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1 January 2013 This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff. Bulletins are available at no cost from our Web site at News From Cahaba GBA Disclaimer Please Route.. 3 General Medicare Questions for Medicare Recipients Holiday Closure Schedule Provider Contact Center & EDI Training Schedule.. 5 Provider Contact Center (PCC) Telephone Number... 5 Using the Interactive Voice Response (IVR) System for Claim Status and Eligibility Requests Medicare Health Insurance Claim (HIC) Number 7 Cahaba s Notification Service Top Electronic Data Interchange (EDI) Claim Rejections 9 Local Coverage Article for Drugs and Biologicals- Chemotherapeutic Agents (A48896)- Bortezomib (Velcade )(J9041) LCD- Draft Local Coverage Determination Open Meetings LCD- Local Coverage Determination Updates CPT/HCPCS Codes Local Coverage Article for Drugs and Biologicals- Chemotherapeutic Agents (A48896)- Q Valid CPT Code/Valid HCPCS Code Versus Provider Miscellaneous Code New Front-End Edits Effect January Claim Specific CERT Errors- November Upcoming Events.. 15 Medicare B Newsline Quality Survey News From CMS News Flash Messages From CMS. 16 Ambulance Medical Condition List and Instructions News From CMS continued Redesign of the Medicare Summary Notice (MSN) Final Implementation And Major Update to Chapter of the Claims Process Manual Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Low Back Pain (CLBP) Quarterly Update to the End Stage Renal Disease (ESRD) Prospective Payment System (PPS) - Revised.. 30 Expansion of Medicare Telehealth Services for Calendar Year (CY) Implementing the Claims-Based Data Collection Requirement for Outpatient Therapy Services Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of Correct Coding Initiative (CCI) Edits, Version Bariatric Surgery for the Treatment of Morbid Obesity National Coverage Determination, Addition of Laparoscopic Sleeve Gastrectomy (LSG) Update to Medicare Deductible, Coinsurance, and Premium Rates for New Place of Service (POS) Code for Place of Employment/Worksite Annual Update to the Therapy Code List Therapy Cap Values for Calendar Year (CY) Calendar Year (CY) 2013 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Provider Contact Charge Payment... Center 55 Calendar Year (CY) 2013 Update for Durable Medical If you have any questions related to articles in this publication, please Equipment, Prosthetics, Orthotics, and Supplies contact a Customer Service Representative at (DMEPOS) Fee Schedule 60 Correct Coding Initiative (CCI) Edits, Version CMS Special Edition Articles Key For Icons All Providers Claims End Stage Renal Disease (ESRD) Radiology Skilled Nursing Facility (SNF) The Medicare B Newsline provides information for those providers who submit claims to Cahaba Government Benefit Administrators, LLC. The CPT codes, descriptors and other data only are copyright 2012 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

2 Disclaimer This educational material was prepared as a tool to assist Medicare providers and other interested parties and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within this module, the ultimate responsibility for the correct submission of claims lies with the provider of services. Cahaba GBA, LLC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of these materials. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. We encourage users to review the specific statues, regulations and other interpretive materials for a full and accurate statement of their contents. Although this material is not copyrighted, CMS prohibits reproduction for profit making purposes. American Medical Association Notice and Disclaimer CPT codes, descriptors and other data only are Copyright 2012 American Medical Association. All rights reserved. ICD-9 Notice The ICD-9-CM codes and descriptors used in this material are copyright 2012 under uniform copyright convention. All rights reserved. Medicare B Newsline January

3 News From Cahaba GBA for All Part B Providers Please Route Remember that this newsletter, and all other Medicare publications, serves as your official notice of Medicare coverage and billing information. If you have any questions about the information included in this newsletter, please call your Provider Contact Center. This bulletin shall be shared with all health care practitioners and managerial members of your provider staff. Bulletins are available at no cost from our website at Routing List Provider/Supplier Administrator Office/Clinic Manager Medical Personnel Billing/Insurance Staff Other Additional Staff General Medicare Questions for Medicare Recipients Do some of your patients have questions regarding their Medicare benefits and you are not sure how to answer? Medicare recipients should call MEDICARE ( ) for all questions related to Medicare services. Questions regarding specific claims will be automatically routed to the appropriate Medicare contractor s call center for response. Please do not ask your patients to contact Medicare on a claim that you accepted assignment on. Medicare B Newsline January

4 2013 Holiday Closure Schedule Cahaba GBA s Medicare offices in Birmingham, Alabama, Douglasville, Georgia, and Chattanooga, Tennessee are closed on the following days in In addition, the Medicare Provider Contact Center (PCC) and the EDI Help Desk closes on federal holidays for continuing education training; therefore, Customer Service Representatives and EDI Representatives will not be available on those days to receive your calls. Holiday / Date New Year s Day Observed January 1, 2013 Tuesday Martin Luther King Birthday January 21, 2013 Monday President s Day February 18, 2013 Monday Good Friday March 29, 2013 Friday Memorial Day May 27, 2013 Monday Independence Day July 4, 2013 Thursday Labor Day September 2, 2013 Monday Columbus Day October 14, 2013 Monday Veterans Day Observed November 11, 2013 Monday Thanksgiving November 28-29, 2013 Thursday/Friday Christmas December 24-25, 2013 Tuesday, Wednesday Closure Schedule All Offices Closed All Offices Closed PCC & EDI Closed for Training All Offices Closed All Offices Closed All Offices Closed All Offices Closed PCC & EDI Closed for Training PCC & EDI Closed for Training All Offices Closed All Offices Closed Medicare B Newsline January

5 Provider Contact Center and EDI Training Schedule Medicare is a continuously changing program, and it is important that we provide correct and accurate answers to your questions. To better serve the provider community, the Centers for Medicare & Medicaid Services (CMS) allows the Provider Contact Centers and EDI Help Desk the opportunity to offer training to our Customer Service and EDI Representatives. Listed below are the closed training dates and times. PCC Training Dates Friday, January 4, 2013 Friday, January 11, 2013 Friday, January 18, 2013 Friday, January 25, 2013 Time 9:30 a.m.- 11:30 a.m. CT/10:30 a.m.- 12:30 p.m. ET 9:30 a.m.- 11:30 a.m. CT/10:30 a.m.- 12:30 p.m. ET 9:30 a.m.- 11:30 a.m. CT/10:30 a.m.- 12:30 p.m. ET 9:30 a.m.- 11:30 a.m. CT/10:30 a.m.- 12:30 p.m. ET Provider Contact Center Telephone Number Our Interactive Voice Response (IVR) system is designed to assist providers in obtaining answers to numerous issues through self-service options. Options on our IVR include information regarding patient eligibility, checks, claims, deductible and other general information. Please note that our Customer Service Representatives (CSRs) are available to answer questions that cannot be answered by the IVR. CSRs are physically located in Birmingham, Alabama and Douglasville, Georgia. When your call is received, it is routed to the next available representative. CSRs are available Monday through Friday 8:00 a.m. until 4:00 p.m. in your time zone. Medicare B Newsline January

6 Using the Interactive Voice Response (IVR) System for Claim Status and Eligibility Requests Cahaba Government Benefit Administrators, LLC is experiencing a high volume of providers who are opting out of the Interactive Voice Response (IVR) system to speak to a Customer Service Representative (CSR) for information that can be accessed through the IVR. The Centers for Medicare and Medicaid Services (CMS) Internet Only Manual (IOM) Chapter 6 Section 50.1 states: Providers shall be required to use IVRs to access claim status and beneficiary eligibility information. CSRs shall refer providers back to the IVR if they have questions about claims status or eligibility that can be handled by the IVR. CSRs may provide claims status and/or eligibility information if it is clear that the provider cannot access the information through the IVR because the IVR is not functioning. If you are requesting whether Cahaba has received a claim or if a claim has finalized, this is considered a claim status request. In addition, according to IOM Chapter 6 Section , If a CSR or written inquiry correspondent receives an inquiry about information that can be found on a Remittance Advice (RA), the CSR/correspondent should take the opportunity to educate the inquirer on how to read the RA, in an effort to encourage the use of self-service. The CSR/correspondent should advise the inquirer that the RA is needed in order to answer any questions for which answers are available on the RA. Providers should also be advised that any billing staff or representatives that make inquiries on his/her behalf will need a copy of the RA. Cahaba CSRs have visibility as to the path the provider takes in the IVR and/or whether they opt out to speak with a representative up front. The CSR will instruct the provider to call back and utilize the IVR if they did not attempt to use this self service option as required by CMS. Provider Contact Center (PCC) Medicare B Newsline January

7 Medicare Health Insurance Claim (HIC) Number A Medicare card is issued to every person who is entitled to Medicare benefits and may be identified by its red, white and blue coloring. This card identifies the Medicare beneficiary and includes the following information: Name (exactly as it appears on the Social Security records); Medicare Health Insurance Claim (HIC) number; Beginning date of Medicare entitlement for hospital and/or medical insurance; Sex and Beneficiary's signature. Three of the top five reasons for claim rejection in any given month are for: The last name submitted for the beneficiary does not match the last name we have on record for the HIC number on the claim. The beneficiary's last name must include apostrophes, spaces, hyphens, etc., if they appear in the beneficiary's last name on his or her Medicare card. The first name submitted for the beneficiary does not match the first name we have on record for the HIC number on the claim. The beneficiary's first name must appear as it does on the beneficiary's Medicare card. This includes spaces, hyphens, apostrophes, etc. The HIC number not matching the name we have on record. The Medicare Claim Number must appear on the claim exactly as it does on the beneficiary s card, without the dashes and with no spaces. It is extremely important that you submit the patient s complete name and HIC number to Medicare or any other health care provider you use (i.e. clinical laboratories, radiology imaging groups, or outpatient therapy providers, etc.). This will ensure that those providers have the correct patient information to file their claims as well. Medicare B Newsline January

8 Cahaba s Notification Service Subscription Process Cahaba GBA recently implemented changes that simplify the process in which providers subscribe to our notification service (Listserv). New members simply provide their name, city, state, zip code, address, and an optional password. In addition, they can select from two different lists to subscribe to: J10 Part A News J10 Part B News Once you are a member, you can edit your profile to: unsubscribe from all lists subscribe to additional lists update your address change your name or address information change what Cahaba lists you are subscribed to. Already a Member? If you enrolled to Cahaba s Listserv prior to November 1, 2009, you will continue to receive messages. However, depending on the selections you made on the subscription form when you originally enrolled, you may receive messages from more than one Cahaba list. To change the list you are subscribed to, access the Edit Your Notification Service Member Profile Web page to review and edit your profile. In order to ensure that you receive your subscription s and announcements from Cahaba GBA, please add us to your contact lists, adjust your spam settings, or follow the instructions from your provider on how to prevent our s from being marked Spam or Junk Mail. Medicare B Newsline January

9 Top Electronic Data Interchange (EDI) Claim Rejections The Electronic Data Interchange (EDI) Department publishes information on the Top 10 EDI Claim Rejections for HIPAA 5010 on our website. The rejections are updated monthly and can be viewed at: Part B: The information published has been extracted from the 277CA transactions created for the month indicated. The 277CA indicates files, batch, and claim level rejections. Information about the 277CA transactions can be found on the Washington Publishing Company's website at For more information about specific edits, visit the CMS website at You can also review the 4010A Audit Trail Reports which identify claims that are accepted and rejected by the Cahaba GBA edit process, and the reason why a claim rejected. Referring to these reports will allow you to correct and resubmit claims quickly, reducing delay of payment. Medicare B Newsline January

10 Local Coverage Article for Drugs and Biologicals - Chemotherapeutic Agents (A48896) Update Effective December 1, 2012, the Cahaba GBA Local Coverage Article for Drugs & Biologicals - Chemotherapeutic Agents (A48896) is being updated. In accordance with the NCCN Drugs & Biologics Compendium, the list of payable ICD-9 diagnosis codes for Bortezomib (Velcade ) (J9041) is expanded to include and for the off-label use in Waldenstrom s Macroglobulinemia/Lymphoplasmacytic Lymphoma. This Article can be accessed from the Local Coverage Determinations (LCDs) and Articles page of our website, (choose your state and select Articles ). LCD Draft Local Coverage Determination Open Meetings 2013 The Cahaba GBA Draft Local Coverage Determination (LCD) Open Meetings for 2013 are tentatively scheduled for: March 5, 2013 July 16, 2013 November 5, 2013 The Draft LCD Open Meetings begin at 10:00 AM (CT) and are held at Cahaba GBA in Birmingham, Alabama. Attendees may participate onsite or telephonically. The Meeting is held to allow the submission of scientific evidence and other information from providers and the general public relating to draft LCDs. Detailed information, including instructions for registration, will be posted on What s New approximately four weeks prior to the Meeting date. Medicare B Newsline January

11 LCD - Local Coverage Determination Updates 2013 CPT/HCPCS Codes Effective: January 1, 2013 Revisions made to Local Coverage Determinations (LCDs) as a result of the Annual CPT/HCPCS Update for 2013 are described below. These code revisions reflect services which are currently addressed in the LCDs and do not establish any new indications within nor restrict the current coverage. Please make note of these revisions, which will become effective January 1, All LCDs are accessible from the Local Coverage Determinations (LCDs) and Articles page of the Cahaba GBA website (select Status of Draft LCDs for your state). Pathology and Laboratory: Circulating Tumor Cells (CTC) Assays (L32293) 0279T and 0280T: These CPT codes are invalid after December 31, 2012 and are being removed from the LCD. Effective January 1, 2013, to report these services, see CPT codes and These codes are being added to the LCD : Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood) 86153: (Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood); physician interpretation and report, when required Surgery: Bioengineered Skin Substitutes (BSS) for the Treatment of Diabetic and Venous Stasis Ulcers of the Lower Extremities (L31428) Q4131 Q4136: These HCPCS codes are being added to the list of HCPCS codes that are Not Separately Payable. Q4131: Epifix, per square centimeter Q4132: Grafix core, per square centimeter Q4133: Grafix prime, per square centimeter Q4134: Hmatrix, per square centimeter Q4135: Mediskin, per square centimeter Q4136: Ez-derm, per square centimeter Medicare B Newsline January

12 Local Coverage Article for Drugs and Biologicals - Chemotherapeutic Agents (A48896) - Update Effective: January 1, 2013 The Local Coverage Article for Drugs and Biologicals - Chemotherapeutic Agents (A48896) is being updated as a result of the Annual CPT/HCPCS Update for This revision does not establish any new indications within nor restrict the current coverage. Please make note of this revision, which will become effective January 1, Q2048 (Injection, doxorubicin hydrochloride, liposomal, doxil, 10 mg) is invalid after December 31, 2012 and is being removed; J9002 (Injection, doxorubicin hydrochloride, liposomal, doxil, 10 mg) is being added effective January 1, This Article can be accessed from the Local Coverage Determinations (LCDs) and Articles page of our website (choose your state and select Articles ). Valid CPT Code/ Valid HCPCS Code Versus Provider Filing Miscellaneous Code Effective February 1, 2013 if a Not Otherwise Classified (NOC) code or Miscellaneous code is used when there is a valid CPT/HCPCS code available, your claim(s) will be denied as invalid for the date of service filed. Example: If a NOC drug code : J3490, J3490,or J9999 is billed when a valid J code is available, the code will be denied as invalid for the date of service filed. If a miscellaneous code: etc., is billed when a valid CPT code is available, the code will be denied as invalid for the date of the services filed. Medicare B Newsline January

13 New Front-End Edits Effect January 2013 Cahaba Government Benefit Administrators,LLC, will be implementing CMS-required front-end edits which will go into effect for claims received after 4:30 p.m. EST, January 4, Below is a list of the edits that we have determined will have the most impact on claims submitted to us. This is not a complete list of the new edits. For a complete list check the edit spreadsheets on the CMS website at Providers, please contact your software vendor, billing service, or clearing house, to make sure that their claims-filing software will be capable of complying with these edits by the above date. Submitters using Cahaba GBA s free billing software, PC-ACE Pro32, version 2.40 or later, should not have claims reject for these edits. Claims that are submitted prior to the above date that are in compliance with these edits will not be rejected. X B.SBR Edit disposition changed to "SBR03 must not be present" X SVD Disposition error code changed to CSCC A7: "Acknowledgement /Rejected for Invalid Information " CSC 512: "Length invalid for receiver's application system" CSC 608: "Paid Service Unit Count" CSC 710: "Line Adjudication Information". X AMT.040 NEW EDIT 277C CSCC A7: "Acknowledgement/Rejected for Invalid Information " CSC 41: Special handling required at payer site CSC 286: Other payer's Explanation of Benefits/payment information CSC 732: Information submitted inconsistent with billing guidelines 2000B loop, SBR03 (Subscriber s group number) must not be sent loop, SVD05 (Paid Service Unit Count) must be greater than 0 and less than 9, Only one decimal place is allowed. If 2000B.SBR01 = "S" then only one iteration of 2320 loop containing an AMT with AMT01 equal to D is allowed. If you have any questions please contact Cahaba GBA EDI Services at (866) Medicare B Newsline January

14 Claim Specific CERT Errors- November 2012 J10 MAC B (Alabama, Georgia, Tennessee) The Comprehensive Error Rate Testing (CERT) Program was implemented by the Centers for Medicare & Medicaid Services (CMS) to monitor the accuracy of claims processing by Medicare contractors, like Cahaba. Contractors are then notified by CERT of the errors and findings. We would like to remind you that should you receive an Additional Documentation Request (ADR) such as a request for records to support services that are involved in a CERT review, you should submit the appropriate documentation to support the services billed, including but not limited to progress note(s) to match the DOS billed, lab results, operative reports, diagnostic tests, physician orders, etc. Medicare requires a legible identifier for services provided/ordered. The method used shall be hand written or an electronic signature (stamp signatures are not acceptable) to sign an order or other medical record documentation for medical review purposes. Providers may appeal unfavorable decisions with additional supporting documentation. For detailed information regarding the Appeals Process, refer to the following link: Please contact the Provider Contact Center for individual questions concerning CERT errors: Alabama, Georgia and Tennessee Providers This summary provides examples of Cahaba s errors identified by CERT. We encourage all providers to review this listing to educate you on common errors. This information will be updated periodically. The intent in providing this information is to prompt you to conduct an internal analysis of Medicare billing and reduce future denials by Medicare. Medicare B Newsline January

15 Upcoming Events. Medicare Part B, Provider Outreach and Education are planning the following educational events: Go-Green Initiatives (Teleconference) Date: January 16, 2013 Time: 10:00 a.m. 10:45 Central, 11:00 a.m. 11:45 Eastern Registration Deadline: January 4, 2013 Medicare Basics Part 1 Understanding the Physician Fee Schedule (Teleconference) Date: January 23, 2013 Time: 10:00 a.m. 10:45 Central, 11:00 a.m. 11:45 Eastern Registration Deadline: January 9, 2013 Medicare 101 Series Part 1 of 2 (Webinar) The Part B Appeals Process Date: January 30, 2013 Time: 10:00 a.m. 11:00 Central, 11:00 a.m. 12:00 Eastern Registration Deadline: January 18, 2013 Medicare 101 Series Part 2 of 2 (Webinar) Medicare Overview Date: February 13, 2013 Time: 10:00 a.m. 11:00 Central, 11:00 a.m. 12:00 Eastern Registration coming soon!! You should watch for future listserv notifications and continue to visit our website at for additional details and/or registration for these events. Please join us! Medicare B Newsline January

16 News Flash Messages from CMS For All Part B Providers ICD-10 Implementation The ICD-10-related implementation date is now October 1, 2014, as announced in final rule CMS-0040-F issued on August 24, This final rule is available at on the Centers for Medicare & Medicaid Services (CMS) website. The switch to the new code set will affect every aspect of how your organization provides care, but with adequate planning and preparation, you can ensure a smooth transition for your practice. Keep Up to Date on ICD-10. Please visit the ICD-10 website for the latest news and resources to help you prepare. Health Plan Identifier (HPID) On August 24, Health and Human Services (HHS) Secretary Kathleen Sebelius announced a final rule that will save time and money for physicians and other health care providers by establishing a unique Health Plan Identifier (HPID). The rule is one of a series of changes required by the Affordable Care Act to cut red tape in the health care system and will save up to $6 billion over ten years. Currently, when a health care provider bills a health plan, that plan may use a wide range of different identifiers that do not have a standard format. As a result, health care providers run into a number of time-consuming problems, such as misrouting of transactions, rejection of transactions due to insurance identification errors, and difficulty determining patient eligibility. The change announced on August 24 will greatly simplify these processes. For more information, see the Fact Sheet related to this final rule. Screening Pelvic Examinations Booklet NEW products from the Medicare Learning Network (MLN) - Screening Pelvic Examinations, Booklet, ICN , Downloadable only. Medicare B Newsline January

17 Providing the Annual Wellness Visit (AWV) Booklet NEW products from the Medicare Learning Network (MLN)- Providing the Annual Wellness Visit (AWV), Booklet, ICN , Downloadable only. Seasonal Flu Vaccination is the Best Protection Against the Flu Influenza Vaccine Prices Are Now Available. Each office visit is an opportunity to check your patients seasonal influenza (flu) and pneumonia immunization status and to start protecting your patients as soon as your seasonal flu vaccine arrives. Ninety percent of flu-related deaths and more than half of flu-related hospitalizations occur in people age 65 and older. Seniors also have an increased risk of getting pneumonia, a complication of the flu. Remind your patients that seasonal flu vaccinations and a pneumococcal vaccination are recommended for optimal protection. Medicare provides coverage for one seasonal influenza virus vaccine per influenza season for all Medicare beneficiaries. Medicare generally provides coverage of pneumococcal vaccination and its administration once in a lifetime for all Medicare beneficiaries. Medicare may provide coverage of additional pneumococcal vaccinations based on risk or uncertainty of beneficiary pneumococcal vaccination status. Medicare provides coverage for these vaccines and their administration with no co-pay or deductible. And don t forget to immunize yourself and your staff. Know what to do about the flu. Remember The influenza vaccine plus its administration and the pneumococcal vaccine plus its administration are covered Part B benefits. The influenza vaccine and pneumococcal vaccine are NOT Part D-covered drugs. CMS has posted the Seasonal Influenza Vaccines Pricing. You may also refer to the MLN Matters Article #MM8047, Influenza Vaccine Payment Allowances - Annual Update for Season. For more information on coverage and billing of the flu vaccine and its administration, please visit the CMS Medicare Learning Network Preventive Services Educational Products and CMS Immunizations web pages. And, while some providers may offer the flu vaccine, others can help their patients locate a vaccine provider within their local community. HealthMap Vaccine Finder is a free, online service where users can search for locations offering flu vaccines. Medicare Claim Submission Guidelines Fact Sheet Revised products from the Medicare Learning Network - "Medicare Claim Submission Guidelines," Fact Sheet, ICN , Hard Copy only. Medicare B Newsline January

18 Medicare FFS Version Health Care Claim Payment/Advice Companion Guide to the Medicare FFS Companion Guides The Centers for Medicare & Medicaid Services has posted an updated Medicare FFS Version Health Care Claim Payment/Advice Companion Guide to the Medicare FFS Companion Guides web page. Advance Beneficiary Notice of Noncoverage (ABN) Booklet REVISED product from the Medicare Learning Network (MLN)- Advance Beneficiary Notice of Noncoverage (ABN) Part A and Part B, Booklet, ICN , Downloadable & Hard Copy. Ordered/Referred Services Are you billing correctly for ordered/referred services? Will you be impacted when the Centers for Medicare & Medicaid Services (CMS) turns on the edits for these services? See the revised MLN Matters articles SE1221, SE1011, and MLN fact sheets Medicare Enrollment Guidelines for Ordering/Referring Providers and The Basics of Medicare Enrollment for Physicians Who Infrequently Receive Medicare Reimbursement to learn what you need to do. Inpatient Rehabilitation Services: Complying with Documentation Requirements REVISED product from the Medicare Learning Network (MLN)- "Inpatient Rehabilitation Services: Complying with Documentation Requirements," Fact Sheet, ICN , Downloadable only. Medicare B Newsline January

19 NEW Product from the Medicare Learning Network (MLN) Safeguarding Your Medical Identity, Web-based Training (WBT) Course Continuing education credits are available to learners who successfully complete this course. See course description for more information. To access the WBT, go to Web-Based Training, and click on Web-Based Training Courses under Related Links at the bottom of the web page. Medicare Secondary Payer Billing Medicare is denying an increasing number of claims, because providers are neither identifying, nor sending claims to, the correct primary payer prior to claims submission. Medicare would like to remind providers, physicians, and suppliers that they have the responsibility to bill correctly and to ensure claims are submitted to the appropriate primary payer. Please refer to the Medicare Secondary Payer (MSP) Manual, Chapters 1, 3, and 5 and MLN Matters Article SE1217 for additional guidance. Electronic Funds Transfer (EFT) Existing regulations at 42 CFR (e)(1)(2) require that at the time of enrollment, enrollment change request or revalidation, providers and suppliers that expect to receive payment from Medicare for services provided must also agree to receive Medicare payments through Electronic Funds Transfer (EFT). Section 1104 of the Affordable Care Act further expands Section 1862 (a) of the Social Security Act by mandating federal payments to providers and suppliers only by electronic means. As part of Medicare s revalidation efforts, all suppliers and providers who are not currently receiving EFT payments will be identified, and required to submit the CMS 588 EFT form with the Provider Enrollment Revalidation application. For more information about provider enrollment revalidation, review the Medicare Learning Network s Special Edition Article SE1126 titled, Further Details on the Revalidation of Provider Enrollment Information at Medicare B Newsline January

20 News from CMS For Part B Providers Update to the Medicare Claims Processing Manual- Ambulance Medical Condition List and Instructions MLN Matters MM6896 Provider Types Affected This article is for ambulance suppliers submitting claims to Medicare contractors (carriers, Fiscal Intermediaries (FIs), and/or A/B Medicare Administrative Contractors (A/B MACs)) for services provided to Medicare beneficiaries. Provider Action Needed This article is based on Change Request (CR) 6896 which updates the Medicare Claims Processing Manual (Chapter 15 (Ambulance), Section 40 (Medical Conditions List and Instructions). CR 5442 (Transmittal 1185, February 23, 2007) provided for an update to the Ambulance Fee Schedule Medical Conditions List and Instructions found in the Medicare Claims Processing Manual. Subsequently, CR 6347 (Transmittal 1696, March 6, 2009) communicated many revisions and updates to most of Chapter 15 of the Medicare Claims Processing Manual. However, the updated Section 40 (Medical Conditions List and Instructions) was not updated properly to reflect the updates made by CR Therefore, CR 6896 updates Section 40, Chapter 15, of the Medicare Claims Processing Manual. CR 6896 is issued primarily for educational guidance and to help ambulance providers and suppliers to communicate the patient's condition to Medicare contractors, as reported by the dispatch center and as observed by the ambulance crew. See the Background and Additional Information sections of this article for further details regarding these changes. Background CR 6896 is being issued to reflect the updates and revisions to the Medicare Claims Processing Manual (Chapter 15 (Ambulance), Section 40 (Medical Conditions List and Instructions)), and the following includes the revised Section 40. These updates and revisions will help ambulance providers and suppliers to communicate the patient's condition to Medicare contractors, as reported by the dispatch center and as observed by the ambulance crew. Use of the medical conditions list does not guarantee payment of the claim or payment for a certain level of service. Ambulance providers and suppliers must retain adequate documentation of dispatch instructions, patient's condition, other on-scene information, and details of the transport (e.g., medications administered, changes in the patient's condition, and miles traveled), all of which may be subject to medical review by the Medicare contractor or other oversight authority. Medicare contractors will rely on medical record Medicare B Newsline January

21 documentation to justify coverage, not simply the Healthcare Common Procedure Coding System (HCPCS) code or the condition code by themselves. All current Medicare ambulance policies remain in place. The Centers for Medicare & Medicaid Services (CMS) issued the Medical Conditions List as guidance via a manual revision as a result of interest expressed in the ambulance industry for this tool. While the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes are not precluded from use on ambulance claims, they are currently not required (per Health Insurance Portability and Accountability Act (HIPAA)) on most ambulance claims, and these codes generally do not trigger a payment or a denial of a claim. Some Medicare Contractors have Local Coverage Determinations (LCD) in place that cite ICD-9-CM that can be added to the claim to assist in documenting that the services are reasonable and necessary, but this is not common. Since ICD-9-CM codes are not required and are not consistently used, not all carriers or fiscal intermediaries edit on this field, and it is not possible to edit on the narrative field. The ICD-9-CM codes are generally not part of the edit process, although the Medical Conditions List in CR 6896 is available for those who do find it helpful in justifying that services are reasonable and necessary. (CR 6896 is available at on the CMS website. The Medical Conditions List in CR 6896 is set up with an initial column of primary ICD-9-CM codes, followed by an alternative column of ICD-9-CM codes. The primary ICD-9-CM code column contains general ICD-9-CM codes that fit the transport conditions as described in the subsequent columns. Ambulance crew or billing staff with limited knowledge of ICD-9-CM coding would be expected to choose the one or one of the two ICD-9-CM codes listed in this column to describe the appropriate ambulance transport and then place the ICD-9-CM code in the space on the claim form designated for an ICD-9-CM code. The option to include other information in the narrative field always exists and can be used whenever an ambulance provider or supplier believes that the information may be useful for claims processing purposes. If an ambulance crew or billing staff member has more comprehensive clinical knowledge, then that person may select an ICD-9-CM code from the alternative ICD-9-CM code column. These ICD-9-CM codes are more specific and detailed. An ICD-9-CM code does not need to be selected from both the primary column and the alternative column. However, in several instances in the alternative ICD-9-CM code column, there is a selection of codes and the word PLUS. In these instances, the ambulance provider or supplier would select an ICD-9-CM code from the first part of the alternative listing (before the word PLUS ) and at least one other ICD-9-CM code from the second part of the alternative listing (after the word PLUS ). The ambulance claim form does provide space for the use of multiple ICD-9-CM codes. Example: The ambulance arrives on the scene. A beneficiary is experiencing the specific abnormal vital sign of elevated blood pressure; however, the beneficiary does not normally suffer from hypertension (ICD-9-CM code (from the alternative column on the Medical Conditions List)). In addition, the beneficiary is extremely dizzy (ICD-9-CM code (fits the PLUS any other code requirement when using the alternative list for this condition (abnormal vital signs)). The ambulance crew can list these two ICD-9-CM codes on the claim form, or the general ICD-9-CM code for this condition (796.4 Other Abnormal Clinical Findings) would work just as well. None of these ICD-9-CM codes will determine whether or not this claim will be paid; they will only assist the Medicare contractor in making a medical review determination provided all other Medicare ambulance coverage policies have been followed. While the medical conditions/icd-9-cm code list is intended to be comprehensive, there may be unusual circumstances that warrant the need for ambulance services using ICD-9-CM codes not on this list. During the medical review process contractors may accept other relevant information from the providers or Medicare B Newsline January

22 suppliers that will build the appropriate case that justifies the need for ambulance transport for a patient condition not found on the list. Because it is critical to accurately communicate the condition of the patient during the ambulance transport, most claims will contain only the ICD-9-CM code that most closely informs the Medicare contractor why the patient required the ambulance transport. This code is intended to correspond to the description of the patient s symptoms and condition once the ambulance personnel are at the patient s side. For example, if an Advanced Life Support (ALS) ambulance responds to a condition on the medical conditions list that warrants an ALS-level response and the patient s condition on-scene also corresponds to an ALS-level condition, the submitted claim need only include the code that most accurately reflects the on-scene condition of the patient as the reason for transport. (All claims are required to have HCPCS codes on them, and may have modifiers as well.) Similarly, if a Basic Life Support (BLS) ambulance responds to a condition on the medical conditions list that warrants a BLS-level response and the patient s condition onscene also corresponds to a BLS-level condition, the submitted claim need only include the code that most accurately reflects the on-scene condition of the patient as the reason for transport. When a request for service is received by ambulance dispatch personnel for a condition that necessitates the skilled assessment of an advanced life support paramedic based upon the medical conditions list, an ALSlevel ambulance would be appropriately sent to the scene. If upon arrival of the ambulance the actual condition encountered by the crew corresponds to a BLS-level situation, this claim would require two separate condition codes from the medical condition list to be processed correctly. The first code would correspond to the reason for transport or the on-scene condition of the patient. Because in this example, this code corresponds to a BLS condition, a second code that corresponds to the dispatch information would be necessary for inclusion on the claim in order to support payment at the ALS level. In these cases, when medical review is performed, the Medicare contractor will analyze all claim information (including both codes) and other supplemental medical documentation to support the level of service billed on the claim. Medicare Contractors may have (or may develop) individual local policies that indicate that some codes are not appropriate for payment in some circumstances. These continue to remain in effect. Information on appropriate use of transportation indicators: When a claim is submitted for payment, an ICD-9-CM code from the medical conditions list that best describes the patient s condition and the medical necessity for the transport may be chosen. In addition to this code, one of the transportation indicators below may be included on the claim to indicate why it was necessary for the patient to be transported in a particular way or circumstance. The provider or supplier will place the transportation indicator in the narrative field on the claim. Air and Ground Transportation Indicators o C1 : Transportation indicator C1 indicates an interfacility transport (to a higher level of care) determined necessary by the originating facility based upon the Emergency Medical Treatment and Active Labor Act (EMTALA) regulations and guidelines. The patient s condition should also be reported on the claim with a code selected from either the emergency or non-emergency category on the list. o C2 : Transportation indicator C2 indicates a patient is being transported from one facility to another because a service or therapy required to treat the patient s condition is not available at the originating facility. The patient s condition should also be reported on the claim with a code selected from either the emergency or non-emergency category on the list. Medicare B Newsline January

23 In addition, the information about what service the patient requires that was not available should be included in the narrative field of the claim. o C3 : Transportation indicator C3 may be included on claims as a secondary code where a response was made to a major incident or mechanism of injury. All such responses regardless of the type of patient or patients found once on scene are appropriately Advanced Level Service responses. A code that describes the patient s condition found on scene should also be included on the claim, but use of this modifier is intended to indicate that the highest level of service available response was medically justified. Some examples of these types of responses would include patient(s) trapped in machinery, explosions, a building fire with persons reported inside, major incidents involving aircraft, buses, subways, trains, watercraft and victims entrapped in vehicles. o C4 : Transportation indicator C4 indicates that an ambulance provided a medically necessary transport, but the number of miles on the claim form appears to be excessive. This should be used only if the facility is on divert status or a particular service is not available at the time of transport only. The provider or supplier must have documentation on file clearly showing why the beneficiary was not transported to the nearest facility and may include this information in the narrative field. Ground Only Transportation Indicators o C5 : Transportation indicator C5 has been added for situations where a patient with an ALS-level condition is encountered, treated and transported by a BLS-level ambulance with no ALS level involvement whatsoever. This situation would occur when ALS resources are not available to respond to the patient encounter for any number of reasons, but the ambulance service is informing you that although the patient transported had an ALS-level condition, the actual service rendered was through a BLS-level ambulance in a situation where an ALS-level ambulance was not available. For example, a BLS ambulance is dispatched at the emergency level to pick up a 76-yearold beneficiary who has undergone cataract surgery at the Eye Surgery Center. The patient is weak and dizzy with a history of high blood pressure, myocardial infarction, and insulindependent diabetes mellitus. Therefore, the on-scene ICD-9-CM equivalent of the medical condition is (unconscious, fainting, syncope, near syncope, weakness, or dizziness ALS Emergency). In this case, the ICD-9-CM code would be entered on the ambulance claim form as well as transportation indicator C5 to provide the further information that the BLS ambulance transported a patient with an ALS-level condition, but there was no intervention by an ALS service. This claim would be paid at the BLS level. o C6 : Transportation indicator C6 has been added for situations when an ALS-level ambulance would always be the appropriate resource chosen based upon medical dispatch protocols to respond to a request for service. If once on scene, the crew determines that the patient requiring transport has a BLS-level condition, this transportation indicator should be included on the claim to indicate why the ALS-level response was center. Claims including this transportation indicator should contain two primary codes. The first condition will indicate the BLS-level condition corresponding to the patient s condition found on-scene and during the transport. The second condition will indicate the ALS-level condition Medicare B Newsline January

24 corresponding to the information at the time of dispatch that indicated the need for an ALSlevel response based upon medically appropriate dispatch protocols. o C7 : Transportation indicator C7 is for those circumstances where IV medications were required en route. C7 is appropriately used for patients requiring ALS level transport in a non-emergent situation primarily because the patient requires monitoring of ongoing medications administered intravenously. Does not apply to self-administered medications. Does not include administration of crystalloid intravenous fluids (i.e., Normal Saline, Lactate Ringers, 5% Dextrose in Water, etc.). The patient s condition should also be reported on the claim with a code selected from the list. Air Only All transportation indicators imply a clinical benefit to the time saved with transporting a patient by an air ambulance versus a ground or water ambulance. D1 Long Distance: patient's condition requires rapid transportation over a long distance. D2 : Under rare and exceptional circumstances, traffic patterns preclude ground transport at the time the response is required. D3 : Time to get to the closest appropriate hospital due to the patient's condition precludes transport by ground ambulance. Unstable patient with need to minimize out-of hospital time to maximize clinical benefits to the patient. D4 : Pick up point not accessible by ground transportation. The revised Medicare Claims Processing Manual (Chapter 15, Section 40) is included as an attachment to CR 6896, and in the attachment you can review the Medical Conditions List which is set up as a series of tables divided into the following principal sections: Emergency Conditions Non-Traumatic; Emergency Conditions Trauma; Non-Emergency; Transportation Indicators; and Air Ambulance Transportation Indicators. Additional Information The official instruction, CR 6896, issued to your carrier, FI, and A/B MAC regarding this change may be viewed at on the CMS website. Medicare B Newsline January

25 Redesign of the Medicare Summary Notice (MSN) Final Implementation And Major Update to Chapter 21 of the Claims Process Manual MLN Matters MM7676 Provider Types Affected Physicians, providers, and suppliers who bill Medicare carriers, Fiscal Intermediaries (FIs), Medicare Administrative Contractors (A/B/ MACs), Regional Home Health Intermediaries (RHHIs), or Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for services provided to Medicare beneficiaries. Provider Action Needed The content and format of the Medicare Summary Notice (MSN) are redesigned, effective January 3, In Change Request (CR) 7676, CMS announces that (effective January 3, 2013) the content and format of the MSN have been redesigned. It also announces relevant manual changes that Medicare contractors will use to implement the newly designed document. Note that MACs will begin phasing the new MSN beginning on January 3, You should make sure that your billing staffs are aware of these MSN changes. Background Section 1806(a) of the Social Security Act (the Act) requires the Centers for Medicare & Medicaid Services (CMS) to provide a Part A, Part B, and/or Durable Medical Equipment (DME) Medicare Summary Notice (MSN) to each Medicare beneficiary. The MSN content and format are impacted by statute, legislation, and court decisions including: The Plain Writing Act of 2010, which requires all government communications to be written in plain language that is easily understood by the target audience; Sections 1806(b), 1816(j), 1842(h)(7), 1848(g), 1869(a)(4), and 1869(a)(4)(C) of the Act; 42 C.F.R. Section ; Section 925 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (P.L ); and Court decisions Gray Panthers v. Schweiker, 652 F. 2d 146, 168 (D.C. Cir. 1980); David v. Heckler, 591 F.Supp (E.D.N.Y 1984); Vorster v. Bowen, 709 F.Supp 934 (C.D. Cal. 1989); and Connecticut Department of Social Services v. Leavitt, 428 F.3d 138 (2d Cir. 2005). CR7676, from which this article is taken, announces that CMS has undertaken a redesign of the MSN, in order to: 1) make the document current and consistent with all applicable statutes and laws, and 2) to render it more easily and widely understood by the beneficiary population that it serves. In addition, CR7676 announces that of the "Medicare Claims Processing Manual" Chapter 21 (Medicare Summary Notices), Sections (MSN Redesign) has been updated to reflect the new MSN designs. Medicare B Newsline January