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

Medicare System Project for Electronic Submission of Medical Documentation

MLN Matters®Number: SE1343

Provider Types Affected
This Special Edition (SE) MLN Matters® Article is intended for all Medicare Fee-For-Service (FFS) providers and suppliers who submit medical documentation to Medicare review contractors.

Provider Action Needed
This article is based on the utilization of the Electronic Submission of Medical Documentation (esMD) via Medicare's esMD Gateway to respond to review contractor's requests for medical documentation.

Background
The Centers for Medicare & Medicaid Services (CMS) uses several types of review contractors to measure, prevent, identify, and correct improper payments or identify potential fraud.
Review contractors find improper payments and potential fraud by reviewing a sample of claims. They request medical documentation from the provider or supplier and manually review the claims against the medical documentation to verify the providers' compliance with Medicare's rules.
As of September 2011, providers are able to respond to these requests for medical documentation electronically using the Electronic Submission of Medical Documentation (esMD) via Medicare's esMD Gateway. Since September 2011, CMS enhanced the esMD Gateway to support several new use cases, for example:

• In September 2012, CMS implemented a Prior Authorization (PA) process via the esMD Gateway for Power Mobility Devices (PMD) for FFS Medicare beneficiaries who reside in seven states with high populations of error prone providers (CA, IL, MI, NY, NC, FL and TX).
• In January 2013, CMS expanded the CMS esMD Gateway to allow Durable Medical Equipment (DME) suppliers and providers to send electronic PA Requests to Medicare review contractors.
• In June 2013, CMS enabled automated Prior Authorization Review Results Responses from Medicare review contractors to Health Information Handlers (HIHs) via the esMD Gateway.

Medicare's esMD system provides an alternative mechanism for submitting medical documentation, PMD PA requests, and PMD result code responses to review contractors. A list of review contractors that will accept esMD transactions, as well as receive PMD PA requests and send PMD PA review results can be found at http://go.cms.gov/RevCon  on the CMS website.
The primary intent of esMD is to reduce provider costs and cycle time by minimizing paper processing and mailing of medical documentation to review contractors.
The number of participants in the CMS esMD Program has grown steadily since its inception.
As of September 30, 2013:

• 449,460 Unique Medical Record Transactions have been submitted;
• 30,199 Medicare Providers are using esMD to respond to medical record requests;
•  55 Medicare Providers use esMD to submit Prior Authorization Requests;
• 24 HIHs are certified by CMS to offer esMD services;
• 27 Review Contractors are approved by CMS to accept medical records via esMD

Medicare providers, including physicians, hospitals, and suppliers must obtain access to a CONNECT-compatible gateway in order to send medical documentation electronically to review contractors.
For example:

• Larger providers, such as hospital chains, may choose to build their own gateway;
• Many providers may choose to obtain gateway services by entering into a contract or other arrangement with a HIH that offers esMD Gateway services.

HIHs contract with providers to supply them with esMD services much the same way that providers contract with claims clearinghouses to supply them with claims submission services.

A listing of the HIHs that have been approved by CMS to offer esMD services can be found at http://go.cms.gov/esmd-HIH  on the CMS website.

HIH's set the price of their esMD provider services. Providers are encouraged to contact one or more of the HIHs to determine what esMD services are available.

While esMD is not mandatory, many healthcare providers find that it reduces costs, increases efficiency, and shortens processing times for certain transactions. CMS has instructed review contractors to not target providers for medical review based on their use of esMD.

The esMD system accepts Portable Document Format (PDF) files, which enables providers to use esMD services as long as they have the proper scanning mechanism. Some HIHs may offer scanning services in addition to their esMD services.

Additional Information
If you have any questions, please contact the review contractor to whom you wish to send esMD transactions. The review contractor toll-free numbers can be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html  on the CMS website.

For more information, visit the esMD webpage at http://www.cms.gov/esmd  on the CMS website, or follow esMD on Twitter @CMSGov (#CMS_esMD).

For more information on the Medicare Recovery Audit program, see the MLN Matters® article SE1024 at http://www.cms.gov/MLNMattersArticles/downloads/SE1024.pdf  on the CMS website.

Contact information for your Recovery Auditor is available at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Downloads/RAC-Contact-Information-AbbrState-Apr2013.pdf  on the CMS website.

Courtesy of Noridian/CMS https://med.noridianmedicare.com/web/jeb/article-detail/-/view/10525/medicare-system-project-for-electronic-submission-of-medical-documentation

Choosing a Medical Billing Partner: 6 Questions to Ask First, This Article Gives You an Idea of What a Provider is Looking For.

By Sherri Dumford, CHBME, MBA Taken from Physician's Practice

In my almost 30 years of experience in healthcare billing, I’ve never seen more rapid change than today. Ever-evolving laws, regulations, and new reimbursement models make it imperative for shrewd physicians and administrators to align themselves with the most astute billing professionals to keep the practice healthy.

Here are the top six questions I advise practice leaders to ask themselves before selecting a billing partner.

1. What qualifications and credentials should I look for?

The billing firm must have policies and procedures that maximize the efficiencies of practice work flow and minimize the time it takes to get paid. In the wake of the HIPAA Omnibus Rule, billing companies also must have a rigorous compliance program that ensures the privacy, security and confidentiality of protected health information (PHI).

Billing company leaders who orient their staff assiduously and support continuous education, keep their firm and your practice on the cutting edge of industry developments. For instance, billing professionals who have achieved certification in the Certified Healthcare Billing and Management Executive (CHBME) program, offered through the Healthcare Billing & Management Association (HBMA), demonstrate a biller’s commitment to further their education.

2. What stipulations are essential to include in a contract?

An effective contract clarifies the billing company’s scope of work in detail, while specifying your practice’s responsibilities and pledge (e.g., to provide sufficient documentation for billing and authorization for services). Individual stipulations may vary from firm to firm, but should always contain the legal names of responsible parties, effective dates (including termination clauses), service reimbursement parameters, and an explanation of how reimbursements will be calculated, along with compliance requirements and scope of work. As always, whenever entering into a contract, seek legal counsel and do not be tempted to use a generic template as your final contract.

3. How can the billing partner help measure the health of my practice?

As reimbursement models continue to evolve, you will rely on your medical billing company to provide you with expert counsel in evaluating not only the health of your organization today, but also to make the appropriate preparations to meet future needs. Choose a billing company experienced in evaluating reimbursement data analytics, as well as one that can assess existing administrative policies, staffing levels, and IT resources so your practice can focus on what it does best— providing quality patient care.

4. What technological capabilities can I expect from a billing company?

Today, billing companies do much more than reimbursements. With their breadth of knowledge and expertise, billing companies may counsel you on the best technology to meet both your needs and regulatory requirements. Their experience with EHRs, practice management and billing systems, and other IT solutions, allows billing companies to integrate systems effectively, regardless of where they originate and reside. Whether you are looking for a new implementation or looking for an upgrade to your existing IT solution, the right billing company will be able to help zero in your focus of certified, respected vendors who have stood the test of time in meeting the clinical, administrative and financial needs of medical practices.

5. How important is it for the billing company to be "connected" to the revenue cycle management industry as a whole?

Because the business of healthcare billing is changing so rapidly, it is critical to partner with a billing firm that is playing an active role in the revenue cycle management industry and is constantly adding to its knowledgebase. You will want to investigate how the billing company is staying current with things like the transition to ICD-10; the use of PQRS (Physician Quality Reporting System) to make quality reporting pay; the types of relationships they have with your local payors; and how they stay abreast of regulatory changes that affect compliance and reimbursement.

As one example, the HBMA is a 700-member strong organization of billing companies that offers numerous educational programs to help members to stay on top of legislative, regulatory, and coding changes.

6. Since ICD-10 is one of the most significant changes the physician community faces, what preparation should I expect from a billing company?

Practices that aren’t prepared for the transition from ICD-9 to ICD-10 may see an immediate hit in revenue on Oct. 1, 2014. It may even serve as a death blow for some. Savvy practices will rely on billing companies that have completed end-to-end testing and have already performed the appropriate training for certified coders and are armed and ready to act in the event reimbursement issues arise due to adjudication issues with payors. This means they are keenly aware of which reimbursements should be based upon contracts, and evaluate any changes in denials or reimbursement trends. These efforts build upon an organization’s ICD-10 proficiency and work to ensure that reimbursement continues to flow to your practice.

Covering the above questions will help you find the best billing partner to help your practice thrive today and remain competitive in the future. But, I'm interested in your thoughts — beyond these six, are there additional questions or areas that should be included? Let me know in the comments section below.
Sherri Dumford, CHBME, MBA, is director of operations and external affairs for the Healthcare Billing and Management Association (HBMA). An established industry veteran, Dumford has worked in healthcare billing for more than 30 years, which includes serving as past president for HBMA. In her current role, she supports all aspects of the HBMA’s daily operations relative to membership, advocacy, and education, in support of HBMA strategic initiatives. E-mail her here. 

Courtesy of Physicians Practice  http://www.physicianspractice.com/blog/choosing-medical-billing-partner-6-questions-ask-first

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I have never had the need to look for any of these codes! Let's see else what Oct. 1, 2014 has in store for us!

Did lots of your patients purchase plans through health insurance exchanges? Here's a helpful link you might want to add to your practice's website.

Physicians Practice

Did lots of your patients purchase plans through health insurance exchanges? Here's a helpful link you might want to add to your practice's website. It provides tips for patients with new insurance.

http://www.whitehouse.gov/share/have-new-insurance-heres-what-you-need-know

Need to verify coverage for patients with marketplace plans? Follow these steps:

Need to verify coverage for patients with marketplace plans? Follow these steps:

First, call the plan number listed on the back of the patient’s insurance card, if you are fortunate enough to have a patient with a plan card.

If not, here are additional steps:...

If the federal government runs the marketplace in your state, you can search through a list of plans and obtain customer service number through that database at
https://data.healthcare.gov/dataset/QHP-Customer-Service-Phone-Numbers/vryg-tdzf?

Sort the database by state and then you can sort by county if necessary. If you still cannot find the contact number, you can call the federal marketplace at 800-318-2596.

If your state runs its own insurance exchange, go to http://www.healthcare.gov to search for your state and phone number information.