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

 

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

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

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

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