DMEPOS Fee Schedule - 2014 April Update Medicare/Noridian

DMEPOS Fee Schedule - 2014 April Update

MLN Matters® Number: MM8645
Related Change Request (CR) #: CR 8645
Related CR Release Date: March 11, 2014
Effective Date: April 1, 2014
Related CR Transmittal #: R2902CP
Implementation: April 7, 2014

Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Part A/B Medicare Administrative Contractors (MACs), Hospice and Home Health (HHHMACs), and Durable Medical Equipment MACs (DME MACs) for DMEPOS items or services paid under the DMEPOS fee schedule.

Provider Action Needed 
The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 8645 that alerts providers and suppliers that CMS issued instructions updating the DMEPOS fee schedule payment amounts. Be sure your billing personnel are aware of these changes.

Background 
CMS updates DMEPOS fee schedules on a quarterly basis, when necessary, in order to implement fee schedule amounts for new and existing codes, as applicable, and apply changes in payment policies. The quarterly update process for the DMEPOS fee schedule is located in the "Medicare Claims Processing Manual", Chapter 23, Section 60, which is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf  on the CMS website.

Key Points of CR8645

Splints, Casts and Certain Intraocular Lenses (IOLs) 
The following are the HCPCS codes for splints, casts, and certain IOLs added to the DMEPOS fee schedule file:

• A4565, Q4001, Q4002, Q4003, Q4004, Q4005, Q4006, Q4007, Q4008, Q4009, Q4010, Q4011, Q4012, Q4013, Q4014, Q4015, Q4016, Q4017, Q4018, Q4019, Q4020, Q4021, Q4022, Q4023, Q4024, Q4025, Q4026, Q4027, Q4028, Q4029, Q4030, Q4031, Q4032, Q4033, Q4034, Q4035, Q4036, Q4037, Q4038, Q4039, Q4040, Q4041, Q4042, Q4043, Q4044, Q4045, Q4046, Q4047, Q4048, Q4049, V2630, V2631, V2632.

As written in the MLN Matters® Article MM8523 (Change to the Reasonable Charge Update for 2014 for Splints, Casts, and Certain Intraocular Lenses) at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8523.pdf , for dates of service on or after April 1, 2014, payment for splints, casts and IOLs inserted in a physician's office will be made using national fee schedule amounts.
For splints and casts, codes A4565 and Q4001-Q4049 are used when supplies are indicated for cast and splint purposes and:

• Payment is in addition to the payment made under the physician fee schedule for the procedure for applying the splint or cast. Per the regulations at 42 CFR Section 414.106, national fee schedule amounts for 2014 for these items were developed using 2013 reasonable charges updated by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June 2013, which is 1.8 percent; and 
• For each year subsequent to 2014, the fee schedule amounts will be updated by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the preceding year, reduced by the productivity adjustment as described in Section 1886(b)(3)(B)(xi)(II) of the Social Security Act.

For intraocular lenses (codes V2630, V2631 and V2632), payment under the DMEPOS fee schedule is only made for lenses implanted in a physician's office:

• For payment of IOLs inserted in a physician's office furnished from April 1, 2014, through December 31, 2014, regulations at 42 CFR Section 414.108 require national fee schedules be established based on the Calendar Year (CY) 2012 national average allowed charges updated by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 24-month period ending with June 2013, which is 3.5 percent;
• For each year subsequent to 2014, the fee schedule amounts will be updated by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the preceding year, adjusted by the productivity adjustment as described in Section 1886(b)(3)(B)(xi)(II) of the Act; and 
• For IOL codes V2630 and V2631, national fee schedules amounts have been established using the fee schedule amounts for comparable code V2632 since there is insufficient allowed charge data for use in calculating the fee schedule amounts.

Subject to coinsurance and deductible rules, Medicare payment for these items is to be equal to the lower of the actual charge for the item or the amount determined under the applicable fee schedule payment methodology.
Payment Category Reclassification of Certain DME  
Effective for dates of service on or after April 1, 2014, certain HCPCS codes for DME are reclassified from the payment category for inexpensive or other routinely purchased DME to the payment category for capped rental items, to align with the regulatory definition of routinely purchased equipment found at 42 CFR Section 414.220(a)(2).
These changes were determined through rulemaking (CMS-1526-F) and as written in the MLN Matters® Article MM8566 titled Rescind/Replace Reclassification of Certain Durable Medical Equipment from the Inexpensive and Routinely Purchased Payment Category to the Capped Rental Payment Category, available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network MLN/MLNMattersArticles/Downloads/MM8566.pdf  on the CMS website.
As part of the April 2014 update to the DMEPOS fee schedule, the methodology used to calculate fee schedule amounts for capped rental items has been used to establish new fee schedule amounts for the following HCPCS codes:

• A4639, A7025, E0117, E0144, E0198, E0300, E0620, E0656, E0657, E0740, E0762, E0764, E0849, E0855, E0856, E0984, E0986, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1010, E1014, E1029, E1030, E1161, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1700, E2227, E2310, E2311, E2312, E2313, E2321, E2322, E2325, E2326, E2327, E2328, E2329, E2330, E2351, E2373, E2374, E2376, E2377, E2378, E2500, E2502, E2504, E2506, E2508, E2510, K0607, K0730.

Consistent with the capped rental payment methodology, only Rental Amounts (RR) will appear on the fee schedule file for the above codes, effective April 1, 2014, and:

• The HCPCS codes transitioning to the capped rental payment category with corresponding KC, KF or KE modifiers will continue to have rental amounts associated with these modifiers on the fee schedule file;
• The capped rental fee schedule amount is calculated based on ten percent of the base year purchase price increased by the covered item update; 
• This is the fee schedule amount for rental months one through three. Beginning with the fourth month, the fee schedule amount is equal to 75 percent of the fee schedule amount paid in each of the first three rental months; and
• All of the payment rules for capped rental items, including guidelines regarding continuous use and transfer of title to the beneficiary following 13 months of continuous use, apply to these codes, effective for claims with dates of service on or after April 1, 2014.

Also effective April 1, 2014, MACs will process and pay claims for capped rental wheelchair accessories on a lump sum purchase basis when used with complex rehabilitative power wheelchairs (wheelchair base codes K0835 – K0864). In this case, the supplier must give the beneficiary the option of purchasing these accessories at the time they are furnished. The purchase fee schedule amount for capped rental accessories furnished in this manner is equal to the rental fee (for months one through three) multiplied by ten. If the beneficiary declines the purchase option, the supplier must furnish the accessory on a rental basis and payment will be made in accordance with the capped rental payment rules.
Specific Coding and Pricing Issues
As part of this update, effective April 1, 2014, HCPCS code L8680 is not included on the 2014 DMEPOS fee schedule file and the coverage indicator is revised to "I" to show it is not payable by Medicare. Note that:

• For neurostimulator devices, HCPCS code L8680 is no longer separately billable for Medicare because payment for electrodes has been incorporated in CPT code 63650 Percutaneous implantation of neurostimulator electrode array, epidural. 
• CMS established non-facility practice expense inputs for CPT code 63650 in the Medicare Physician Fee Schedule Final Rule (published November 27, 2013). As a result, practitioners should not report electrode(s) using code L8680 in conjunction with a lead implantation procedure furnished in any setting for Medicare.  
• Also, this change for code L8680 will be available on the HCPCS Quarterly Update website at http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS_Quarterly_Update.html  on the CMS website.

Additional Information
The official instruction, CR8645, issued to your MAC regarding this change is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2902CP.pdf  on the CMS website.

Last Updated Mar 14, 2014

Cerumen Removal - CPT 69210 Noridian/Medicare

Cerumen Removal - CPT 69210

Effective in 2014, the American Medical Association (AMA) CPT manual identifies CPT code 69210 (removal impacted cerumen requiring instrumentation, unilateral) as a unilateral procedure. CMS has determined that, regardless of unilateral or bilateral, 69210 will remain bilateral and will allow only one unit per date of service billed. Appending modifier 50 is not acceptable.
The work Relative Value Unit (RVU) was maintained at 0.61.

For further details, consult the Federal Register/Volume 78, No. 237 / Tuesday, December 10, 2013/Rules and Regulations 74341(14) Cerumen Removal (69210) at http://www.gpo.gov/fdsys/pkg/FR-2013-12-10/html/2013-28696.htm .

Last Updated Mar 07, 2014

ICD-10 Limited End to End Testing with Submitters Noridian/Medicare

ICD-10 Limited End to End Testing with Submitters

MLN Matters® Number: MM8602
Related CR Release Date: February 21, 2014
Related CR Transmittal #: R1352OTN
Related Change Request (CR) #: CR8602
Effective Date: July 7, 2014
Implementation Date: July 7, 2014

Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers who submit claims to Medicare Claims Administration Contractors (Durable Medical Equipment Medicare Administrative Contractors (DME MACs), A/B Medicare Administrative Contractors (A/B MACs), and/or Home Health and Hospices (HH & H MACs) for services provided to Medicare beneficiaries.

What You Need to Know
This article is based on Change Request (CR) 8602 which instructs providers and clearinghouses on how to volunteer to be chosen for ICD-10 End to End testing with Medicare in July 2014. Potential testers must complete the volunteer form on the MAC website by March 24, 2014.

Background
The International Classification of Disease, Tenth Revision, (ICD-10) must be implemented by October 1, 2014. While system changes to implement this project have been completed and tested in previous releases, the industry has requested the opportunity to test with the Centers for Medicare & Medicaid Services (CMS).
Change Request (CR) 8602 will allow for a small subset of Medicare claims submitters to test with MACs and the Common Electronic Data Interchange (CEDI) contractor to demonstrate that CMS systems are ready for the ICD-10 implementation. This additional testing effort will further ensure a successful transition to ICD-10.
To facilitate this testing, CR8602 requires MACs to do the following:

• Conduct a limited end to end testing with submitters in July 2014. Test claims will be submitted July 21-25, 2014.
• Each MAC (and CEDI with assistance from DME MACs) will select 32 submitters to participate in the end-to-end testing. The Railroad Retirement Board (RRB) contractor will select 16 submitters.) Testers will be selected randomly from a list of volunteers. At least five, but not more than ten of the testers will be a clearinghouse, and submitters should be a mix of provider types.
• By March 7, 2014, the MACs and CEDI will post a volunteer form to their website to collect volunteer information with which to select volunteers. The form will provide information to verify that volunteers are ready to test, meet the requirements to test, and collect needed data about the tester (how they submit claims, what type of claims will be tested, etc.). Volunteers must submit the completed forms to the MACs and CEDI by March 24, 2014.
• By April 14, 2014, the MACs and CEDI (for the DME MACs) will notify the volunteers that they have been selected to test and provide them with the information needed for the testing, such as:
  • How to submit test claims (for example, what test indicators should be set);
  • What dates of service may be used for testing;
  • How many claims may be submitted for testing (Test claims volume is limited to a total of 50 claims for the entire testing week, submitted in no more than three files);
  • Request for National Provider Identifiers (NPIs) and Health Insurance Claim Numbers (HICNs) that will be used in testing (no more than 5 NPIs and 10 HICNs per submitter);
  • Notice that if more than 50 claims are submitted, they may not be processed;
  • Notice that claims submitted with NPIs or HICNs not previously submitted for testing, likely will not be completed; and
  • Notice of potential Protected Health Information (PHI) on test remittances not submitted (and instructions to report PHI found to the MAC).
  • MACs and CEDI (for the DME MACs) will collect information from the selected test volunteers to request the HICNs, NPIs, and Provider Transaction Access Numbers (PTANs) the testers will use during the testing. The forms for this information must be completed and returned to the MAC/CEDI by May 2, 2014. If these forms are not returned by May 2, the tester may lose the opportunity to test.
  • CEDI will instruct suppliers to submit claims with ICD-10 codes with Dates of Service (DOS) 10/1/2014 through 10/15/2014. They may also submit claims with ICD-9 codes with DOS before 10/1/2014.
  • MACs will instruct testers to submit test claims with ICD-10 codes with DOS on or after 10/1/2014. They may also submit test claims with ICD-9 codes with DOS before 10/1/2014.
  • MACs and CEDI will be prepared to support increased call volume from testers during the testing window, and up to 2 weeks following the receipt of the Electronic Remittance Advices (ERAs) from testing. MACs and CEDI will provide information to the testers on who to contact for testing questions. There may be separate contacts for front end questions and remittance questions.
  • MACs will post an announcement about the testing to their websites.

Additional Information
The official instruction, CR 8602, issued to your MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1352OTN.pdf  on the CMS website.

Last Updated Mar 10, 2014

Road to 10: The Small Physician Practice's Route to ICD-10 From CMS

CMS has created “Road to 10” to help you jump start the transition to ICD-10.

 

Built with the help of small practice physicians, “Road to 10” is a no-cost tool that will help you:

• Get an overview of ICD-10
• Explore Specialty References by selecting a specialty
• Click the BUILD YOUR ACTION PLAN box to create your personal action plan

To get started and learn more about ICD-10, navigate through the links on the left side of the page. If you’re ready to start building an action plan, select the BUILD YOUR ACTION PLAN box after you follow the link below:

http://www.roadto10.org/

Specialties include: Family Practice, Pediatrics, OB/GYN, Cardiology, Orthopedics, Internal Medicine and other.

Claims Processing Guidance for Implementing ICD-10 - A Re-Issue of MM7492 (Medicare/Noridian)

Claims Processing Guidance for Implementing ICD-10 - A Re-Issue of MM7492

MLN Matters® Number: SE1408
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
Provider Types Affected

This article is intended for all physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs (HH&H MACs), and Durable Medical Equipment MACs (DME MACs)) for services provided to Medicare beneficiaries.

Provider Action Needed
For dates of service on and after October 1, 2014, entities covered under the Health Insurance Portability and Accountability Act (HIPAA) are required to use the International Classification of Diseases, 10th Edition (ICD-10) code sets in standard transactions adopted under HIPAA. The HIPAA standard health care claim transactions are among those for which ICD-10 codes must be used for dates of service on and after October 1, 2014. 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 ICD-10. This article updates MM7492 to reflect the October 1, 2014, 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) with FROM dates of service (on professional and supplier claims) or dates of discharge/through dates (on institutional claims) on or after October 1, 2014. Institutional claims containing ICD-9 codes for services on or after October 1, 2014, will be Returned to Provider (RTP) as unprocessable. Likewise, professional and supplier claims containing ICD-9 codes for dates of services on or after October 1, 2014, 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 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, 2014, submit claims with the appropriate ICD-9 diagnosis code. For dates of service on or after October 1, 2014, 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 service prior to October 1, 2014, submit with the appropriate ICD-9 procedure code. For claims with dates of service on or after October 1, 2014, 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, 2014. Institutional claims containing ICD-10 codes for services prior to October 1, 2014, will be Returned to Provider (RTP). Likewise, professional and supplier claims containing ICD-10 codes for services prior to October 1, 2014, will be returned as unprocessable. Please submit these claims with the appropriate ICD-9 code.

Claims that Span the ICD-10 Implementation Date
The Centers for Medicare & Medicaid Services (CMS) has identified potential claims processing issues for institutional, professional, and supplier claims that span the implementation date; that is, where ICD-9 codes are effective for the portion of the services that were rendered on September 30, 2014, and earlier and where ICD-10 codes are effective for the portion of the services that were rendered October 1, 2014, and later. In some cases, depending upon the policies associated with those services, there cannot be a break in service or time (i.e., anesthesia) although the new ICD-10 code set must be used effective October 1, 2014. 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 Type(s)	Facility Type/Services	Claims Processing Requirement	Use FROM or THROUGH Date
11X	Inpatient Hospitals (incl. TERFHA hospitals, Prospective Payment System (PPS) hospitals, Long Term Care Hospitals (LTCHs), Critical Access Hospitals (CAHs)	If the hospital claim has a discharge and/or through date on or after 10/1/14, then the entire claim is billed using ICD-10.	THROUGH
12X	Inpatient Part B Hospital Services	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
13X	Outpatient Hospital	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
14X	Non-patient Laboratory Services	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
18X	Swing Beds	If the [Swing bed or SNF] claim has a discharge and/or through date on or after 10/1/14, then the entire claim is billed using ICD-10.	THROUGH
21X	Skilled Nursing (Inpatient Part A)	If the [Swing bed or SNF] claim has a discharge and/or through date on or after 10/1/14, then the entire claim is billed using ICD-10.	THROUGH
22X	Skilled Nursing Facilities (Inpatient Part B)	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
23X	Skilled Nursing Facilities (Outpatient)	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
32X	Home Health (Inpatient Part B)	Allow HHAs to use the payment group code derived from ICD-9 codes on claims which span 10/1/2014, but require those claims to be submitted using ICD-10 codes.	THROUGH
3X2	Home Health – Request for Anticipated Payment (RAPs)*	* NOTE - RAPs can report either an ICD-9 code or an ICD-10 code based on the one (1) date reported. Since these dates will be equal to each other, there is no requirement needed. The corresponding final claim, however, will need to use an ICD-10 code if the HH episode spans beyond 10/1/2014.	*See Note
34X	Home Health – (Outpatient )	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
71X	Rural Health Clinics	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/20143 and later.	FROM
72X	End Stage Renal Disease (ESRD)	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
73X	Federally Qualified Health Clinics (prior to 4/1/10)	N/A – Always ICD-9 code set.	N/A
74X	Outpatient Therapy	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
75X	Comprehensive Outpatient Rehab facilities	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
76X	Community Mental Health Clinics	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
77X	Federally Qualified Health Clinics (effective 4/4/10)	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
81X	Hospice- Hospital	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
82X	Hospice – Non hospital	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
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 on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM

Table B - Special Outpatient Claims Processing Circumstances

Scenario	Claims Processing Requirement	Use FROM or THROUGH Date
3-day /1-day Payment Window	Since all outpatient services (with a few exceptions) are required to be bundled on the inpatient bill if rendered within three (3) days of an inpatient stay; if the inpatient hospital discharge is on or after 10/1/2014, the claim must be billed with ICD-10 for those bundled outpatient services.	THROUGH

 Table C – Professional Claims 

Type of Claim	Claims Processing Requirement	Use FROM or THROUGH Date
All anesthesia claims	Anesthesia procedures that begin on 9/30/14 but end on 10/1/14 are to be billed with ICD-9 diagnosis codes and use 9/30/14 as both the FROM and THROUGH date.	FROM

Table D –Supplier Claims

Supplier Type	Claims Processing Requirement	Use FROM or THROUGH/TO Date
DMEPOS	Billing for certain items or supplies (such as capped rentals or monthly supplies) may span the ICD-10 compliance date of 10/1/14 (i.e., the FROM date of service occurs prior to 10/1/14 and the TO date of service occurs after 10/1/14).	FROM

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, 2014. 

Three Facts Physicians Should Know About Overpayment Liability

By Ericka L. Adler from Physicians Practice

If there is one thing that is certain in the healthcare industry today, it’s the increasing number of audits and recoupment actions.  Every day my colleagues and I receive notices from CMS detailing new investigations and recoupment actions.  Accordingly, many of our clients have become increasingly concerned about their actions, and how the actions of other practice physicians can impact liability for the practice as a whole.  Their general concerns are not liability for fraud or illegal conduct, but simple, unintentional overpayments.

Below are some of our physicians' most commonly asked questions and our answers related to these issues:

1. What liability does a practice have for recoupment of payment for services rendered by its physician providers?

Under Medicare, and assuming the services were billed under a number assigned to the practice, Medicare will look to the practice for the recoupment of payments for services rendered by its employed physicians.  For independent contractors, however, Medicare can look to both the practice and the independent contractor for recoupment, as Medicare policies dictate that independent contractors only can assign their right to receive payment to the practice if they maintain “joint and several” liability for overpayments.  If you’re an independent contractor physician, you should pay attention to the group’s billing practices to minimize your exposure. For non-Medicare payments, the provider agreement with the payer controls recoupment.  Generally, however, the payer will recoup payments from the party who received such payment.  Accordingly, if the physician's services were billed under the practice's billing number, then the practice likely would be responsible for the recouped amount.

2. What happens if the practice no longer provides services and dissolves? Medicare and other payers have no greater claim to recoup money owed to them than any other creditor upon dissolution.  Once the practice dissolves and all assets liquidated, payers likely will not be able to recoup any amount from the practice.  They may, however, attempt to collect through other methods.

If the physicians form a new practice after dissolution, a payer may successfully argue the new entity is a successor to the prior entity, and therefore, it should be able to look to the new entity to recoup the amounts due.  Whether the two entities are so closely related as to be deemed successors is very fact-specific and varies from state to state.  If your practice intends to defeat a recoupment action by going out of business, you should consult legal counsel to avoid successor liability.
If an overpayment is attributable to the services of an independent contractor of the practice, then Medicare can look to the independent contractor for payment as set for above.  Again, a commercial-payer's ability to act accordingly is dependent upon the specific payer agreement.

Under limited circumstances, a payer may attempt to obtain amounts owed by the dissolved practice from its individual owners.  This concept is known as "piercing the corporate veil" and occurs when a practice-entity operates in such a way that it is not deemed separate and distinct from its owners. The ability for creditors to hold owners liable for the debts of an entity under this doctrine is uncommon, but still is a theoretical possibility.  Accordingly, it is important to follow the advice of legal counsel when forming and operating your practice as a corporate entity.

3. If a physician is employed by two practices, can payers offset overpayments attributable to services provided by such physician on behalf of Practice A from payments attributable to services provide by physician on behalf of Practice B?

There is no clear law or policy allowing Medicare to recoup funds owed by one practice from another when the services were provided by the same physician.  Any right a commercial payer has in this regard likely would be set forth in the payer agreement. As illustrated by the foregoing, whether a physician is liable for an overpayment is not determined solely by whether such action is attributable to that physician.  If you practice medicine through a group, you should always remain informed of the billing practices and actions of your colleagues to minimize your legal exposure.

Article from Physicians Practice: http://www.physicianspractice.com/blog/three-facts-physicians-should-know-about-overpayment-liability?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=21022014

Code Chaos: Another nightmare for doctors, courtesy of the federal government

Mar 10, 2014, Vol. 19, No. 25 • By STEPHEN F. HAYES from The Weekly Standard
Jacksonville, Fla. Ever considered suicide by jellyfish? Have you ended up in the hospital after being injured during the forced landing of your spacecraft? Or been hurt when you were sucked into the engine of an airplane or when your horse-drawn carriage collided with a trolley?

 

Chances are slim.

But should any of these unfortunate injuries befall you after October 1, 2014, your doctor, courtesy of the federal government, will have a code to record it. On that date, the United States is scheduled to implement a new system for recording injuries, medical diagnoses, and inpatient procedures called ICD-10​—​the 10th version of the International Classification of Diseases propagated by the World Health Organization in Geneva, Switzerland. So these exotic injuries, codeless for so many years, will henceforth be known, respectively, as T63622A (Toxic effect of contact with other jellyfish, intentional self-harm, initial encounter), V9542XA (Forced landing of spacecraft injuring occupant, initial encounter), V9733XA (Sucked into jet engine, initial encounter), and V80731A (Occupant of animal-drawn vehicle injured in collision with streetcar, initial encounter).

The coming changes are vast. The number of codes will explode​—​from 17,000 under the current system to 155,000 under the new one, according to the Centers for Medicare and Medicaid Services (CMS).

The transition to ICD-10 was planned long before Congress passed the Affordable Care Act in 2010. But Obama administration officials say it is a critical part of the coming reforms. “ICD-10 is the foundation for health care reform,” said Jeff Hinson, a CMS regional administrator, in a conference call about ICD-10 for providers in Colorado.

It will affect almost every part of the U.S. health care system​—​providers and payers, physicians and researchers, hospitals and clinics, the government and the private sector. That system​—​already stressed with doctor shortages, electronic medical records mandates, and the broader chaos of Obamacare​—​is nowhere near ready. And that has lots of people worried.

Health care professionals use ICD codes to talk to one another. The codes record diagnoses and services provided, and third-party payers​—​government, insurance companies​—​use the codes to determine reimbursements and to deter fraud. Coding errors can mean unpaid claims or costly audits​—​or both.

Virtually everyone agrees that the transition will mean decreased productivity and lost revenue, at least for a time. Some experts, dismissed as alarmists by ICD-10 enthusiasts, are predicting widespread chaos in a sector of the economy that can little afford it.

“I’m very nervous about whether once we flip that switch on October 1 this is all going to work,” says William Harvey, an assistant professor of medicine and the clinical director of the Division of Rheumatology at Tufts Medical Center in Boston.

But nobody really knows just what to expect. And remarkably, despite the embarrassing failures of HealthCare.gov, until recently the federal government had no plans to conduct end-to-end testing of the system before the launch this fall.

In a letter to CMS administrator Marilyn Tavenner on February 18, 2014, four Republican senators pressed for comprehensive testing. The senators​—​Tom Coburn, Rand Paul, John Barrasso, and John Boozman​—​are all physicians and expressed deep concern that CMS is planning only one week of “front-end” testing. After receiving the letter, CMS hastily announced that it will offer limited end-to-end testing to “a small group of providers” at some point in “summer 2014” and promised that “details about the end-to-end testing process will be disseminated at a later date.”

That’s hardly reassuring. One health care consultant, a longtime ICD-10 proponent, put it this way: “This is probably going to be the most painful year we’ve seen in the history of U.S. health care.”

On a foggy Thursday morning in early January, 30 medical coders gathered in a nondescript meeting room on the third floor of the downtown Hyatt Regency in Jacksonville. They paid between $585 and $985 each to attend a two-day “boot camp” on the new codes taught by Annie Boynton, from the American Academy of Professional Coders. On the black cloth covering each table were the day’s necessities: a Hyatt Regency pad of paper and pen, a coffee cup and saucer, a jar full of hard candy, a glass and a sweating metal pitcher filled with ice water. At each place, students found a thin spiral book​—​the “ICD-10-CD General Code Set Manual” for 2014​—​and a six-pound, phone-book-thick “ICD-10 Complete Draft Code Set.” 

Boynton began by asking the students to introduce themselves, to describe the practice that employs them, and, as an icebreaker, to tell everyone the first album that they’d purchased. She started in the back of the room, where, in an effort to remain unobtrusive, I had chosen to sit.

Left with no choice, I told the class that I was a journalist working on an ICD-10 story, and admitted, reluctantly, that my first album was Asia by Asia. (The signature song of that debut album, “Heat of the Moment,” played in my head for the rest of the day, as it may now do in yours.) Others in the class—with one exception, all of them females—came from a variety of fields that will be directly affected by the coming changes. There was an obstetrics coder, a Medicare contractor, a hospital administrator, and an owner of two urgent care clinics (Britney Spears, Def Leppard, the Monkees, and Michael Jackson, respectively).

Boynton, whose first album was Tiffany, is a native of northern Maine who now lives in Boston. The computer she uses for her PowerPoint presentation features a large “Eat Lobster” sticker, and her favorite descriptor, not surprisingly, is “wicked,” used as both a positive and a negative qualifier.

Boynton knows her stuff. She is the director of communication/adoption and training for UnitedHealth Group and she helped write the ICD-10 curriculum for the group sponsoring this course, the American Association of Professional Coders. A list of her credentials, displayed on the large screen at the front of the room, contains more letters than the alphabet: BS, RHIT, CPCO, CCS, CPC, CCS-P, CPC-H, CPC-P, CPC-I. She’s been working on the ICD-10 transition for nearly a decade.

She began the session with a straightforward question: “How many of your practices have begun to prepare for the transition to ICD-10?” Just three hands went up. Boynton smiled and shook her head in amazement. She’s not surprised. “I gave a speech to providers in California last month and only 7 of the 300 doctors in attendance had begun preparing for the transition,” she tells the class.

A survey of physician practices released in mid-January backs her up: Seventy-four percent of those surveyed reported that they’d done nothing at all to prepare. (Despite this lack of preparation, most expressed confidence that they’d be ready.)

“How many of you work for a physician who doesn’t think ICD-10 is even going to go live?” she asks. Almost everyone raises a hand. “If I had a nickel for every one, I’d be on a beach somewhere with a fruity drink in my hand. It’s 5 o’clock somewhere, right?”

Boynton launches into a brief history of ICD-10 and the debate surrounding its implementation. The current coding system, ICD-9, has been in place for nearly 30 years. Although it has expanded gradually, with additional codes to reflect new diseases, the latest innovations in treatment, and improvements in medical technology, it is nearing something close to its capacity. ICD-10 proponents​—​and Boynton is one of them​—​say there is no choice but to move to a more sophisticated code set.

Other developed countries began their implementation of ICD-10 some 20 years ago, after the World Health Organ-ization released its basic version of the new code set. But their versions of ICD-10 won’t be nearly as complicated as the U.S. version. Boynton says that only 10 other countries use the codes for reimbursements​—​one of the main functions of ICD-10 in the United States. And payment systems elsewhere are far less complicated, in part because there is usually just one payer: the government.

The multiplicity of payers in the U.S. system partly explains why ICD-10 will be vastly more complicated here. But, paradoxically, if government explains the simplicity of ICD-10 codes elsewhere, government largely explains the complexity of the ICD-10 codes here. And those codes are complex.

“If you sustain an injury falling off a toilet seat on a spaceship in Jacksonville after this class, there’s probably a code for that,” says Boynton.

There are codes for those “bitten” by a crocodile, “struck” by a crocodile, and “crushed” by a crocodile. There is also a code for injuries sustained through “other contact” with crocodiles. “I just don’t want to know about ‘other contact,’ especially with farm animals,” says Boynton, to sustained laughter. “That joke doesn’t fly in Montana.”

Boynton’s “personal favorite” is code V9027XA: “Drowning and submersion due to falling or jumping from burning water-skis, initial encounter.”

It’s the favorite of many who have studied ICD-10 codes (and the “white whale” for others). In the reporting that I had done before attending the ICD-10 boot camp, I’d had no fewer than five people mention it to me. The obvious question: Has anyone ever drowned because he’d jumped from burning water-skis? Do we need codes for things that have never actually happened?

For the answer, I turned to experts at the USA Water Ski Foundation and Hall of Fame. I was introduced to Lynn Novakofski, who was described to me as “a walking history book of water-skiing.”

His answer seems to confirm suspicions. “In my 60 years of skiing, I am not aware of a drowning caused by ‘burning skis,’ ” he told me. “Back in the ’50s, a popular act in water-ski shows was to pour gasoline on the water in front of a ski jump, light it on fire, and a ‘daredevil’ skier would jump over the flames. I have even seen the ski jumper kick off his skis in midair, dive headfirst into the flames, and swim under water​—​while everyone in the audience held their breath​—​to surface a safe distance from the burning oil. More recently, I have on occasion seen skiers, usually barefooting, skimming along with a water and oil soaked towel on fire billowing out behind them. This has a bit more potential for singeing the skin, but all the skier needs to do is drop into the water and the flames are quenched.”

Even if no one in the United States has drowned after jumping or falling off of burning water-skis, it’s possible such a tragedy has occurred overseas. I checked with Dr. Lorenzo Benassa, chairman of the medical committee at the International Waterski and Wakeboard Federation, who reported, after consulting “literature from the past 20 years” that he found “no cases” of “burning water-ski injuries.” He added: “In our experience, we have never heard of something similar.”

What about an injury short of drowning? Lynn Novakofski allows that there may have been some “minor injuries” as a result of stunts like the ones he’d seen years ago. But he didn’t recall hearing of any.

In any case, ICD-10 has those covered, too. There is a code for a mere “burn due to water-skis on fire” (V9107XA) and for someone being “hit or struck by falling object due to accident on water-skis” (V9137XA) or jumping from “crushed water-skis” (V9037XD). More generally, there’s “other injury due to accident to water-skis” (V9187X) and “other injury due to other accident on board water-skis” (V9387XA). And there’s the rather inexplicable code V9227XA: “Drowning and submersion due to being washed overboard from water-skis.”

“An injury from your water-skis catching on fire?” says Senator Tom Coburn, a physician who is leaving Congress later this year. “Eighty percent of these codes will never be used.”

How do these kinds of injuries​—​real or imaginary​—​get their own codes? This is one of the great mysteries of ICD-10. No one from any of the U.S. government agencies responsible for ICD-10 regulation and compliance would agree to an interview for this article, despite more than two-dozen requests over the course of two months.

That’s odd, since the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) are in the middle of a major public awareness campaign on ICD-10. If you follow CMS on Twitter, your feed is bombarded with tweets conveying the urgency of ICD-10 compliance. “Next CMSeHealth Summit on #ICD10 will be held on Feb 14. Register to attend via webcast here,” read a tweet from @CMSGov on February 3. The next day: “ICD10 is only 239 days away. Check out this CMS blog post on the last year before ICD-10” and “Need an overview of #ICD10? Check out the Intro Guide to ICD-10.” And the day after that: “Are you in a small or rural practice preparing for #ICD10? CMS has a fact sheet with tips for your practice” and “Not sure how your clearinghouse can help you with #ICD10? Read this to find out.”

Despite this urgency, public affairs officials from HHS, CMS, and the National Center for Health Statistics (NCHS) at the Centers for Disease Control all declined repeated requests for interviews. A spokesman for the NCHS provided this overview of the process on background: A contractor developed a prototype of the U.S. ICD-10 code set after reviewing recommendations from the World Health Organization; NCHS offered “enhancements” to that code set and revised it further after consulting with physicians, clinical coders, and other users of the previous version, ICD-9.

The objective was greater detail, more specificity. The new code set introduces the concept of “laterality” to ICD coding, allowing physicians to identify in code, for instance, whether a hand injury is a right-hand injury or a left-hand injury. But ICD-10 also adds thousands upon thousands of new injury codes​—​some 37,000 new musculoskeletal and injury codes all together, according to an ICD-10 expert who consults with CMS.

“There were 9 codes for bites in ICD-9,” says Boynton. “There are over 300 in ICD-10.”

Virtually every conceivable malady or injury has a code. There’s code V9102XA for someone who is “crushed between fishing boat and other watercraft or other object due to collision, initial encounter.” Or T71232A, “Asphyxiation due to being trapped in a (discarded) refrigerator, intentional self-harm, initial encounter.” If you are hurt in an abattoir, there’s code Y9286, “slaughterhouse as the place of occurrence of the external cause.” Code F521 is “sexual aversion disorder,” not to be confused with code G4482, “headache associated with sexual activity.”

Some codes appear to be anticipatory rather than descriptive. Has anyone in the history of mankind ever attacked another human with frog venom? Or sought contact with the same for the purposes of intentional self-harm? Probably not​—​and not just because frogs don’t produce venom.

But code T63813A is “toxic effect of contact with venomous frog, assault, initial encounter.” I asked Dr. Kyle Summers, one of the world’s leading experts on poisonous frogs, about this. He told me that frogs do not produce “venom,” and therefore, while some are poisonous, none are “venomous.” Summers further explained that while members of the Embera tribe of western Colombia have used batrachotoxin from the skin of frogs in the genus Phyllobates on the tips of blow-darts to kill monkeys, he did not know of any incidents in which the darts have been used on human enemies and had “not heard of anyone intentionally hurting themselves by contact with a poison frog. But,” he added, “I have not researched the issue.” Other codes describe occurrences that would seem unlikely to result in any kind of injury at all, such as code W20XXA, “contact with non-venomous frogs.”

Back in Jacksonville, Boynton moves from a general discussion of ICD-10 to some specifics. She explains in tremendous detail how the new codes offer several different ways of codifying engagements with patients—“initial encounter,” a “subsequent encounter,” and “sequela.” The “initial encounter” in codespeak is not limited to the “initial encounter” as one might understand it in plain English, Boynton explains. There could, in fact, be several initial encounters with a patient, if those subsequent visits involved the initial injury and treatment. Bewildered looks spread across the class like bad herpes (A6000 or one of the other 38 herpes codes), and the resultant confusion led to a series of questions about the meanings of “initial” and “subsequent.” One student asked the question that seemed to be on the mind of everyone in the room: “So a subsequent visit would still be an initial encounter?” And then, after a brief explanation, another question: “Wait, there could be five initial encounters with the same physician?” 

After lunch, the class plunged deeper still into the intricacies of the new coding. Boynton walked the class through “excludes” codes, meant to prevent using two codes that would seem to contradict one another, and the advent of the “placeholder” character, intended to allow coders to fill all seven characters of a code in which not every character has meaning. (“X can be a placeholder, but it can also be a code character.”) Boynton is a very clear communicator and managed to keep the interest of most of my classmates by alternating between code minutiae, issuing stark warnings about the consequences of failing to understand ICD-10, and dropping the occasional codeworld inside joke.

But the system is complex and the scope of change is immense. “Learning these codes makes learning Mandarin seem easy,” she tells a frustrated student. This is what has so many in the health care world nervous.

The introduction of a system with exponentially more codes, and far more complicated codes, will inevitably mean many more coding errors. The default position of payers, whether government or the private sector, will be to deny all claims that are not coded correctly. In many cases, providers will be left with a lose-lose choice: forgo payment altogether or dedicate valuable time and resources to appealing the denied claims. Hospitals, large physician practices, and other big institutions can absorb some of the losses and have the workforce at their disposal to challenge the denials. Small practices do not.

“When you have a provider who hasn’t prepared, who doesn’t know the codes, ​and they have every claim rejected because of improper coding for three months, that’s going to put people out of business,” Boynton tells me over breakfast before the second day of training.

“Most practices in the United States are small businesses,” says Senator Coburn, an obstetrician and family practice doctor from Muskogee, Oklahoma. “This could ruin them.”

An ICD-10 preparation plan from the Health Information and Management Systems Society (HIMSS) advises practices to have a minimum of six months revenue in reserve to help avoid that possibility. Such warnings have been coming for years. Financial institutions have begun offering lines of credit targeted to potential ICD-10 shortfalls. “With potential disruptions becoming more and more probable as the industry hurtles haphazardly towards October 1, 2014, having half a year’s cash or credit on hand may be vital to keeping your doors open,” writes Jennifer Bresnick in EHR Intelligence, a website that tracks news on electronic health records and medical technology.

A 2008 study on the costs of implementing ICD-10 from the health care IT firm Nachimson Advisors warned that “significant changes in reimbursement patterns will disrupt provider cash flow for a considerable period of time.” The study projected that the total cost of the ICD-10 implementation would be $83,290 for a small practice (3 physicians and 2 administrative staffers), $285,195 for a medium practice (10 providers, 1 professional coder, and 6 administrative staffers), and $2.7 million for a large practice (100 providers, 10 full-time coding staffers, and 54 medical records staffers). Boynton says those numbers seem on target five years later.

Coburn believes the new system will require doctors to spend more time coding. “You’re just not going to trust a nurse to do that,” he says. “If they put in the wrong code, they’re going to hammer you. The penalties are getting more severe. If you fail a recovery audit, they don’t just take your money, they penalize you on top of that.”

Coburn’s concerns go beyond the likelihood of a rough transition to ICD-10 to the long-term effect the changes could have on the doctor-patient relationship. The specificity of the codes will require doctors to spend more of their time on documentation. “Let’s say it takes you an extra two minutes per patient to do the coding yourself,” he says. “It doesn’t sound like much. But if you see 30 or 40 patients a day, that’s at least an extra hour you’re spending on this stuff. That minute or two that you’re not spending talking with the patient might be the minute when you learn something critical to your diagnosis or treatment plan.”

His prescription: “Delay it forever. The health care system can’t take another cost, especially right now.”

Coburn has introduced legislation to do just that, but most industry experts believe the prospects for a delay are poor. ICD-10 implementation has already been delayed twice, most recently in April 2012, giving “covered entities” an extra year that expires at the end of September. “I’d be shocked” if there’s a further delay, says Holly Louie, the ICD-10 coordinator for the Healthcare Billing and Management Association.

CMS administrator Jeff Hinson, in his conference call with Colorado providers, offered a stern warning about the October 1, 2014, compliance date. “You need to know that the deadline is firm,” he said. “The deadline is firm.”

That could spell disaster.

Despite desperate pleas from virtually every corner of the health care industry, the federal government has offered no details for comprehensive end-to-end testing of the new coding system before it goes live in seven months. “In meetings over the past two or three years between commercial payers and CMS, we were told that if everything went relatively smoothly, and we just saw the typical hiccups associated with a major transition like this, there could be as much as a one-year disruption in cash flow​—​for both large and small practices,” says Louie. “And that’s when we thought there would be end-to-end testing.”

Coburn, along with the other Republican physicians in the Senate, is trying to force CMS to perform comprehensive testing or to delay the start date. “Given the size and scope of the potential transition to ICD-10, the brevity and limited scope of this test is worrisome,” they wrote in their letter to Tavenner.

Annie Boynton, the ICD-10 trainer, says that 20 of the 50 states have done “nothing” to update their systems for ICD-10. “The sector of the industry that scares me the most is government,” says Boynton. “Historically, they are not great with major regulatory implementation rollouts,” she adds with a knowing smile. “HealthCare.gov was a perfect example. When [Health and Human Services] Secretary Sebelius was sitting in front of Congress, the Energy and Commerce Committee, answering all those questions, I had this really sinking feeling that in 2015, we’re going to be there again.”

 

Stephen F. Hayes is a senior writer at The Weekly Standard.

 from http://www.weeklystandard.com/articles/code-chaos_783576.html?page=1

Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 - Correction CR February 2014

Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 - Correction CR

MLN Matters® Number: MM8597
Related Change Request (CR) #: CR 8597
Related CR Release Date: February 14, 2014
Effective Date: May 15, 2014
Related CR Transmittal #: R2878CP
Implementation Date: May 15, 2014

Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, (including Home Health Agencies) and suppliers that submit claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice Medicare Administrative Contractors (H&HH MACs), and Durable Medical Equipment Medicare Administrative Contractors (DME MACs), for services to Medicare beneficiaries.

What You Need to Know 
This article, based on Change Request (CR) 8597, provides the removal of language that was erroneously included in CR8404 and in the "Medicare Claims Processing Manual," Chapter 30, Sections 50.3 and 50.6.2. It also provides clarified manual instructions regarding home health agency issuance of the Advance Beneficiary Notice of Noncoverage (ABN) to dual eligible beneficiaries.

Background
The ABN is an Office of Management and Budget (OMB)-approved written notice issued by providers and suppliers for items and services provided under Medicare Part B, including hospital outpatient services, and care provided under Part A by home health agencies (HHAs), hospices, and religious non-medical healthcare institutes only.

Key Points of CR8597

• With the exception of Durable Medical Equipment Prosthetic, Orthotics & Supplies (DMEPOS) suppliers, providers and suppliers who are not enrolled in Medicare cannot issue the ABN to beneficiaries. DMEPOS suppliers not enrolled as Medicare suppliers are required by statute to provide ABN notification prior to furnishing any items or services to Medicare beneficiaries. 
• An example of an approved customization of the ABN which can be used by providers of laboratory services (Sample Lab ABN) is now available for download at http://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html
• When issuing ABNs to dual eligibles or beneficiaries having a secondary insurer, HHAs are permitted to direct the beneficiary to select a particular option box on the notice to facilitate coverage by another payer. This is an exception to the usual ABN issuance guidelines prohibiting the notifier from selecting one of the options for the beneficiary. When a Medicare claim denial is necessary to facilitate payment by Medicaid or a secondary insurer, HHAs should instruct beneficiaries to select Option 1 on the ABN. HHAs may add a statement in the "Additional Information" section to help a dual eligible better understand the payment situation such as, "We will submit a claim for this care with your other insurance," or "Your Medical Assistance plan will pay for this care." HHAs may also use the "Additional Information" on the ABN to include agency specific information on secondary insurance claims or a blank line for the beneficiary to insert secondary insurance information. Agencies can pre-print language in the "Additional Information" section of the notice.
• Some States have specific rules established regarding HHA completion of liability notices in situations where dual eligibles need to accept liability for Medicare noncovered care that will be covered by Medicaid. Medicaid has the authority to make this assertion under Title XIX of the Act, where Medicaid is recognized as the "payer of last resort", meaning other Federal programs like Medicare (Title XVIII) must pay in accordance with their own policies before Medicaid picks up any remaining charges. In the past, some States directed HHAs to select the third checkbox on the HHABN to indicate the choice to bill Medicare. On the ABN, the first check box under the "Options" section indicates the choice to bill Medicare and is similar to the third checkbox on the outgoing HHABN. Note: If there has been a State directive to submit a Medicare claim for a denial, HHAs must mark the first check box when issuing the ABN. 
• HHAs serving dual eligibles should comply with existing HHABN State policy within their jurisdiction as applicable to the ABN unless the State instructs otherwise. The appropriate option selection for dual eligibles will vary depending on the State's Medicaid directive. If the HHA's State Medicaid office does NOT want a claim filed with Medicare prior to filing a claim with Medicaid, the HHA should direct the beneficiary to choose Option 2. When Option 2 is chosen based on State guidance, but the HHA is aware that the State sometimes asks for a Medicare claim submission at a later time, the HHA must add a statement in the "Additional Information" box such as "Medicaid will pay for these services. Sometimes, Medicaid asks us to file a claim with Medicare. We will file a claim with Medicare if requested by your Medicaid plan."

Additional Information
The official instruction, CR8597, issued to your MAC regarding this change, may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2878CP.pdf  on the CMS website.
 

Last Updated Feb 19, 2014

HCPCS Codes Subject to and Excluded from CLIA Edits: NOridian/Medicare

HCPCS Codes Subject to and Excluded from CLIA Edits

MLN Matters®Number: MM8567
Related Change Request (CR) #: CR 8567
Related CR Release Date: January 17, 2014
Effective Date: January 1, 2014
Related CR Transmittal #: R2857CP
Implementation Date: April 7, 2014
Provider Types Affected

This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment Medicare Administrative Contractors (DME/MACs), for services to Medicare beneficiaries.

Provider Action Needed
This article is based on Change Request (CR) 8567 which informs MACs about changes to HCPCS codes that are new for 2014 and are subject to Clinical Laboratory Improvement Amendments (CLIA) edits. The CLIA regulations require a facility to be appropriately certified for each test performed. Make sure your billing staffs are aware of these changes.

Background
The Clinical Laboratory Improvement Amendments (CLIA) regulations require a facility to be appropriately certified for each test performed. To ensure that Medicare and Medicaid only pay for laboratory tests performed in certified facilities, each claim for a HCPCS code that is considered a CLIA laboratory test is currently edited at the CLIA certificate level.
The HCPCS codes are considered a laboratory test under CLIA change each year. Contractors need to be informed about the new HCPCS codes that are both subject to CLIA edits and excluded from CLIA edits.

The HCPCS codes listed below are new for 2014 and are subject to CLIA edits. The list does not include new HCPCS codes for waived tests or provider-performed procedures. The HCPCS codes listed below require a facility to have either a CLIA certificate of registration (certificate type code 9), a CLIA certificate of compliance (certificate type code 1), or a CLIA certificate of accreditation (certificate type code 3). A facility without a valid, current, CLIA certificate, with a current CLIA certificate of waiver (certificate type code 2) or with a current CLIA certificate for provider-performed microscopy procedures (certificate type code 4) must not be permitted to be paid for these tests.

• G0461 - Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex antibody stain; 
• G0462 - Immunohistochemistry or immunocytochemistry, per specimen; each additional single or multiplex antibody stain (list separately in addition to code for primary procedure); 
• 80155 - Caffeine level; 
• 80159 - Clozapine level; 
• 80169 - Everolimus level; 
• 80171 - Gabapentin level; 
• 80175 - Lamotrigine level; 
• 80177 - Levetiracetam level; 
• 80180 - Mycophenolate (mycophenolic acid) level; 
• 80183 - Oxcarbazepine level; 
• 80199 - Tiagabine level; 
• 80203 - Zonisamide level; 
• 81287 - MGMT (O-6-methylguanine-DNA methyltransferase) gene analysis;
• 81504 - Genetic profiling on oncology biopsy lesions; 
• 81507 - DNA analysis using maternal plasma; and 
• 87661 - Infectious agent detection by nucleic acid (dna or rna); trichomonas vaginalis, amplified probe technique. 

In 2014, there was one new HCPCS code for immunohistochemistry or immunocytochemistry [i.e., 88343 - Immunohistochemistry or immunocytochemistry, each separately identifiable antibody per block, cytologic preparation, or hematologic smear; each additional separately identifiable antibody per slide (list separately in addition to code for primary procedure)]. The testing described by this code is subject to the CLIA regulations. It is not payable by Medicare in calendar year (CY) 2014. Therefore, this new code was not included in CR 8567.

Additional Information
The official instruction, CR 8567 issued to your MAC regarding this change may be viewed at http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads /R2857CP.pdf  on the Centers for Medicare & Medicaid Services (CMS) website.   

Last Updated Jan 23, 2014

CMS 1500 Claim Form Instructions: Revised for Form Version 02/12

MLN Matters® Number: MM8509
Related Change Request (CR) #: CR 8509
Related CR Release Date: December 27, 2013
Effective Date: January 6, 2014
Related CR Transmittal #: R2842CP
Implementation Date: January 6, 2014
Provider Types Affected

 This MLN Matters® Article is intended for physicians and other providers submitting claims to Medicare contractors (carriers, A/B Medicare Administrative Contractors (A/B MACs), and Durable Medical Equipment Medicare Administrative Contractors (DME/MACs)) for services provided to Medicare beneficiaries.

Provider Action Needed
This change request (CR) 8509 revises the current CMS 1500 claim form instructions to reflect the revised CMS 1500 claim form, version 02/12.
Form Version 02/12 will replace the current CMS 1500 claim form, 08/05, effective with claims received on and after April 1, 2014:

• Medicare will begin accepting claims on the revised form, 02/12, on January 6, 2014;
• Medicare will continue to accept claims on the old form, 08/05, through March 31, 2014;
• On April 1, 2014, Medicare will accept paper claims on only the revised CMS 1500 claim form, 02/12; and
• On and after April 1, 2014, Medicare will no longer accept claims on the old CMS 1500 claim form, 08/05.

Make sure that your billing staff are aware of these instructions for the revised form version 02/12.

Background
The National Uniform Claim Committee (NUCC) recently revised the CMS 1500 claim form. On June 10, 2013, the White House Office of Management and Budget (OMB) approved the revised form, 02/12. The revised form has a number of changes. Those most notable for Medicare are new indicators to differentiate between ICD-9 and ICD-10 codes on a claim, and qualifiers to identify whether certain providers are being identified as having performed an ordering, referring, or supervising role in the furnishing of the service. In addition, the revised form uses letters, instead of numbers, as diagnosis code pointers, and expands the number of possible diagnosis codes on a claim to 12.
The qualifiers that are appropriate for identifying an ordering, referring, or supervising role are as follows:

• DN - Referring Provider
• DK - Ordering Provider
• DQ - Supervising Provider

Providers should enter the qualifier to the left of the dotted vertical line on item 17.
The Administrative Simplification Compliance Act (ASCA) requires Medicare claims to be sent electronically unless certain exceptions are met. Those providers meeting these exceptions are permitted to submit their claims to Medicare on paper. Medicare requires that the paper format for professional and supplier paper claims be the CMS 1500 claim form. Medicare therefore supports the implementation of the CMS 1500 claim form and its revisions for use by its professional providers and suppliers meeting an ASCA exception. More information about ASCA exceptions can be found in Chapter 24 of the "Medicare Claims Processing Manual" which is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c24.pdf  on the Centers for Medicare & Medicaid Services (CMS) website.

Additional Information
The official instruction, CR 8509 issued to your MAC regarding this change may be viewed at
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2842CP.pdf  on the CMS website. CR 8509 contains the instructions for completing the revised CMS 1500 claim form (02/12), which will become part of Chapter 26 in the "Medicare Claims Processing Manual" (Pub. 100-04).

Last Updated Jan 29, 2014

Modifier and HCPCS Changes for 2014 for Medicare

The following new and deleted National Level II modifiers and HCPCS are effective for dates of service on/after January 1, 2014.

In compliance with the Health Insurance Portability and Accountability Act (HIPAA), CMS eliminated the 3-month grace period for discontinued codes in Change Request (CR) 3093 dated February 6, 2004. Effective for dates of services on/after January 1, 2010, there is no grace period for billing discontinued HCPCS codes.

NOTE: The inclusions of modifiers or codes in this article do not necessarily indicate coverage. New modifiers and HCPCS identified as Durable Medical Equipment (DME) are not included in this listing.

This taken from Noridian website, CMS update: https://med.noridianmedicare.com/web/jeb/article-detail/-/view/10525/modifier-and-hcpcs-changes-for-2014 Also follow this link to see deleted codes for 2014.

New Modifiers for 2014

Modifier	Description
AO	Alternate payment method declined by provider of service
JE	Administered via dialysate
PM	Post mortem

New 2014 HCPCS

HCPCS	Description
A4555	Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only
A9520	Technetium tc-99m, tilmanocept, diagnostic, up to 0.5 millicuries
A9575	Injection, gadoterate meglumine, 0.1 ml
A9599	Radiopharmaceutical, diagnostic, for beta-amyloid positron emission tomography (pet) imaging, per study dose
C1841	Retinal prosthesis, includes all internal and external components
C5271	Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area
C5272	Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure)
C5273	Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children
C5274	Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary procedure)
C5275	Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area
C5276	Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure)
C5277	Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children
C5278	Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary procedure)
C9132	Prothrombin complex concentrate (human), kcentra, per i.u. of factor ix activity
C9133	Factor ix (antihemophilic factor, recombinant), rixibus, per i.u.
C9441	Injection, ferric carboxymaltose, 1 mg
C9497	Loxapine, inhalation powder, 10 mg
C9735	Anoscopy; with directed submucosal injection(s), any substance
C9737	Laparoscopy, surgical, esophageal sphincter augmentation with device (eg, magnetic band)
D0393	Treatment simulation using 3d image volume
D0394	Digital subtraction of two or more images or image volumes of the same modality
D0395	Fusion of two or more 3d image volumes of one or more modalities
D0601	Caries risk assessment and documentation, with a finding of low risk
D0602	Caries risk assessment and documentation, with a finding of moderate risk
D0603	Caries risk assessment and documentation, with a finding of high risk
D1999	Unspecified preventive procedure, by report
D2921	Reattachment of tooth fragment, incisal edge or cusp
D2941	Interim therapeutic restoration - primary dentition
D2949	Restorative foundation for an indirect restoration
D3355	Pulpal regeneration - initial visit
D3356	Pulpal regeneration - interim medication replacement
D3357	Pulpal regeneration - completion of treatment
D3427	Periradicular surgery without apicoectomy
D3428	Bone graft in conjunction with periradicular surgery - per tooth, single site
D3429	Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the same surgical site
D3431	Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery
D3432	Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery
D4921	Gingival irrigation - per quadrant
D5863	Overdenture - complete maxillary
D5864	Overdenture - partial maxillary
D5865	Overdenture - complete mandibular
D5866	Overdenture - partial mandibular
D5994	Peridontal medicament carrier with peripheral seal - laboratory processed
D6011	Second stage implant surgery
D6013	Surgical placement of mini implant
D6052	Semi-precision attachment abutment
D8694	Repair of fixed retainers, includes reattachment
D9985	Sales tax
G0461	Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex antibody stain
G0462	Immunohistochemistry or immunocytochemistry, per specimen; each additional single or multiplex antibody stain (list separately in addition to code for primary procedure)
G0463	Hospital outpatient clinic visit for assessment and management of a patient
G9187	Bundled payments for care improvement initiative home visit for patient assessment performed by a qualified health care professional for individuals not considered homebound including, but not limited to, assessment of safety, falls, clinical status, fluid status, medication reconciliation/management, patient compliance with orders/plan of care, performance of activities of daily living, appropriateness of care setting; (for use only in the meidcare-approved bundled payments for care improvement initiative); may not be billed for a 30-day period covered by a transitional care management code
G9188	Beta-blocker therapy not prescribed, reason not given
G9189	Beta-blocker therapy prescribed or currently being taken
G9190	Documentation of medical reason(s) for not prescribing beta-blocker therapy (eg, allergy, intolerance, other medical reasons)
G9191	Documentation of patient reason(s) for not prescribing beta-blocker therapy (eg, patient declined, other patient reasons)
G9192	Documentation of system reason(s) for not prescribing beta-blocker therapy (eg, other reasons attributable to the health care system)
G9193	Clinician documented that patient with a diagnosis of major depression was not an eligible candidate for antidepressant medication treatment or patient did not have a diagnosis of major depression
G9194	Patient with a diagnosis of major depression documented as being treated with antidepressant medication during the entire 180 day (6 month) continuation treatment phase
G9195	Patient with a diagnosis of major depression not documented as being treated with antidepressant medication during the entire 180 day (6 months) continuation treatment phase
G9196	Documentation of medical reason(s) for not ordering first or second generation cephalosporin for antimicrobial prophylaxis
G9197	Documentation of order for first or second generation cephalosporin for antimicrobial prophylaxis
G9198	Order for first or second generation cephalosporin for antimicrobial prophylaxis was not documented, reason not given
G9199	Venous thromboembolism (vte) prophylaxis not administered the day of or the day after hospital admission for documented reasons (eg, patient is ambulatory, patient expired during inpatient stay, patient already on warfarin or another anticoagulant, other medical reason(s) or eg, patient left against medical advice, other patient reason(s))
G9200	Venous thromboembolism (vte) prophylaxis was not administered the day of or the day after hospital admission, reason not given
G9201	Venous thromboembolism (vte) prophylaxis administered the day of or the day after hospital admission
G9202	Patients with a positive hepatitis c antibody test
G9203	Rna testing for hepatitis c documented as performed within 12 months prior to initiation of antiviral treatment for hepatitis c
G9204	Rna testing for hepatitis c was not documented as performed within 12 months prior to initiation of antiviral treatment for hepatitis c, reason not given
G9205	Patient starting antiviral treatmentfor hepatitis c during the measurement period
G9206	Patient starting antiviral treatment for hepatitis c during the measurement period
G9207	Hepatitis c genotype testing documented as performed within 12 months prior to initiation of antiviral treatment for hepatitis c
G9208	Hepatitis c genotype testing was not documented as performed within 12 months prior to initiation of antiviral treatment for hepatitis c, reason not given
G9209	Hepatitis c quantitative rna testing documented as performed between 4-12 weeks after the initiation of antiviral treatment
G9210	Hepatitis c quantitative rna testing not performed between 4-12 weeks after the initiation of antiviral treatment for reasons documented by clinician (eg, patients whose treatment was discontinued during the testing period prior to testing, other medical reasons, patient declined, other patient reasons)
G9211	Hepatitis c quantitative rna testing was not documented as performed between 4-12 weeks after the initiation of antiviral treatment, reason not given
G9212	Dsm-ivtm criteria for major depressive disorder documented at the initial evaluation
G9213	Dsm-iv-tr criteria for major depressive disorder not documented at the initial evaluation, reason not otherwise specified
G9214	Cd4+ cell count or cd4+ cell percentage results documented
G9215	Cd4+ cell count or percentage not documented as performed, reason not given
G9216	Pcp prophylaxis was not prescribed at time of diagnosis of hiv, reason not given
G9217	Pcp prophylaxis was not prescribed within 3 months of low cd4+ cell count below 00 cells/mm3, reason not given
G9218	Pcp prophylaxis was not prescribed within 3 months oflow cd4+ cell count below 500 cells/mm3 or a cd4 percentage below 15%, reason not given
G9219	Pneumocystis jiroveci pneumonia prophylaxis not prescribed within 3 months of low cd4+ cell count below 200 cells/mm3 for medical reason (i.e., patient's cd4+ cell count above threshold within 3 months after cd4+ cell count below threshold, indicating that the patient's cd4+ levels are within an acceptable range and the patient does not require pcp prophylaxis)
G9220	Pneumocystis jiroveci pneumonia prophylaxis not prescribed within 3 months of low cd4+ cell count below 500 cells/mm3 or a cd4 percentage below 15% for medical reason (i.e., patient's cd4+ cell count above threshold within 3 months after cd4+ cell count below threshold, indicating that the patient's cd4+ levels are within an acceptable range and the patient does not require pcp prophylaxis)
G9221	Pneumocystis jiroveci pneumonia prophlaxis prescribed
G9222	Pneumocystis jiroveci pneumonia prophylaxis prescribed wthin 3 months of low cd4+ cell count below 200 cells/mm3
G9223	Pneumocystis jiroveci pneumonia prophylaxis prescribed within 3 months of low cd4+ cell count below 500 cells/mm3 or a cd4 percentage below 15%
G9224	Documentation of medical reason for not performing foot exam (e.g., patient with bilateral foot/leg amputation)
G9225	Foot exam was not performed, reason not given
G9226	Foot examination performed (includes examination through visual inspection, sensory exam with monofilament, and pulse exam - report when all of the 3 components are completed)
G9227	Functional outcome assessment documented, care plan not documented, documentation the patient is not eligible for a care plan
G9228	Chlamydia, gonorrhea and syphilis screening results documented (report when results are present for all of the 3 screenings)
G9229	Chlamydia, gonorrhea, and syphilis not screened, due to documented reason (patient refusal is the only allowed exclusion)
G9230	Chlamydia, gonorrhea, and syphilis not screened, reason not given
G9231	Documentation of end stage renal disease (esrd), dialysis, renal transplant or pregnancy
G9232	Clinician treating major depressive disorder did not communicate to clinician treating comorbid condition for specified patient reason
G9233	All quality actions for the applicable measures in the total knee replacement measures group have been performed for this patient
G9234	I intend to report the total knee replacement measures group
G9235	All quality actions for the applicable measures in the general surgery measures group have been performed for this patient
G9236	All quality actions for the applicable measures in the optimizing patient exposure to ionizing radiation measures group have been performed for this patient
G9237	I intend to report the general surgery measures group
G9238	I intend to report the optimizing patient exposure to ionizing radiation measures group
G9239	Documentation of reasons for patient initiaiting maintenance hemodialysis with a catheter as the mode of vascular access (eg, patient has a maturing avf/avg, time-limited trial of hemodialysis, patients undergoing palliative dialysis, other medical reasons, patient declined avf/avg, other patient reasons, patient followed by reporting nephrologist for fewer than 90 days, other system reasons)
G9240	Patient whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated
G9241	Patient whose mode of vascular access is not a catheter at the time maintenance hemodialysis is initiated
G9242	Documentation of viral load equal to or greater than 200 copies/ml
G9243	Documentation of viral load less than 200 copies/ml
G9244	Antiretroviral thereapy not prescribed
G9245	Antiretroviral therapy prescribed
G9246	Patient did not have at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits
G9247	Patient had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits
G9248	Patient did not have a medical visit in the last 6 months
G9249	Patient had a medical visit in the last 6 months
G9250	Documentation of patient pain brought to a comfortable level within 48 hours from initial assessment
G9251	Documentation of patient with pain not brought to a comfortable level within 48 hours from initial assessment
G9252	Adenoma(s) or other neoplasm detected during screening colonoscopy
G9253	Adenoma(s) or other neoplasm not detected during screening colonoscopy
G9254	Documentation of patient discharged to home later than post-operative day 2 following cas
G9255	Documentation of patient discharged to home no later than post operative day 2 following cas
G9256	Documentation of patient death following cas
G9257	Documentation of patient stroke following cas
G9258	Documentation of patient stroke following cea
G9259	Documentation of patient survival and absence of stroke following cas
G9260	Documentation of patient death following cea
G9261	Documentation of patient survival and absence of stroke following cea
G9262	Documentation of patient death in the hospital following endovascular aaa repair
G9263	Documentation of patient survival in the hospital following endovascular aaa repair
G9264	Documentation of patient receiving maintenance hemodialysis for greater than or equal to 90 days with a catheter for documented reasons (eg, patient is undergoing palliative dialysis with a catheter, patient approved by a qualified transplant program and scheduled to receive a living donor kidney transplant, other medical reasons, patient declined avf/avg, other patient reasons)
G9265	Patient receiving maintenance hemodialysis for greater than or equal to 90 days with a catheter as the mode of vascular access
G9266	Patient receiving maintenance hemodialysis for greater than or equal to 90 days without a catheter as the mode of vascular access
G9267	Documentation of patient with one or more complications or mortality within 30 days
G9268	Documentation of patient with one or more complications within 90 days
G9269	Documentation of patient without one or more complications and without mortality within 30 days
G9270	Documentation of patient without one or more complications within 90 days
G9271	Ldl value < 100
G9272	Ldl value >= 100
G9273	Blood pressure has a systolic value of < 140 and a diastolic value of < 90
G9274	Blood pressure has a systolic value of =140 and a diastolic value of = 90 or systolic value < 140 and diastolic value = 90 or systolic value = 140 and diastolic value < 90
G9275	Documentation that patient is a current non-tobacco user
G9276	Documentation that patient is a current tobacco user
G9277	Documentation that the patient is on daily aspirin or has documentation of a valid contraindication to aspirin automatic contraindications include anti-coagulant use, allergy, and history of gastrointestinal bleed; additionally, any reason documented by the physician as a reason for not taking daily aspirin is acceptable (examples include non-steroidal anti-inflammatory agents, risk for drug interaction, or uncontrolled hypertension defined as > 180 systolic or > 110 diastolic)
G9278	Documentation that the patient is not on daily aspirin regimen
G9279	Pneumococcal screening performed and documentation of vaccination received prior to discharge
G9280	Pneumococcal vaccination not administered prior to discharge, reason not specified
G9281	Screening performed and documentation that vaccination not indicated/patient refusal
G9282	Documentation of medical reason(s) for not reporting the histological type or nsclc-nos classification with an explanation (e.g., biopsy taken for other purposes in a patient with a history of non-small cell lung cancer or other documented medical reasons)
G9283	Non small cell lung cancer biopsy and cytology specimen report documents classification into specific histologic type or classified as nsclc-nos with an explanation
G9284	Non small cell lung cancer biopsy and cytology specimen report does not document classification into specific histologic type or classified as nsclc-nos with an explanation
G9285	Specimen site other than anatomic location of lung or is not classified as non small cell lung cancer
G9286	Documentation of antibiotic regimen prescribed within 7 days of diagnosis or within 10 days after onset of symptoms
G9287	No antibiotic regimen prescribed within 7 days of diagnosis or within 10 days after onset of symptoms
G9288	Documentation of medical reason(s) for not reporting the histological type or nsclc-nos classification with an explanation (e.g., a solitary fibrous tumor in a person with a history of non-small cell carcinoma or other documented medical reasons )
G9289	Non small cell lung cancer biopsy and cytology specimen report documents classification into specific histologic type or classified as nsclc-nos with an explanation
G9290	Non small cell lung cancer biopsy and cytology specimen report does not document classification into specific histologic type or classified as nsclc-nos with an explanation
G9291	Specimen site other than anatomic location of lung, is not classified as non small cell lung cancer  or classified as nsclc-nos
G9292	Documentation of medical reason(s) for not reporting pt category and a statement on thickness and ulceration and for pt1, mitotic rate (e.g., negative skin biopsies in a patient with a history of melanoma or other documented medical reasons)
G9293	Pathology report does not include the pt category and a statement on thickness and ulceration and for pt1, mitotic rate
G9294	Pathology report includes the pt category and a statement on thickness and ulceration and for pt1, mitotic rate
G9295	Specimen site other than anatomic cutaneous location
G9296	Patients with documented shared decision-making including discussion of conservative (non-surgical) therapy prior to the procedure
G9297	Shared decision-making including discussion of conservative (non-surgical) therapy prior to the procedure not documented, reason not given
G9298	Patients who are evaluated for venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure including history of dvt, pe, mi, arrhythmia and stroke
G9299	Patients who are not evaluated for venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure including history of dvt, pe, mi, arrhythmia and stroke, reason not given
G9300	Documentation of medical reason(s) for not completely infusing the prophylactic antibiotic prior to the inflation of the proximal tourniquet (e.g., a tourniquet was not used)
G9301	Patients who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet
G9302	Prophylactic antibiotic not completely infused prior to the inflation of the proximal tourniquet, reason not given
G9303	Operative report does not identify the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of the prosthetic implant, reason not given
G9304	Operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of the prosthetic implant
G9305	Intervention for presence of leak of endoluminal contents through an anastomosis not required
G9306	Intervention for presence of leak of endoluminal contents through an anastomosis required
G9307	No return to the operating room for a surgical procedure, for any reason, within 30 days of the principal operative procedure
G9308	Unplanned return to the operating room for a surgical procedure, for any reason, within 30 days of the principal operative procedure
G9309	No unplanned hospital readmission within 30 days of principal procedure
G9310	Unplanned hospital readmission within 30 days of principal procedure
G9311	No surgical site infection
G9312	Surgical site infection
G9313	Amoxicillin, with or without clavulanate, not prescribed as first line antibiotic at the time of diagnosis for documented reason (eg, cystic fibrosis, immotile cilia disorders, ciliary dyskinesia, immune deficiency, prior history of sinus surgery within the past 12 months, and anatomic abnormalities, such as deviated nasal septum, resistant organisms, allergy to medication, recurrent sinusitis, chronic sinusitis, or other reasons)
G9314	Amoxicillin, with or without clavulanate, not prescribed as first line antibiotic at the time of diagnosis, reason not given
G9315	Documentation amoxicillin, with or without clavulanate, prescribed as a first line antibiotic at the time of diagnosis
G9316	Documentation of patient-specific risk assessment with a risk calculator based on multi-institutional clinical data, the specific risk calculator used, and communication of risk assessment from risk calculator with the patient or family
G9317	Documentation of patient-specific risk assessment with a risk calculator based on multi-institutional clinical data, the specific risk calculator used, and communication of risk assessment from risk calculator with the patient or family not completed
G9318	Imaging study named according to standardized nomenclature
G9319	Imaging study not named according to standardized nomenclature, reason not given
G9320	Documentation of medical reason(s) for not naming ct studies according to a standardized nomenclature provided (eg, ct studies performed for radiation treatment planning or image-guided radiation treatment delivery)
G9321	Count of previous ct (any type of ct) and cardiac nuclear medicine (myocardial perfusion) studies documented in the 12-month period prior to the current study
G9322	Count of previous ct and cardiac nuclear medicine (myocardial perfusion) studies not documented in the 12-month period prior to the current study, reason not given
G9323	Documentation of medical reason(s) for not counting previous ct and cardiac nuclear medicine (myocardial perfusion) studies (eg, ct studies performed for radiation treatment planning or image-guided radiation treatment delivery)
G9324	All necessary data elements not included, reason not given
G9325	Ct studies not reported to a radiation dose index registry due to medical reasons (eg, ct studies performed for radiation treatment planning or image-guided radiation treatment delivery)
G9326	Ct studies performed not reported to a radiation dose index registry, reason not given
G9327	Ct studies performed reported to a radiation dose index registry with all necessary data elements
G9328	Dicom format image data availability not documented in final report due to medical reasons (eg, ct studies performed for radiation treatment planning or image-guided radiation treatment delivery)
G9329	Dicom format image data available to non-affiliated external entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study not documented in final report, reason not given
G9340	Final report documented that dicom format image data available to non-affiliated external entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study
G9341	Search conducted for prior patient ct imaging studies completed at non-affiliated external entities within the past 12-months and are available through a secure, authorized, media-free, shared archive prior to an imaging study being performed
G9342	Search conducted for prior patient imaging studies completed at non-affiliated external entities within the past 12-months and are available through a secure, authorized, media-free, shared archive prior to an imaging study being performed not completed, reason not given
G9343	Search for prior patient completed dicom format images not completed due to medical reasons (eg, ct studies performed for radiation treatment planning or image-guided radiation treatment delivery)
G9344	Search for prior patient completed dicom format images not completed due to system reasons (ie, facility does not have archival abilities through a shared archival system)
G9345	Follow-up recommendations according to recommended guidelines for incidentally detected pulmonary nodules (eg, follow-up ct imaging studies needed or that no follow-up is needed) based at a minimum on nodule size and patient risk factors documented
G9346	Follow-up recommendations according to recommended guidelines for incidentally detected pulmonary nodules not documented due to medical reasons (eg, patients with known malignant disease, patients with unexplained fever, ct studied performed for radiation treatment planning or image-guided radiation treatment delivery)
G9347	Follow-up recommendations according to recommended guidelines for incidentally detected pulmonary nodules not documented, reason not given
G9348	Ct scan of the paranasal sinuses ordered at the time of diagnosis for documented reasons (eg, persons with sinusitis symptoms lasting at least 7 to 10 days, antibiotic resistance, immunocompromised, recurrent sinusitis, acute frontal sinusitis, acute sphenoid sinusitis, periorbital cellulitis, or other medical)
G9349	Documentation of a ct scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis
G9350	Ct scan of the paranasal sinuses not ordered at the time of diagnosis or received within 28 days after date of diagnosis
G9351	More than one ct scan of the paranasal sinuses ordered or received within 90 days after diagnosis
G9352	More than one ct scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis, reason not given
G9353	More than one ct scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis for documented reasons (eg, patients with complications, second ct obtained prior to surgery, other medical reasons)
G9354	More than one ct scan of the paranasal sinuses not ordered within 90 days after the date of diagnosis
G9355	Elective delivery or early induction not performed
G9356	Elective delivery or early induction performed
G9357	Post-partum screenings, evaluations and education performed
G9358	Post-partum screenings, evaluations and education not performed
G9359	Documentation of negative or managed positive tb screen with further evidence that tb is not active
G9360	No documentation of negative or managed positive tb screen
J0401	Injection, aripiprazole, extended release, 1 mg
J0717	Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)
J1442	Injection, filgrastim (g-csf), 1 microgram
J1446	Injection, tbo-filgrastim, 5 micrograms
J1556	Injection, immune globulin (bivigam), 500 mg
J1602	Injection, golimumab, 1 mg, for intravenous use
J3060	Injection, taliglucerace alfa, 10 units
J3489	Injection, zoledronic acid, 1 mg
J7301	Levonorgestrel-releasing intrauterine contraceptive system (skyla), 13.5 mg
J9047	Injection, carfilzomib, 1 mg
J9262	Injection, omacetaxine mepesuccinate, 0.01 mg
J9306	Injection, pertuzumab, 1 mg
J9354	Injection, ado-trastuzumab emtansine, 1 mg
J9371	Injection, vincristine sulfate liposome, 1 mg
J9400	Injection, ziv-aflibercept, 1 mg
L8679	Implantable neurostimulator, pulse generator, any type
Q0507	Miscellaneous supply or accessory for use with an external ventricular assist device
Q0508	Miscellaneous supply or accessory for use with an implanted ventricular assist device
Q0509	Miscellaneous supply or accessory for use with any implanted ventricular assist device for which payment was not made under medicare part a
Q2028	Injection, sculptra, 0.5 mg
Q2050	Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10mg
Q2052	Services, supplies and accessories used in the home under the medicare intravenous immune globulin (ivig) demonstration
Q3027	Injection, interferon beta-1a, 1 mcg for intramuscular use
Q3028	Injection, interferon beta-1a, 1 mcg for subcutaneous use
Q4137	Amnioexcel or biodexcel, per square centimeter
Q4138	Biodfence dryflex, per square centimeter
Q4139	Amniomatrix or biodmatrix, injectable, 1 cc
Q4140	Biodfence, per square centimeter
Q4141	Alloskin ac, per square centimeter
Q4142	Xcm biologic tissue matrix, per square centimeter
Q4143	Repriza, per square centimeter
Q4145	Epifix, injectable, 1 mg
Q4146	Tensix, per square centimeter
Q4147	Architect extracellular matrix, per square centimeter
Q4148	Neox 1k, per square centimeter
Q4149	Excellagen, 0.1 cc
S9960	Ambulance service, conventional air services, nonemergency transport, one way (fixed wing)
S9961	Ambulance service, conventional air service, nonemergency transport, one way (rotary wing)
T4544	Adult sized disposable incontinence product, protective underwear/pull-on, above extra large, each