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Medicare Bulletin - May 2015

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1. MLN Matters Number SE1508 Related Change Request CR N A Related CR Release Date N A Effective Date N A Related CR Transmittal N A Implementation Date N A Provider Types Affected This article is intended for Rural Health Clinics RHCs Federally Qualified Health Centers FQHCs and Critical Access Hospitals CAHs who submit claims to Medicare Administrative Contractors MACs for services furnished to Medicare beneficiaries What You Need to Know In this informational article the Centers for Medicare amp Medicaid Services CMS provides answers to some frequently asked questions raised by staff at RHCs FQHCs and CAHs Frequently Asked Questions RHCs and FQHCs Question If furnish professional Medicare Part B services only at an RHC or an FQHC are the services eligible for PQRS This newsletter should be shared with all health care practitioners and managerial members of RETURN TO the provider supplier staff Newsletters issued after January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 05 MAY 2015 11 Answer No if you furnish Medicare Part B professional services only at an RHC or an FQHC such services are not eligible for either the PQRS incentive payment or for the PQRS negative payment adjustment Question I m an Eligible Professional EP and furnish professional
2. provided an Advance Beneficiary Notice ABN to the patient indicating a signed ABN is on file Group Code CO Contractual Obligation assigning financial liability to the provider if a claim is received with a GZ modifier The provider or supplier expects a medical necessity denial however did not provide an Advance Beneficiary Notice ABN to the patient indicating no signed ABN is on file Note For modifier GZ use CARC 50 and MSN 8 81 If the provider supplier should have known that Medicare would not pay for the denied items or services and did not tell you in writing before providing them that Medicare probably would deny payment you may be entitled to a refund of any amounts you paid However if the provider supplier requests a review of this claim within 30 days a refund is not required until we complete our review If you paid for this service and do not hear anything about a refund within the next 30 days contact your provider supplier Additional Information The official instruction CR9087 issued to your MAC regarding this change is available at http www cms hhs gov Regulations and Guidance Guidance Transmittals Downloads R1478OTN pdf on the CMS website The spreadsheet attachments to CR9087 are available at http www cms hhs gov Regulations and Guidance Guidance Transmittals Downloads R1478OTN zip on the CMS website MM7818 is available for review at http www cms gov Outreach and Education Me
3. congestive heart failure dizziness or confusion NOTE The final decision memorandum addresses Medicare policy specific to implanted permanent cardiac pacemakers single chamber or dual chamber for the treatment of non reversible symptomatic bradycardia due to sinus node dysfunction and second and or third degree atrioventricular block Medicare coverage of removal replacement of implanted permanent cardiac pacemakers single chamber or dual chamber for the above noted indications were not addressed in the final decision Therefore it is expected that MACs will continue to apply the reasonable and necessary standard in determining local coverage within their respective jurisdictions for removal replacement of implanted permanent cardiac pacemakers single chamber or dual chamber Cardiac Pacemaker Healthcare Common Procedure Coding System HCPCS and Current Procedural Terminology CPT Codes Professional claims Effective for claims with dates of service on or after August 13 2013 MACs shall pay for implanted permanent cardiac pacemakers single chamber or dual chamber for one of the following CPT codes if the claim contains at least one of the designated diagnosis codes in addition to the KX modifier e 33206 Insertion or replacement of permanent pacemaker with transvenous electrode s atrial e 33207 Insertion or replacement of permanent pacemaker with transvenous electrode s ventricular or e 33208
4. Insertion or replacement of permanent pacemaker with transvenous electrode s atrial and ventricular Institutional claims Effective for claims with dates of service on or after August 13 2013 MACs shall pay for implanted permanent cardiac pacemakers single chamber or dual chamber for the following HCPCS codes if the claim contains at least one of the designated CPT codes and at least one of the designated diagnosis codes in addition to the KX modifier e C1785 Pacemaker dual chamber rate responsive implantable e C1786 Pacemaker single chamber rate responsive implantable e C2619 Pacemaker dual chamber nonrate responsive implantable e C2620 Pacemaker single chamber nonrate responsive implantable e 33206 Insertion or replacement of permanent pacemaker with transvenous electrode s atrial e 33207 Insertion or replacement of permanent pacemaker with transvenous electrode s ventricular e 33208 Insertion or replacement of permanent pacemaker with transvenous electrode s atrial and ventricular MACs have discretion to cover or not cover the following CPT codes e 33227 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator single lead system or e 33228 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator dual lead system This newsletter should be shared with all health
5. Newsletters MEDICARE BULLETIN GR 2015 05 MAY 2015 37 Multimedia Items 2014 12 15 Provider Compliance html 7DLPage 3 amp DLSort 2 amp DLSort Dir ascending Podcast ICN 909016 downloadable only Medicare Basics Commonly Used Acronyms Educational Tool ICN 908999 downloadable http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads Acronyms Educational Tool ICN908999 pdf e REVISED product from the Medicare Learning Network Medicare Physician Fee Schedule http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads MedcrePhysFeeSched fctsht pdf Fact Sheet ICN 006814 Medicare Learning Network MLN Suite of Products amp Resources for Rural Health Providers http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads Rural Health Suite ICN908465 pdf Educational Tool ICN 908465 Downloadable Avoiding Medicare Fraud amp Abuse A Roadmap for Physicians Web based Training WBT http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts WebBasedTraining html Telehealth Services Fact sheet ICN 901705 hitp www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads TelehealthSrvcsfctsht pdf x m Z E 2 x lt Qo O v gt D j w e RELEASED product from the Medicare
6. s health record to address his or her chronic care needs An answering machine does not meet this requirement 8 What is the definition of comprehensive regarding the care plan As stated on page 5 of the CMS CCM Fact Sheet A comprehensive care plan for all health issues typically includes but is not limited to the following elements v Problem list v Expected outcome and prognosis v Measurable treatment goals v Symptom management v Planned interventions and identification of the individuals responsible for each intervention gt Medication management gt Community social services ordered gt A description of how services of agencies and specialists outside the practice will be directed coordinated gt Schedule for periodic review and when applicable revision of the care plan Also keep in mind if you have specific questions about appropriate coding that you cannot resolve on your own the appropriate first step would be to review the HCPCS or CPT codes and or the regulation governing payment for the year of service This newsletter should be shared with all health care practitioners and managerial members of RETURN TO the provider supplier staff Newsletters issued after January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 05 MAY 2015 4 Providers are
7. 2014 Related CR Transmittal R181NCD Implementation Date April 6 2015 Note This article was revised on March 28 2015 to reflect the revised CR9095 issued on March 27 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 This newsletter should be shared with all health care practitioners and managerial members of RETURN TO the provider supplier staff Newsletters issued after January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 05 MAY 2015 x m Z E 2 x lt Qo O z gt D j w 30 Provider Types Affected This MLN Matters Article is intended for physicians providers and suppliers who submit claims to Medicare Administrative Contractors MACs for services provided to Medicare beneficiaries Provider Action Needed Effective December 18 2014 Change Request CR 9095 removes Sections 50 6 Tinnitus masking 160 4 Stereotactic Cingulotomy as a Means of Psychosurgery 160 6 Carotid Sinus Nerve Stimulator 160 9 Electroencephalographic EEG Monitoring During Open Heart Surgery 190 4 Electron Microscope 220 7 Xenon Scan and 220 8 Nuclear Radiology Procedure from the Medicare National Coverage Determinations Manual or the NCD Manual Providers and the
8. Healgen Morphine Test Cup G0434QW October 17 2014 Healgen Morphine Test Cassette G0433QW October 29 2014 Chembio Diagnostic Systems Inc DPP HIV 1 2 Assay Oral Fluid and 87389QW from December 5 2014 to December 31 2014 Oregenics Alere Determine HIV 1 2 Ag Ab Combo fingerstick Whole Blood and 87806QW on and after January 1 2015 Oregenics Alere Determine HIV 1 2 Ag Ab Combo fingerstick Whole Blood G0434QW December 10 2014 Transmetron Invitro Pro Drug Test Cups G0434QW December 10 2014 Coastline Medical Management Coastline Explorer Cup Cassette Dip Card Format 86780QW December 15 2014 Diagnostics Direct LLC Syphilis Health Check FingerStick Whole Blood x m Z E 2 x lt Qo O gt D j w This newsletter should be shared with all t the provider supplier staff Newsletters alth a o and a R a of RETURN TO er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 05 MAY 2015 22 e G0434QW December 19 2014 On Site Testing Specialists Inc On Site Testing Specialist Single Multi Panel Drug Screen Dip Card Tests e G0434QW December 19 2014 On Site Testing Specialists Inc On Site Testing Specialist Single Multi Panel Drug Screen Dip Card with OPI 2000 Tests and e 87502QW January 5 2015 Alere i Influenza A amp B
9. Medicare Part B services at an RHC FQHC and also furnish services at a non RHC FQHC setting Are the non RHC FQHC services eligible for the 2015 PQRS incentive payment or for the PQRS negative payment adjustment Answer Yes for an EP who furnishes professional Medicare Part B services at an RHC FQHC and also furnishes services at a non RHC FQHC setting the non RHC FQHC services may be eligible for the PQRS incentive payment or the negative payment adjustment The PQRS program applies a negative payment adjustment to practices with EPs identified on claims by their individual National Provider Identifier NPI and Tax Identification Number TIN or group practices participating via the Group Practice Reporting Option GPRO referred to as PQRS group practices who do not satisfactorily report data on quality measures for covered Medicare Physician Fee Schedule services furnished to Medicare Part B Fee For Service beneficiaries A negative payment adjustment may be triggered in future year s if an EP furnishes services but does not report them Question Under what circumstances are professional Medicare Part B services furnished by an EP ata setting outside an RHC FQHC subject to the 2015 PQRS 1 5 percent negative payment adjustment if he or she has not satisfactorily reported 2013 PQRS quality measures Answer There are two circumstances under which professional Medicare Part B services furnished by an EP at a setting outside an RHC FQHC ma
10. November 17 21 2014 e March 2 6 2015 e June 1 5 2015 x m Z E 2 x lt Qo O gt D j w The concept of trading partner testing was originally designed to validate the trading partners ability to meet technical compliance and performance processing standards during the Health Insurance Portability and Accountability Act of 1996 HIPAA 5010 implementation While submitters may acknowledgement test ICD 10 claims at any time through implementation the ICD 10 testing weeks have been created to generate awareness and interest and to instill confidence in the provider community that CMS and the MACs are ready and prepared for the ICD 10 implementation These testing weeks will allow trading partner s access to MACs and CEDI for testing with real time help desk support The event will be conducted virtually and will be posted on the CMS website the CEDI website and each MAC s website Key Points of the Testing Process for CR8858 e Test claims with ICD 10 codes must be submitted with current dates of service since testing does not support future dates of service e Claims will be subject to existing NPI validation edits e MACs and CEDI will be staffed to handle increased call volume during this week e Test claims will receive the 277CA or 999 acknowledgement as appropriate to confirm that the claim was accepted or rejected by Medicare e Test claims will be subject to all existing EDI front end edit
11. Test Direct Nasal swab only From December 5 2014 to December 31 2014 the CPT code 87389QW has been assigned for the detection of antigen to HIV 1 and antibodies to HIV 1 and HIV 2 performed using the Oregenics Alere Determine HIV 1 2 Ag Ab Combo fingerstick Whole Blood On and after January 1 2015 the CPT code assigned to Oregenics Alere Determine HIV 1 2 Ag Ab Combo fingerstick Whole Blood will be 87806QW The new CPT code 86780QW has been assigned for the immunochromatographic assay for the detection of Treponema pallidum syphilis antibodies in whole blood performed using the Diagnostics Direct LLC Syphilis Health Check FingerStick Whole Blood The new CPT code 87502QW has been assigned for the differential and qualitative detection of influenza A and influenza B viral nucleic acids using isothermal nucleic acid amplification technology performed using the Alere i Influenza A amp B Test Direct Nasal swab only Additional Information The official instruction CR9072 issued to your MAC regarding this change is available at http www cms hhs gov Regulations and Guidance Guidance Transmittals Downloads R3207CP pdf on the CMS website If you have questions please contact your MAC at their toll free number The number is available at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles index html under How Does It Work Kentucky amp Ohio MM9078 National Coverage Det
12. a 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 x m Z E 2 x lt Qo O z gt D j w e February is American Heart Month A time to raise awareness about heart disease and heart disease management and prevention strategies Initiatives such as Million Hearts http millionhearts hhs gov resources toolkits html a national initiative to prevent a million heart attacks and strokes by 2017 provide health care professionals and other partners with resources that you can use to help enhance your prevention efforts Medicare provides coverage for a variety of preventive services that can help identify risk factors and provide information and tools that can assist your Medicare patients in making informed decisions about heart healthy lifestyle choices Read more http www cms gov Medicare Prevention PrevntionGenInfo Health Observance Mesages New Items 2015 02 12 American Heart Month html DLPage 1 amp DLSort 0 amp DLSortDir descending e National Nutrition Month The Centers for Medicare amp Medicaid Services reminds health care professionals that March is National Nutrition Month a time to Bite into a Healthy Lifestyle with informed food choices now and throughout the year Medicare provides coverage for a variety of nutrition related health services that can help eligible be
13. care practitioners and managerial members of RETURN TO the provider supplier staff Newsletters issued after January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 05 MAY 2015 x m Z E 2 x lt Qo O gt D j w 25 Cardiac Pacemaker ICD 9 ICD 10 Diagnosis Codes Professional claims Claims with dates of service on and after August 13 2013 for implanted permanent cardiac pacemakers single chamber or dual chamber are covered if submitted with one of the following CPT codes 33206 33207 or 33208 and that contain at least one of the following ICD 9 ICD 10 diagnosis codes upon ICD 10 implementation listed below in addition to the KX modifier e 426 0 Atrioventricular block complete 144 2 Atrioventricular block complete 426 12 Mobitz type II atrioventricular block 144 1 Atrioventricular block second degree 426 13 Other second degree atrioventricular block 144 1 Atrioventricular block second degree e 427 81 Sinoatrial node dysfunction 149 5 Sick sinus syndrome or 746 86 Congenital heart block Q24 6 Congenital heart block The following diagnosis codes can be covered at your MACs discretion if submitted with at least one of the CPT codes and diagnosis codes listed above in addition to the KX modifier e 426 10 Atrioventricular block unspecified 144 30 Unspecifie
14. days versus 29 days for paper claims aims Claim Submission ts Medicare Primary Or Socosdaryt Gilling Provider information Submitting eClaims allows Part B providers to x m Z E 2 x lt Qo O gt D j w e Submit ALL types of Part B claims To CGS including Medicare Secondary Payer MSP claims e Attach up to five documents to the eClaim e Make corrections to eClaims that are rejected due to our front end editing e Track the status of each claim submitted through myCGS e Take advantage of benefits of submitting electronic claims including FASTER processing and payments e Save money by using this FREE claim submission option If you need additional information regarding eClaim submission please refer to the following resources e myCGS User Manual Chapter 2 Claims Tab http www cgsmedicare com pdf mycgs chapter2 pdf e myCGS Claim Submission Job Aid http www cgsmedicare com partb edi pdf mycgs_claim_submission_job_aid pdf e MSP eClaims http www cgsmedicare com partb pubs news 2015 0215 cope28475 html If you are not a registered myCGS user please refer to information this and other functions available to you at http www cgsmedicare com partb myCGS index html Kentucky amp Ohio SE1507 Physician Feedback Quality and Resource Use Reports QRURs and Value Based Modifier Program Overview amp Implementation The Centers for Medicare amp Medicaid Servi
15. http www cms gov Regulations and Guidance Guidance Transmittals Downloads R177NCD pdf on the CMS website If you have any questions please contact your MAC at their toll free number That number is available at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles index html under How Does It Work x m Z E 2 x lt Qo O gt D j w Kentucky amp Ohio MM9011 Revised Incorporation of Revalidation Policies into Pub 100 08 Program Integrity Manual PIM Chapter 15 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 2015 MLN Matters Articles html MLN Matters Number MM 9011 Revised Related Change Request CR CR 9011 Related CR Release Date February 25 2015 Effective Date May 15 2015 Related CR Transmittal R578PI Implementation Date May 15 2015 Note This article was revised on February 27 2015 to reflect the revised CR9011 issued on February 25 In the article the CR release date transmittal number and the Web address for accessing CR9011 are revised All other information remains the same Provider Types Affected This MLN Matters Article is intended for pr
16. in the CY 2016 Medicare Physician Fee Schedule proposed and final rules respectively For more information on future years of the Value Modifier please visit http www cms gov Medicare Medicare Fee for Service Payment PhysicianFeedbackProgram ValueBasedPaymentModifier html on the CMS website GO What You Need to Do Participate in the Physician Quality Reporting System PQRS every year to avoid an automatic downward payment adjustment under the Value Modifier during the associated payment year The data reported to PQRS for a given calendar year are used to calculate the Value Modifier for the calendar year that follows it by 2 years For example PQRS quality data for Calendar Year 2013 were used to calculate the Value Modifier affecting payments in 2015 PQRS quality data are reported during the first quarter of the year following a given performance year Physician groups should register to participate in the PQRS Group Practice Reporting Option GPRO in the fall of each year to report data for that year Beginning with the 2016 Value Modifier based on 2014 performance EPs in a group have the option to participate in PQRS as individuals providing at least 50 of the group report Use the information provided in your group s Quality and Resource Use Report QRUR as described below to improve your performance on the quality and cost measures that are This newsletter should be shared with all health care practitione
17. that CMS considers to be laboratory tests under CLIA and thus requiring certification change each year Make sure your billing staffs are aware of these changes Background The Clinical Laboratory Improvement Amendments of 1988 CLIA regulations require a facility to be appropriately certified for each test performed To ensure that Medicare amp Medicaid only pay for laboratory tests categorized as waived complexity under CLIA in facilities with a CLIA certificate of waiver laboratory claims are currently edited at the CLIA certificate level Listed below are the latest tests approved by FDA as waived tests under CLIA The Current Procedural Terminology CPT codes for the following new tests must have the modifier QW This newsletter should be shared with all health care practitioners and managerial members of RETURN TO er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS the provider supplier staff Newsletters MEDICARE BULLETIN GR 2015 05 MAY 2015 x m Z E 2 x lt Qo O gt D j w 21 to be recognized as a waived test The CPT code effective date and description for the latest tests approved by the FDA as waived tests under CLIA are the following G0434QW September 18 2014 CLlAwaived Inc Rapid Drug Test Cup Cassette Dip Card format 86308QW September 23 2014 AimStep Mono Whole Blo
18. to 69 96 Kentucky example CPT code 96422 non facility setting Work RVU 0 17 Work GPCI 1 00 Fully Implemented Non Facility PE RVU 4 51 PE GPCI 0 872 MP RVU 0 10 MP GPCI 0 795 0 17 1 00 4 51 0 872 0 10 0 795 35 7547 MPFS amount 0 17 3 93272 0 0795 35 7547 MPFS amount 4 18222 35 7547 149 534021 round to 149 53 Ohio example CPT code 45378 no modifiers facility setting Work RVU 3 69 Work GPCI 1 00 Fully Implemented Facility PE RVU 1 94 PE GPCI 0 918 MP RVU 0 56 MP GPCI 0 993 3 69 1 00 1 94 0 918 0 56 0 993 35 7547 MPFS amount 3 69 1 78092 0 55608 35 7547 MPFS amount 6 027 35 7547 215 493577 round to 215 49 x m Z E 2 x lt Qo O gt D j w Reference e To access MPFS amounts directly refer to the CMS PFS Look Up Tool http Awww cms gov apps physician fee schedule search search criteria aspx or e Use the CGS tool to search the MPFS Kentucky and Ohio fees http www cgsmedicare com partb fees index html e CMS MLN Matters article MM9081 http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads MM9081 pdf Emergency Update to the Calendar Year CY 2015 Medicare Physician Fee Schedule Database MPFSDB Kentucky amp Ohio myCGS Web Portal eClaims myCGS our secure web portal is a self service application created sp
19. to provide comparative performance information to individual physicians and groups as part of Medicare s efforts to improve the quality and efficiency of medical care The program which is specific to Fee For Service Medicare not Medicare Advantage contains two primary components e The Physician Quality and Resource Use Reports QRURs and e The Value Based Incentive Payment Modifier Value Modifier What is a Quality and Resource Use Report CMS has already provided annual QRURs to groups with at least one physician and physicians who are solo practitioners to provide feedback on the quality of care furnished to Medicare beneficiaries and the cost of that care Beginning in 2015 CMS will provide QRURs based on 2014 performance to all groups and solo practitioners including non physician groups and solo practitioners Groups and solo practitioners can use the information provided in the QRURs to improve the care they provide to Medicare beneficiaries and to improve performance on quality and cost measures used to calculate the Value Modifier The QRURs include information about a TINs performance on PQRS quality measures 3 claims based outcome measures and claims based cost measures The reports contain detailed information on care provided both inside a group and outside the group to help improve care coordination and efficiency For more information about QRURs see http www cms gov Medicare Medicare Fee for Service Paymen
20. Affordable Quality Healthcare CAQH Committee on Operating Rules for Information Exchange CORE messages where appropriate Remittance Advice Remark Code RARC N386 This decision was based on a National Coverage Determination NCD An NCD provides a coverage determination as to whether a particular item or service is covered along with Claim Adjustment Reason Code CARC 50 These are noncovered services because this is not deemed a medical necessity by the payer CARC 96 Non covered charge s At least one Remark Code must be provided may be comprised of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an ALERT and or CARC 119 Benefit maximum for this time period or occurrence has been reached 3 When denying claims associated with the attached NCDs except where otherwise indicated your MACs will use Group Code PR Patient Responsibility assigning financial responsibility to the beneficiary if a claim is received with occurrence code 32 Advance Beneficiary Notice or with occurrence code 32 and a GA modifier The provider or supplier has This newsletter should be shared with all health care practitioners and managerial members of RETURN TO January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS the provider supplier staff Newsletters MEDICARE BULLETIN GR 2015 05 MAY 2015 29
21. CGS follows these rules unless otherwise directed 3 Since this is a non face to face code does incident to apply or will this be covered under general supervision Inthe Medicare Physician Fee Schedule Database http www cms gov apps physician fee schedule overview aspx the physician supervision indicator for CPT code 99490 is listed as O09 which is defined in the CMS Medicare Claims Processing Manual Pub 100 04 chapter 23 http www cms gov Regulations and Guidance Guidance Manuals Downloads clm104c23 pdf as concept does not apply Note that the services counted toward the 20 minutes must be provided by clinical staff 4 Do you have a list of recommended chronic conditions that supports the requirement for patients to be eligible As stated on page 2 of the CMS CCM Fact Sheet http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads ChronicCare Management pdf Examples of chronic conditions include but are not limited to the following gt Alzheimer s disease and related dementia gt Osteoporosis gt Arthritis osteoarthritis and rheumatoid gt Additional resources are located on page 10 of gt Asthma the CMS CCM Fact Sheet http www cms gov gt Atrial fibrillation Outreach and Education Medicare Learning gt Autism spectrum disorders Network MLN MLNProducts Downloads Chronic gt Cancer CareManagement pdf g
22. Clinic Medicare will deny claims submitted without one of the POS codes noted above with the following messages e CARC 171 Payment denied when performed by this type of provider in this type of facility Note Refer to the 835 Healthcare Policy Identification Segment loop 2110 Service Payment Information REF if present Payment Information REF if present A e RARC N574 Our records indicate the ordering referring provider is of a type specialty that Z cannot order refer Please verify that the claim ordering referring information is accurate or contact the ordering referring provider Cc e Group Code CO if claim received without GZ modifier z For professional claims with dates of service on or after June 2 2014 CMS will allow coverage lt for HCV screening HCPCS G0472 only when submitted with one of the following place of service POS codes Ro 11 Physician s Office 71 State or Local Public Health Clinic 22 Outpatient Hospital 81 Independent Laboratory I gt A j 00 e RARC N428 Not covered when performed in this place of service e Group Code CO if claim received without GZ modifier Other Billing Information for Both Professional and Institutional Claims On both institutional and professional claims Medicare will deny claims line items for HCPCS G0472 with dates of service on or after June 2 2014 where it is reported more than once in a lifetime for beneficiaries born from 1945 thro
23. Doctor of Dental Surgery Doctor of Dental Medicine or Doctor of Chiropractic Beginning with 2018 payments the Value Modifier will apply to non physician EP s payments as well These include Non Physician Practitioners e g Nurse Practitioners Physician Assistants and Clinical Nurse Specialists Occupational Therapists Physical Therapists Speech Language Pathologists and Audiologists The Value Modifier is applied to the Medicare paid amounts for the items and services billed under the MPFS so that beneficiary cost sharing is not affected Application of the Value Modifier at the TIN level means that if a physician changes groups from TIN A in the performance period CY 2013 to TIN B in the payment adjustment period CY 2015 then CMS would apply TIN B s Value Modifier to the physician s payments for items and services provided during 2015 and billed under TIN B What If Think There is an Error in My Value Modifier If a physician group believes that CMS has made an error in the calculation of the group s Value Modifier then the group may request a correction through our informal review process For the 2016 Value Modifier and beyond informal review must be requested no later than 60 days after receipt of the QRUR If upon review CMS determines that we have made an error in the calculation of the quality composite and we are unable to recalculate it then we will classify the TIN as average quality For the 2016 Va
24. Learning Network The 2013 Physician Quality Reporting System PQRS http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads 2013 PQRS Updates ICN909056 pdf Booklet ICN 909056 Downloadable only MEDICARE LEARNING NETWORK 3A Valuable Educational Resource The Medicare Learning Network MLN i 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 This newsletter should be shared with all health care practitioners and managerial members of RETURN TO the provider supplier staff Newsletters issued after January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 05 MAY 2015 36
25. MAY 2015 WWW CGSMEDICARE COM Medicare Bulletin Jurisdiction 15 Reaching Out to the Medicare Community CELERIAN GROUP COMPANY 2015 Copyright CGS Administrators LLC AN m L C O AN lt Ro O O U gt AU OO Medicare Bulletin Jurisdiction 15 KENTUCKY amp OHIO Administration myCGS Web Portal eClaims Coverage LCDs amp NCDs Chronic Care Management CPT Code 99490 MM9078 National Coverage Determination NCD for Single Chamber and Dual Chamber Permanent Cardiac Pacemakers MM9095 Removal of Multiple National Coverage Determinations Using an Expedited Process Enrollment amp Credentialing MM9011 Revised Incorporation of Revalidation Policies into Pub 100 08 Program Integrity Manual PIM Chapter 15 MM9065 Revised Incorporation of Certain Provider Enrollment Policies in CMS 6045 F into Pub 100 08 Program Integrity Manual PIM Chapter 15 Fee Schedules amp Reimbursement Medicare Physician Fee Schedule MPFS How Are Fees Calculated MM9100 Revised April 2015 Update of the Ambulatory Surgical Center ASC Payment System MM9104 Quarterly Update to the Medicare Physician Fee Schedule Database MPFSD B April Calendar Year CY 2015 Update ICD 10 MM8858 Revised International Classification of Diseases 10th Revision ICD 10 Testing Acknowledgement Testing with Providers MM9087 Revised ICD 10 Conversion Coding Infrastruct
26. Y 2015 Update 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 2015 MLN Matters Articles html MLN Matters Number MM9104 Related Change Request CR CR 9104 Related CR Release Date February 27 2015 Effective Date April 1 2015 Related CR Transmittal R3205CP Implementation Date April 6 2015 Provider Types Affected This MLN Matters Article is intended for physicians other providers and suppliers submitting claims to Medicare Administrative Contractors MACs for services to provided Medicare beneficiaries Provider Action Needed Change Request CR 9104 informs MACs about the release of payment files based upon the CY 2015 Medicare Physician Fee Schedule MPFS Final Rule Make sure that your billing staffs are aware of these changes Background Payment files were issued to MACs based upon the Calendar Year CY 2015 MPFS Final Rule published in the Federal Register on December 19 2014 to be effective for services furnished between January 1 2015 and December 31 2015 Section 1848 c 4 of the Social Security Act authorizes the Secretary to establish ancillary policies necessary to implement relative values for physicians services Under curre
27. actual charge as applicable with revenue codes 096X 097X or 098X Note Separate guidance shall be issued for FQHCs that are authorized to bill under the prospectivepayment system Professional Billing Requirements For professional claims with dates of service on or after June 2 2014 CMS will allow coverage for HCPCS G0472 only when services are submitted by the following provider specialties found on the provider s enrollment record 01 General Practice 08 Family Practice 11 Internal Medicine 16 Obstetrics Gynecology 37 Pediatric Medicine 38 Geriatric Medicine 42 Certified Nurse Midwife 50 Nurse Practitioner 89 Certified Clinical Nurse Specialist 97 Physician Assistant Medicare will deny claims submitted for these services by providers other than the specialty types noted above When denying such claims Medicare will use the following messages e CARC 184 The prescribing ordering provider is not eligible to prescribe order the service This newsletter should be shared with all health care practitioners and managerial members of RETURN TO er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS the provider supplier staff Newsletters MEDICARE BULLETIN GR 2015 05 MAY 2015 17 NOTE Refer to the 835 Healthcare Policy Identification Segment loop 2110 Service 49 Independent
28. amber using one of the following HCPCS and or CPT codes C1785 C1786 C2619 C2620 33206 33207 or 33208 ICD 10 diagnosis code R55 is not covered even if the claim contains one of the valid diagnosis codes listed above MACs will use the following messages when denying claims for implanted permanent cardiac pacemakers single chamber or dual chamber containing one of the following HCPCS and or CPT codes C1785 C1786 C2619 C2620 33206 33207 or 33208 and ICD 10 diagnosis code R55 with the following messages e CARC 96 Non covered charge s e RARC N569 Not covered when performed for the reported diagnosis e Group Code CO assigning financial liability to the provider if a claim is received with a GZ modifier indicating no signed Advance Beneficiary Notice ABN is on file e Group Code PR assigning financial liability to the beneficiary if a claim is received with occurrence code 32 indicating a signed ABN is on file or occurrence code 32 is present with modifier GA Additional Information The official instruction CR 9078 was issued to your MAC via two transmittals The first transmittal updates the Medicare Claims Processing Manual and it is available This newsletter should be shared with all health care practitioners and managerial members of RETURN TO er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS the
29. as not satisfactorily reported 2013 PQRS quality measures Please note that this applies only to Tax ID and the rendering NPI used for Medicare billings on UB 04 claims An EP who furnishes Medicare Part B services at a CAH and the CAH is paid under Method Il may be eligible for PQRS beginning in 2014 for the 2014 PQRS incentive payment and will be subject to the 2016 PQRS negative adjustment payment if he or she does not report by the deadline specified for each reporting method Any physician reported NPI at either the claim level or the line level of a UB 04 claim is considered eligible to participate in PQRS Question lm a CAH provider paid under Method II Am required to report line item rendering NPI information Answer Yes a CAH provider paid under Method II is required to report the rendering NPI at the line level if it is different than the rendering NPI at the claim level For more information about this billing standard requirement refer to MLN Matters Article MM7578 titled Fiscal Intermediary Shared System FISS and Common Working File CWF System Enhancement for Storing Line Level Rendering Physicians Practitioners National Provider Identifier NPI Information located at http Awww cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads MM7578 pdf on the CMS website Additional Information If you have any questions please contact your MAC at their toll free number That numb
30. ave a procedure status of I 80300 80301 80302 80303 80304 80320 80321 80322 80323 80324 80325 80326 80327 80328 80329 80330 80331 80332 80333 80334 80335 80336 80337 80338 80339 80340 80341 80342 80343 80344 80345 80346 80347 80348 80349 80350 80351 80352 80353 80354 80355 80356 80357 80358 80359 80360 80361 80362 80363 80364 80365 80366 80367 80368 80369 80370 80371 80372 80373 80374 80375 80376 and 80377 x m Z E 2 x lt Qo O gt D j w Effective for services on or after April 1 2015 the following codes will have a procedure status of X 81500 81503 81506 81508 81509 81510 81511 81512 and 81599 Also effective for services on or after April 1 2015 new code Q9975 is added with a short descriptor of Factor VIII FC Fusion Recomb and a long descriptor of Injection Factor VIII FC Fusion Protein Recombinant per iu The procedure status code for Q9975 is E and it has a global surgery modifier of XXX Finally S8032 was transposed as S0832 in the January 2015 MPFS S0832 has been replaced with S8032 in the April 2015 MPFS Note MACs will not search their files to either retract payment for claims already paid or to retroactively pay claims which were impacted by the above changes MACs will adjust claims that you bring to their attention Additional Information The official instruction CR9104 iss
31. ayment System OPPS Section 1833 t 6 B of the Social Security Act the Act requires that under the OPPS categories of devices be eligible for transitional pass through payments for at least 2 but not more than 3 years Section 1833 t 6 B ii IV of the Act requires that additional categories be created for transitional pass through payment of new medical devices not described by current or expired categories of devices This policy was implemented in the 2008 revised ASC payment system CMS is establishing one new HCPCS device pass through category as of April 1 2015 for the OPPS and the ASC payment systems The table below provides a listing of new coding and payment information concerning the new device category for transitional pass through payment HCPCS code C2623 Catheter transluminal angioplasty drug coated non laser is assigned ASC PI J7 OPPS pass through device paid separately when provided integral to a surgical procedure on ASC list payment contractor priced New Device Pass Through Code HCPCS HCPCS Short Descriptor Long descriptor ASC PI C2623 Cath translumin drug coat Catheter transluminal angioplasty drug coated J7 non laser This newsletter should be shared with all health care practitioners and managerial members of RETURN TO the provider supplier staff Newsletters iss er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyrig
32. c Practice Cost Index GPCI e Practice Expense PE which differs for facility vs non facility settings and is adjusted based on the GPCI e Malpractice Insurance MP which is adjusted based on the GPCI e Conversion Factor CF which adjusts fees by state e Inthe formula below RVU stands for Relative Value Units Formula The formula for calculating the MPFS from the CMS website uses the Fully Implemented Non Facility PE RVU instead of the Transitioned Non Facility PE RVU 2015 Non Facility Pricing Amount Work RVU Work GPCI Fully Implemented Non Facility PE RVU PE GPCI MP RVU MP GPCI Conversion Factor CF Conversion Factor CF for January March 2015 35 7547 Examples How does the math work Ohio example CPT code 99213 non facility setting Work RVU 0 97 Work GPCI 1 00 Fully Implemented Non Facility PE RVU 1 01 PE GPCI 0 918 MP RVU 0 06 MP GPCI 0 993 0 97 1 00 1 01 0 918 0 06 0 993 35 7547 MPFS amount This newsletter should be shared with all health care practitioners and managerial members of RETURN TO the provider supplier staff Newsletters issued after January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 05 MAY 2015 5 0 97 0 92718 0 05958 35 7547 MPFS amount 1 956576 35 7547 69 9633668 round
33. ces CMS has issued the following Special Edition Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2015 MLN Matters Articles html MLN Matters Number N A 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 This newsletter should be shared with all health care practitioners and managerial members of RETURN TO the provider supplier staff Newsletters issued after January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 05 MAY 2015 if Provider Types Affected This MLN Matters Special Edition is intended for physicians and non physician practitioners Nurse Practitioners Physician Assistants and Clinical Nurse Specialists Occupational Therapists Physical Therapists Speech Language Pathologists and Audiologists submitting claims to Medicare Administrative Contractors MACs for services provided to Medicare beneficiaries Provider Action Needed STOP Impact to You This Special Edition Article provides an overview of the Physician Feedback and Value Based Modifier Program Under the Value Modifier Program performance on quality and cost mea
34. ces are reasonable and necessary under the Social Security Act Section 1862 a 1 A see http www ssa gov OP_Home ssact title18 1862 htm consistent with the existing guidance for making such decisions when there is no NCD Additional Information The official instruction CR9095 issued to your MAC regarding this change is available at http www cms hhs gov Regulations and Guidance Guidance Transmittals Downloads R181NCD pdf on the CMS website If you have any questions please contact your MAC at their toll free number That number is available at http www cms gov Outreach and Education Medicare Learning Net work MLN MLNMattersArticles index html under How Does It Work This newsletter should be shared with all health care practitioners and managerial members of RETURN TO the provider supplier staff Newsletters er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 05 MAY 2015 x m Z E 2 x lt Qo O gt D j w 31 Kentucky amp Ohio MM9100 Revised April 2015 Update of the Ambulatory Surgical Center ASC Payment System 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 Ou
35. d atrioventricular block e 426 11 First degree atrioventricular block 144 0 Atrioventricular block first degree e 426 4 Right bundle branch block 145 10 Unspecified right bundle branch block l45 19 Other right bundle branch block e 427 0 Paroxysmal supraventricular tachycardia 147 1 Supraventricular tachycardia e 427 31 Atrial fibrillation 148 1 Persistent atrial fibrillation 148 91 Unspecified atrial fibrillation e 427 32 Atrial flutter 148 3 Typical atrial flutter 148 4 Atypical atrial flutter or 148 91 Unspecified atrial fibrillation or e 780 2 Syncope and collapse R55 Syncope and collapse R55 is the ICD 10 dx code but is not payable upon implementation of ICD 10 and is only included here for information purposes Institutional claims For coverage of claims with dates of service on and after August 13 2013 for implanted permanent cardiac pacemakers single chamber or dual chamber using HCPCS codes C1785 C1786 C2619 C2620 33206 33207 or 33208 the claim must contain at least one of the following procedure codes e 37 81 Initial insertion of single chamber device not specified as rate responsive e 37 82 Initial insertion of single chamber device rate responsive e 37 83 Initial insertion of single chamber device and at least one of the following diagnosis codes in addition to the KX modifier e 426 0 Atrioventricular block complete 426 12 Mobitz type II atrioventricular block 426 13 Other second d
36. de correctly and documenting your services appropriately please refer to the following questions and answers 1 CPT for 99490 is defined as clinical staff time directed by a physician or other Qualified Health Care Provider QHCP Can you define what constitutes clinical staff RN LPN Certified MA pharmacist etc Page 2 of the CMS Chronic Care Management CCM Fact Sheet http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads ChronicCareManagement pdf states Eligible practitioners must act within their State licensure scope of practice and Medicare statutory benefit The CCM service may be billed most frequently by primary care physicians although specialty physicians who meet all of the billing requirements may bill the service The CCM service is not within the scope of practice of limited license physicians and practitioners such as clinical psychologists podiatrists or dentists therefore these practitioners cannot furnish or bill the service However CMS expects referral to or consultation with such physicians and practitioners by the billing provider to coordinate and manage care Please note Only one practitioner can furnish and be paid for the service during a calendar month 2 Is your expectation the same as noted in the introduction section of CPT Yes additional rules and guidelines are available in the narrative section of the CPT manual
37. dicare Learning Network MLN MLNMattersArticles downloads MM7818 pdf on the CMS website MM8109 is available for review at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads MM8109 pdf on the CMS website MM8197 is available for review at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads MM8197 pdf on the CMS website MM8691 is available for review at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads MM8691 pdf on the CMS website If you have any questions please contact your MAC at their toll free number That number is available at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles index html under How Does It Work Kentucky amp Ohio MM9095 Revised Removal of Multiple National Coverage Determinations Using an Expedited Process 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 2015 MLN Matters Articles html MLN Matters Number MM9095 Revised Related Change Request CR CR 9095 Related CR Release Date March 27 2015 Effective Date December 18
38. dministrative Contractors MACs for Hepatitis C Virus HCV screening services provided to Medicare beneficiaries What You Need to Know Change Request CR 8871 states effective June 2 2014 the Centers for Medicare amp Medicaid Services CMS will cover screening for Hepatitis C Virus HCV consistent with the grade B recommendations by the United States Preventive Services Task Force USPSTF for the prevention or early detection of an illness or disability and is appropriate for individuals entitled to benefits under Medicare Part A or enrolled under Part B Make sure your billing staffs are aware of these changes Background Hepatitis C Virus HCV is an infection that attacks the liver and is a major cause of chronic liver disease Inflammation over long periods of time usually decades can cause scarring called cirrhosis A cirrhotic liver fails to perform the normal functions of the liver which leads to liver failure Cirrhotic livers are more prone to become cancerous and liver failure leads to serious complications even death HCV is reported to be the leading cause of chronic hepatitis cirrhosis and liver cancer and a primary indication for liver transplant in the Western World This newsletter should be shared with all health care practitioners and managerial members of RETURN TO the provider supplier staff Newsletters er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Co
39. e subparts entered their doing business as name as their LBN when applying for their NPIs Once a contractor determines for certain that this situation exists the contractor shall ask the provider to correct its NPPES information The provider can 1 change its LBN in NPPES to read in accordance with the IRS CP 575 and 2 report its doing business as name in NPPES as an Other Name and indicate the type of other name as a doing business as name Additional Information The official instruction for CR9011 issued to your MAC regarding this change is available at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R578PI pdf on the CMS website If you have questions please contact your MAC at their toll free number The number is available at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles index html under How Does It Work x m Z E 2 x lt Qo O gt D j w Kentucky amp Ohio MM9065 Revised Incorporation of Certain Provider Enrollment Policies in CMS 6045 F into Pub 100 08 Program Integrity Manual PIM Chapter 15 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 MLNMatter
40. ecifically for CGS J15 providers Registered users have access to the following information and functions Beneficiary eligibility including Medicare entitlement preventive benefits Medicare Secondary Payer MSP information and Medicare Advantage Plan enrollment Checking the status of claims View and or print remittance advices RAs Access to financial information including payment floor amounts and last three Medicare check amounts Submission of Redeterminations first level appeal and track the status of submitted requests Submit authorization for immediate offset eOffset of demanded overpayments Submit requests for Reopening of previously processed claims This newsletter should be shared with all health care practitioners and managerial members of RETURN TO the provider supplier staff Newsletters issued after January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 05 MAY 2015 6 myCGS was recently enhanced to accept Part B claims eClaim submissions are available to ALL Part B providers registered to use myCGS This includes current electronic claim submitters as well as providers who are authorized to submit paper CMS 1500 claim forms to CGS The exciting part about the eClaim enhancement is IT S FREE And all eClaims are processed as electronic claims which can be paid in as few as 14
41. eet the high risk definition as defined above but who were born from 1945 through 1965 A single once in a lifetime screening test is covered for these individuals x m Z E 2 x lt Qo O gt D j w The determination of high risk for HCV is identified by the primary care physician or practitioner who assesses the patient s history which is part of any complete medical history typically part of an annual wellness visit and considered in the development of a comprehensive prevention plan The medical record should be a reflection of the service provided General Claims Processing Requirements for Claims with Dates of Service on and After June 2 2014 1 New HCPCS G0472 short descriptor Hep C screen high risk other and long descriptor Hepatitis C antibody screening for individual at high risk and other covered indication s will be used HCPCS G0472 will appear in the January 2016 recurring updates of the Clinical Laboratory Fee Schedule CLFS and the Integrated Outpatient Code Editor IOCE with a June 2 2014 effective date MACs shall apply contractor pricing to claims with dates of service June 2 2014 through December 31 2015 that contain HCPCS G0472 MACs will not automatically adjust claims that may be processed in error but will adjust such claims that you bring to their attention 2 Beneficiary coinsurance and deductibles do not apply to HCPCS G0472 3 For services provided to beneficiar
42. egree atrioventricular block e 427 81 Sinoatrial node dysfunction or e 746 86 Congenital heart block The following diagnosis codes can be covered at the MAC s discretion if submitted with at least one of the diagnosis codes listed above in addition to the KX modifier e 426 10 Atrioventricular block unspecified 144 30 Unspecified atrioventricular block This newsletter should be shared with all health care practitioners and managerial members of RETURN TO er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS the provider supplier staff Newsletters MEDICARE BULLETIN GR 2015 05 MAY 2015 x m Z E 2 x lt Qo O gt D j w 26 e 426 11 First degree atrioventricular block 144 0 Atrioventricular block first degree e 426 4 Right bundle branch block 145 10 Unspecified right bundle branch block 145 19 Other right bundle branch block e 427 0 Paroxysmal supraventricular tachycardia 147 1 Supraventricular tachycardia e 427 31 Atrial fibrillation 148 1 Persistent atrial fibrillation 148 91 Unspecified atrial fibrillation e 427 32 Atrial flutter 148 3 Typical atrial flutter 148 4 Atypical atrial flutter or 148 91 Unspecified atrial fibrillation or e 780 2 Syncope and collapse R55 Syncope and collapse R55 is the ICD 10 dx code but is not payable upon implementation of CD 10 and is on
43. enda_Updates html on the CMS website 4 Drugs and Biologicals Based on ASP Methodology with Restated Payment Rates Some drugs and biologicals based on ASP methodology may have payment rates that are corrected retroactively These retroactive corrections typically occur on a quarterly basis The list of drugs and biologicals with corrected payments rates will be accessible on the first date of the quarter at http cms gov Medicare Medicare Fee for Service Payment ASCPayment index html on the CMS website Suppliers who think they may have received an incorrect payment for drugs and biologicals impacted by these corrections may request MAC adjustment of the previously processed claims a Revised ASC Payment Indicator for HCPCS Codes J0365 Effective April 1 2015 the ASC payment indicator for HCPCS code J0365 Injection aprotonin 10 000 kiu will change from K2 to Y5 This code is listed in the following table 3 along with the effective date for the revised status indicator x m Z E 2 x lt Qo O I gt D j w Drugs and Biologicals with Revised ASC Payment Indicators HCPCS Code Long Descriptor ASC PI Effective Date J0365 Injection aprotonin 10 000 kiu Y5 4 1 2015 b Other Changes to CY 2015 HCPCS Codes for Certain Drugs Biologicals and Radiopharmaceuticals Effective April 1 2015 HCPCS code Q9975 Factor VIII FC Fusion Recomb will replace HCPCS code C9136 Factor vii
44. er is available at http www cms gov Outreach and Education Medicare Learning Net work MLN MLNMattersArticles index html under How Does It Work Kentucky amp Ohio MM8858 Revised International Classification of Diseases 10th Revision ICD 10 Testing Acknowledgement Testing with Providers 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 2015 MLN Matters Articles html MLN Matters Number MM8858 Revised Implementation Date November 17 Related CR Release Date February 24 2015 through 21 2014 for the November Related CR Transmittal R14720TN Testing Week March 2 through 6 2015 for Related Change Request CR CR 8858 the March Testing Week June 1 through Effective Date 30 Days From Issuance See test dates 5 2015 for the June Testing Week Note This article was revised on February 27 2015 to reflect the revised CR8858 issued on February 24 In the article the CR release date transmittal number and the Web address for accessing CR8858 are revised All other information remains the same Provider Types Affected This MLN Matters Article is intended for physicians other providers and suppliers submitting claims to Medicare Administ
45. ermination NCD for Single Chamber and Dual Chamber Permanent Cardiac Pacemakers The Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2015 MLN Matters Articles html MLN Matters Number MM9078 Related Change Request CR CR 9078 Related CR Release Date February 20 2015 Effective Date August 13 2013 Related CR Transmittal R3204CP and R179NCD Implementation Date July 6 2015 Note This article was revised on February 27 2015 to reflect the revised CR9011 issued on February 25 In the article the CR release date transmittal number and the Web address for accessing CR9011 are revised All other information remains the same Provider Types Affected This MLN Matters Article is intended for physicians providers and suppliers submitting claims to Medicare Administrative Contractors MACs for single chamber and dual chamber permanent cardiac pacemaker services provided to Medicare beneficiaries Provider Action Needed Change Request CR 9078 informs MACs that the Centers for Medicare amp Medicaid Services CMS issued a National Coverage Determination NCD and concluded that This newsletter should be shared with all health care practitioners and manageria
46. expected to make appropriate coding decisions based on Medicare instructions http www cms gov Regulations and Guidance Guidance Manuals Internet Only Manuals lOMs html and other information available Additional Resources e CMS Fact Sheet for Chronic Care Management D Users GC24 AppData Local Microsoft Windows Temporary Internet Files Content Outlook DSK231S1 ohttp www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads ChronicCareManagement pdf e CGS Fact Sheets http www cgsmedicare com partb mr checklists html e CMS Evaluation and Management Services Guide D Users GC24 AppData Local Microsoft Windows Temporary Internet Files Content Outlook DSK231S1 o http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts downloads eval_mgmt_serv_guide ICN006764 pdf Kentucky amp Ohio Medicare Physician Fee Schedule MPFS How Are Fees Calculated x m Z E 2 x lt Qo O I gt D j w Medicare contractors including CGS reimburse some services based on the CMS Medicare Physician Fee Schedule MPFS CMS calculates fee schedule amounts and provides these amounts directly to Medicare contractors including CGS and these amounts become the basis for payment for services that are paid based on the MPFS This article explains how the fees are calculated based on a standard formula and the following variables e Geographi
47. for lluvien is 0 01 mg Because each implant is a fixed dose containing 0 19 mg of fluocinlone acetonide ASCs should report 19 units of C9450 for each implant b Drugs and Biologicals with Payments Based on Average Sales Price ASP Effective April 1 2015 For CY 2015 payment for non pass through drugs biologicals and therapeutic radiopharmaceuticals is made at a single rate of ASP 6 percent which provides payment for both the acquisition cost and pharmacy overhead costs associated This newsletter should be shared with all health care practitioners and managerial members of RETURN TO er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS the provider supplier staff Newsletters MEDICARE BULLETIN GR 2015 05 MAY 2015 33 with the drug biological or therapeutic radiopharmaceutical Additionally in CY 2015 a single payment of ASP 6 percent for pass through drugs biologicals and radiopharmaceuticals is made to provide payment for both the acquisition cost and pharmacy overhead costs of these pass through items Payments for drugs and biologicals based on ASPs will be updated on a quarterly basis as later quarter ASP submissions become available Updated payment rates effective April 1 2015 are available the April 2015 ASC Addendum BB which is at http www cms gov Medicare Medicare Fee for Service Payment ASCPayment 11 Add
48. gestive heart failure dizziness or confusion The following indications are covered for implanted permanent single chamber or dual chamber cardiac pacemakers 1 Documented non reversible symptomatic bradycardia due to sinus node dysfunction x m Z E 2 x lt Qo O gt D j w 2 Documented non reversible symptomatic bradycardia due to second degree and or third degree atrioventricular block The following indications are non covered for implanted permanent single chamber or dual chamber cardiac pacemakers 1 Reversible causes of bradycardia such as electrolyte abnormalities medications or drugs and hypothermia Asymptomatic first degree atrioventricular block exception Asymptomatic sinus bradycardia Asymptomatic sino atrial block or asymptomatic sinus arrest exception OY OO NS Ineffective atrial contractions for example chronic atrial fibrillation or flutter or giant left atrium without symptomatic bradycardia exception 6 Asymptomatic second degree atrioventricular block of Mobitz Type unless the QRS complexes are prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of the His Bundle a component of the electrical conduction system of the heart 7 Syncope of undetermined cause exception 8 Bradycardia during sleep 9 Right bundle branch block with left axis deviation and other forms of fascicular or bundle branch block w
49. ht CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 05 MAY 2015 x m Z E 2 x lt Qo O z gt D j w 32 a Device Offset from Payment The C2623 device should always be billed with CPT Code 37224 Revascularization endovascular open or percutaneous femoral popliteal artery s unilateral with transluminal angioplasty or CPT Code 37226 Revascularization endovascular open or percutaneous femoral popliteal artery s unilateral with transluminal stent placement s includes angioplasty within the same vessel when performed The Centers for Medicare amp Medicare Services CMS has determined that a portion of the OPPS payment associated with the cost of HCPCS code C2623 is reflected in the OPPS payment for CPT codes 37224 and 37226 The ASC Code Pair File will be used to establish the reduced ASC payment amount for CPT codes 37224 and 37226 only when billed with HCPCS code C2623 b Billing Instructions for CPT codes 37224 and 37226 Pass through category C2623 Catheter transluminal angioplasty drug coated non laser is to be billed and paid for as a pass through device only when provided with CPT Code 37224 Revascularization endovascular open or percutaneous femoral popliteal artery s unilateral with transluminal angioplasty or CPT Code 37226 Revascularization endovascular open or percutaneous femoral popliteal artery s unilateral with transluminal
50. i Eloctate The payment indicator for Q9975 will remain K2 Code C9136 has a termination date of March 31 2015 The following table describes the HCPCS code change and effective date New HCPCS Codes for Certain Drugs and Biologicals Effective April 1 2015 HCPCS Code Short Descriptor Long Descriptor ASC PI Effective Date Q9975 Factor VIII FC Injection factor viii fc fusion K2 04 01 2015 Fusion Recomb protein recombinant per i u 5 Billing Guidance for Corneal Allograft Tissue ASCs can bill for corneal allograft tissue used for coverage CPT code 66180 or revision CPT code 66185 of a glaucoma aqueous shunt with HCPCS code V2785 Contractors pay for corneal tissue acquisition reported with HCPCS code V2785 based on acquisition invoice cost 6 Coverage Determinations The fact that a drug device procedure or service is assigned a HCPCS code and a payment rate under the ASC payment system 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 Your MAC determines whether a drug device procedure or other service meets all program requirements for coverage for example that it is reasonable and necessary to treat the beneficiary s condition and whether it is excluded from payment This newsletter should be shared with all health care practitioners and managerial members of RETURN TO the provider supplie
51. ies born between the years 1945 and 1965 who are not considered high risk HCV screening is limited to once per lifetime claims shall be submitted with HCPCS G0472 4 For those determined to be high risk initially claims must be submitted with HCPCS G0472 and ICD 9 diagnosis code V69 8 other problems related to life style ICD 10 diagnosis code 272 89 other problems related to lifestyle once ICD 10 is implemented 5 Screening may occur on an annual basis if appropriate as defined in the policy Claims for adults at high risk who have had continued illicit injection drug use since the prior negative screening shall be submitted with HCPCS G0472 ICD diagnosis code V69 8 Z72 89 and This newsletter should be shared with all health care practitioners and managerial members of RETURN TO January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS the provider supplier staff Newsletters MEDICARE BULLETIN GR 2015 05 MAY 2015 16 ICD diagnosis code 304 91 unspecified drug dependence continuous F19 20 other psychoactive substance abuse uncomplicated once ICD 10 is implemented Note Annual is defined as 11 full months must pass following the month of the last negative HCV screening Institutional Billing Requirements Effective for claims with dates of service on and after June 2 2014 institutiona
52. ing NCD process Make sure that your billing staffs are aware of these spreadsheets attached to CR9087 for the following 13 NCDs NCD NCD Title 20 29 Hyperbaric Oxygen Therapy 20 9 1 Ventricular Assist Devices x m Z E 2 x lt Qo O gt D j w This newsletter should be shared with all the provider supplier staff Newsletters sh alth O and os a a of RETURN TO er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 05 MAY 2015 28 Background CR9087 s purpose is to 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 POS TOB provider specialties and so forth The requirements described in CR9087 reflect the operational changes that are necessary to implement the conversion of the Medicare shared system diagnosis codes specific to the attached Medicare NCD spreadsheets NCD NCD Title PN 50 3 Cochlear Implantation m 80 2 Photodynamic Therapy Z 80 2 1 Ocular Photodynamic Therapy OPT 80 3 Photosensitive Drugs 80 3 1 Verteporfin O 110 10 Intravenous Iron The
53. ir staffs should be aware that removing an NCD results in coverage determinations being at the discretion of local MACs within their respective jurisdictions Background CR9095 removes seven NCDs from Publication 100 03 NCD Manual pursuant to the expedited process that was established in an August 7 2013 Federal Register FR notice 78 FR 48164 The FR notice is available at http www cms gov Medicare Coverage DeterminationProcess Downloads FR08072013 pdf on the Centers for Medicare amp Medicaid Services CMS website A CMS decision memorandum dated December 18 2014 contains a summary of the expedited removal process and explicitly removes seven NCDs from the NCD Manual sections as follows e 50 6 Tinnitus masking e 160 4 Stereotactic Cingulotomy as a Means of Psychosurgery e 160 6 Carotid Sinus Nerve Stimulator e 160 9 Electroencephalographic EEG Monitoring During Open Heart Surgery e 190 4 Electron Microscope e 220 7 Xenon Scan and e 220 8 Nuclear Radiology Procedure You can review the CMS decision memorandum at http www cms gov medicare coverage database details medicare coverage document details aspx MCDId 29 amp mcdtypename Natio nal Coverage Determinations Proposed for Removal amp MCDIndexType 7 amp bc AgAEAAAAAA AAAA 3d 3d amp on the CMS website In the absence of an NCD MACs should revert to historical standing policy and consider whether any Medicare claims for these servi
54. ithout syncope or other symptoms of intermittent atrioventricular block exception 10 Asymptomatic bradycardia in post myocardial infarction patients about to initiate long term beta blocker drug therapy 11 Frequent or persistent supraventricular tachycardias except where the pacemaker is specifically for the control of tachycardia exception 12 Aclinical condition in which pacing takes place only intermittently and briefly and which is not associated with a reasonable likelihood that pacing needs will become prolonged MACs will determine coverage under section 1862 a 1 A of the Social Security Act for any other indications for the implantation and use of single chamber or dual chamber cardiac pacemakers that are not specifically addressed in this NCD NOTES MACs shall accept the inclusion of the KX modifier on the claim line s as an attestation by the practitioner and or This newsletter should be shared with all health care practitioners an ageri oers RETURN TO the provider supplier staff Newsletters issued after Jar F t c ee a a E lt TABLE OF CONTENTS website at http www cgsmedicare com 2 7 MEDICARE BULLETIN GR 2015 05 MAY 2015 24 provider of the service that documentation is on file verifying the patient has non reversible symptomatic bradycardia symptoms of bradycardia are symptoms that can be directly attributable to a heart rate less than 60 beats per minute for example syncope seizures
55. ity high cost care to an upward adjustment of positive 2 X for low cost high quality care The X in the upward adjustment represents an adjustment factor that is used to redistribute payment reductions taken from groups that do not successfully report and those that perform poorly on quality and cost measures to those groups that perform well In future years the quality tiering approach will be mandatory but in 2016 and 2017 group sizes that are new to the Value Modifier will only be eligible for upward or neutral adjustments under quality tiering Policies for the 2018 Value Modifier will be made in the 2018 Physician Fee Schedule rule As the Value Modifier s application to smaller group sizes and groups of non physician EPs is gradually phased in the maximum available incentives and maximum downward adjustments are gradually increased More information on the Value Modifier is available at http www cms gov Medicare Medicare Fee for Service Payment PhysicianFeedbackProgram ValueBasedPaymentModifier html on the CMS website What Payments are Affected by the Value Modifier In 2015 CMS applies the Value Modifier adjustment at the TIN level to the items and services billed by physicians in the group not to other eligible professionals that also may bill under the TIN A Physician is defined for the Value Modifier Program as a Doctor of Medicine Doctor of Osteopathy Doctor of Podiatric Medicine Doctor of Optometry
56. l members of RETURN TO the provider supplier staff Newsletters er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 05 MAY 2015 x m Z E 2 x lt Qo O gt D j w 23 implanted permanent cardiac pacemakers single chamber or dual chamber are reasonable and necessary for the treatment of non reversible symptomatic bradycardia due to sinus node dysfunction and second and or third degree atrioventricular block Make sure that your billing staffs are aware of these changes Background Permanent cardiac pacemakers refer to a group of self contained battery operated implanted devices that send electrical stimulation to the heart through one or more implanted leads Single chamber pacemakers typically target either the right atrium or right ventricle Dual chamber pacemakers stimulate both the right atrium and the right ventricle On August 13 2013 CMS issued an NCD in which CMS concluded that implanted permanent cardiac pacemakers single chamber or dual chamber are reasonable and necessary for the treatment of non reversible symptomatic bradycardia due to sinus node dysfunction and second and or third degree atrioventricular block Symptoms of bradycardia are symptoms that can be directly attributable to a heart rate less than 60 beats per minute for example syncope seizures con
57. l providers may use types of bill TOB 13X 71X 77X and 85X when submitting claims for HCV screening HCPCS G0472 Medicare will deny G0472 service line items on other TOBs using the following messages e Claim Adjustment Reason Code CARC 170 Payment denied when performed billed by this type of provider Note Refer to the 835 Healthcare Policy Identification Segment loop 2110 Service Payment Information REF if present e Remittance Advice Remarks Code RARC N95 This provider type provider specialty may not bill this service e Group Code CO contractual obligation If claim received without a GZ modifier The service is paid on the following basis x m Z E 2 x lt Qo O gt D j w e Outpatient hospitals TOB 13X based on the Outpatient Prospective Payment System e Rural Health Clinics RHCs TOB 71X and Federally Qualified Health Centers FQHCs 77X For RHCs and FQHCs that are authorized to bill under the All Inclusive Rate AIR system payment for the professional component is included in the AIR For FQHCs authorized to bill under the FQHC Prospective Payment System PPS payment for the professional component is included in the FQHC PPS rate HCV screening is not a stand alone payable visit for RHCs and FQHCs e Critical Access Hospitals CAHs TOB 85X based on reasonable cost and e CAH Method II TOB 85X based on 115 percent of the lesser of the MPFS amount or
58. lue Modifier and beyond if we are able to receive and utilize corrected quality data then we will recalculate the quality composite If we determine we made an error in the calculation of the cost composite then we will re compute the cost composite to correct the error Who Can I Contact for Further Information Physician Value Help Desk for Value Modifier questions Monday Friday 8 00 a m 8 00 p m EST Phone 1 888 734 6433 press option 3 QualityNet Help Desk for PQRS questions 1 866 288 8912 TTY 1 877 715 6222 7 00 a m 7 00 p m CST M F or qnetsupport hcqis org This newsletter should be shared with all health care practitioners and managerial members of RETURN TO er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS the provider supplier staff Newsletters MEDICARE BULLETIN GR 2015 05 MAY 2015 x m Z E 2 x lt Qo O gt D j w 10 You will be asked to provide basic information such as name practice address phone and e mail address Additional Information More information about the full implementation of the CMS Physician Feedback Value Based Payment Modifier Program is available at http www cms gov Medicare Medicare Fee for Service Payment PhysicianFeedbackProgram ValueBasedPaymentModifier html on the CMS website A summary of the 2015 Physician Value ba
59. ly included here for information purposes Professional claims MACs shall return claims lines for implanted permanent cardiac pacemakers single chamber or dual chamber containing one of the following CPT codes 33206 33207 or 33208 as unprocessable when the KX modifier is not present When returning such claims MACs shall use the following messages x m Z E 2 x lt Qo O gt D j w e Claim Adjustment Reason Code CARC 4 The procedure code is inconsistent with the modifier used or a required modifier is missing e Remittance Advice Remarks Code RARC N517 Resubmit a new claim with the requested information Institutional claims MACs shall return to providers claims for implanted permanent cardiac pacemakers single chamber or dual chamber when any of the following are not present on the claim At least one HCPCS code C1785 C1786 C2619 or C2620 at least one CPT code 33206 33207 33208 33227 33228 at least one diagnosis code 426 0 144 2 426 12 144 1 426 13 144 1 427 81 149 5 746 86 Q24 6 at least one procedure code 37 81 0JH604Z OJH634Z OJH804Z 0JH834Z 37 82 0JH605Z OJH635Z OJH805Z OJH835Z 38 83 OJH606Z OJH636Z OJH806Z 0JH836Z and the KX modifier is not present on the claim Cardiac Pacemaker Non covered ICD ICD 10 Diagnosis Code For claims with dates of service on or after implementation of ICD 10 for implanted permanent cardiac pacemakers single chamber or dual ch
60. m PQRS Timeline located at http www cms gov Medicare Quality Initiatives Patient Assessment Instruments PQRS Downloads 2015 17_CMS_PQRS_Timeline pdf on the CMS website To find general PQRS information including information about payment adjustments visit http cms gov Medicare Quality Initiatives Patient Assessment Instruments PQRS index html on the CMS website For additional questions contact the QualityNet Help Desk at 1 866 288 8912 TTY 1 877 715 6222 or via qnetsupport hcqis org The Help Desk is available from 7 00 a m to 7 00 p m Central Time Monday through Friday This newsletter should be shared with all health care practitioners and managerial members of RETURN TO er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS the provider supplier staff Newsletters MEDICARE BULLETIN GR 2015 05 MAY 2015 x m Z E 2 x lt Qo O gt D j w 12 Frequently Asked Questions CAHs Question lm an EP who furnishes professional Medicare Part B services at a CAH and the CAH is paid under the Optional Payment Method Method II Are my services eligible for PQRS Answer Not in 2013 An EP who furnishes Medicare Part B services at a CAH and the CAH is paid under Method II is not eligible for the 2013 PQRS incentive payment or for the 2015 PQRS negative payment adjustment if he or she h
61. neficiaries reach their nutrition and dietary goals Read more http www cms gov Medicare Prevention PrevntionGenInfo Health Observance Mesages New ltems 2015 03 05 National Nutrition Month html DLPage 1 amp DLSort 0 amp DLSortDir descending to learn about nutrition related health services covered by Medicare e Coding for ICD 10 CM More of the Basics MLN Connects Video In this MLN Connects video on Coding for ICD 10 CM More of the Basics https www youtube com watch v s86pxXhhOG 7c amp list eUUhHHT RPxz8awulGaTMh3SAkA Sue Bowman from the American Health Information Management Association AHIMA and Nelly Leon Chisen from the American Hospital Association AHA provide a basic introduction to ICD 10 CM coding The objective of this video is to enhance viewers understanding of the characteristics and unique features of ICD 10 CM as well as similarities and differences between ICD 9 CM and ICD 10 CM Run time 36 minutes e NEW product from the Medicare Learning Network MLN Provider Compliance Tips for Computed Tomography CT Scans http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts MLN This newsletter should be shared with all health care practitioners and managerial members of RETURN TO er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS the provider supplier staff
62. nt law the conversion factor will be adjusted for services furnished on or after April 1 2015 The files with the new conversion factor will be provided with the April quarterly update This newsletter should be shared with all health care practitioners and managerial members of RETURN TO the provider supplier staff Newsletters er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 05 MAY 2015 35 In the final rule Centers for Medicare amp Medicaid Services CMS announced a conversion factor of 28 2239 for this period resulting in an average reduction of 21 2 percent from the CY 2014 rates In most prior years Congress has taken action to avert large across the board reductions in Provider Fee Schedule rates before they went into effect CMS supports legislation to permanently change the Sustainable Growth Rate to provide more stability for Medicare beneficiaries and providers while promoting efficient high quality care Changes for certain CPT HCPCS codes included in the April update to the 2015 MPFSDB are as follows e J1826 Procedure Status E e J9010 Procedure Status N e 77063 Type of Service 1 e 93355 Multiple Surgery Indicator 2 and Type of Service 4 e 93644 Type of Service 2 Code G0279 has a new short descriptor of Tomosynthesis mammo In addition the following codes h
63. od G0434QW September 26 2014 Polymed Therapeutics FaStep Marijuana Panel Dip G0434QW September 26 2014 Polymed Therapeutics FaStep Marijuana Quick Cup G0434QW September 26 2014 Polymed Therapeutics FaStep Marijuana Strip G0434QW September 26 2014 Polymed Therapeutics FaStep Marijuana Turn Key Split Cup G0434QW September 26 2014 Polymed Therapeutics FaStep Methamphetamine Panel Dip G0434QW September 26 2014 Polymed Therapeutics FaStep Methamphetamine Quick Cup G0434QW September 26 2014 Polymed Therapeutics FaStep Methamphetamine Strip G0434QW September 26 2014 Polymed Therapeutics FaStep Methamphetamine Turn Key Split Cup G0434QW October 9 2014 Chemtron Biotech Inc Chemtrue Single Multi Panel Drug Screen Dip Card Tests G0434QW October 9 2014 Chemtron Biotech Inc Chemtrue Single Multi Panel Drug Screen Cassette Tests G0434QW October 9 2014 Chemtron Biotech Inc Chemtrue Multi Panel Drug Screen Dip Card Tests G0434QW October 9 2014 Chemtron Biotech Inc Chemtrue Multi Panel Drug Screen Dip Card with OPI 2000 Test G0434QW October 17 2014 Healgen Oxazepam Test Strip G0434 QW October 17 2014 Healgen Oxazepam Test Dip Card G0434QW October 17 2014 Healgen Oxazepam Test Cup G0434QW October 17 2014 Healgen Oxazepam Test Cassette G0434QW October 17 2014 Healgen Morphine Test Strip G0434QW October 17 2014 Healgen Morphine Test Dip Card G0434QW October 17 2014
64. ov Outreach and Education Medicare Learning Network MLN MLNMattersArticles index html under How Does It Work Kentucky amp Ohio MM9072 New Waived Tests 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 2015 MLN Matters Articles html MLN Matters Number MM9072 Related Change Request CR CR 9072 Related CR Release Date February 27 2015 Effective Date April 1 2015 Related CR Transmittal R3207CP Implementation Date April 6 2015 Provider Types Affected This MLN Matters Article is intended for clinical diagnostic laboratories submitting claims to Medicare Administrative Contractors MACs for testing services provided to Medicare beneficiaries Provider Action Needed Change Request CR 9072 informs MACs about the changes in the new Clinical Laboratory Improvement Amendments of 1988 CLIA waived tests approved by the Food and Drug Administration FDA Since these tests are marketed immediately after approval Centers for Medicare amp Medicaid Services CMS must notify its MACs of the new tests to allow MACs to accurately process claims CLIA requires that for each test it performs a laboratory facility must be appropriately certified The CPT codes
65. oviders and suppliers submitting claims to Medicare Administrative Contractors MACs including Home Health amp Hospice HH amp H MACs for services provided to Medicare beneficiaries What You Need to Know The Centers for Medicare amp Medicaid Services CMS issued Change Request CR 9011 to incorporate various existing Medicare enrollment revalidation policies into Chapter 15 of the Program Integrity Manual PIM Background CR9011 incorporates various existing revalidation policies into the PIM As these policies were previously established via business requirements those business requirements are not being repeated in this article The new polices announced in CR9011 are as follows e When processing a voluntary termination of a reassignment the MAC will contact the group to confirm that the group member s Provider Transaction Access Number PTAN is being This newsletter should be shared with all health care practitioners and managerial members of RETURN TO the provider supplier staff Newsletters er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 05 MAY 2015 19 terminated from all locations and if multiple group member PTANSs exist for multiple group locations each PTAN is terminated e Many enrolled providers may actually be subparts of other enrolled providers and some of thos
66. pdates July 6 2015 For ICD 9 and and all local system edits ICD 9 and ICD 10 July 1 2015 For ICD 10 shared system edits all ICD 9 shared system edits October 1 2015 For all ICD 10 shared system edits or whenever ICD 10 is implemented Note This article was revised on March 13 2015 to add a link to the attachments to CR9087 All other information remains the same Provider Types Affected This MLN Matters Article is intended for physicians other providers and suppliers submitting claims to Medicare Administrative Contractors MACs for services provided to Medicare beneficiaries Provider Action Needed This article is based on Change Request CR 9087 which is the second 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 CR7818 CR8109 CR8197 and CR 8691 Links to related MLN Matters Articles MM7818 MM8109 MM8197 and MM8691 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 updates No policy related changes are included with these updates Any policy related changes to NCDs continue to be implemented via the current long stand
67. provider supplier staff Newsletters MEDICARE BULLETIN GR 2015 05 MAY 2015 27 at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R3204CP pdf on the CMS website The second updates the Medicare National Coverage Determination Manual and it is available at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R179NCD pdf on the CMS website If you have questions please contact your MAC at their toll free number The number is available at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles index html under How Does It Work Kentucky amp Ohio MM9087 Revised ICD 10 Conversion Coding Infrastructure Revisions ICD 9 Updates to National Coverage Determinations NCDs 2nd 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 2015 MLN Matters Articles html MLN Matters Number MM9087 Revised Implementation Date Related CR Release Date March 6 2015 April 6 2015 For Related CR Transmittal R14780TN designated ICD 9 updates Related Change Request CR CR 9087 and all local system edits Effective Date April 6 2015 For designated ICD 9 u
68. pyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 05 MAY 2015 x m Z E 2 x lt Qo O gt D j w 15 Prior to June 2 2014 CMS did not cover screening for HCV in adults Pursuant to 1861 ddd of the Social Security Act CMS may add coverage of additional preventive services through the National Coverage Determination NCD process Effective June 2 2014 CMS will cover screening for HCV with the appropriate U S Food and Drug Administration FDA approved cleared laboratory tests used consistently with FDA approved labeling and in compliance with the Clinical Laboratory Improvement Act CLIA regulations and point of care tests such as rapid anti body tests that are performed in outpatient clinics and physician offices when ordered by the beneficiary s primary care physician or practitioner within the context of a primary care setting and performed by an eligible Medicare provider for these services for beneficiaries who meet either of the following conditions 1 Adults at high risk for HCV infection High risk is defined as persons with a current or past history of illicit injection drug use and persons who have a history of receiving a blood transfusion prior to 1992 Repeat screening for high risk persons is covered annually only for persons who have had continued illicit injection drug use since the prior negative screening test 2 Adults who do not m
69. r Hepatitis C Virus HCV in Adults 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 2015 MLN Matters Articles html MLN Matters Number MM8871 Revised Effective Date June 2 2014 Related CR Release Date March 11 2015 Implementation Date January 5 2015 for Related CR Transmittal non shared MAC edits and CWF analysis April R3215CP and R177NCD 6 2015 for remaining shared system edits Related Change Request CR CR 8871 Note This article was revised on March 13 2015 to reflect the revised CR8871 issued on March 11 The article was revised to 1 replace January 1 2015 MPFSDB with January 1 2016 CLFS on page 3 2 remove 50 FQHC and 72 RHC from the list of place of service codes in the middle of page 5 3 clarify payment method for Type of Bill 13X 4 add clarifying language for FQHC and RHC and remove incorrect language regarding claims processing for FQHC and RHC 5 clarify MAC claims processing prior to January 1 2016 instead of January 1 2015 on page 3 All other information remains the same Provider Types Affected This MLN Matters Article is intended for physicians other providers and suppliers submitting claims to Medicare A
70. r staff Newsletters er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 05 MAY 2015 34 7 Claim Adjustment Your MAC will adjust as appropriate claims that you bring to their attention that 7 Have dates of service January 1 2015 March 31 2015 and were originally processed prior to the installation of the revised January 2015 ASC DRUG File 2 Have dates of service July 1 2014 September 30 2014 and were originally processed prior to the installation of the revised July 2014 ASC DRUG File 3 Have dates of service October 1 2014 December 30 2014 and were originally processed prior to the installation of the revised October 2014 ASC DRUG File Additional Information The official instruction CR9100 issued to your MAC regarding this change is available at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R3214CP pdf on the CMS website If you have any questions please contact your MAC at their toll free number That number is available at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles index html under How Does It Work x m Z E 2 x lt Qo O gt D j w Kentucky amp Ohio MM9104 Quarterly Update to the Medicare Physician Fee Schedule Database MPFSDB April Calendar Year C
71. rapy A 150 3 Bone Mineral Density Studies lt 160 18 Vagus Nerve Stimulation Ro 180 1 Medical Nutrition Therapy 210 2 Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer TE 250 3 Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases gt A j WU Please note that there are 10 spreadsheets attached to CR9087 These spreadsheets relate to 13 NCDs and provide pertinent policy coding information necessary to implement ICD 10 Further you should be aware that NCD policies may contain specific covered non covered and or discretionary diagnosis coding These spreadsheets are designated as such and are based on current NCD policies and their corresponding edits Nationally covered and non covered diagnosis code editing is finite and cannot be revised without subsequent discussions with CMS Discretionary code lists are to be regarded as CMS compilation of discretionary codes based on current analysis interpretation Local MACs may or may not expand discretionary lists based on their individual local authority within their respective jurisdictions Nothing contained in CR9087 should be construed as new policy Some coding details are as follows 1 The ICD 10 diagnosis procedure codes associated with the NCDs attached to CR9087 are not to be implemented until October 1 2015 or until ICD 10 is implemented 2 Your MAC will use default Council for
72. rative Contractors MACs including Home This newsletter should be shared with all health care practitioners and managerial members of RETURN TO er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS the provider supplier staff Newsletters MEDICARE BULLETIN GR 2015 05 MAY 2015 x m Z E 2 x lt Qo O gt D j w 13 Health amp Hospice HH amp H MACs and Durable Medical Equipment DME MACs for services provided to Medicare beneficiaries Provider Action Needed Change Request CR 8858 instructs MACs to promote three specific acknowledgement testing weeks with providers and provide data and statistics to the Centers for Medicare amp Medicaid Services CMS to demonstrate readiness for the International Classification for Disease 10th Edition Clinical Modification ICD 10 transition Make sure that your billing staffs are aware of these ICD 10 testing opportunities Background The Centers for Medicare and Medicaid Services CMS is in the process of implementing ICD 10 All covered entities must be fully compliant on October 1 2015 CR8858 instructs all MACs and the DME MAC Common Electronic Data Interchange CEDI contractor to promote ICD 10 Acknowledgement Testing with trading partners during three separate testing weeks and to collect data about the testing These testing weeks will be e
73. rrence has been reached for initial high risk screening or e CARC 167 This these diagnosis es is are not covered Note Refer to the 835 Healthcare Policy Identification Segment loop 2110 Service Payment Information REF if present for subsequent annual high risk screening This newsletter should be shared with all health care practitioners and managerial members of RETURN TO er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS the provider supplier staff Newsletters MEDICARE BULLETIN GR 2015 05 MAY 2015 18 e RARC N386 This decision was based on a National Coverage Determination NCD An NCD provides a coverage determination as to whether a particular item or service is covered A copy of this policy is available at http www cms gov mcd search asp on the CMS website If you do not have web access you may contact the contractor to request a copy of the NCD e Group Code CO if claim received without GZ modifier Additional Information The official instruction CR8871 was issued to your MAC regarding this change via two transmittals The first transmittal updates the Medicare Claims Processing Manual and it is available at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R3215CP pdf on the CMS website The second transmittal updates the NCD Manual and it is available at
74. rs and managerial members of RETURN TO er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS the provider supplier staff Newsletters MEDICARE BULLETIN GR 2015 05 MAY 2015 x m Z E 2 x lt Qo O gt D j w used to calculate the Value Modifier Also make sure that your billing staff is aware of these new payment adjustments Download your QRUR to understand how you performed on the cost and quality measures used to calculate the Value Modifier Information on how to access these reports which contain valuable information on the quality and cost of care provided to the Medicare beneficiaries you or your group serve is available at http www cms gov Medicare Medicare Fee for Service Payment PhysicianFeedbackProgram index html on the CMS website Background The Social Security Act requires that CMS establish a Value Modifier that provides for differential payment under the Medicare Physician Fee Schedule MPFS based upon the quality of care furnished compared to cost during a performance period By law the Value Modifier is to be applied to e Specific physicians and groups of physicians that CMS determines appropriate starting January 1 2015 and All physicians and groups of physicians by January 1 2017 Accordingly CMS established the Physician Feedback Value Based Payment Modifier Program
75. s including Submitter authentication and NPI validation e Testing will not confirm claim payment or produce a remittance advice e MACs and CEDI will be appropriately staffed to handle increased call volume on their Electronic Data Interchange EDI help desk numbers especially during the hours of 9 00 a m to 4 00 p m local MAC time during this week e Your MAC will announce and promote these testing weeks via their listserv messages and their website This newsletter should be shared with all health care practitioners and managerial members of RETURN TO er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS the provider supplier staff Newsletters MEDICARE BULLETIN GR 2015 05 MAY 2015 14 Additional Information The official instruction CR8858 issued to your MAC regarding this change is available at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R14720TN pdf on the CMS website The EDI help desk numbers for institutional claim submitters are available at http www cms gov Medicare Billing ElectronicBillingEDITrans downloads EDIHelplinePartA pdf on the CMS website and the numbers for professional claims submitters are available at http www cms gov Medicare Billing ElectronicBillingEDITrans downloads EDIHelplinePartB pdf on the CMS website Kentucky amp Ohio MM8871 Screening fo
76. sArticles 2015 MLN Matters Articles html MLN Matters Number MM9065 Revised Related Change Request CR CR 9065 Related CR Release Date March 4 2015 Effective Date May 28 2015 Related CR Transmittal R582PI Implementation Date May 28 2015 Note This article was revised on March 6 2015 to reflect the revised CR9065 issued on March 4 In the article we replaced the reference to 42 CFR 405 879 on page 2 with 42 CFR 405 809 In addition the CR release date transmittal number and the Web address for CR9065 All other information remains the same Provider Types Affected This MLN Matters Article is intended for physicians other providers and suppliers who submit claims to Medicare Administrative Contractors MACs for services provided to Medicare beneficiaries Provider Action Needed Change Request CR 9065 on which this article is based incorporates provisions in Final Rule CMS 6045 F into the Medicare Program Integrity Manual or PIM CR9065 also addresses several minor provider enrollment policy issues that have arisen recently Make sure that your billing staffs are aware of these changes Background The Centers for Medicare amp Medicaid Services CMS Final Rule CMS 6045 F entitled Medicare Program Requirements for the Medicare Incentive Reward Program and Provider Enrollment was published in the Federal Register Vol 79 No 234 on December 5 2014 This newsle
77. sed payment modifier policies can be found at http www cms gov Medicare Medicare Fee for Service Payment PhysicianFeedbackProgram Downloads CY2015ValueModifierPolicies pdf on the CMS website You can review the timeline 2012 2017 for the Physician Feedback Value Based Payment Modifier Program at http www cms gov Medicare Medicare Fee for Service Payment PhysicianFeedbackProgram Background html on the CMS website More information about the Value Modifier program is available at http www cms gov Medicare Medicare Fee for Service Payment PhysicianFeedbackProgram index html on the CMS website x m Z E 2 x lt Qo O gt D j w You can find out more about the PQRS program at http www cms gov Medicare Quality Initiatives Patient Assessment Instruments PQRS index html on the CMS website Kentucky amp Ohio SE1508 Guidance on the Physician Quality Reporting System PQRS 2013 Reporting Year and 2015 Payment Adjustment for Rural Health Clinics RHCs Federally Qualified Health Centers FQHCs and Critical Access Hospitals CAHs The Centers for Medicare amp Medicaid Services CMS has issued the following Special Edition Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2015 MLN Matters Articles html
78. stent placement s includes angioplasty within the same vessel when performed beginning on and after C2623 s effective date of April 1 2015 x m Z E 2 x lt Qo O I gt D j w 2 New Services No New services have been assigned for payment in the ASC payment system effective April 1 2015 3 Drugs Biologicals and Radiopharmaceuticals a New April 2015 HCPCS Codes for Certain Drugs Biologicals and Radiopharmaceuticals For April 2015 six new HCPCS codes shown in the table below have been created for reporting drugs and biologicals in the ASC setting where there have not previously been specific codes available New April 2015 HCPCS Codes Effective for Certain Drugs Biologicals and Radiopharmaceuticals HCPCS Code Long Descriptor ASC PI C9445 Injection c 1 esterase inhibitor recombinant Ruconest 10 units K2 C9448 Netupitant 300mg and palonosetron 0 5 mg oral K2 C9449 Injection blinatumomab 1 mcg K2 C94502 Injection fluocinolone acetonide intravitreal implant 0 01 mg K2 C9451 Injection peramivir 1 mg K2 C9452 Injection ceftolozane 50 mg and tazobactam 25 mg K2 Notes 1 HCPCS codes listed in the above table are new codes effective April 1 2015 2 HCPCS code C9450 is associated with lluvien and should not be used to report any other fluocinolone acetonide intravitreal implant e g Retisert ASCs should note that the dosage descriptor
79. sures can translate into payment incentives for providers who provide high quality efficient care while providers who underperform may be subject to a downward adjustment CAUTION What You Need to Know Beginning on January 1 2015 the Centers for Medicare amp Medicaid Services CMS began applying a Value Based Payment Modifier Value Modifier to physician payments under the Medicare Physician Fee Schedule for physicians in groups with 100 or more Eligible Professionals EPs EPs consist of physicians practitioners physical or occupational therapists qualified speech language pathologists and qualified audiologists A group is defined by its Medicare enrolled Taxpayer Identification Number TIN The Value Modifier Program is being gradually phased in as follows e In 2015 the payment adjustments will apply to physicians in groups of 100 or more Eligible Professionals EPs based on a 2013 performance period e In 2016 the payment adjustments will apply to physicians in groups of 10 or more EPs based on 2014 performance e In 2017 the payment adjustments will apply to physician solo practitioners and physicians in groups of 2 or more EPs based on 2015 performance and e Beginning 2018 the payment adjustments will also apply to non physician EPs who are solo practitioners or are in groups of 2 or more EPs Please note that the performance period for the Value Modifier that will be applied in 2018 will be proposed and finalized
80. t Chronic Obstructive Pulmonary Disease gt Documentation in the patient s medical record should gt Depression support that the patient s chronic conditions meet gt Diabetes the standards per the CPT narrative they must gt Heart failure place the patient at significant risk of death acute gt Hypertension exacerbation decompensation or functional decline gt Ischemic heart disease This newsletter should be shared with all health care practitioners and managerial members of RETURN TO er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS the provider supplier staff Newsletters MEDICARE BULLETIN GR 2015 05 MAY 2015 x m Z E 2 x lt Qo O z gt D j w 5 The CCM code is per calendar month and the non face to face work would be done throughout the month What date of service will you require last date of the month As stated on page 1 of the CMS CCM Fact Sheet http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads ChronicCareManagement pdf Chronic care management services consist ofat least 20 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month Page 9 of the CMS CCM Fact Sheet http www cms gov Outreach and Education Medicare Learning Network MLN MLNProduc
81. t PhysicianFeedbackProgram Background html on the CMS website What is the Value based Payment Modifier Value Modifier The Value Modifier can be upward downward or neutral meaning no adjustment and it applies to the Medicare paid amount of physician payments under the Medicare Physician Fee Schedule Beginning on January 1 2015 CMS is applying the Value Modifier to Medicare Physician Fee Schedule Payments made to physicians in group practices with 100 or more EPs billing under a single TIN In 2015 groups of 100 or more EPs that met the minimum PQRS reporting requirement had the option to elect whether they wished to have their Value Modifier calculated based on quality performance For those groups who elected this quality tiering approach CMS determined each group s Value Modifier adjustment for 2015 based on their performance on PQRS measures and claims based outcome and cost measures in 2013 This newsletter should be shared with all health care practitioners and managerial members of RETURN TO er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS the provider supplier staff Newsletters MEDICARE BULLETIN GR 2015 05 MAY 2015 x m Z E 2 x lt Qo O gt D j w The Value Modifier payment adjustment for CY 2015 ranges from a downward adjustment of negative 1 percent for low qual
82. ters for Disease Control and Prevention CDC Influenza Flu http www cdc gov FLU Web page for the latest information on flu including the CDC 2014 2015 recommendations for the prevention and control of influenza antiviral information CDC flu mobile app Q amp As toolkit for long term care employers and other free resources Review the CDC s Antiviral Drugs http www cdc gov flu professionals antivirals index htm website for information about how antiviral medications can be used to prevent or treat influenza when influenza activity is present in your community and view the updated Influenza Antiviral Medications Summary for Clinicians A CDC Health Update reminding clinicians about the importance of flu antiviral medications was distributed via the CDC Health Alert Network on January 9 2015 and is available at http emergency cdc gov HAN han00375 asp on the Internet e MLN Matters Articles Index Have you ever tried to search MLN Matters articles for information regarding a certain issue but you did not know what year it was published To assist you next time in your search try the CMS article indexes that are published at http www cms gov outreach and education medicare learning network mIn MLNMattersArticles on the CMS website These indexes resemble the index in the back of a book and contain keywords found in the articles including HCPCS codes and modifiers These are published every month Just search on
83. treach and Education Medicare Learning Network MLN MLNMattersArticles 2015 MLN Matters Articles html MLN Matters Number MM9100 Revised Related Change Request CR April 1 2015 Related CR Release Date March 11 2015 Effective Date April 1 2015 Related CR Transmittal R3214CP Implementation Date April 6 2015 Note This article was revised on March 13 2015 to reflect the revised CR9100 issued on March 11 The CR was revised to correct the short descriptor for Q9975 In addition the CR transmittal number release date and the Web address for accessing the CR are revised All other information remains the same Provider Types Affected This MLN Matters Article is intended for physicians and Ambulatory Surgical Centers ASCs submitting claims to Medicare Administrative Contractors MACs for services provided to Medicare beneficiaries Provider Action Needed Change Request CR 9100 describes changes to and billing instructions for various payment policies implemented in the April 2015 ASC payment system update and includes updates to the Healthcare Common Procedure Coding System HCPCS Make sure your billing staffs are aware of these changes Key Points of CR9100 1 New Device Pass Through Category and Device Offset from Payment Additional payments may be made to the ASC for covered ancillary services including certain implantable devices with pass through status under the Outpatient Prospective P
84. ts Downloads ChronicCare Management pdf states CPT code 99490 cannot be billed during the same calendar month as CPT codes 99495 99496 Transitional Care Management Healthcare Common Procedure Coding System HCPCS codes G0181 G0182 home health care supervision hospice care supervision or CPT codes 90951 90970 certain End Stage Renal Disease services Also consult CPT instructions for additional codes that cannot be billed during the same service period as CPT code 99490 There may be additional restrictions on billing for practitioners participating in a CMS sponsored model or demonstration program Claims should be submitted with the date of service on which the 20 minute requirement was met x m Z E 2 x lt Qo O gt D j w 6 Since this is a timed code would you expect to see start and stop times documented in order to support the 20 minutes Yes time must be documented as either total time OR start stop times 7 There is a requirement that patients be able to reach providers 24 7 Does an answering machine meet the expectation No As stated on page 4 of the CMS CCM Fact Sheet Access to care is a key requirement in order to submit claims for chronic care management Providers must ensure 24 hour a day 7 day a week access to care management services and patients must have a means to make timely contact with health care practitioners in the practice who have access to the patient
85. tter should be shared with all health care practitioners and managerial members of RETURN TO the provider supplier staff Newsletters er January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 05 MAY 2015 20 See http www gpo gov fdsys pkg FR 2014 12 05 html 2014 28505 htm on the Internet As mentioned CR9065 incorporates provisions in CMS 6045 F into the PIM in Chapter 15 Medicare Enrollment which is included as an attachment to CR9065 One such change outlined in CR9065 is that if a supplier submits a Corrective Action Plan CAP for a revocation based in part on 42 CFR 424 535 a 1 the MAC shall A only consider the portion of the CAP pertaining to a 1 and B notify the supplier in its decision letter or if the MAC wishes via letter or e mail prior to issuing the decision letter that under 42 CFR 405 809 the CAP was will be reviewed only with respect to the a 1 revocation reason See the full Manual revision attached to CR9065 for details on other updates Additional Information The official instruction CR9065 issued to your MAC regarding this change may be viewed at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R582PI pdf on the CMS website If you have questions please contact your MAC at their toll free number The number is available at http www cms g
86. ued to your MAC regarding this change is available at http www cms hhs gov Regulations and Guidance Guidance Transmittals Downloads R3205CP pdf on the CMS website If you have any questions please contact your MAC at their toll free number which is available at http www cms gov Research Statistics Data and Systems Monitoring Programs provider compliance interactive map index html on the CMS website Kentucky amp Ohio News Flash Items e Seasonal Flu Vaccinations For information on coverage and billing of the influenza vaccine and its administration please refer to MLN Matters Article MM8890 http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads MM8890 pdf Influenza Vaccine Payment Allowances Annual Update for 2014 2015 Season and MLN Matters Article SE1431 http www cms gov Outreach and Education Medicare Learning Network MLN This newsletter should be shared with all health care practitioners and managerial members of RETURN TO the provider supplier staff Newsletters issued after January 1997 are available at no cost from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 05 MAY 2015 36 MLNMattersArticles Downloads SE1431 pdf 2014 2015 Influenza Flu Resources for Health Care Professionals Also check out the following resources from the Cen
87. ugh 1965 and who are not high risk Medicare will also line item deny when more than one HCV screening is billed for the same high risk beneficiary prior to their annual eligibility criteria being met In denying these claims Medicare will use e CARC 119 Benefit maximum for this time period or occurrence has been reached e RARC N386 This decision was based on a National Coverage Determination NCD An NCD provides a coverage determination as to whether a particular item or service is covered A copy of this policy is available at http www cms gov mcd search asp on the CMS website If you do not have web access you may contact the contractor to request a copy of the NCD e Group Code CO if claim received without GZ modifier When applying the annual frequency limitation MACs will allow both a claim for a professional service and a claim for a facility fee In addition remember that the initial HCV screening for beneficiaries at high risk must also contain ICD 9 diagnosis code V69 8 ICD 10 code Z72 89 once ICD 10 is implemented Then for the subsequent annual screenings for high risk beneficiaries you must include ICD 9 code V69 8 and 304 91 ICD 10 of Z72 89 and F19 20 once ICD 10 is implemented Failure to include the diagnosis code s for high risk beneficiaries will result in denial of the line item In denying these payments Medicare will use the following e CARC 119 Benefit maximum for this time period or occu
88. ure Revisions ICD 9 Updates to National Coverage Determinations NCDs 2nd Maintenance CR Incentive Programs E1507 Physician Feedback Quality and Resource Use Reports QRURs and Value Based Modifier Program Overview amp Implementation SE1508 Guidance on the Physician Quality Reporting System PQRS 2013 Reporting Year and 2015 Payment Adjustment for Rural Health Clinics RHC s Federally Qualified Health Centers FQHC s and Critical Access Hospitals CAH s 23 30 20 32 35 28 Laboratory amp Pathology MM9072 New Waived Tests 21 Preventive amp Screening Services MM8871 Screening for Hepatitis C Virus HCV in Adults 15 NEWS FLASH News Flash Items 38 Medi Lear Net Official Information Health Care Professionals Can Trust http go cms gov MLNGenInfo Articles contained in this edition are current as of March 28 2015 Bold italicized material is excerpted from the American Medical Association Current Procedural Terminology CPT codes Descriptions and other data only are copyrighted 2009 American Medical Association All rights reserved Applicable FARS DFARS apply MEDICARE BULLETIN GR 2015 05 MAY 2015 g LYVd OIHO 8 AMONLNAM 2 Kentucky amp Ohio Chronic Care Management CPT Code 99490 CGS has received multiple questions regarding CPT code 99490 Chronic Care Management To assist you in determining whether you are submitting this co
89. y be subject to the 2015 PQRS negative payment adjustment if he or she has not satisfactorily reported 2013 PQRS quality measures 1 The non RHC FQHC services furnished by the EP are billed under his or her own TIN NPI combination as reported via Provider Enrollment Chain and Ownership System PECOS The 2015 PQRS payment adjustment applies to the EP as an individual not to the clinic or the facility and 2 The non RHC FQHC services an EP furnished are billed under a group practice s TIN which may be registered to participate in the 2013 PQRS under the GPRO registration or self nomination The 2015 PQRS payment adjustment applies to the EP under the group practice s TIN which applies to the entire group practice For more information about how the 2015 PQRS 1 5 percent negative payment adjustment applies to RHC FQHC providers refer to Listserv 2015 PQRS Payment Adjustment and Providers who Rendered Services at RHCs FQHCs located at http www cms gov Medicare Quality Initiatives Patient Assessment Instruments PQRS Downloads CMS_listserv_2015 PQRS_PA_RHC_FQHC _final pdf and FAQ on 2015 PQRS Payment Adjustment and Providers who Render Services at RHCs FQHCs located at http www cms gov Medicare Quality Initiatives Patient Assessment Instruments PQRS Downloads CMS_FAQ_2015_PQRS_PA RHC_FQHC _final pdf on CMS website To find timeline information refer to 2015 2017 Physician Quality Reporting Syste

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