calculated as follows Base payment rate x FQHC GAF x 1 3416 PPS rate To qualify for an encounter based payment a FQHC visit must meet all applicable coverage requirements Additional information on
65. is 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 07 JULY 2014 26 In compliance with the statutory requirements of the Affordable Care Act CMS established a national encounter based prospective payment rate for all FQHCs determined based on an average of the reasonable costs of all FQHCs FQHCs will transition to the FQHC PPS based on their cost reporting periods For FQHCs with cost reporting periods beginning before October 1 2014 MACs shall continue to pay the FQHCs using the current AIR system For FQHCs with cost reporting periods beginning on or after October 1 2014 MACs shall pay the FQHCs using the FQHC PPS Under the FQHC PPS Medicare will pay FQHCs based on the lesser of their actual charges or the PPS rate for all FQHC services furnished to a beneficiary on the same day when a medically necessary face to face FQHC visit is furnished to a Medicare beneficiary Medicare will allow for an additional payment when an illness or injury occurs subsequent to the initial visit or when a mental health visit is furnished on the same day as a medical visit The PPS rate will be adjusted when a FQHC furnishes care to a patient who is new to the FQHC or to a beneficiary receiving an
66. le preventive services is made under the all inclusive rate when all of the program requirements are met Lab and technical components should continue to be billed as non RHC services Basic RHC Billing for Preventive Services When one or more preventive service that meets the specified criteria is provided as part of an RHC visit charges for these services must be deducted from the total charge for purposes of calculating beneficiary coinsurance and deductible For example if the total charge for the visit is 150 and 50 of that is for a qualified preventive service the beneficiary coinsurance and deductible is based on 100 of the total charge To ensure coinsurance and deductible are waived for qualified preventive services RHCs must report an additional revenue line with the appropriate site of service revenue code in the 052X series with the approved preventive service HCPCS code and the associated charges For example the service lines should be reported as follows 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 07 JULY 2014 31 Line Revenue Code HCPCS Code Date of Service Charges 1 052X 01 01 2011 100 00 2 052X Preventive Service Code 01 01 2011 0 00
67. linical trial claim includes e Condition code 30 ICD 9 code of V70 7 ICD 10 code Z00 6 in either the primary or secondary positions and e Modifier QO and or Q1 as appropriate outpatient claims only For professional claims the 8 digit clinical trial number preceded by the 2 alpha characters of CT use CT only on paper claims must be placed in Field 19 of the paper claim Form CMS 1500 e g CT12345678 or the electronic equivalent 837P in Loop 2300 REF02 REF01 P4 do not use CT on the electronic claim e g 12345678 when a Clinical trial claim includes ICD 9 code of V70 7 ICD 10 code Z00 6 in either the primary or secondary positions and e Modifier QO and or Q1 as appropriate outpatient claims only Medicare Part B clinical trial registry study claims with dates of service on and after January 1 2014 not containing an 8 digit clinical trial number will be returned as unprocessable to the provider for inclusion of the trial number using the messages listed below e Claim Adjustment Reason Code CARC 16 Claim service lacks information which is needed for adjudication At least one Remark Code must be provided may be comprised of either National Council for Prescription Drug Programs NCPDP Reject Reason Code or Remittance Advice Remark Code RARC that is not an ALERT e RARC MASO Missing incomplete invalid Investigational Device Exemption number This newsletter should be shared with all health ca
68. lung Cover Cover Ovary Cover Cover Brain Cover Cover Cervix Cover with exceptions Cover Small cell lung Cover Cover Soft tissue sarcoma Cover Cover Pancreas Cover Cover Testes Cover Cover Prostate Non cover Cover Thyroid Cover Cover a d female Cover with exceptions Cover Melanoma Cover with exceptions Cover All other solid tumors Cover Cover Myeloma Cover Cover a s cancers not Cover Cover Cervix Nationally non covered for the initial diagnosis of cervical cancer related to initial anti tumor treatment strategy All other indications for initial anti tumor treatment strategy for cervical cancer are nationally covered Breast Nationally non covered for initial diagnosis and or staging of axillary lymph nodes Nationally covered for initial staging of metastatic disease All other indications for initial anti tumor treatment strategy for breast cancer are nationally covered Melanoma Nationally non covered for initial staging of regional lymph nodes All other indications for initial anti tumor treatment strategy for melanoma are nationally covered Additional Information The official instruction CR 8739 issued to your MAC regarding this change is available at in two transmittals at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R2932CP pdf and http www cms gov Regulations and Guidance Guidance Transmittals Downloads R168NCD pdf on the CMS website RETURN TO TABL
69. m PPS for Medicare FQHCs The Social Security Act Section 1834 0 1 B as amended by the Affordable Care Act addresses collection of data necessary to develop and implement the new Medicare FQHC PPS Specifically the Affordable Care Act grants the Secretary of Health and Human Services the authority to require FQHCs to submit such information as may be required in order to develop and implement the Medicare FQHC PPS including the reporting of services using HCPCS 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 07 JULY 2014 32 codes The Affordable Care Act requires that the Secretary impose this data collection submission requirement no later than January 1 2011 Beginning with dates of service on or after January 1 2011 when billing Medicare FQHCs must report all services provided during the encounter visit by listing the appropriate HCPCS code The additional revenue lines with detailed HCPCS code s are for information and data gathering purposes in order to develop the FQHC PPS set to be implemented in 2014 The additional data will not be utilized to determine current Medicare payment to FQHCs The Medicare claims processing system will continue to make payments under the
70. ments and notes the differences between RHCs and FQHCs Element RHCs FQHCs All except 002x 024x 029x 045x 054x 056x 060x 065x 067x 072x 080x 088x 093x or 096 310x Revenue Codes 052X series Required for Preventive Services HCPCS code only excluding Flu and PPV Required for all services rendered during encounter visit Modifier 59 Not applicable at this time a be used to report two distinct unrelated visits on the same DSMT and MNT Not separately payable All inclusive payment rate November 2013 Manual Updates In November 2013 CR 8504 updated Chapter 13 of the Medicare Benefit Policy Manual to reflect numerous updates that were effective on January 1 2014 The MLN Matters article MM8504 which relates to CR 8504 is available at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads MM8504 pdf on the CMS website A m Z C O PN ey Ro O a T gt A J gt The FQHC PPS FQHCs will transition to the FQHC PPS based on their cost reporting periods For FQHCs with cost reporting periods beginning before October 1 2014 MACs shall continue to pay the FQHCs using the current AIR system For FQHCs with cost reporting periods beginning on or after October 1 2014 MACs shall pay the FQHCs using the FQHC PPS Under the FQHC PPS Medicare will pay FQHCs based on the lesser of their actual charges or the PPS rate for all FQHC
71. must be deducted from the total charge for purposes of calculating beneficiary coinsurance correctly For example if the total charge for the visit is 350 00 and 50 00 of that is for a qualified preventive service the beneficiary coinsurance and deductible is based on 300 00 of the total charge Example A Line Rev Code HCPCS code Date of Service Charges 1 0521 Office Visit 01 01 300 00 2 0636 Penicillin Injection 01 01 125 00 3 0271 Wound Cleaning 01 01 125 00 4 0771 Preventive Service Code 01 01 50 00 When reporting multiple services on the same day that are unrelated modifier 59 must be used to report these services e g treatment for an ear infection in the morning and treatment for injury to a limb in the afternoon Line Rev Code HCPCS code Modifier Date of Service Charges 1 0521 Office Visit 01 01 150 00 2 0479 Removal of Wax From Ear 01 01 100 00 3 0521 Office Visit 59 01 01 450 00 4 0271 Wound Cleaning 01 01 150 00 5 0279 Bone Setting With Casting 01 01 300 00 When reporting an additional encounter for IPPE the revenue lines should be reflected as follows Example C Line Rev Code HCPCS code Date of Service Charges 1 0521 Office Visit 01 01 75 00 2 0419 Breathing Treatment 01 01 75 00 3 0521 IPPE G0402 01 01 150 00 V LYVd OIHO 8 AWONLNA As of January 01 2011 for data collection and analysis for th
72. nd it is available at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R167NCD pdf on the CMS website The second transmittal updates the Medicare Claims Processing Manual and it is available at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R2959CP pdf on the same site Fee Schedule MM8664 Revised April Update to the Calendar Year CY 2014 Medicare Physician Fee Schedule Database MPFSDB The Centers for Medicare amp Medicaid Services CMS has revised 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 MM8664 Revised Related Change Request CR CR 8664 Related CR Release Date April 4 2014 Effective Date January 1 2014 Related CR Transmittal R2923CP Implementation Date April 7 2014 Note This article was revised on April 8 2014 to reflect the revised CR 8664 issued on April 4 The CR was revised to reflect the President signing into law the Protecting Access to Medicare Act of 2014 on April 1 2014 thus averting the expiration of the 0 5 update to the physician fee schedule conversion factor and the 1 0 work floor GPCI which will now remain in effect until December 31 2014 Similar changes w
73. ne contains modifier 59 Modifier 59 signifies that the conditions being treated are totally unrelated and services are provided at separate times of the day e g treatment for an ear infection in the morning and treatment for injury to a limb in the afternoon Services subject to the Medicare outpatient mental health treatment limitation are billed under revenue code 0900 Diabetes Self Management Training DSMT is billed under revenue code 052x and HCPCS code G0108 and Medical Nutrition Therapy MNT is billed under revenue code 052x and HCPCS code 97802 97803 or G0270 and The Initial Preventive Physical Examination IPPE billed under revenue code 052X and HCPCS code G0402 This is a once in a lifetime benefit HCPCS coding is required Note Modifier 59 is not required for DSMT MNT or IPPE in order to receive an additional encounter payment 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 07 JULY 2014 33 When reporting multiple services on FQHC claims the 052X revenue line should include the total charges for all of the services provided during the encounter For preventive services with a grade of A or B from the USPSTF the charges for these services
74. ns is available at http www cms gov Medicare Coding OutpatientCodeEdit index html on the CMS website The summary of key changes for providers is in the following table Effective Date Modification Modify the effective begin date for edit 86 from 10 1 2013 to 10 1 2014 to be applied for claims with 10 1 2014 D hospice bill types 81X and 82X 4 1 2014 Modify the logic for packaged laboratory services If packaged laboratory services are submitted on a 13X bill type with modifier L1 change the Status Indicator SI from N to A 7 4 2014 Make Healthcare Common Procedure Coding System HCPCS Ambulatory Payment Classification APC SI changes as specified by CMS data change files 7 1 2014 Implement version 20 2 of the NCCI as modified for applicable institutional providers 1 1 2014 Add new modifier L1 Separately payable lab test to the valid modifier list 7 1 2014 Add new modifier SZ Habilitative services to the valid modifier list Updated documentation in Appendix F a and Appendix L to include bill type 13x for laboratory services 1 1 2014 reported with modifier L1 Documentation change only modified Appendix N List B PHP Services to note the add on codes 7 1 2014 in a separate list as part of PHP List C referred to in Appendix C a Partial Hospitalization Logic effective v10 0 Additional Information The official instruction CR 8764 issued to your MAC regarding this change i
75. ong descriptor Payment Copayment Brachytherapy source cesium 131 chloride solution 18 97 3 80 per millicurie Brachytx C2644 7 01 2014 U 2644 cesium43t chloride Category Ill Current Procedural Terminology CPT Codes The American Medical Association AMA releases Category III CPT codes twice per year 1 in January for implementation beginning the following July and 2 in July for implementation beginning the following January For the July 2014 update CMS is implementing in the OPPS 27 Category III CPT codes that the AMA released in January 2014 for implementation on July 1 2014 Of the 27 Category III CPT codes shown in Table 2 below 17 of the Category III CPT codes are separately payable under the hospital OPPS The Sls and APCs for these codes are shown in Table 2 below Payment rates for these services can be found in Addendum B of the July 2014 OPPS Update that is posted at http www cms gov Medicare Medicare Fee for Service Payment HospitalOutpatientPPS Addendum A and Addendum B Updates html on the CMS website Table 2 27 Category Ill CPT Codes Implemented as of July 1 2014 CY 2014 July 2014 OPPS July 2014 CPT Code CY 2014 Long Descriptor Status Indicator OPPS APC 0347T Placement of interstitial device s in bone for radiostereometric analysis Q2 0420 RSA Radiologic examination radiostereometric analysis RSA spine
76. or 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 8739 which advises MACs effective for dates of service on 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 07 JULY 2014 15 or after June 11 2013 to cover three FDG PET scans 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 your MAC Make sure your billing staffs are aware of these changes Background CMS has reconsidered 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 CR8739 The term FDG PET includes PET computed tomography CT and PET magnetic resonance MRI CMS is revising the NCD Manual Section 220 6 to refl
77. p 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 MM8773 Related Change Request CR CR 8773 Related CR Release Date June 6 2014 Effective Date July 1 2014 Related CR Transmittal R2974CP 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 administrative contractors MACs including home health and hospice HHH MACs for services provided to Medicare beneficiaries aA m Z mr O PN lt Ro O Hs T gt AD a gt Provider Action Needed This article is based on CR 8773 which amends the payment files that were issued to MACs based upon the CY 2014 MPFS Final Rule as modified by the Pathway for SGR Reform Act of 2013 Section 101 passed on December 18 2013 and further modified by section 101 of the Protecting Access to Medicare Act of 2014 on April 1 2014 Make sure your billing staffs are aware of these changes Background The Social Security Act Section 1848 c 4 available at http www socialsecurity gov OP_Home ssact title18 1848 htm authorizes CMS to establish ancillary policies
78. p w dye Phys Diag 74174 TC Supv Correction TC 02 01 01 2014 i Ct angio abdom w o amp w dye Phys Diag 74175 TC Supv Correction TC 02 01 01 2014 93880 TC Extracranial bilat study Phys Diag Supv 01 01 01 2014 Correction TC Extracranial uni Itd study Phys Diag 93882 TC Supv Correction TC 01 01 01 2014 Fluoroguide for vein device Phys Diag 77001 TC Supv Correction TC 03 01 01 2014 t Needle localization by xray Phys Diag 77002 TC Supv Correction TC 03 01 01 2014 f Fluoroguide for spine inject Phys Diag 77003 TC Supv Correction TC 03 01 01 2014 Additional Information The official instruction CR 8664 issued to your MAC regarding this change may be viewed at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R2923CP 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 07 JULY 2014 23 Fee Schedule MM8773 July Update to the Calendar Year CY 2014 Medicare Physician Fee Schedule Database MPFSDB The Centers for Medicare am
79. r AWV and includes a typical bundle of Medicare covered services that would be furnished per diem to a patient receiving an IPPE or AWV 4 G0469 FQHC visit mental health new patient A medically necessary face to face mental health encounter one on one between a new patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare covered services that would be furnished per diem to a patient receiving a mental health visit 5 G0470 FQHC visit mental health established patient A medically necessary face to face mental health encounter one on one between an established patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare covered services that would be furnished per diem to a patient receiving a mental health visit FQHCs shall use the specific payment code that corresponds to the type of visit that qualifies the encounter for Medicare payment and these codes will correspond to the appropriate PPS rates Each FQHC shall report a charge for the FQHC visit code that would reflect the sum of regular rates charged to both beneficiaries and other paying patients for a typical bundle of services that would be furnished per diem to a Medicare beneficiary Basic Billing Requirements When reporting an encounter visit for payment the claim 77X TOB must contain a FQHC specific payment code G04
80. r 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 MM8684 Related Change Request CR CR 8684 Related CR Release Date May 23 2014 Effective Date October 1 2014 Related CR Transmittal R2967CP Implementation Date October 6 2014 Provider Types Affected 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 amp hospice MACs HH amp H MACs for services to Medicare beneficiaries Provider Action Needed This article is based on CR 8684 which informs the MACs of the changes to Claim Status Category Codes and Claim Status Codes Make sure that your billing personnel are aware of these changes Background The Health Insurance Portability and Accountability Act HIPAA requires all health care benefit payers to use only Claim Status Category Codes and Claim Status Codes approved by the national Code Maintenance Committee in the X12 276 277 Health Care Claim Status Request and Response format adopted as the standard for national use This newslette
81. r 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 07 JULY 2014 5 e g previous HIPAA named versions included 004010X093A1 more recent HIPAA named versions 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 htip 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 June 2014 committee meeting will be posted on these sites on or about July 1 2014 Included in the code lists are specific details including the date when a code was added changed or deleted These code changes will 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 8684 Additional Information The offi
82. re 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 07 JULY 2014 aA m Z mr O PN lt Ro O Hs T gt A a gt 14 for FDA approved clinical trial services e RARC MA130 Your claim contains incomplete and or invalid information and no appeal rights are afforded because the claim is unprocessable Please submit a new claim with the complete correct information e Group Code Contractual Obligation CO Note This is a reminder clarification that clinical trials that are also investigational device exemption IDE trials must continue to report the associated IDE number on the claim form as well Additional Information The official instruction CR 8401 issued to your Medicare contractor regarding this change may be viewed at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R2955CP pdf on the CMS website See MLN Matters Article SE1344 http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads SE1344 pdf for information on an interim alternative method of satisfying the requirement in CR 8401 for providers who do not have the ability to submit the clinical trial number for trial related claims aA m
83. ression PILD for lumbar spinal stenosis LSS for beneficiaries enrolled in an approved clinical trial Background PILD is a procedure that was proposed as a treatment for symptomatic LSS unresponsive to conservative therapy PILD is a posterior decompression of the lumbar spine performed under indirect image guidance without any direct visualization of the surgical area It is generally described as a non invasive procedure using specially designed instruments to percutaneously remove a portion of the lamina and debulk the ligamentum flavum The procedure is performed under x ray guidance e g fluoroscopic CT with the assistance of contrast media to identify and monitor the compressed area via epiduragram CMS currently does not cover PILD and moreover after careful consideration determines that PILD for lumbar spinal stenosis LSS is not reasonable and necessary under section 1862 a 1 A of the Social Security Act the Act However CMS has determined that effective for claims with dates of service on or after January 9 2014 Medicare will cover PILD only when it is provided in a clinical study under section 1862 a 1 E of the Act through CED for beneficiaries with LSS who are enrolled in an approved clinical study that meets the criteria described in the National Coverage Determinations NCD Manual at NCD150 13 Specific Payment Actions e On or after January 9 2014 effective for hospital outpatient procedures on type o
84. rmination request You can attach up to 5 documents up to 5 MB each At least one document is required The documents must be in a PDF format A m Z mr O PN lt Ro O Hs gt A 5j gt 8 To add an attachment select the Browse button and a window will open allowing you to locate the document on your computer that you wish to attach Repeat this process to attach each additional document Step 8 Click on Browse to locate and select the document that you wish to attach Attachments Please attach all documentation up to 5 MB each that you would lik ou should also include any documentation to support your redetermination request xamples of supporting documentation would include Attachment 1 Step 9 Type the name of the person completing the form 08 23 2013 Step 10 And click the Submit button Required Field A J15 B 1000 Subrnit Clear 9 Below the attachments section complete the Name field by typing the name of the person who completed the form 10 Click the Submit button to submit your redetermination requests 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 11 An e signature box will appear asking you to verify that the information entered
85. rs Number SE1039 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 At the time this article was first published in 2010 the information reflected Medicare policy correctly at that time Since then more current information is available and new articles have been released This article was updated on June 5 2014 to refer to some of the key new articles Provider Types Affected This article is for Rural Health Clinics RHCs and Federally Qualified Health Centers FQHCs submitting claims to Medicare contractors fiscal intermediaries Fls and or A B Medicare administrative contractors A B MACs for services provided to Medicare beneficiaries What You Need to Know This Special Edition article is based on CR 7038 CR 7208 and CR 8743 and it provides a billing guide for FQHCs and RHCs It describes the information FQHCs are required to submit in order for CMS to develop and implement a Prospective Payment System PPS for Medicare FQHCs It also explains how RHCs should bill for certain preventive services under the Affordable Care Act Effective for dates of service on or after January 1 2011 coinsurance and deductible are not applicable for the Initial Preventive Physical Examination IPPE provided by RHCs However to ensure coinsurance and deductible are not applied detailed Healthcare Common Procedure Coding System HCPCS
86. s available at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R2957CP 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 Administration News Flash Messages from the Centers for Medicare amp Medicaid Services CMS e Products from the Medicare Learning Network MLN REVISED Telehealth Services Fact sheet ICN 901705 available at http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads TelehealthSrvcsfctsht pdf REVISED Advance Payment Accountable Care Organization Fact Sheet ICN 907403 downloadable at http www cms gov Medicare Medicare Fee for Service Payment sharedsavingsprogram Downloads ACO_Advance_Payment_Factsheet ICN907403 pdf NEW Information on the National Physician Payment Transparency Program Open Payments Podcast ICN 908961 downloadable only at http www cms gov 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 07 JULY 2014 A m Z mr O PN lt Ro O a 1 gt A 5j gt Outreach and Educa
87. service codes co surgery indicators etc see the tables in CR 8773 The Web address for CR 8773 is in the Additional Information section below In addition to the codes that were added codes J2271 Morphine SO4 injection 100mg and J2275 Morphine sulfate injection have a change in their procedure status code from E to l effective July 1 2014 Also Section 651 of Medicare Modernization Act MMA required the Secretary of Health and Human Services to conduct a demonstration for up to 2 years to evaluate the feasibility and advisability of expanding coverage for chiropractic services under Medicare The demonstration expanded Medicare coverage to include A care for neuromusculoskeletal conditions typical among eligible beneficiaries and B diagnostic and other services that a chiropractor is legally authorized to perform by the state or jurisdiction in which such treatment is provided The demonstration which ended on March 31 2007 was required to be budget neutral as section 651 f 1 B of MMA mandates the Secretary to ensure that the aggregate payments made by the Secretary under the Medicare program do not exceed the amount which the Secretary would 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
88. t no cost from our website at o http www cgsmedicare com 2014 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2014 07 JULY 2014 A m Z O PN ma Ro O He U gt Bu 5j gt oT Table 2 27 Category Ill CPT Codes Implemented as of July 1 2014 CY 2014 CPT Code CY 2014 Long Descriptor July 2014 OPPS Status Indicator July 2014 OPPS APC 0359T Behavior identification assessment by the physician or other qualified health care professional face to face with patient and caregiver s includes administration of standardized and non standardized tests detailed behavioral history patient observation and caregiver interview interpretation of test results discussion of findings and recommendations with the primary guardian s caregiver s and preparation of report 0632 0360T Observational behavioral follow up assessment includes physician or other qualified health care professional direction with interpretation and report administered by one technician first 30 minutes of technician time face to face with the patient 0632 0361T Observational behavioral follow up assessment includes physician or other qualified health care professional direction with interpretation and report administered by one technician each additional 30 minutes of technician time face to face with the patient List separately in addition to code for primary service
89. te correct information and d Group Code Contractual Obligation CO e MACs will accept the numeric 8 digit clinical trial identifier number preceded by the two alpha characters of CT when placed in Field 19 of paper Form CMS 1500 or when entered WITHOUT the CT prefix in the electronic 837P in Loop 2300 REFO2 REFO1 P4 NOTE The CT prefix is required on a paper claim but it is not required on an electronic claim For PILD claims submitted without a clinical trial identifier number they will follow the requirements outlined in CR8401 Mandatory Reporting of an 8 Digit Clinical Trial Number on Claims released on October 30 2013 You can find the associated MLN Matters article at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads MM8401 pdf on the CMS website MACs will not search their files to adjust claims already processed but will adjust claims that you bring to their attention Finally you should note that endoscopically assisted laminotomy laminectomy which requires open and direct visualization as well as other open lumbar decompression procedures for LSS are not within the scope of this NCD aA m Z mr O PN lt Ro O Hs T gt AD a gt Additional Information The official instruction CR 8757 issued to your MAC consists of two transmittals The first updates the Medicare National Coverage Determinations Manual a
90. the coverage requirements for FQHC visits can be found in the Medicare Benefit Policy Manual Pub 100 02 Chapter 13 which is available at http www cms gov Regulations and Guidance Guidance Manuals Downloads bp102c13 pdf on the CMS website FQHC Specific Payment Codes CMS is establishing five specific payment codes to be used by FQHCs submitting claims under the PPS 1 G0466 FQHC visit new patient A medically necessary face to face encounter one on one between a new patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare covered services that would be furnished per diem to a patient receiving a FQHC visit 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 07 JULY 2014 21 2 G0467 FQHC visit established patient A medically necessary face to face encounter one on one between an established patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare covered services that would be furnished per diem to a patient receiving a FQHC visit 3 G0468 FQHC visit IPPE or AWV A FQHC visit that includes an IPPE o
91. tion Medicare Learning Network MLN MLNProducts MLN Multimedia Items ICN908961 Podcast html REVISED Improving Quality of Care for Medicare Patients Accountable Care Organizations Fact Sheet ICN 907407 downloadable at htip www cms gov Medicare Medicare Fee for Service Payment sharedsavingsprogram Downloads ACO _ Quality Factsheet_ICN907407 pdf REVISED Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse Booklet ICN 907798 EPUB QR at hitp www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads Reduce Alcohol Misuse ICN907798 pdf NEW Medicare Enrollment Guidelines for Ordering Referring Providers Fact Sheet ICN 906223 Downloadable EPUB QR at hitp www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads MedEnroll_OrderReferProv_FactSheet_ICN906223 pdf 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 Awww 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 modifiers These are published every month Just s
92. to 5MB in size The forms and attachments are automatically entered into our workflow This makes form processing more efficient and cost effective NOTE The Select a Topic field on the Secure Forms page defaults to Appeals The Select a Type field defaults to First level appeal on a Medicare Claim 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 07 JULY 2014 10 3 Redetermination requests must be submitted within 120 days of the initial determination i e date on the Medicare remittance advice If you need to verify that the redetermination request is timely click on the Appeals Calculator link Get Status Secure Forms Eo Go To page Select Form You have 29 unread message s and 0 alerts Welcome to secure forms You can now submit forms to CGS Administrators securely through Step 3 7 five PDF attachments to each form Each attachment can be up to 5MB in size The forms and ls the redetermination entered into our workflow This makes form processing more efficient and cost effective i request timely To begin please select an answer to the questions from the drop down selections below
93. to be determined for ICD 10 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 and hospice MACs HH amp H MACs and durable medical equipment MACs DME MACs for services to Medicare beneficiaries Provider Action Needed This article is based on CR 8691 which is the first maintenance update of ICD 10 conversions and coding updates specific to National Coverage Determinations NCDs The majority of the NCDs included are a result of feedback received from previous ICD 10 NCD CRs specifically CR 7818 CR 8109 and CR 8197 Links to related MLN Matters Articles MM7818 MM8109 and MM8197 are available in the additional information section of this article Some are the result of revisions required to other NCD related CRs released separately that also included ICD 10 Edits to ICD 10 coding specific to NCDs will be included in subsequent quarterly recurring updates No policy related changes are included with these recurring updates Any policy related changes to NCDs continue to be implemented via the current long standing NCD process Make sure that your billing staffs are aware of these changes to the following 29 NCDs 20 5 ECU Using Protein A Columns 20 7 PTA 20 20 ECP Therapy 20 29 HBO Therapy 50 3 Cochlear Implants 70 2 1 Diabetic Peripheral Neuropathy 80 2 Photodynamic Therapy 80
94. ts through the myCGS Web Portal It s fast easy and cost effective Redeterminations the first level of appeal and supporting medical records can be submitted through the myCGS Web portal This allows providers to save the cost of printing and mailing paper documents Once submitted providers have the ability to monitor the status of these redeterminations within myCGS Redetermination requests are submitted through the Forms tab If you do not have access to the Forms tab but believe you should talk with your myCGS Provider Administrator for your agency organization and they can update your security If your agency organization has not yet registered for myCGS visit the myCGS registration Web page at http cgsmedicare com mycgs index html today aA m Z mr O PN lt Ro O Hs gt A a gt Submitting a Redetermination Request using myCGS 1 Select the Forms tab Step 1 Click Forms You have O unread message s and O alerts 2 From the Go To page field drop down box select Secure Forms The Secure Forms page will display Step 2 Select Secure Forms You have 29 unread message s and O alerts Help Go To page Seley AT ETAT Secure Forms Welcome to secure forms You can now submit forms to CGS Administrators securely through myCGS You may attach up to five PDF attachments to each form Each attachment can be up
95. y 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 07 JULY 2014 41 ICD 10 MM8691 ICD 10 Conversion Coding Infrastructure Revisions ICD 9 Updates to National Coverage Determinations NCDs Maintenance CR 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 MM8691 Related CR Transmittal R13880TN Related CR Release Date May 23 2014 Related Change Request CR CR 8691 Effective Date July 1 2014 ICD 9 updates local system edits October 1 2014 designated ICD 9 shared system edits October 1 2015 or whenever ICD 10 is implemented ICD 10 updates determined for ICD 10 Implementation Date July 7 2014 designated ICD 9 updates local system edits October 6 2014 or whenever ICD 10 is implemented ICD 10 updates
96. y will use a Claims Adjustment Reason Code CARC 50 These are non covered services because this is not deemed a medical necessity by the payer b Remittance Advice Remarks Code RARC N386 This decision was based on a National Coverage Determination NCD An NCD provides a coverage determination as to whether a particular item or service is covered A copy of this policy is available at hittp www cms hhs gov mcd search asp If you do not have Web access you may contact the contractor to request a copy of the NCD and aA m Z mr O PN lt Ro O Hs U gt A a gt c Group Code Contractual Obligation CO e MACs will return the professional PILD claim as unprocessable when billed with a diagnosis code other than 724 01 724 03 ICD 9 or M48 05 M48 07 ICD 10 using a CARC B22 This payment is adjusted based on the diagnosis b RARC N704 Alert You may not appeal this decision but can resubmit this claim service with corrected information if warranted and c Group Code Contractual Obligation CO e MACs will return the professional PILD claim as unprocessable when billed in a place of service other than 22 outpatient or 24 ambulatory surgical center using a CARC 58 Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service b RARC N704 Alert You may not appeal this decision but can resubmit this claim servi

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