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

Vitamin B 12 Injection LCD Retirement - Effective March 7, 2014 Medicare/Noridian

Vitamin B 12 Injection LCD Retirement - Effective March 7, 2014

The following Local Coverage Determination (LCD) has been revised under contractor numbers 01111 (California), 01211 (Hawaii and Territories), 01311 (Nevada), 01911 (Former NO-CA, HI and Territories).

Medicare Coverage Database (MCD) Number/Contractor Determination Number: L33502
Policy Name: Vitamin B 12 Injection
Effective Date: 03/07/2014

NOTE: LCDs are retired due to lack of evidence of current need(s) for the education and/or edits or in some cases because the material is addressed by a National Coverage Determination (NCD), a coverage provision in a CMS interpretative manual, another LCD or an article.  Retirement does not mean that medical necessity has changed or that the LCD no longer reflects appropriate criteria. The guidance in the retired LCD may be helpful in assessing medical necessity.
To access the Noridian Retired LCDs from our website, follow the instructions below.

• Go to https://med.noridianmedicare.com/web/jeb/policies/lcd/retired
  • The End User Agreement for Providers will appear if you have not recently visited the website. Select "Accept" (if necessary).
• Select the state/contract of interest. This link will redirect you to the state specific listing of retired LCDs on the CMS MCD.

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

Physicians Should Prepare Now for Medicare Cuts

By David Doyle from Physicians Practice

Roughly 27 percent of Americans on Medicare are enrolled in a Medicare Advantage plan. Federal funding for this Medicare alternative has already been cut by 6.5 percent this year, and additional cuts are planned. Preliminary 2015 rates for Medicare Advantage will be announced in February and finalized in April.

Hospitals are responding to existing and upcoming Medicare cuts by trimming staff. Lawrence + Memorial Hospital in New London, Conn., reduced its workforce by 33 positions in September 2013. In its press release, the hospital specifically blamed a predicted “$260 billion reduction in Medicare outlays between 2013 and 2022.” Other hospitals are also cutting staff and will continue to do so if Medicare cuts become too cumbersome — bad news for the thousands of doctors who recently sold their practices to healthcare systems.

Cuts to Medicare reimbursement rates and Medicare Advantage are impacting private practices as well. Last November the nation’s largest provider of Medicare Advantage Plans, UnitedHealth Group, sent termination letters to physicians in 10 states. According to an article in The Wall Street Journal, these letters cited “significant changes and pressures in the health care environment.” UnitedHealth Group hopes to trim the program to between 85 and 90 percent of its current size by the end of 2014.

These sudden, drastic cuts threaten patient care and will even force many patients to stop visiting specific physicians midtreatment. However, some practices are fighting back. Judge Stefan R. Underhill, the United States District Judge for the District of Connecticut, issued a temporary injunction in December that prohibits UnitedHealth Group’s planned dismissals in Fairfield and Hartford Counties. Another lawsuit in the state of New York is still pending. The American Medical Association even weighed in when it recently joined with 30 medical associations and physician advocacy groups to oppose “wide-spread terminations in the Medicare Advantage program.”

Additional debates over the future of Medicare cuts will likely ensue over the next few months, but what can practices do in the meantime?

As cuts to Medicare and Medicare Advantage reimbursement rates go into effect, practices that serve Medicare patients must ensure that it’s still profitable for them to do so.

Begin by calculating the amount of time a physician can spend with a Medicare patient before the practice loses money. Next, consult your patient records from the last three months to determine whether physicians are exceeding this mark. If the practice loses money every time it sees a Medicare patient, you must set a strict time limit for physician consultations and monitor any changes over the next three months. If at the end of this time you discover that treating Medicare patients is still a net loss for the practice, then it might be time to reconsider your patient base.

Practices that are removed from Medicare Advantage networks will also need to adjust. If your practice is one of these, and you haven’t already done so, you must inform your affected patients as soon as possible. According to The Washington Post, many patients don’t understand that these terminations were not their physicians’ fault. Help your patients by either referring them to physicians within their network whom you trust, or recommending alternative Medicare Advantage networks that your practice still belongs to.

Taking precautionary measure now will help protect your practice’s long-term viability and reputation without leaving your patients out in the cold.

Courtesy of Physicians Practice http://www.physicianspractice.com/blog/physicians-should-prepare-now-medicare-cuts?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=11022014

Redetermination Requests and Submission of Documentation - Update Medicare/Noridian 03/2014

Redetermination Requests and Submission of Documentation - Update

Providers requesting a redetermination must send the request in writing stating what they are appealing and reason why they are appealing. Providers can choose to send the written request on company letterhead or by completing CMS form 20027. Noridian recommends the use of the Interactive Redetermination Form that is downloadable from the Noridian website under the Forms section.

Redetermination Requests
*At a minimum, the request letter must contain the following information:

• Beneficiary name;
• Medicare health insurance claim (HIC) number;
• The specific service(s) and/or item(s) for which the redetermination is being requested;
• The specific date(s) of the service; and
• The name and signature of the party or the representative of the party.

*These elements are included on the Noridian Interactive Form.
Send only one (1) request form or letter per beneficiary denial. When submitting a Redetermination, please attach the required documentation to support the appealable item(s). Redetermination requests should include *ALL medical documentation pertaining to the claim or line item. Reasonable and necessary denials must include a copy of the Advance Beneficiary Notice (ABN) signed by the beneficiary if available. Also attach a corrected UB04 form.
*Noridian suggests referencing the Medical Documentation Requirements found under Resources in the Appeals Section under Browse by Topic.

Resources
The following resources can be found on the Noridian website – Appeals section:

• Medical Documentation Requirements – Alphabetized by Item/Service
• Signature Requirements – Explanation of valid signature and alternatives
• Inquiries and Solutions – Answers the common Redetermination and  Reconsideration questions including Recovery Auditor (RA) appeal questions
• Appeals Not Necessary for Certain Reason Codes - A line item or claim rejection occurs, providers may adjust the claim through the normal claim submission process, if the change does not affect liability.
• Remark Codes – Explains Remittance Advice Remark Codes (RARCs) that are used to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC)

 

Last Updated Mar 05, 2014 from Noridian https://med.noridianmedicare.com/web/jeb/article-detail/-/view/10525/redetermination-requests-and-submission-of-documentation-update

 

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. 

Health Insurance Exchange Problems Hit Patients, Practices Hard

By P.j. Cloud-moulds from Physicians Practice

Wow, what a week!  What a year, I should say.  The state of California has seen many, many changes since January 1. How these changes are affecting physicians and practices is mind-boggling.

Here are a few of the biggest changes practices are experiencing: 1. A new California law allows patients to walk into a physical therapy office without a prior prescription and receive treatment for a specific number of visits or days.  The problem is that some insurance companies still require a prescription from a licensed physician.  Unfortunately, insurance companies often don't share this information at the verification level with the physical therapist, and the claim is denied or delayed in payment.  This has been a treat to figure out, but most of the patients have primary-care physicians that the physical therapist can fax the evaluation to, and this seems to satisfy the insurance companies need for a prescription. 2. The next change relates to the California workers compensation fee schedule.  It transitioned from very specific 30-minute timed codes to the Medicare Fee Schedule.  The problem is that very few of the workers compensation plans actually implemented this change and they are pulling the, “We didn't know” card.  Senate leaders in Sacramento have filed complaints against many of these plans. Liberty Mutual, your time to pay up has come!  I strongly advise practices to review their workers compensation claims with their healthcare and billing staff to make sure they are using the updated fee schedule, that the workers compensation plans are paying per the fee schedule, and that someone is following up with these types of claims. 3. Our latest fiasco has been my favorite so far:  Covered California. It really should be called Uncovered California.  This blog article is certainly not long enough to list all of the fiascos that we uncovered this week, but let me name a few.  Blue Shield created a “narrowed network" and many physicians that participate with Blue Shield are not in network on the new exchange plans. That means that if a patient purchases a Blue Shield exchange plan and calls for an appointment and a practice's front-office staff mistakenly believes it is in network, the patient may have to pay out-of-network rates around a 50 percent coinsurance for receiving services at your practice.   I have identified a common group number of X001004 and alpha prefixes of XEA, XEC, XED, XEK followed by 900.  These two are tip-offs that the patient is on exchange, off exchange, or underwritten.  All of these scenarios claims are processing out of network.Some of the health cards have the “Covered California” logo on them, some don't.  All of the plans indicate that they are some sort of PPO, so practices usually don't think twice about not being in network.  Patients are angry and up in arms about all of this.  While trying to figure this all out, I came across the Blue Shield Facebook page. If you want a laugh, take a look.  The company's canned responses are similar to the recorded messages and disclaimers you get when you call.  Blue Cross of California also has several new plans in which many providers are considered out of network.  Practices in the state of California may want to spend a few hours to identify patients with the alpha prefix JQD, JQM, JQN and VXB with corresponding group numbers of 0RX, 0RY (zero not “O”).  It is imperative that practices discuss these out-of-network issues with their staff so that they are aware when patients call and start yelling about getting their bills.

Article From Physicians Practice  http://www.physicianspractice.com/blog/health-insurance-exchange-problems-hit-patients-practices-hard?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=18022014

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

ICD-10 Testing Approach: Medicare/Noridian

ICD-10 Testing Approach

MLN Matters® Number: SE1409
Related Change Request (CR) #: N/A
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 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. Be sure you are ready. This MLN Matters® Special Edition article is intended to convey the testing approach that the Centers for Medicare & Medicaid Services (CMS) is taking for ICD-10 implementation.

Background
The implementation of International Classification of Diseases, 10th Edition (ICD-10) represents a significant code set change that impacts the entire health care community. As the ICD-10 implementation date of October 1, 2014, approaches, CMS is taking a comprehensive four-pronged approach to preparedness and testing to ensure that CMS as well as the Medicare Fee-For-Service (FFS) provider community is ready.
When "you" is used in this publication, we are referring to the FFS provider community.
The four-pronged approach includes:

• CMS internal testing of its claims processing systems; 
• Provider-initiated Beta testing tools; 
• Acknowledgement testing; and 
• End-to-end testing.

Each approach is discussed in more detail below

CMS Internal Testing of Its Claims Processing Systems
CMS has a very mature and rigorous testing program for its Medicare FFS claims processing systems that supports the implementation of four quarterly releases per year. Each release is supported by a three-tiered and time-sensitive testing methodology:

• Alpha testing is performed by each FFS claims processing system maintainer for 4weeks; 
• Beta testing is performed by a separate Integration Contractor for 8 weeks; and
• Acceptance testing is performed by each MAC for 4 weeks to ensure that local coverage requirements are met and the systems are functioning as expected. 

CMS began installing and testing system changes to support ICD-10 in 2011. As of October 1, 2013, all Medicare FFS claims processing systems were ready for ICD-10 implementation. CMS continues to test its ICD-10 software changes with each quarterly release.

Provider-Initiated Beta Testing Tools
To help you prepare for ICD-10, CMS recommends that you leverage the variety of Beta versions of its software that include ICD-10 codes as well as National Coverage Determination (NCD) code crosswalks to test the readiness of your own systems. The following testing tools are available for download:

• NCDs converted from International Classification of Diseases, 9th Edition (ICD-9) to ICD-10 located at http://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html  on the CMS website;
• The ICD-10 Medicare Severity-Diagnosis Related Groups (MS-DRGs) conversion project (along with payment logic and software replicating the current MS-DRGs), which used the General Equivalence Mappings to convert ICD-9 codes to International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM) codes, located at http://cms.hhs.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html  on the CMS website. On this web page, you can also find current versions of the ICD-10-CM MS-DRG Grouper, Medicare Code Editor (available from National Technical Information Service), and MS-DRG Definitions Manual that will allow you to analyze any payment impact from the conversion of the MS-DRGs from ICD-9-CM to ICD-10-CM codes and to compare the same version in both ICD-9-CM and ICD-10-CM; and  
• A pilot version of the October 2013 Integrated Outpatient Code Editor (IOCE) that utilizes ICD-10-CM located at http://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/Downloads/ICD-10-IOCE-Code-Lists.pdf  on the CMS website. The final version of the IOCE that utilizes ICD-10-CM is scheduled for release in August 2014.

Crosswalks for Local Coverage Determinations (LCDs) will be available in April 2014.
If you will not be able to complete the necessary systems changes to submit claims with ICD-10 codes by October 1, 2014, you should investigate downloading the free billing software that CMS offers from their MACs. The software has been updated to support ICD-10 codes and requires an internet connection. Alternatively, many MACs offer provider internet portals, and some MACs offer a subset of these portals that you can register for to ensure that you have the flexibility to submit professional claims this way as a contingency.

Acknowledgement Testing
CMS will offer ICD-10 acknowledgement testing from March 3–7, 2014. This testing will allow all providers, billing companies, and clearinghouses the opportunity to determine whether CMS will be able to accept their claims with ICD-10 codes. While test claims will not be adjudicated, the MACs will return an acknowledgment to the submitter (a 277A) that confirms whether the submitted test claims were accepted or rejected. For more information about acknowledgement testing, refer to the information on your MAC's website.
CMS is exploring offering other weeks of acknowledgement testing after it analyzes the results of the March 2014 testing week.

End-to-End Testing
In summer 2014, CMS will offer end-to-end testing to a small sample group of providers. Details about the end-to-end testing process will be disseminated at a later date.
End-to-end testing includes the submission of test claims to CMS with ICD-10 codes and the provider's receipt of a Remittance Advice (RA) that explains the adjudication of the claims. The goal of this testing is to demonstrate that:

• Providers or submitters are able to successfully submit claims containing ICD-10 codes to the Medicare FFS claims systems; 
• CMS software changes made to support ICD-10 result in appropriately adjudicated claims (based on the pricing data used for testing purposes); and
• Accurate RAs are produced.  

The small sample group of providers who participate in end-to-end testing will be selected to represent a broad cross-section of provider types, claims types, and submitter types. 
 

Last Updated Feb 21, 2014

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

Medicare Redeterminations: Top Five Requested Codes and Tips

Redeterminations: Top Five Requested Codes and Tips

Noridian conducted data analysis on the top procedure codes from redetermination requests submitted since October 2013. Below are the top five CPT/HCPCS codes, resources and tips to assist your office when submitting such requests.
CPT 88305 - Pathology Examination of Tissue Using a Microscope

• These appeals were denied because the requesting party failed to provide the following:
  • Indicate requirement of a valid order/intent to order.
  • Documentation must be signed and dated by the performing provider.
    • CMS Internet Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.6 
  • Pathology Reports - Include surgery/procedure notes when biopsies taken.
    • CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 30 

CPT 99214 - Established Patient Office or Other Outpatient

• These appeals were denied because the requesting party failed to provide the following:
  • Evaluation and Management (E/M) outpatient/office notes must be dated and signed by the performing provider. Medical necessity is required for this level of service. Services must meet requirements of this code, including two of the three components:
    • Detailed history
    • Detailed exam
    • Medical decision making of moderate complexity located in CPT book
  • For further clarification:
    • CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 30 
    • CMS IOM Publication100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.7 
    • CMS 1995 Documentation Guidelines for Evaluation and Management Services 
    • CMS 1997 Documentation Guidelines for Evaluation and Management Services 

CPT 99232 - Subsequent Hospital Inpatient Care, Typically 25 Minutes

• These appeals were denied because the requesting party failed to provide the following:
  • 99232 should only be billed once per day by providers of the same group/specialty. Exception: Multiple visits in same the day for unrelated issues. Medical necessity is required for this level of service. Documentation must support additional services.
    • CMS 1995 Documentation Guidelines for Evaluation and Management Services 
    • CMS 1997 Documentation Guidelines for Evaluation and Management Services 
  • Documentation submitted with the redetermination request must be signed and dated by the performing provider and must meet two of the three key components
    • Expanded problem focused history
    • Expanded problem focused exam or
    • Medical decision making of moderate complexity
  • For further clarification:
    • CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 30 
    • CMS IOM Publication 100-04, Medicare Claims Processing Manual,  Chapter 12, Section 30.6.9 

CPT 99233 - Subsequent Hospital Inpatient Care, Typically 35 Minutes

• These appeals were denied because the requesting party failed to provide the following:
  • Provides the same instructions as those for 99232 with the following exception:
  • 99233 should meet two of the three components:
    • Detailed interval history
    • Detailed exam
    • Medical decision making of high complexity
  • Medical necessity is required for this level of service.
  • For further clarification:
    • CMS 1995 Documentation Guidelines for Evaluation and Management Services 
    • CMS 1997 Documentation Guidelines for Evaluation and Management Services 
  • 99233 should only be billed once per day by providers of the same group/specialty. Exception: Multiple visits in the same day for unrelated issues. Documentation must support additional services.
  • For further clarification:
    • CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 30 
    • CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.9 

HCPCS A0425 - Ground Mileage, per Statute Mile

• These appeals were denied because the requesting party failed to provide the following:
  • Include the following documentation in the request:
    • Trip report which must be signed and dated by a crew member.
    • Discharge notes
    • Progress notes that support the necessity of the ambulance trip
    • Certification for medical necessity of the ambulance transport 
    • CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 10 
    • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 15 

Published: 01/30/14

Last Updated Jan 30, 2014

From Noridian: https://med.noridianmedicare.com/web/jeb/article-detail/-/view/10525/redeterminations-top-five-requested-codes-and-tips

New CMS-1500 Claim Form Must Be Submitted on April 1, 2014

The CMS-1500 claim form has been updated for ICD-10. Form Version 02/12 will replace the CMS-1500 claim form, 08/05, effective for claims received on/after April 1, 2014.
Below are key dates for compliance with the claim submission rules:

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

The grace period for providers to transition to the new form expires on April 1, 2014. Providers need to plan ahead to ensure that claims submitted on the "old" 08/05 claim form mailed or sent via a courier service reach the Noridian offices located in Fargo, ND by March 31, 2014. Claims on the "old" claim form received on/after April 1, 2014 will not be processed. Providers will receive a letter stating that the incorrect form was submitted and that they will need to submit the claims on the current, 02/12 version of the paper claim form.
Note: Updating the print layout for the new claim form will require fairly significant adjustments. The revised form, version 02/12, has a number of revisions which require changes to the print layout for proper data alignment.
Those most notable changes to the 02/12 claim form are for Items 17, 21 and 24E.
Item 17 must have a qualifier entered to the left of the dotted vertical line in Item 17 to indicate the type of provider being reported in this field, as outlined below:

• DN - Referring Provider
• DK - Ordering Provider (this is the appropriate qualifier for DME claims)
• DQ - Supervising Provider

Item 21 now allows for 12 diagnosis codes, rather than 4 and the diagnosis pointers have changed from 1-4 to A-L. In addition, the diagnosis codes are now read left to right, rather than up and down.
Item 24E now requires the corresponding alphabetic, rather than numeric, diagnosis pointer. See Item 21.
Providers are encouraged to start their claim form transition now, by updating your print layouts and obtaining the new claim form for testing. Proper preparation and testing will ensure your ability to properly submit claims on the new form by April 1, 2014.
For more information, see the following:

• CMS Medicare Learning Network (MLN) Matters (MM) 8509 at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8509.pdf 

• CMS-1500 Instructions for 02/12 Version at https://med.noridianmedicare.com/web/jeb/topics/claim-submission/instructions

Last Updated Feb 06, 2014

Medicare eRx HCPCS G8553 Deleted 12/31/2013

eRx HCPCS G8553 Deleted

Effective for claims billed with dates of service 01/01/2014, HCPCS G8553 is no longer valid. Because Electronic Prescribing (eRx) reporting is not being monitored during 2014, no new code will be created. The eRx incentive program finalized on 12/31/13; however, providers are encouraged to continue to electronically prescribe as it is a measure under Electronic Health Records (EHR) and should be reported as such.

Individual eligible professionals and group practices who participated in the eRx Group Practice Reporting Option (GPRO) who were not successful electronic prescribers will be subject to a 2.0% payment adjustment on their Medicare Part B services provided January 1, 2014 through December 31, 2014.

To avoid the 2014 eRx payment adjustment, individual eligible professionals and group practices must have been successful 2013 electronic prescribers, reporting HCPCS G8553 on at least 10 billable Medicare Part B Physician Fee Schedule (PFS) services provided from January 1, 2013 through June 30, 2013.

Review the CMS 2014 eRx Payment Adjustment Information Fact Sheet for more detailed information, including how an eligible professional or group practice can request a hardship exemption to the 2014 eRx payment adjustment or to request an informal application review. The deadline to request an informal review is February 28, 2014. See instructions in the above mentioned fact sheet. 
 

Last Updated Jan 15, 2014

2013 PQRS - Medicare EHR Incentive Pilot: Submit Quality Data by February 28, 2014

The Physician Quality Reporting System (PQRS) Medicare EHR Incentive Pilot allows eligible professionals to meet the clinical quality measure (CQM) reporting requirement for the Medicare EHR Incentive Program through electronic submission while also reporting for the PQRS program. 
Are you an eligible professional  who is participating or wishes to participate in the 2013 PQRS-Medicare EHR Incentive Pilot ? You can now submit your 2013 quality data.

If you would like to participate in the pilot you must submit 12 months of CQM data by February 28, 2014 at 11:59 pm ET.

Steps to Successfully Participate

To successfully participate in the pilot, you must do the following by February 28, 2014:

1. Register for an IACS account (for EHR submission only)
2. Indicate intent to report CQMs using pilot in EHR Registration & Attestation System
3. Generate required reporting files
4. Test data submission
5. Submit quality data

If you cannot submit your CQM data for 12 months electronically through PQRS, you must return to the EHR Attestation System and deselect the electronic reporting option.  Please note: if you do not submit your 2013 quality data or deselect the electronic reporting option in the EHR Attestation System, you will not receive an EHR incentive payment.

For More Information
For further guidance on the 2013 PQRS-Medicare EHR Incentive Pilot, please read the Participation Guide  and Quick-Reference Guide .

If you have additional questions, please contact QualityNet Help Desk at 866-288-8912 (TTY 877-715-6222) or via qnetsupport@sdps.org. The Held Desk is available Monday through Friday from 7 a.m.-7 p.m. CST.

Source: CMSLISTS Email Update dated January 15, 2014

Last Updated Jan 16, 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