Medicare Bulletin - September 2015
Contents
1. In addition the temporary moratorium on new part B ground ambulance suppliers is being extended for an additional 6 months in the areas stated in Table 2 below Table 2 Part B Ambulance Suppliers Under 6 month Temporary Moratorium City and State Counties Houston TX Harris Chambers Galveston Montgomery Brazoria Fort Bend Liberty Waller Philadelphia PA Bucks PA Montgomery PA Burlington NJ Gloucester NJ Delaware PA Philadelphia PA Camden NJ 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 09 SEPTEMBER 2015 17 Initial provider enrollment applications and change of information applications to add additional practice locations received from home health agencies home health agency sub units and Part B ground ambulance suppliers in the above listed counties will be denied in accordance with 42 CFR 424 570 c Application fees that are paid for applications that are denied due to the temporary moratoria will be refunded Note Home health agencies home health agency sub units and Part B ground ambulance suppliers are afforded appeal rights However the scope of review will be limited to whether t2. Background The Average Sales Price ASP methodology is based on quarterly data submitted to CMS by manufacturers CMS will supply Medicare contractors with the ASP and Not Otherwise Classified NOC drug pricing files for Medicare Part B drugs on a quarterly basis Payment allowance limits under the OPPS are incorporated into the Outpatient Code Editor OCE through separate instructions that can be located in the Medicare Claims Processing Manual Chapter 4 Part B Hospital Including Inpatient Hospital Part B and OPPS Section 50 Outpatient PRICER https www cms gov Regulations and Guidance Guidance Manuals Downloads clm104c04 pdf The following table shows how the quarterly payment files will be applied Files Effective Dates of Service October 2015 ASP and ASP NOC October 1 2015 through December 31 2015 July 2015 ASP and ASP NOC July 1 2015 through September 30 2015 April 2015 ASP and ASP NOC April 1 2015 through June 30 2015 January 2015 ASP and ASP NOC January 1 2015 through March 31 2015 October 2014 ASP and ASP NOC October 1 2014 through December 31 2014 x m Z E 2 x lt Qo O z gt D j w NOTE The absence or presence of a HCPCS code and its associated payment limit does not indicate Medicare coverage of the drug or biological Similarly the inclusion of a payment limit within a specific column does not indicate Medicare coverage of the drug in tha
3. A Re Issue of MM 7492 13 17 12 13 Laboratory amp Pathology MoPath GeneSight Assay for Refractory Depression Claims Submission Reminders Part B 6 Preventive Services MM9200 Screening for Hepatitis C Virus HCV in Adults Implementation of Additional Common Working File CWF and Shared System Maintainer SSMs Edits ooo 10 NEWS FLASH News Flash Items 19 Medi Lear Net Official Information Health Care Professionals Can Trust http go cms gov MLNGenInfo Articles contained in this edition are current as of July 28 2015 Bold italicized material is excerpted from the American Medical Association Current Procedural Terminology CPT codes Descriptions and other data only are copyrighted 2015 American Medical Association All rights reserved Applicable FARS DFARS apply MEDICARE BULLETIN GR 2015 09 SEPTEMBER 2015 g LYVd OIHO 8 AMONLNAM The Medicare Learning Network MLN offered by the Centers for Medicare amp Medicaid Services CMS includes a variety of educational resources for health care providers Access Web based training courses national provider conference calls materials from past conference calls MLN articles and much more To stay informed about all of the CMS MLN products refer to http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads MailingLists_FactSheet pdf and Medicare Lear
4. Number MM9248 Related Change Request CR CR 9248 Related CR Release Date July 10 2015 Effective Date October 1 2015 Related CR Transmittal R3290CP Implementation Date October 5 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 provided to Medicare beneficiaries Provider Action Needed Change Request CR 9248 which instructs MACs to download and implement the October 2015 Average Sales Price ASP drug pricing files and if released by CMS the July 2015 April 2015 January 2015 and October 2014 ASP drug pricing files for Medicare Part B drugs Medicare will use these files to determine the payment limit for claims for separately payable Medicare Part B drugs processed or reprocessed on or after October 5 2015 with dates of service October 1 2015 through December 31 2015 MACs will not search and adjust claims that have already been processed unless brought to their attention Make sure your billing staffs are aware of these changes 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 09 SEPTEMBER 2015 11
5. Revised Quarterly Healthcare Common Procedure Coding System HCPCS Drug Biological Code Changes July 2015 Update 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 MM9167 Revised Related Change Request CR CR 9167 Related CR Release Date July 10 2015 Effective Date July 1 2015 Related CR Transmittal R3292CP Implementation Date July 6 2015 Note This article was revised on July 20 to reflect the revised CR9167 issued on July 10 In the article language has been modified to clarify the use of Q9977 Also the CR release date transmittal number and the Web address for accessing CR9167 are revised On July 22 2015 the article was revised further to include additional language from the revised CR9167 This additional language is in the note box on page 3 of this article All other information remains the same x m Z E 2 x lt Qo O gt D j w Provider Types Affected This MLN Matters Article is intended for physicians providers and suppliers submitting claims to Medicare Administrative Contractors MACs including Durable Medical Equipment Medicare Administrative Contractor
6. through 9 30 2015 and all ICD 10 codes placed on the other claim with DOS beginning 10 1 2015 and later 82X Hospice Non hospital Split Claims Require providers split the claim so all ICD 9 codes remain FROM on one claim with Dates of Service DOS through 9 30 2015 and all ICD 10 codes placed on the other claim with DOS beginning 10 1 2015 and later 83X Hospice Hospital Based N A N A 85X Critical Access Hospital Split Claims Require providers split the claim so all ICD 9 codes remain FROM on one claim with Dates of Service DOS through 9 30 2015 and all ICD 10 codes placed on the other claim with DOS beginning 10 1 2015 and later Table B Special Outpatient Claims Processing Circumstances Use FROM or Scenario Claims Processing Requirement THROUGH Date 3 day 1 day Since all outpatient services with a few exceptions are required to be bundled on the inpatient THROUGH Payment Window bill if rendered within three 3 days of an inpatient stay if the inpatient hospital discharge is on or after 10 1 2015 the claim must be billed with ICD 10 for those bundled outpatient services Nie bh are ay Zoo n all health D os and E Mone of e proviaer supplier sta ewsletters er January 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 09 SEPTEMBER 2015 x m Z 2 x lt Ro O a gt D j w 1
7. 5 Table C Professional Claims Use FROM or Type of Claim Claims Processing Requirement THROUGH Date All anesthesia Anesthesia procedures that begin on 9 30 2015 but end on 10 1 2015 are to be billed with FROM claims ICD 9 diagnosis codes and use 9 30 2015 as both the FROM and THROUGH date Table D Supplier Claims Use FROM or Type of Claim Claims Processing Requirement THROUGH Date DMEPOS Billing for certain items or supplies such as capped rentals or monthly supplies may span the FROM ICD 10 compliance date of 10 1 2015 i e the FROM date of service occurs prior to 10 1 2015 and the TO date of service occurs after 10 1 2015 Additional Information You may also want to review SE1239 at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads SE1239 pdf on the CMS website SE1239 announces the revised ICD 10 implementation date of October 1 2015 You may also want to review SE1410 at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles Downloads SE1410 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 SE1425 Revised Extension of Provider Enrollment Moratoria for Home Health Agencie
8. Patient eligibility Claim status and deductible Redetermination status Checks issued and General information e To access information via the IVR you must provide the following information National Provider Identifier Provider Transaction Access Number PTAN Provider Tax Identification Number TIN last 5 digits myCGS e Your Electronic Gateway to Self Service myCGS The Jurisdiction 15 Web Portal http www cgsmedicare com partb myCGS index html x m Z E 2 x lt Qo O gt D j w The following information is available through myCGS Patient eligibility Claim status View and print Remittance Advices RAs Payment information payment floor and recently issued check data Immediate Offset eOffset Submit Part B claims Submit Part B Reopenings Submit Redetermination requests and check the status of submitted requests and Submit medical review additional development requests ADRs documentation Please remind your billing staff to use these resources before contacting a CGS Customer Service Representative CSR for beneficiary eligibility and or claim status information Kentucky amp Ohio Mohs Micrographic Surgery Claim Submission Reminders Our Part B Medical Review department has noticed an increase in the number of claims submitted for Mohs Micrographic Surgery MMS with CPT code 17311 17315 performed on the trunk or extremities that
9. SEPTEMBER 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 Ea D gt AU OO Medicare Bulletin Ju risdiction 15 KENTUCKY amp OHIO Administration Checking Beneficiary Eligibility and Claim Status Use myCGS to Submit Your Responses to Medical Review MR Additional Documentation Requests ADRs Letter From The Home Health Contractor Medical Directors CMDs Coding Billing Update for Zoledronic Acid J3489 Mohs Micrographic Surgery Claim Submission Reminders Not Otherwise Classified NOC Drugs Clarification on Required Information MM9167 Revised Quarterly Healthcare Common Procedure Coding System HCPCS Drug Biological Code Changes July 2015 Update SE1315 Rescinded Pulmonary Procedures and Evaluation amp Management E M Services Enrollment amp Credentialing SE1425 Revised Extension of Provider Enrollment Moratoria for Home Health Agencies and Part B Ambulance Suppliers Fee Schedules amp Reimbursement MM9248 October 2015 Quarterly Average Sales Price ASP Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files ICD 10 SE1408 Revised Medicare Fee For Service FFS Claims Processing Guidance for Implementing International Classification of Diseases 10th Edition ICD 10
10. al records of the face to face visit if it was done in the hospital setting in order to substantiate the reason home health care is needed In review to qualify for the Medicare Home Health Benefit beneficiaries must have Medicare Part A and or Part B and meet all of the following requirements e Be confined to the home e Need skilled services Be under the care of a physician e Receive services under a plan of care established and periodically reviewed by a physician and e Have a face to face encounter with a physician or allowed non physician practitioner NPP reviewed and counter signed by the physician Your Home Health Hospice Medicare contractor s website may be accessed to obtain information regarding eligibility and documentation requirements Additional references are as follows e CMS MLN Article MMo119 Revised Manual Updates to Clarify Requirements for Physician Certification and Recertification of Patient Eligibility for Home Health Services e Certifying Patients for the Medicare Home Health Benefit e Medicare Home Health Agency HHA Center Sincerely Contractor Medical Directors Home Health Hospice Medicare Contractors CMS CENTERS FOR MEDICARE amp MEDICAID SERVICES 2015 CGS Administrators LLC CGS Administrators LLC is a Medicare Part A B Home Health and Hospice and DME Medicare Administrative Contractor for the Centers for Medicare amp Medicaid Services Kentucky amp Ohio MM9167
11. anner or various versions of commercially available software Attach up to 5 PDF documents up to 5MB each Save PDF documents in a folder on your system to allow easy access Saved PDF documents help to identify what medical records were submitted to CGS e myCGS validates the patient and claim information you enter ensuring the documentation is matched correctly to the claim being reviewed e myCGS provides a Secure Form Received message confirming CGS has received the MR ADR documentation you submitted myCGS provides a second message Secure Form Confirmation which assigns a Submission ID to your MR ADR submission that can be used to track the status of your response e myCG amp eliminates doubts that all the documentation you faxed was received and matched with the appropriate claim e myCGS amp eliminates personnel from mishandling the medical record documentation e myCGS eliminates postage expense For detailed instructions about submitting your documentation in response to an MR ADR refer to Chapter 7 Forms Tab at http www cgsmedicare com pdf mycgs chapter _partb pdf of the myCGS User Manual or the myCGS MR ADR Job Aid at http cgsmedicare com partb pubs news 2015 0415 cope28413 html If you do not have access to myCGS refer to the Your Electronic Gateway to Self Service myCGS The Jurisdiction 15 Web Portal Web page at http www cgsmedicare com partb myCGS index htm
12. at http www cms gov mcd search asp If you do not have Web access you may contact the contractor to request a copy of the NCD and Group Code CO assigning financial liability to the provider Note Only HCPCS G0472 as noted above should be reported for this new HCV screening benefit CPT code 86803 HCV rapid antibody test is not appropriate for reporting screening under this policy Additional Information The official instruction CR9200 issued to your MAC regarding this change is available at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R3285CP pdf on the CMS website x m Z E 2 x lt Qo O gt D j w 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 MM9248 October 2015 Quarterly Average Sales Price ASP Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files 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
13. do not include documentation as noted in the General Information section of the Mohs Micrographic Surgery Local Coverage Determination LCD L31877 http www cms gov medicare coverage database details Icd details aspx LCDId 318 77 amp Contrid 228 amp ver 258 amp ContrVer 2 amp CntrctrSelected 228 2 amp Cntrctr 228 amp name CGS Admi nistrators 2c LLC 15102 2c MAC Part B amp DocType All amp DocStatus Active amp s 22 amp bc A ggAAAIAAAAAAA 3d 3d amp To ensure your claims are processed in the most efficient manner please keep in mind documentation identifying one or more of the qualifying terms listed under Indications 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 09 SEPTEMBER 2015 4 and Limitations of Coverage must be included This information may be submitted either in the documentation field of your electronic claim as an attachment to a myCGS eClaim http www cgsmedicare com partb pubs news 2015 0415 cope29055 html using the PWK segment http www cgsmedicare com partb pubs news 2013 0213 cope21311 html process or in Item 19 of your CMS 1500 claim form Including this documentation upon initial submission w
14. e same year would have major ramifications for CMS quality demonstration and risk adjustment programs Claims that Span the ICD 10 Implementation Date There may be times when a claim spans the ICD 10 implementation date for institutional professional and supplier claims For example the beneficiary is admitted as an inpatient in late September 2015 and is discharged after October 1 2015 Another example is a DME claim for monthly billing that spans between September and October 2015 that is the monthly billing dates are September 15 2015 October 14 2015 The following tables provide further guidance to providers for claims that span the periods where ICD 9 and ICD 10 codes may both be applicable Table A Institutional Providers Bill Use FROM or Type s Facility Type Services Claims Processing Requirement THROUGH Date 11X Inpatient Hospitals incl If the hospital claim has a discharge and or through date on or after 10 1 15 THROUGH TERFHA hospitals then the entire claim is billed using ICD 10 Prospective Payment System PPS hospitals Long Term Care Hospitals LTCHs Critical Access Hospitals CAHs 12X Inpatient Part B Hospital Split Claims Require providers split the claim so all CD 9 codes remain FROM Services on one claim with Dates of Service DOS through 9 30 2015 and all ICD 10 codes placed on the other claim with DOS beginning 10 1 2015 and later 13X Outpatient Hospital Spli
15. earn more about Medicare covered preventive service e NEW products from the Medicare Learning Network The DMEPOS Competitive Bidding Program Repairs and Replacements Fact Sheet Fact Sheet ICN 905283 downloadable https www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads DME_Repair Replacement_Factsheet_ICN905283 pdf e Revised product from the Medicare Learning Network MLN ICD 10 CM PCS Billing and Payment Frequently Asked Questions Fact Sheet ICN 908974 https Awww cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads ICD 10BillingandPaymentFAQs pdf Internet based PECOS Contact Information Fact Sheet ICN 903766 downloadable http www cms gov Outreach and Education Medicare Learning Network MLN MLNProducts Downloads MedEnroll_ PECOS_Contact_FactSheet_ICN903766 pdf ICD 10 CM Classification Enhancements http www cms gov Medicare Coding CD10 downloads ICD 10QuickRefer pdf Fact Sheet ICN 903187 Downloadable only 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 09 SEPTEMBER 2015 18
16. f new practice locations in a particular geographic area x m Z E 2 x lt Qo O gt D j w On July 28 2015 CMS announced in a Federal Register notice http federalregister gov a 2015 18327 the extension of temporary moratoria on the enrollment of new home health agencies home health agency sub units and part B ambulance suppliers in designated geographic locations The moratoria initially became effective on July 30 2013 and the implementation was announced in the Federal Register which may be accessed on the internet at https federalregister gov a 2013 18394 The moratoria were expanded on January 30 2014 and the expansion was announced in the Federal Register which may be accessed at https federalregister gov a 2014 02166 Moratoria Extension Effective July 29 2015 the temporary moratorium on new home health agencies and home health agency sub units is being extended for an additional 6 months in the areas stated in Table 1 below Table 1 Home Health Agencies and Home Health Agency Sub units under Temporary Moratorium City and State Counties City and State Counties Fort Lauderdale FL Broward Dallas TX Collin Ellis Rockwall Dallas Kaufman Tarrant Denton Miami FL Miami Dade Houston TX Brazoria Galveston Montgomery Monroe Chambers Harris Waller Fort Bend Liberty Detroit MI Macomb Washtenaw Chicago IL Cook Kane McHenry Monroe Wayne DuPage Lake Will Oakland
17. from our website at http www cgsmedicare com 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 09 SEPTEMBER 2015 12 Kentucky amp Ohio SE1408 Revised Medicare Fee For Service FFS Claims Processing Guidance for Implementing International Classification of Diseases 10th Edition ICD 10 A Re Issue of MM 492 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 SE1408 Revised Related Change Request CR 7492 Related CR Release Date N A Effective Date October 1 2014 Related CR Transmittal N A Implementation Date N A Note This article was revised on June 27 2015 to clarify language under Claims that Span the ICD 10 Implementation Date All other information remains the same Provider Types Affected This article is intended for all physicians providers and suppliers submitting claims to Medicare Administrative Contractors MACs including Home Health amp Hospice MACs HH amp H MACs and Durable Medical Equipment MACs DME MACs for services provided to Medicare beneficiaries Provider Action Needed For dates of service on and after Octobe
18. he temporary moratorium applies to the provider or supplier appealing the denial CMS basis for imposing a temporary moratorium is not subject to review Additional Information For more information regarding CMS use of temporary moratoria please review MLN Matters article MM7350 at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads MM7350 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 x m Z E 2 x lt Qo O gt D j w e June is Men s Health Month Medicare provides coverage of a wide range of preventive services subject to certain eligibility and coverage requirements that are especially meaningful to men in helping to prevent and detect disease You can help your patients make the most of their benefits by talking with them about their risk factors for disease and encouraging them to take advantage of the preventive services covered by Medicare that are most appropriate for them Continue reading https www cms gov Medicare Prevention PrevntionGenInfo Health Observance Mesages New tems 2015 06 11 Mens Health html DLPage 1 amp DLEntries 10 amp DLSort 0 amp DLSortDir descending to l
19. ight CGS Administrators LLC TABLE OF CONTENTS MEDICARE BULLETIN GR 2015 09 SEPTEMBER 2015 5 e For paper claims the documentation must be in Item 19 New NOC Code for Compounded Drugs As a result of Change Request CR 9167 http www cms gov Regulations and Guidance Guidance Transmittals Downloads R3254CP pdf effective for claims with dates of service on and after July 1 2015 claims for compounded drugs must be submitted using the new compounded drug not otherwise classified NOC HCPCS code Q9977 Using HCPCS code Q9977 is intended to distinguish compounded drugs which may include biologicals from the other drug NOC codes listed above The same claim submission instructions noted above apply to HCPCS code Q9977 Kentucky amp Ohio Use myCGS to Submit Your Responses to Medical Review MR Additional Documentation Requests ADRs x m Z E 2 x lt Qo O I gt D j w myCGS is our free secure online Web portal where providers can now respond to medical review MR additional documentation requests ADRs When medical records are requested to correctly adjudicate a claim myCGS is a convenient way to ensure an accurate and timely response Documentation in response to an MR ADR must be received by CGS on before 45 calendar days of the request Why myCGS e myCGS allows you to submit attachments as PDF Portable Document Format documents Save documents in a PDF format by using a sc
20. ill help avoid delays in processing as additional documentation request ADR letters will be sent if this information is not received Kentucky amp Ohio MoPath GeneSight Assay for Refractory Depression Claims Submission Reminders Part B The Medical Review department has noticed an increase in claim submissions for GeneSight with referrals from specialties other than licensed psychiatrists As indicated in LCD L35437 MoPath GeneSight Assay for Refractory Depression and its ICD 10 equivalent L35443 this test should only be ordered referred by a licensed psychiatrist If any other specialty orders refers this test it will be considered not medically necessary x m Z E 2 x lt Qo O z gt D j w To ensure your claims are processed in the most efficient manner please enter the name of the test GeneSight in the narrative comment section on electronic claims in loop 2400 NTEO2 for Part B For paper claims submit the test name in Item 19 for Part B A payable ICD 9 code if appropriate is needed for payment consideration https Awww cms gov medicare coverage database license cpt license aspx from overview and quick search aspx amp npage medicare coverage database details Icd details aspx amp LCDId 35437 amp Contrid 228 amp ver 3 amp ContrVer 2 amp CntrctrSelected 228 2 amp Cntrctr 22 8 amp name CGS Administrators 2c LLC 15102 2c MAC Part B amp DocType Active amp D ocStatus Active amp s 22 am
21. l for additional information 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 09 SEPTEMBER 2015 6 TWO VANTAGE WAY NASHVILLE TN 37228 1504 C6SMEDICARE COM C G S A B MAC JURISDICTION 15 Kentucky amp Ohio A CELERIAN GROUP COMPANY We IMPACT lives Dear Colleague Medicare has changed the physician documentation requirements for certification of home health care for dates of service effective January 1 2015 While clinicians still need to certify benefit eligibility and a face to face encounter is still required the need for extra documentation e g the narrative has been scaled back or eliminated These remaining requirements may be billed in the following manner a face to face encounter with a physician or allowed non physician practitioner is billed with an evaluation and management E amp M code and the certification is billed with Go180 Go179 for recertification The home health agency will provide medical records from the office or hospital setting describing the patient s condition and supporting his her eligibility for home care prior to your completion of the certification document The agency may need progress notes from you or hospit
22. ll ICD 9 codes remain FROM on one claim with Dates of Service DOS through 9 30 2015 and all ICD 10 codes placed on the other claim with DOS beginning 10 1 2015 and later 72X End Stage Renal Disease Split Claims Require providers split the claim so all ICD 9 codes remain FROM ESRD on one claim with Dates of Service DOS through 9 30 2015 and all ICD 10 codes placed on the other claim with DOS beginning 10 1 2015 and later 173X Federally Qualified Health N A Always ICD 9 code set N A Clinics prior to 4 1 10 74X Outpatient Therapy Split Claims Require providers split the claim so all ICD 9 codes remain FROM on one claim with Dates of Service DOS through 9 30 2015 and all ICD 10 codes placed on the other claim with DOS beginning 10 1 2015 and later 75X Comprehensive Split Claims Require providers split the claim so all ICD 9 codes remain FROM Outpatient Rehab facilities on one claim with Dates of Service DOS through 9 30 2015 and all ICD 10 codes placed on the other claim with DOS beginning 10 1 2015 and later 71X Federally Qualified Health Split Claims Require providers split the claim so all ICD 9 codes remain FROM Clinics effective 4 4 10 on one claim with Dates of Service DOS through 9 30 2015 and all ICD 10 codes placed on the other claim with DOS beginning 10 1 2015 and later 81X Hospice Hospital Split Claims Require providers split the claim so all ICD 9 codes remain FROM on one claim with Dates of Service DOS
23. m is billed using ICD 10 22X Skilled Nursing Facilities Split Claims Require providers split the claim so all ICD 9 codes remain FROM Inpatient Part B on one claim with Dates of Service DOS through 9 30 2015 and all ICD 10 codes placed on the other claim with DOS beginning 10 1 2015 and later 23X Skilled Nursing Facilities Split Claims Require providers split the claim so all ICD 9 codes remain FROM Outpatient on one claim with Dates of Service DOS through 9 30 2015 and all ICD 10 codes placed on the other claim with DOS beginning 10 1 2015 and later 32X Home Health Inpatient Allow HHAs to use the payment group code derived from ICD 9 codes on THROUGH Part B claims which span 10 1 2015 but require those claims to be submitted using ICD 10 codes 3X2 Home Health Request NOTE RAPs can report either an ICD 9 code or an ICD 10 code based See Note for Anticipated Payment on the one 1 date reported Since these dates will be equal to each other RAPs there is no requirement needed The corresponding final claim however will need to use an ICD 10 code if the HH episode spans beyond 10 1 2015 34X Home Health Split Claims Require providers split the claim so all ICD 9 codes remain FROM Outpatient on one claim with Dates of Service DOS through 9 30 2015 and all ICD 10 codes placed on the other claim with DOS beginning 10 1 2015 and later 71X Rural Health Clinics Split Claims Require providers split the claim so a
24. n 50 1 http www cms gov manuals downloads com109c06 pdf which states Providers shall be required to use IVRs to access claim status and beneficiary eligibility information CSRs shall refer providers back to the IVR if they have questions about claims status or eligibility that can be handled by the IVR CSRs may provide claims status and or eligibility information if it is clear that the provider cannot access the information through the IVR because the IVR is not functioning Available Self Service Tools CGS offers the IVR for providers to check Medicare beneficiary eligibility and claim status In addition the CGS Web portal myCGS is available Both tools allow providers access to this information 24 hours a day seven days a week however information that can only be obtained by accessing other systems may not be available 24 7 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 09 SEPTEMBER 2015 3 Interactive Voice Response IVR 1 866 290 4036 e CGS Jurisdiction 15 Part B Interactive Voice Response IVR User Guide http www cgsmedicare com partb cs partb_ivr_user_guide pdf e Obtain the following information via the CGS IVR
25. nin g subscribe to the CMS electronic mailing lists Learn more about what the CMS MLN offers at http Awww cms gov Network Outreach and Education Medicare Learning Network MLN MLNGenInfo index html on the CMS website x m Z E x lt Qo z O gt D j w Kentucky amp Ohio Billing Update for Zoledronic Acid J3489 CGS has been made aware of a potential program vulnerability based on the coding and billing of zoledronic acid Prior to 2014 coding was in place for zoledronic acid marketed under the brand names Zometa J3487 and Reclast J3488 Effective in 2014 the HCPCS code J3489 was developed and is now used to reflect both drugs which have different dosages and administration frequency beginning with service date September 1 2015 When administering Reclast CGS will require the KX modifier to be appended to the claim submissions Kentucky amp Ohio Checking Beneficiary Eligibility and Claim Status CGS has seen an increase in calls to the Provider Contact Center from providers asking for Medicare beneficiary eligibility information and wanting to check the status of submitted claims According to the Centers for Medicare amp Medicaid Services CMS providers are required to use the Interactive Voice Response IVR system for claim status and eligibility information Refer to the CMS Medicare Contractor Beneficiary and Provider Communications Manual Pub 100 09 Chapter 6 sectio
26. nnual is defined as 11 full months must pass following the month of the last negative HCV screening e HCV screening HCPCS code G0472 is a technical service only and there is no professional fee e CR9200 also removes the following facilities as valid for HCV screening services RHC TOB 71X FQHC TOB 77X and CAH Method Il professional services TOB 85X with revenue code 096X 097X or 098X e MACs will line item deny claims for HCV screening HCPCS G0472 for beneficiaries born prior to 1945 and after 1965 who are not high risk with the following messages 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 09 SEPTEMBER 2015 10 CARC 96 Non covered charge s At least one Remark Code must be provided may be comprised of either the NCPDP Reject Reason sic Code or Remittance Advice Remark Code that is not an ALERT Note Refer to the 835 Healthcare Policy Identification Segment loop 2110 Service Payment Information REF if present 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
27. nstructions As indicated in CR8871 and replicated in CR9200 for ease of reference only CMS covers screening for HCV with the appropriate U S Food and Drug Administration FDA approved cleared laboratory tests and point of care tests such as rapid anti body tests that are performed in outpatient clinics and physician offices used consistent with FDA approved labeling and in compliance with the Clinical Laboratory Improvement Act regulations 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 A screening test is covered for 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 A single screening test is covered for adults who do not meet the high risk definition as defined above but who were born from 1945 through 1965 x m Z E 2 x lt Qo O z gt D j w The determination of high risk for HCV is identified by the primary care physician or practitioner who assesses the patien
28. o 1945 or after 1965 with no risk factors for HCV are not eligible for HCV screening benefits as described in CR8871 Transmittal 3215 dated March 11 2015 CR9200 also removes Rural Health Clinics RHCs Federally Qualified Health Centers FQHCs and Method II Critical Access Hospitals CAHs as valid facilities for these HCV screening services Make sure that your billing staffs are aware of these changes Background Effective June 2 2014 the Centers for Medicare amp Medicaid Services CMS covers screening for HCV consistent with the grade B recommendations by the United States Preventive Services Task Force 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 This policy was implemented in CR8871 You may want to review the related MLN Matters article 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 09 SEPTEMBER 2015 x m Z E 2 x lt Qo O gt D j w 9 MM8871 https www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles downloads MM8871 pdf for additional claims processing i
29. p bc AggAAAIAAAAAAA 3d 3d amp https Awww cms gov medicare coverage database license cpt license aspx from overview and quick search aspx amp npage medicare coverage database details Icd details aspx amp LCDId 35443 amp Contrld 228 amp ver 2 amp ContrVer 2 amp CntrctrSelected 228 2 amp Cntrctr 22 8 amp name CGS tAdministrators 2c LLC 15102 2c MAC Part B amp LCntretr 228 28 amp Do cType Future amp bc AgACAAIAAAAAAA 3d 3d amp Kentucky amp Ohio Not Otherwise Classified NOC Drugs Clarification on Required Information Claims for HCPCS codes J9999 not otherwise classified anti neoplastic drugs J3490 unclassified drugs and or J3590 unclassified biological drugs must be submitted with additional qualifying information These claims must include e The name of the drug e The National Drug Code NDC number e The exact dosage given Claim Submission For electronic claims Loop Element 2400 SV101 7 must be completed for Not Otherwise Classified NOC codes The required documentation name NDC and dosage may be submitted in Loop Element 2400 SV101 7 If additional space is needed Loop 2400 NTE 02 may be utilized in addition to SV101 7 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 Copyr
30. r 1 2015 entities covered under the Health Insurance Portability and Accountability Act HIPAA are required to use the ICD 10 code sets in standard transactions adopted under HIPAA The HIPAA standard health care claim transactions are among those for which ICD 10 codes must be used for dates of service on and after October 1 2015 As a result of CR7492 and related MLN Matters Article MM7492 guidance was provided on processing certain claims for dates of service near the original October 1 2013 implementation date for CD 10 This article updates MM7492 to reflect the October 1 2015 implementation date Make sure your billing and coding staffs are aware of these changes Key Points of SE1408 General Reporting of ICD 10 As with ICD 9 codes today providers and suppliers are still required to report all characters of a valid ICD 10 code on claims ICD 10 diagnosis codes have different rules regarding specificity and providers suppliers are required to submit the most specific diagnosis codes based upon the information that is available at the time Please refer to http www cms gov Medicare Coding ICD10 index html for more information on the format of ICD 10 codes In addition ICD 10 Procedure Codes PCs will only be utilized by inpatient hospital claims as is currently the case with ICD 9 procedure codes General Claims Submissions Information ICD 9 codes will no longer be accepted on claims including electronic and paper wi
31. rvice prior to October 1 2015 submit with the appropriate ICD 9 procedure code For claims with dates of service on or after October 1 2015 submit with the appropriate ICD 10 procedure code Remember that ICD 10 codes may only be used for services provided on or after October 1 2015 Institutional claims containing ICD 10 codes for services prior to October 1 2015 will be Returned to Provider RTP Likewise professional and supplier claims containing ICD 10 codes for services prior to October 1 2015 will be returned as unprocessable Please submit these claims with the appropriate ICD 9 code Will the Centers for Medicare amp Medicaid Services CMS allow for dual processing of ICD 9 and ICD 10 codes accept and process both ICD 9 and ICD 10 codes for dates of service on and after October 1 2015 No CMS will not allow for dual processing of ICD 9 and ICD 10 codes after ICD 10 implementation on October 1 2015 Many providers and payers including Medicare have already coded their systems to only allow ICD 10 codes beginning October 1 2015 The scope of systems changes and testing needed to allow for dual processing would require significant resources and could not be accomplished by the October 1 2015 implementation date Should CMS allow for dual processing it would force all entities with which we share data including our trading partners to also allow for dual processing In addition having a mix of ICD 9 and ICD 10 codes in th
32. s DME MACs and Home Health amp Hospice HH amp H MACs for services provided to Medicare beneficiaries Provider Action Needed This article is based on Change Request CR 9167 and informs Medicare providers about the updating of specific drug and biological HCPCS codes that occur quarterly It alerts providers that the July file includes new HCPCS Codes CR9167 also updates Chapter 17 Section 20 1 2 Average Sales Price ASP Payment Methodology in the Claims Processing Manual to address the use of a compounded drug not otherwise classified NOC code on claims for compounded drugs Make sure that your billing staffs are aware of these changes Summary of New HCPCS Codes in CR9167 CR9167 adds the following HCPCS codes with the effective dates noted Table 1 New HCPCS Codes in CR9167 Effective for Claims with HCPCS Type of Dates of Service on or after Code Long Description Short Description Service TOS March 6 2015 Q5101 Injection Filgrastim G CSF Inj filgrastim g csf 1 P Biosimilar 1 microgram biosim July 1 2015 Q9976 Injection Ferric Pyrophosphate Inj Ferric le Citrate Solution 0 1 mg of iron Pyrophosphate Cit July 1 2015 Q9978 Netupitant 300 mg and Netupitant 1 Palonosetron 0 5 mg oral Palonosetron oral July 1 2015 Q9977 Compounded Drug Not Compounded Drug 1 P Otherwise Classified NOC Note The Medicare Physician Fee Schedule Status Indica
33. s and Part B Ambulance Suppliers 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 SE1425 Revised Related Change Request CR N A Related CR Release Date N A Effective Date N A Related CR Transmittal N A Implementation Date N A Note This article was revised on July 27 2015 to reflect an extension of the temporary moratoria for an additional 6 months as noted in the article Provider Types Affected This MLN Matters Article is intended for home health agencies home health agency sub units and part B ground ambulance suppliers in certain geographic areas of Florida Illinois Michigan Texas Pennsylvania and New Jersey that provide services to Medicare Medicaid and CHIP beneficiaries Provider Action Needed STOP Impact to You Effective July 29 2015 the temporary moratoria on new home health agencies home health agency sub units and part B ground ambulance suppliers are being extended for an additional 6 months in certain geographic locations This newsletter should be shared with all health care practitioners and managerial members of RETURN TO the provider supplier staff Newsletters iss
34. se 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 MM9200 Screening for Hepatitis C Virus HCV in Adults Implementation of Additional Common Working File CWF and Shared System Maintainer SSMs Edits The Centers for Medicare amp Medicaid Services CMS has issued the following Medicare Learning Network MLN Matters article This MLN Matters article and other CMS articles can be found on the CMS website at http www cms gov Outreach and Education Medicare Learning Network MLN MLNMattersArticles 2015 MLN Matters Articles html MLN Matters Number MM9200 Implementation Date For FISS shared Related CR Release Date June 19 2015 system edits split between October 5 2015 Related CR Transmittal R3285CP and January 4 2016 releases July 20 2015 Related Change Request CR CR9200 For non shared MAC edits October 5 2015 Effective Date June 2 2014 For CWF shared systems edits Provider Types Affected This MLN Matters Article is intended for physicians other providers and suppliers submitting claims to Medicare Administrative Contractors MACs for Hepatitis C Virus HCV screening services provided to Medicare beneficiaries Provider Action Needed Change Request CR 9200 informs providers that beneficiaries born prior t
35. t 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 Key Points e For services provided to beneficiaries born between the years 1945 and 1965 who are not considered high risk as defined in the policy HCV screening is limited to once per lifetime New HCPCS code 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 e Beneficiaries born prior to 1945 or after 1965 with no risk factors are not eligible for this benefit e For those beneficiaries determined to be high risk initially as defined in the policy regardless of birth year ICD 9 diagnosis code V69 8 other problems related to life style when ICD 10 is implemented ICD 10 diagnosis code 272 89 other problems related to lifestyle is required in addition to HCPCS G0472 e Coverage of a sub set of the above high risk beneficiaries may occur on an annual basis if appropriate as defined in the policy regardless of birth year denoted by the presence of HCPCS G0472 ICD diagnosis code V69 8 Z72 89 and ICD diagnosis code 304 91 unspecified drug dependence continuous F19 20 other psychoactive substance abuse uncomplicated once ICD 10 is implemented A
36. t Claims Require providers split the claim so all ICD 9 codes remain FROM on one claim with Dates of Service DOS through 9 30 2015 and all ICD 10 codes placed on the other claim with DOS beginning 10 1 2015 and later 14X Non patient Laboratory Split Claims Require providers split the claim so all ICD 9 codes remain FROM Services on one claim with Dates of Service DOS through 9 30 2015 and all ICD 10 codes placed on the other claim with DOS beginning 10 1 2015 and later 18X Swing Beds If the Swing bed or SNF claim has a discharge and or through date onor THROUGH after 10 1 2015 then the entire claim is billed using ICD 10 alth care practitioners and managerial members of RETURN TO January 1997 are available at no cost from our 2015 Copyright CGS Administrators LLC TABLE OF CONTENTS website at http www cgsmedicare com 2 MEDICARE BULLETIN GR 2015 09 SEPTEMBER 2015 This newsletter should be shared with a the provider supplier staff Newsletters x m Z E 2 x lt Qo O gt D j w 14 Table A Institutional Providers Bill Use FROM or Type s Facility Type Services Claims Processing Requirement THROUGH Date 21X Skilled Nursing Inpatient If the Swing bed or SNF claim has a discharge and or through date onor THROUGH Part A after 10 1 2015 then the entire clai
37. t specific category The local MAC processing the claim shall make these determinations Additional Information The official instruction CR9248 issued to your MAC regarding this change is available at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R3290CP 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 SE1315 Rescinded Pulmonary Procedures and Evaluation amp Management E M Services 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 SE1315 Rescinded Related Change Request CR Not Applicable Related CR Release Date N A Effective Date N A Related CR Transmittal N A Implementation Date N A Note This article was rescinded on July 27 2015 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
38. th FROM dates of service on professional and supplier claims or dates of discharge through dates on institutional claims on or after October 1 2015 Institutional claims containing ICD 9 codes for services on or after October 1 2015 will be Returned to Provider RTP as unprocessable Likewise professional and supplier claims containing CD 9 codes for dates of services on or after October 1 2015 will also be returned as unprocessable You will be required to re submit these claims with the appropriate ICD 10 code A claim cannot contain both ICD 9 codes 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 09 SEPTEMBER 2015 x m Z E 2 x lt Qo O z gt D j w 13 and ICD 10 codes Medicare will RTP all claims that are billed with both ICD 9 and ICD 10 diagnosis codes on the same claim For dates of service prior to October 1 2015 submit claims with the appropriate ICD 9 diagnosis code For dates of service on or after October 1 2015 submit with the appropriate ICD 10 diagnosis code Likewise Medicare will also RTP all claims that are billed with both ICD 9 and ICD 10 procedure codes on the same claim For claims with dates of se
39. tor for all four codes above is E CR9167 also updates Section 20 1 2 Average Sales Price ASP Payment Methodology in Chapter 17 of the Medicare Claims Processing Manual to address the use of a compounded drug NOC code on claims for compounded drugs 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 09 SEPTEMBER 2015 8 Please note The new compounded drug code Q9977 Compounded Drug Not Otherwise Classified is not a replacement for existing codes It is intended to distinguish compounded drugs which may include biologicals from other not otherwise classified codes such as J3490 J3590 J7799 J9999 and existing specific codes for compounded nebulized drugs The implementation of Q9977 as a means of identifying compounded drug claims does not affect existing payment policy for compounded drugs as outlined in the Medicare Claims Processing Manual Chapter 17 Section 20 1 2 Additional Information The official instruction CR 9167 issued to your MAC regarding this change is available at http www cms gov Regulations and Guidance Guidance Transmittals Downloads R3292CP pdf on the CMS website If you have any questions plea
40. ued 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 09 SEPTEMBER 2015 x m Z 2 x lt Ro O O ns gt D j w 16 CAUTION What You Need to Know During the 6 month temporary moratoria initial provider enrollment applications and change of information applications to add additional practice locations received from home health agencies home health agency sub units and part B ground ambulance suppliers in the moratoria counties will be denied Application fees that are paid for applications that are denied due to the temporary moratoria will be refunded GO What You Need to Do Effective July 29 2015 home health agencies home health agency sub units and part B ground ambulance suppliers should not submit initial enrollment applications or change of information applications to add additional practice locations until the 6 month moratoria has expired CMS will announce in the Federal Register when the moratorium has been lifted extended or changed Background In accordance with 42 CFR 424 570 c http www gpo gov fdsys pkg CFR 2012 title42 vol3 pdf CFR 2012 title42 vol3 sec424 570 pdf the Centers for Medicare amp Medicaid Services CMS may impose a moratorium on the enrollment of new Medicare providers and suppliers of a specific type or the establishment o
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