Medicare Bulletin - February 2014

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AMedicare BulletinJurisdiction 15

FEBRUARY 2014 • WWW.CGSMEDICARE.COM

Reaching Out to the Medicare

Community

© 2014 Copyright, CGS Administrators, LLC.

www.cgsmedicare.com

Medicare BulletinJurisdiction 15

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Bold, italicized material is excerpted from the American Medical Association Current Procedural Terminology CPT codes. Descriptions and other data only are copyrighted 2009 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

MEDICARE BULLETIN • GR 2014-02 FEBRUARY 2014 2

GENERAL INFORMATION

2014 Provider Contact Center (PCC) Training and Holiday Closure Schedule 4

Introducing the myCGS Web Portal 4

MLN Connects ™ Provider e-News 5

MM8271 Rescinded: Informational Unsolicited Response (IUR) or Reject for Add-On Codes Billed without Respective Primary Codes 6

MM8394: Recalcitrant Provider Procedures 6

MM8539: Quarterly Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement 8

MM8548: January 2014 Integrated Outpatient Code Editor (I/OCE) Specifications Version 15.0 9

News Flash Messages from the Centers for Medicare & Medicaid Services (CMS) 11

CLINICAL TRIALS

CGS IDE Submission Requirements 13

SE1344: Further Information on Mandatory Reporting of an 8-Digit Clinical Trial Number on Claims 15

Use of an 8-Digit Registry Number on Clinical Trial Claims 16

COVERAGE

Breast Imaging Mammography LCD L31856 Update 17

Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) Scans: Solitary Pulmonary Nodule – Revised 18

MM8484 (Revised): Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity 19

MM8553 (Revised): Expansion of Medicare Telehealth Services for CY 2014 21

New Local Coverage Determinations (LCD) 22

END-STAGE RENAL DISEASE

MM8472 (Revised): Implementation of Changes in the End-Stage Renal Disease Prospective Payment System (ESRD PPS) for Calendar Year (CY) 2014 23

FEE SCHEDULE

MM8523: Change to the Reasonable Charge Update for 2014 for Splints, Casts, and Certain Intraocular Lenses 26

MM8531: Calendar Year (CY) 2014 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule 28

MM8533: Summary of Policies in the Calendar Year (CY) 2014 Medicare Physician Fee Schedule (MPFS) Final Rule and the Telehealth Originating Site Facility Fee Payment Amount 33

HOSPITAL

Change Request 8508 (Revised): Immediate Suspension of Postpayment Patient Status Reviews of Inpatient Hospital Admissions 10/1/13-12/31/13 37

SE1342: Systematic Validation of Payment Group Codes for Prospective Payment Systems (PPS) Based on Patient Assessments 38

MEDICAL REVIEW

SE1343: Medicare System Project for Electronic Submission of Medical Documentation (esMD) 42

RHC/FQHC

MM8469: Announcement of Medicare Rural Health Clinic (RHC) and Federally Qualified Health Centers (FQHC) Payment Rate Increases 44

Medicare BulletinJurisdiction 15

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Bold, italicized material is excerpted from the American Medical Association Current Procedural Terminology CPT codes. Descriptions and other data only are copyrighted 2009 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

MEDICARE BULLETIN • GR 2014-02 FEBRUARY 2014 3

THERAPY

MM8458 (Revised): Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius 45

HELPFUL INFORMATION

Contact Information for CGS Part A 48

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This newsletter should be shared with all health care practitioners and managerial members of the provider/supplier staff. Newsletters are available at no cost from our website at http://www.cgsmedicare.com. © 2014 Copyright, CGS Administrators, LLC.

MEDICARE BULLETIN • GR 2014-02 FEBRUARY 2014

RETURN TO TABLE OF CONTENTS

4

General Information

2014 Provider Contact Center (PCC) Training and Holiday Closure 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 the opportunity to offer training to our customer service representatives (CSRs). The CGS Part A PCC (1.866.590.6703) will continue to close up to eight hours per month for CSR training and staff development. The Interactive Voice Response (IVR) unit will be available during these scheduled training sessions for automated customer service transactions.

Listed below is the training closer date and time for February:

Date PCC/Office ClosedFebruary 17, 2014, President’s Day PCC Closed 8:00 a.m. to 4:30 p.m. ET

For your reference, access the “Kentucky/Ohio Part A 2014 Holiday/Training Closure Schedule” at https://www.cgsmedicare.com/parta/help/holiday_schedule.pdf for a complete list of PCC closures.

General Information

Introducing the myCGS Web Portal

This article is the first in a series of articles to introduce the myCGS Web portal to all providers that submit claims to CGS. The information below is intended to provide you with a general overview of the myCGS Web portal, including who should register, how to register, and what information can be accessed through myCGS. In the coming months, additional articles will contain more detailed information about each of the features available in myCGS.

What is myCGS?

myCGS is an Internet-based, self-service application for providers that submit Medicare claims to CGS.

What information is available via myCGS?

myCGS allows users to access the following information:

yy Beneficiary eligibility, such as patient information and Medicare entitlement, hospital and skilled nursing facility stay dates, preventive benefits, home health episodes, hospice elections, and Medicare secondary payer information

yy Checking the status of claims

yy Remittance advices, for viewing and/or printing

yy Financial information, including payment floor amounts and the last 3 Medicare check amounts

yy Submit redetermination requests and status checks

yy E-offset

http://www.cgsmedicare.com

https://www.cgsmedicare.com/parta/help/holiday_schedule.pdf

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What is the cost to use myCGS?

There is no cost to use myCGS. The application is free of charge, and available from the http://www.cgsmedicare.com website.

What do I need to do to get access to myCGS?

Providers wanting to access the myCGS Web portal must have a signed Electronic Data Interchange (EDI) Enrollment Agreement on file with CGS in order to register. An Online EDI Application is available at: http://www.cgsmedicare.com/medicare_dynamic/edi_application/disclaimer.html

In addition, each provider (NPI/PTAN combination) needs to identify one person with their organization to register for myCGS. Two key factors should be considered:

yy This person should be someone who will use the myCGS portal; and

yy This person should be someone of authority, as they are responsible for establishing additional myCGS users for their organization.

The person who registers for myCGS will become the “Provider Administrator” for your organization. The provider administrator can create additional users, referred to as “Provider Users.”

How do I register for myCGS?

Registration is fast and easy. To register for myCGS, go to the myCGS homepage, http://www.cgsmedicare.com/mycgs/index.html and click on the “Register for myCGS” button. Complete the online form with the requested information, check the “I agree” box, and click “Submit.”

To assist providers with the myCGS registration process, refer to the “myCGS Web Portal Registration Checklist” at: http://www.cgsmedicare.com/ohb/myCGS/myCGS_Checklist.pdf.

Where can I go for more information about myCGS?

Providers wanting more information about myCGS can access the myCGS User Manual at http://www.cgsmedicare.com/myCGS/Manual.html. The user manual is divided into chapters, and is aligned with the various Tabs available in myCGS. “Chapter 1: Overview of myCGS” is available at http://www.cgsmedicare.com/pdf/myCGS/Chapter1.pdf. Chapter 1 provides an introduction to myCGS, including the Provider Administrator and Provider User roles, as well as information about how to register, establishing, updating and resetting passwords, and how to log in and log out of myCGS.

Once you have reviewed the myCGS User Manual, you are ready to register for myCGS. If you encounter any issues during registration, contact the CGS EDI Department at 1.866.590.6703 (Option 2).

General Information

MLN Connects™ Provider e-News

The MLN Connects™ Provider e-News contains a week’s worth of Medicare-related messages issued by the Centers of Medicare & Medicaid Services (CMS). These messages ensure planned, coordinated messages are delivered timely about Medicare-related topics. The following provides access to the weekly messages. Please share with appropriate staff. If you wish to receive the listserv directly from CMS, please contact CMS at [email protected].



http://www.cgsmedicare.com/medicare_dynamic/edi_application/disclaimer.html

http://www.cgsmedicare.com/medicare_dynamic/edi_application/disclaimer.html

http://www.cgsmedicare.com/mycgs/index.html

http://www.cgsmedicare.com/ohb/myCGS/myCGS_Checklist.pdf

http://www.cgsmedicare.com/ohb/myCGS/myCGS_Checklist.pdf

http://www.cgsmedicare.com/myCGS/Manual.html

http://www.cgsmedicare.com/pdf/myCGS/Chapter1.pdf

mailto:[email protected]

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yy December 19, 2013: https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-12-19-Enews.pdf

yy December 30, 2013: https://www.cgsmedicare.com/parta/pubs/news/2013/1213/cope24264.html

yy January 9, 2014: https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2014-01-09enews.pdf

General Information

MM8271 Rescinded: Informational Unsolicited Response (IUR) or Reject for Add-On Codes Billed without Respective Primary Codes

The Centers for Medicare & Medicaid Services (CMS) has rescinded the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2013-Transmittals.html.

MLN Matters® Number: MM8271 Rescinded Related Change Request (CR) #: CR 8271Related CR Release Date: July 26, 2013 Effective Date: January 1, 2014Related CR Transmittal #: R1262OTN Implementation Date: January 6, 2014

Note: This article was rescinded on November 27, 2013, because CR 8271 was rescinded. CR 8271 will not be replaced.

Provider Types Affected

This MLN Matters® article is intended for physicians and other providers submitting claims to Medicare contractors (fiscal intermediaries (FIs) and Part A Medicare administrative contractors for services to Medicare beneficiaries.

General Information

MM8394: Recalcitrant Provider Procedures

The Centers for Medicare & Medicaid Services (CMS) has issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2013-Transmittals.html

MLN Matters® Number: MM8394 Related CR Release Date: December 13, 2013Related CR Transmittal #: R495PI Implementation Date: January 15, 2014

Related Change Request (CR) #: CR 8394 Effective Date: January 15, 2014 - This process is currently in effect and this is a clarification through a manual update.


This MLN Matters® article is intended for physicians, other providers, and suppliers submitting claims to Medicare administrative contractors (MACs), including durable medical equipment Medicare administrative contractors (DME MACs) for services or items to Medicare beneficiaries.


https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-12-19-Enews.pdf

https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-12-19-Enews.pdf

https://www.cgsmedicare.com/parta/pubs/news/2013/1213/cope24264.html

https://www.cgsmedicare.com/parta/pubs/news/2013/1213/cope24264.html

https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2014-01-09enews.pdf

https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2014-01-09enews.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2013-Transmittals.html




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What You Need To Know

The CR that this article refers to explains how MACs will address recalcitrant providers and suppliers. CMS has learned from contractors that some providers are abusing the Medicare program and not changing inappropriate behavior even after contractors provide them extensive education to address these behaviors. These noncompliant providers who refuse to comply with CMS rules, result in contractors’ placing these providers on prepay medical review and causing an administrative burden.

Background

Over the years, CMS has heard from Medicare contractors that some providers are abusing the Medicare program; and, even after extensive educational efforts, do not change their inappropriate behavior.

Notes: In this context:1. Providers are defined as both providers and suppliers, under their current definitions found in

the Code of Federal Regulations (CFR) at 42 CFR, Section 400.202); and2. Recalcitrant providers are defined as those who abuse the Medicare program and do not

change their inappropriate behavior even after their Medicare contractors have given them extensive provider education addressing these behaviors.

The behavior of these recalcitrant providers who refuse to comply with CMS requirements has resulted in their being placed on prepay medical review for long periods of time, requiring the extensive use of contractor resources; that (while, indeed, protecting Trust Fund dollars) would be better utilized for other types of more productive oversight activity.

Accordingly, CMS is encouraging contractors to take advantage of current sanctions to address this problem of recalcitrant providers. The two authorities that may be appropriate to impose such a sanction are 1128A (a)(1)(E) of the Social Security Act (the Act), or 1128(b)(6)of the Act; which you can find at http://www.ssa.gov/OP_Home/ssact/title11/1128.htm on the internet. Both of these sanctions are delegated to the Office of the Inspector General (OIG), who will work with CMS to pursue these cases.

CR 8394, from which this article is taken, updates chapter 4 Section 4.27 of the Medicare Program Integrity Manual by adding a section formalizing the process for addressing recalcitrant providers and suppliers.

Note: Any provider referred as a potential recalcitrant provider case should be an “outlier,” meaning a provider who has been the least receptive to changing and has a significant history of non-compliance. For any case submitted, it is important to remember that different mitigating or aggravating circumstances may need to be applied.

Additional Information

The official instruction, CR 8394, issued to your MAC regarding this change is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R495PI.pdf on the CMS website. You will find the updated Medicare Program Integrity Manual, Chapter 4 (Benefit Integrity), Section 27 (Recalcitrant Providers) as an attachment to that CR.

If you have any questions, please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1.866.590.6703 and choose Option 1.


http://www.ssa.gov/OP_Home/ssact/title11/1128.htm


http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R495PI.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R495PI.pdf

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General Information

MM8539: Quarterly Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement


MLN Matters® Number: MM8539 Related CR Release Date: December 13, 2013Related CR Transmittal #: R2835CP

Related Change Request (CR) #: CR 8539 Effective Date: April 1, 2014 Implementation Date: April 7, 2014


This MLN Matters® article is intended for providers and suppliers who submit claims to Medicare administrative contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed

This article is based on CR 8539, which provides the annual update to Home Health (HH) consolidated billing effective for dates of service on or after April 1, 2014. The new codes were effective January 1, 2014, but were overlooked and a 2014 annual HH consolidated billing update was not published. The following of Healthcare Common Procedure Coding System (HCPCS) codes are added to the HH consolidated billing non-routine supply code list:

yy A7047 - Oral Interface Used With Respiratory Suction Pump, each;

yy A6531 - Gradient Compression Stocking, Below Knee, 30-40 MMHG, Each; and

yy A6532 - Gradient Compression Stocking, Below Knee, 40-50 MMHG, Each.

Note that A7047 is a new HCPCS code in 2014. Codes A6531 and A6532 are existing codes added due to their similarity to code A6545, which has been subject to HH consolidated billing since 2009.

The following HCPCS codes are added to the HH consolidated billing therapy code list:

yy 92521 - Evaluation of speech fluency (e.g., stuttering, cluttering);

yy 92522 - Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria);

yy 92523 - with evaluation of language comprehension and expression (e.g., receptive and expressive language); and

yy 92524 - Behavioral and qualitative analysis of voice and resonance.

These four new speech evaluation codes replace code 92506. Make sure that your billing staffs are aware of these changes.

Background

CMS periodically updates the lists of HCPCS codes that are subject to the consolidated billing provision of the Home Health Prospective Payment System (HH PPS). With the exception of therapies performed by physicians, supplies incidental to physician services and supplies used in institutional settings, services appearing on this list that are submitted on claims to MACs will not be paid separately on dates when a beneficiary for whom such a service is being billed is in a home health episode (i.e., under a home


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health plan of care administered by a home health agency). Medicare will only directly reimburse the primary home health agencies that have opened such episodes during the episode periods. Therapies performed by physicians, supplies incidental to physician services and supplies used in institutional settings are not subject to HH consolidated billing.

The HH consolidated billing code lists are updated annually, to reflect the annual changes to the HCPCS code set itself. Additional updates may occur as frequently as quarterly in order to reflect the creation of temporary HCPCS codes (e.g., ‘K’ codes) throughout the calendar year. The new coding identified in each update describes the same services that were used to determine the applicable HH PPS payment rates. No additional services will be added by these updates; that is, new updates are required by changes to the coding system, not because the services subject to HH consolidated billing are being redefined.


The official instruction, CR 8539, issued to your MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2835CP.pdf on the CMS website.


General Information

MM8548: January 2014 Integrated Outpatient Code Editor (I/OCE) Specifications Version 15.0



Related Change Request (CR) #: CR 8548 Effective Date: January 1, 2014 Implementation Date: January 6, 2014


This MLN Matters® article is intended for physicians, other providers, and suppliers submitting claims to Medicare administrative contractors (MACs) for outpatient services provided to Medicare beneficiaries and paid under the Outpatient Prospective Payment System (OPPS) and for outpatient claims from any non-OPPS provider not paid under the OPPS, and for claims for limited services when provided in a home health agency not under the Home Health Prospective Payment System or claims for services to a hospice patient for the treatment of a non-terminal illness.


This article is based on CR 8548 which informs the MACs that the I/OCE was updated for January 1, 2014. Make sure that your billing staffs are aware of these changes. See the “Background” and “Additional Information” sections of this article for further details regarding these changes.


http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2835CP.pdf


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Background

The I/OCE routes all institutional outpatient claims (which includes non-OPPS hospital claims) through a single integrated OCE, eliminating the need to update, install, and maintain two separate OCE software packages on a quarterly basis. The full list of I/OCE specifications is available at http://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/index.html on the CMS website. There is a summary of the changes for January 2014 in Appendix M of Attachment A of CR 8548 and that summary is captured in the following key points.

Effective January 1, 2014, (except as noted below) Medicare will:

yy Modify Extended Assessment and Management (EAM) composite Ambulatory Payment Classification (APC) assignment criteria (appendix K) by:

y� Deleting composite APCs 8002 and 8003

y� Adding new EAM composite 8009

yy Deactivate special logic to make separate payment for certain skin substitute products when billed with specified skin substitute application procedures (appendix N).

yy Implement new edit to require that specific skin substitute products (high cost vs. low cost) be submitted with specific skin substitute application procedures (appendix N). Edit 87 is affected.

y� Edit description: Skin substitute application procedure without appropriate skin substitute product code (Return to Provider (RTP))

y� Edit criteria: A list A skin substitute application procedure is submitted without a list A skin substitute product; or a list B skin substitute application procedure is submitted without a list B skin substitute product on the same date of service.

yy Change the Status Indicator (SI) from N to A for any laboratory code (code list) submitted on 14x bill type.

yy Deactivate the logic for assignment of payment adjustment flags 7 and 8 with modifiers FB and FC for offset payment reduction.

yy Deactivate Payment Adjustment Flags 7 and 8.

yy Modify edit 75 (Incorrect billing of modifier FB or FC) to apply if modifier FB or FC is submitted on any line/any SI on a claim.

yy Deactivate edit 78 ((Nuclear medicine)- Claim lacks required radiolabeled product).

yy Deactivate edit 85 (Claim lacks required device code or required procedure code).

yy Add code 97610 to the ‘Sometimes Therapy’ list/logic (Change SI to A if submitted with a therapy revenue code or therapy modifier).

yy Implement mid-quarter Food and Drug Administration (FDA) approval coverage for code 90688. Edit 67 is affected. Effective August 16, 2013.

yy Make HCPCS/APC/SI changes as specified by CMS (data change files).

yy Implement version 20.0 of the NCCI (as modified for applicable institutional providers). [All edits combined in a single file, in code1/code2 format; mutually exclusive pairs no longer differentiated]. Edits 20 and 40 are affected.

yy Add new modifier PM (Post mortem) to the valid modifier list. Edit 22 is affected.

yy Update procedure/sex conflict edit list. Edit 8 is affected.

yy Update procedure/device & device/procedure edit requirements. Edits 71 and 77 are affected.


http://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/index.html

http://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/index.html

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yy Update the add-on/primary procedure pair edit requirements for Partial Hospitalization Program (PHP) claims (G0463 added as a primary code when reported with psychiatric add-on codes) - edit 84.

yy Revise SI descriptions as follows:

y� S = Procedure or service, not discounted when multiple

y� T = Procedure or service, multiple reduction applies

yy Update appendix F, G, K, N.

yy Add new flags & code lists to data files (HcpcsMap) and user manuals (app B) for edit 87.

yy Remove code lists from user manuals (app B, C) for deactivated edit (78) & modifier FB/FC logic.


The official instruction, CR 8548 issued to your MAC regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2838CP.pdf on the CMS website.


General Information

News Flash Messages from the Centers for Medicare & Medicaid Services (CMS)

yy Revised Medicare Learning Network® (MLN) product: Medicare Enrollment and Claim Submission Guidelines, Booklet, ICN 906764, downloadable and hard copy at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedicareClaimSubmissionGuidelines-ICN906764.pdf

yy The September 2013 ICD-10-CM/PCS Billing and Payment Frequently Asked Questions Fact Sheet (ICN 908974) was released and is now available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/September-2013-ICD-10-CM-PCS-Billing-Payment-FAQs-Fact-Sheet-ICN908974.pdf in downloadable format. This fact sheet is designed to provide education on the International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS). It includes the following information: ICD-10-CM/PCS compliance date and billing and payment Frequently Asked Questions.

yy Generally, Medicare Part B covers one flu vaccination and its administration per flu season for beneficiaries without co-pay or deductible. Now is the perfect time to vaccinate beneficiaries. Health care providers are encouraged to get a flu vaccine to help protect themselves from the flu and to keep from spreading it to their family, co-workers, and patients. Note: The flu vaccine is not a Part D-covered drug. For more information, visit:

y� MLN Matters® Article #MM8433 at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8433.pdf, “Influenza Vaccine Payment Allowances - Annual Update for 2013-2014 Season”

y� MLN Matters® Article #SE1336 at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1336.pdf, “2013-2014 Influenza (Flu) Resources for Health Care Professionals”




http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedicareClaimSubmissionGuidelines-ICN906764.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedicareClaimSubmissionGuidelines-ICN906764.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/September-2013-ICD-10-CM-PCS-Billing-Payment-FAQs-Fact-Sheet-ICN908974.pdf




http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8433.pdf


http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1336.pdf


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y� HealthMap Vaccine Finder (http://vaccine.healthmap.org/) - A free, online service where users can search for locations offering flu and other adult vaccines. While some providers may offer flu vaccines, those that don’t can help their patients locate flu vaccines within their local community.

y� The CDC website for Free Resources (http://www.cdc.gov/flu/freeresources/), including prescription-style tear-pads (http://wwwn.cdc.gov/pubs/ncird.aspx#Flu) that allow you to give a customized flu shot reminder to patients at high-risk for complications from the flu.

yy REVISED Medicare Learning Network® (MLN) product: “Quick Reference Information: Medicare Immunization Billing,” Educational Tool, ICN 006799, downloadable at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/qr_immun_bill.pdf

yy Revised Medicare Learning Network® (MLN) product: “Medical Privacy of Protected Health Information”, Fact Sheet, ICN 006942, downloadable at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/SE0726FactSheet.pdf

yy RELEASED Medicare Learning Network® (MLN) product: “Transitional Care Management Services,” Fact Sheet, ICN 908628, Hard Copy only at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf

yy MLN Connects. Videos on ICD-10 - Are you ready to transition to ICD-10 on October 1, 2014? MLN Connects™ videos on the CMS YouTube Channel can help you prepare.

y� ICD-10: Implementation for Physicians, Partial Code Freeze, and MS-DRG Conversion Project - http://www.youtube.com/watch?v=WLGofe1nPAo&feature=youtu.be

y� Video slideshow presentations from MLN Connects National Provider Calls:

y� August 22, 2013 — ICD-10 Basics - http://www.youtube.com/watch?v=1dzEIbGDymY&feature=youtu.be

y� April 18, 2013 — Begin Transitioning to ICD-10 in 2013 - http://www.youtube.com/watch?v=2mJBkYGG7iM&list=PLaV7m2-zFKpihHxb4AiWNjbsIUUKCGljK&index=31

yy In September 2012, the Centers for Medicare & Medicaid Services (CMS) announced the availability of a new electronic mailing list for those who refer Medicare beneficiaries for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). Referral agents play a critical role in providing information and services to Medicare beneficiaries. To ensure you give Medicare patients the most current DMEPOS Competitive Bidding Program information, CMS strongly encourages you to review the information sent from this new electronic mailing list. In addition, please share the information you receive from the mailing list and the link to the “mailing list for referral agents” subscriber Web page at https://public.govdelivery.com/accounts/USCMS/subscriber/new?pop=t&topic_id=USCMS_7814 with others who refer Medicare beneficiaries for DMEPOS. Thank you for signing up!

yy The September 2013 ICD-10-CM/PCS Billing and Payment Frequently Asked Questions Fact Sheet (ICN 908974) at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/September-2013-ICD-10-CM-PCS-Billing-Payment-FAQs-Fact-Sheet-ICN908974.pdf was released and is now available in downloadable format. This fact sheet is designed to provide education on the International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS). It includes the following


http://vaccine.healthmap.org

http://www.cdc.gov/flu/freeresources

http://wwwn.cdc.gov/pubs/ncird.aspx

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/qr_immun_bill.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/qr_immun_bill.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/SE0726FactSheet.pdf



http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf



http://www.youtube.com/watch?v=WLGofe1nPAo&feature=youtu.be

http://www.youtube.com/watch?v=WLGofe1nPAo&feature=youtu.be

http://www.youtube.com/watch?v=1dzEIbGDymY&feature=youtu.be

http://www.youtube.com/watch?v=1dzEIbGDymY&feature=youtu.be

http://www.youtube.com/watch?v=2mJBkYGG7iM&list=PLaV7m2-zFKpihHxb4AiWNjbsIUUKCGljK&index=31



https://public.govdelivery.com/accounts/USCMS/subscriber/new?pop=t&topic_id=USCMS_7814

https://public.govdelivery.com/accounts/USCMS/subscriber/new?pop=t&topic_id=USCMS_7814




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information: ICD-10-CM/PCS compliance date and billing and payment Frequently Asked Questions.

yy REVISED Medicare Learning Network® (MLN) product: “Contractor Entities At A Glance: Who May Contact You About Specific Centers for Medicare & Medicaid Services (CMS) Activities”, Educational Tool, ICN 906983, downloadable at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ContractorEntityGuide_ICN906983.pdf

yy NEW Medicare Learning Network® (MLN) product, “Vaccine Payments Under Medicare Part D”, Fact Sheet, ICN 908764, downloadable at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Vaccines-Part-D-Factsheet-ICN908764.pdf

Clinical Trials

CGS IDE Submission Requirements

CMS may consider for Medicare coverage certain devices with an FDA approved investigational device exemption (IDE) that have been categorized as Category B (Nonexperimental/investigational) device.

yy Category B (Nonexperimental/investigational) device refers to a device for which the incremental risk is the primary risk in question (that is, initial questions of safety and effectiveness of that device type have been resolved), or it is known that the device type can be safe and effective because, for example, other manufacturers have obtained FDA premarket approval or clearance for that device type.

yy Investigational device exemption (IDE) refers to an FDA-approved IDE application that permits a device, which would otherwise be subject to marketing approval or clearance, to be shipped lawfully for the purpose of conducting a clinical study in accordance with 21 U.S.C. 360j(g) and 21 CFR part 812.

yy The FDA notifies CMS, when it notifies the sponsor, that the device is categorized by FDA as Category A (Experimental) or Category B (Nonexperimental)

Routine care items and services refers to items and services that are otherwise generally available to Medicare beneficiaries (that is, a benefit category exists, it is not statutorily excluded, and there is no national noncoverage decision) that are furnished during a clinical study and that would be otherwise furnished even if the beneficiary were not enrolled in a clinical study.

yy Medicare may make payment for a Category B (Nonexperimental/investigational) IDE device and routine care items and services furnished in an FDA-approved Category B Nonexperimental/investigational) IDE study if CMS (or its designated entity) determines prior to the submission of the first related claim that the Medicare coverage IDE study criteria in § 405.212 are met.

CMS (or its designated entity) must review the following to determine if the Medicare coverage IDE study criteria in § 405.212 are met for purposes of coverage of items and services:

1. FDA approval letter of the IDE

2. IDE study protocol

3. IRB approval letter

4. NCT number

5. Supporting materials, as needed


http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ContractorEntityGuide_ICN906983.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ContractorEntityGuide_ICN906983.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Vaccines-Part-D-Factsheet-ICN908764.pdf



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For Medicare coverage of items and services described in § 405.211, a Category A (Experimental) or Category B (Nonexperimental/investigational) IDE study must meet all of the following criteria:

1. The principal purpose of the study is to test whether the device improves health outcomes of appropriately selected patients.

2. The rationale for the study is well supported by available scientific and medical information, or it is intended to clarify or establish the health outcomes of interventions already in common clinical use.

3. The study results are not anticipated to unjustifiably duplicate existing knowledge.

4. The study design is methodologically appropriate and the anticipated number of enrolled subjects is adequate to confidently answer the research question(s) being asked in the study.

5. The study is sponsored by an organization or individual capable of successfully completing the study.

6. The study is in compliance with all applicable Federal regulations concerning the protection of human subjects found at 21 CFR parts 50, 56,and 812 and 45 CFR part 46.

7. Where appropriate, the study is not designed to exclusively test toxicity or disease pathophysiology in healthy individuals. Studies of all medical technologies measuring therapeutic outcomes as one of the objectives may be exempt from this criterion only if the disease or condition being studied is life threatening and the patient has no other viable treatment options.

8. The study is registered with the National Institutes of Health’s National Library of Medicine’s http://www.ClinicalTrials.gov.

9. The study protocol describes the method and timing of release of results on all pre-specified outcomes, including release of negative outcomes and that the release should be hastened if the study is terminated early.

10. The study protocol must describe how Medicare beneficiaries may be affected by the device under investigation, and how the study results are or are not expected to be generalizable to the Medicare beneficiary population. Generalizability to populations eligible for Medicare due to age, disability, or other eligibility status must be explicitly described.

Requests for IDE approval must include the following:

1. CGS IDE Submission form

a. CGS IDE Submission Form (http://www.cgsmedicare.com/forms/IDE_RequestForm.pdf)

2. FULL copy of unredacted FDA approval letter including trial summary of the IDE

3. Current IDE study protocol, (when submission is an extension include the most recent version)

4. IRB approval letter (which must include the date of approval and expiration)

5. NCT number

6. Summary of study related Adverse Events

7. Supporting materials, as requested by CGS


http://www.ClinicalTrials.gov

http://www.cgsmedicare.com/forms/IDE_RequestForm.pdf

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Resources:

yy Clinical Trials.Gov: http://clinicaltrials.gov/

yy Additional information regarding NCT number can be found at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8401.pdf

yy CGS Information regarding HUD Approvals: https://www.cgsmedicare.com/parta/pubs/news/2013/1213/cope24209C.html

yy Federal Register / Vol. 78, No. 237 / Tuesday, December 10, 2013 / Rules and Regulations: http://www.gpo.gov/fdsys/pkg/FR-2013-12-10/pdf/FR-2013-12-10.pdf 74810, 405 Federal Health Insurance for the Aged and Disabled

Clinical Trials

SE1344: Further Information on Mandatory Reporting of an 8-Digit Clinical Trial Number on Claims

The Centers for Medicare & Medicaid Services (CMS) has issued the following Special Edition Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2013-Transmittals.html

MLN Matters® Number: SE1344 Related CR Release Date: October 30, 2013Related CR Transmittal #: 2805



This MLN Matters® article is intended for physicians, providers, and suppliers submitting claims to Medicare administrative contractors (MACs), including durable medical equipment MACs (DME MACs) for items and services provided in clinical trials to Medicare beneficiaries.


This article is related to CR 8401, which requires, effective January 1, 2014, the mandatory reporting of a clinical trial identifier number on claims for items and services provided in clinical trials that are qualified for coverage as specified in the Medicare National Coverage Determination (NCD) Manual, Section 310.1.

The clinical trial identifier number to be reported is the same number that has been reported voluntarily since the implementation of CR 5790, dated January 18, 2008. That is the number assigned by the National Library of Medicine (NLM) http://clinicaltrials.gov/ website when a new study appears in the NLM Clinical Trials data base.

Since the release of CR 8401, CMS has learned that some physicians, providers, and suppliers do not have the capability at this time to submit the clinical trial identifier number associated with trial-related claims. This article presents those physicians, providers, and suppliers with an alternative means of satisfying the CR 8401 requirements until January 1, 2015. At that time, such providers must fully comply with CR 8401. Make sure that your billing staffs are aware of the requirement and the implementation changes and dates.


http://clinicaltrials.gov

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8401.pdf



https://www.cgsmedicare.com/parta/pubs/news/2013/1213/cope24209C.html

https://www.cgsmedicare.com/parta/pubs/news/2013/1213/cope24209C.html

http://www.gpo.gov/fdsys/pkg/FR-2013-12-10/pdf/FR-2013-12-10.pdf



http://clinicaltrials.gov

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Background

CMS understands that implementing CR 8401 by January 1, 2014, would create an undue hardship on a number of its stakeholders. As a result, for physicians, providers, and suppliers who do not have the capacity at this time to report the clinical trials identifier number associated with trial-related claims, CMS is providing an option to submit a generic number in place of the actual National Clinical Trials (NCT) number.

Beginning January 1, 2014, and continuing no later than through December 31, 2014, those above-mentioned physicians, providers, and suppliers may instead report an 8-digit, generic number of 99999999 using the instructions in CR 8401. This will allow trial-related claims to process appropriately if they are prepared according to instructions in CR 8401. Keep in mind that trial-related claims will be returned if they do not contain either the actual clinical trial identifier number or the 8-digit generic number 99999999 – you may not leave those indicated fields blank. That said, CMS encourages those affected by CR 8401 to update their internal claims processing procedures as expeditiously as possible so they can begin reporting the actual clinical trial identifier number as CR 8401 instructs.

Note: This in no way precludes those already reporting and/or able to report the actual clinical trial number on clinical trial-related claims from doing so. Beginning January 1, 2015, without further notice, CR 8401 shall be fully implemented.

Note: For clarification, the clinical trial identifier number is required for all items/services provided in relation to participation in a clinical trial, clinical study, or registry that may result from coverage with evidence development (CED), the Medicare Clinical Trial Policy, or a CMS-approved investigational device exemption (IDE) study. For IDE trials, both the IDE and the clinical trial identifier number are required. Specifically, include the clinical trial identifier number if: the beneficiary is enrolled in an approved clinical trial; AND, the claim is for the investigational item or service, AND/OR, the costs are related to the investigational item or service, AND/OR, the costs are related to routine care for the condition in the clinical trial.


The official instruction, CR 8401, issued to your MAC regarding this change, may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2805CP.pdf on the CMS website. The MLN Matters® article related to CR 8401 is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8401.pdf

Section 310.1 of the Medicare National Coverage Determination (NCD) Manual is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf on the CMS website.


Clinical Trials

Use of an 8-Digit Registry Number on Clinical Trial Claims

Effective January 1, 2014, the Centers for Medicare & Medicaid Services (CMS) will require inclusion of an 8-digit clinical trial number on claims associated with clinical trial participation. Clinical trial related claims submitted to Medicare for dates of services on or after January 1, 2014, will be returned to the provider if the 8-digit clinical trial number is not present.






http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf

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The 8-digit clinical trial number, also called the National Clinical Trial (NCT) Number or Clinical Trials identifier (IDE number), can be found on the ClinicalTrials.gov website

http://clinicaltrials.gov/

Note: For physicians, providers, and suppliers who do not have the capacity at this time to report the clinical trials identifier number associated with trial-related claims, refer to the Medicare Learning Network (MLN) Matters® article, SE1344 at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1344.pdf for information about an option to submit a generic number in place of the actual National Clinical trials (NC) number. The SE1344 article is also published in this bulletin.

This 8-digit NCT number will be added to the list of other required data:

yy Institutional clinical trial claims are identified through the presence of all of the following elements:

y� Value Code D4 and corresponding 8-digit clinical trial number (when present on the claim);

y� ICD-9 diagnosis code V70.7;

y� Condition Code 30; and

y� HCPCS modifier Q1: outpatient claims only. (See MM5805 related to CR5805 for more information regarding modifier Q1.)

yy Practitioner/DME clinical trial claims are identified through the presence of all of the following elements:

y� ICD-9 diagnosis code V70.7;

y� HCPCS modifier Q1; and

y� 8-digit clinical trial number (when present on the claim).

On institutional claims, the 8-digit numeric clinical trial number should be placed in the value amount of value code D4 on the paper claim UB-40 (Form Locators 39-41) or in Loop 2300, HI – Value Information segment, qualifier BE on the 837I.

On professional claims, the clinical trial registry number should be preceded by the two alpha characters of “CT” and placed in Field 19 of the paper Form CMS-1500 or it should be entered WITHOUT the “CT” prefix in the electronic 837P in Loop 2300 REF02(REF01=P4).Medical record documentation of clinical trial title, sponsor name and sponsor protocol number should be kept on file with each participating facility.

Coverage

Breast Imaging Mammography LCD L31856 Update

CGS has updated the Breast Imaging Mammography LCD L31856. We have removed the following statement: ‘‘Once clinical and mammographic stability has been established, the routine use of diagnostic mammography over screening mammography is not warranted.” Based on current information concerning the use of a diagnostic mammogram for diagnosing breast cancer and tracking changes for high risk patients once established as at risk, this limitation is no longer valid.




http://clinicaltrials.gov/



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Coverage

Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) Scans: Solitary Pulmonary Nodule – Revised

The following information is a revision to an article previously published in the November 2013 Kentucky & Ohio Medicare Bulletin. The revised material is shown as bold italics text.

CMS continues to nationally cover one FDG PET study for beneficiaries who have cancers that are biopsy proven or strongly suspected based on other diagnostic testing when the beneficiary’s treating physician determines that the FDG PET study is needed to determine the location and/or extent of the tumor for therapeutic purposes related to the initial anti-tumor treatment strategy

Effective for services performed on or after October 1, 2013, CGS shall accept and pay for ONE PET scan for solitary pulmonary nodule ONLY after other tests have been performed and the physician has continued suspicion that the nodule is cancerous AND needs the PET scan to guide subsequent testing/therapy.

Submit claims as follows:

yy PET CT: Use CPT code 78815, PET imaging with attenuation correction (acCT) and anatomical localization imaging; skull base to mid-thigh, AND

y� HCPCS modifier PI (Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing; short descriptor: PET tumor init tx strat), AND

y� ICD-9 code 793.11, Solitary pulmonary nodule; coin lesion lung; solitary pulmonary nodule, subsegmental branch of the bronchial tree

yy Non CT PET: use CPT code 78811, PET imaging limited area if performed without concurrent CT attenuation correction (acCT)

Reminder: Medical records must be made available upon request and must clearly establish the medical necessity of this service.

Reference:

yy CMS MLN Matters article MM6632, “FDG PET for Solid Tumors and Myeloma” - http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6632.pdf




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Coverage

MM8484 (Revised): Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity

The Centers for Medicare & Medicaid Services (CMS) has issued a revision to the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2013-Transmittals.html

MLN Matters® Number: MM8484 Revised Related CR Release Date: December 23, 2013Related CR Transmittal #: R2841CP and R158NCD

Related Change Request (CR) #: CR 8484 Effective Date: September 24, 2013 Implementation Date: December 17, 2013

Note: This article was revised on December 26, 2013, to reflect the revised CR 8484 issued on December 23. The CR was revised to add the relevant ICD-10 codes to the revised Section 150.5.1 of the Medicare Claims Processing Manual and to make technical corrections to the revised sections of the Medicare National Coverage Determinations Manual. The revised portions of those manuals are attached to the CR transmittals and the Web addresses for those transmittals are available in the “Additional Information” section of this article.


This MLN Matters® article is intended for physicians, providers and suppliers submitting claims to Medicare Administrative Contractors (MACs) for bariatric surgery services to Medicare beneficiaries.

What You Need to Know

This article is based on CR 8484, which informs Medicare contractors that:

yy Effective for dates of service on and after September 24, 2013, facility certification will no longer be required for coverage of covered bariatric surgery procedures;

yy The Centers for Medicare & Medicaid Services (CMS) has determined that no changes be made to the bariatric surgery procedures that are deemed covered in Section 100.1 of the National Coverage Determination (NCD) Manual; and

yy CMS is clarifying in the NCD Manual that, under the existing policy, the local MACs have the authority to make coverage decisions for any bariatric surgery procedures not specifically identified as covered or non-covered by an NCD.

Be sure that your billing staffs are aware of these updates.

Background

CR 8484 is due to a reconsideration of Section 100.1 of the NCD Manual currently titled, Bariatric Surgery for Treatment of Morbid Obesity. On January 24, 2013, CMS initiated a national coverage analysis (NCA) for the reconsideration of the requirement that covered bariatric surgery procedures are only covered when performed in facilities that are certified. CMS also made changes to the NCD which are defined below.

In 2006, CMS established a NCD on Bariatric Surgery for the Treatment of Morbid Obesity (NCD Manual, Section 100.1). For Medicare beneficiaries who have a Body Mass Index (BMI) > 35, have at least one co-morbidity related to obesity, and who have been previously unsuccessful with medical treatment for obesity, the following procedures were determined to be reasonable and necessary:




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yy Open and laparoscopic Roux-en-Y gastric bypass (RYGBP);

yy Laparoscopic adjustable gastric banding (LAGB); and

yy Open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS).

In addition, the NCD stipulates that these bariatric procedures are covered only when performed at facilities that are: (1) Certified by the American College of Surgeons (ACS) as a Level 1 Bariatric Surgery Center, or (2) Certified by the American Society for Bariatric Surgery (ASBS) as a Bariatric Surgery Center of Excellence (BSCOE) (Program Standards and requirements in effect on February 15, 2006). The 2006 NCD specifically non-covered open vertical banded gastroplasty, laparoscopic vertical banded gastroplasty, open sleeve gastrectomy, laparoscopic sleeve gastrectomy, and open adjustable gastric banding because there was a paucity of evidence to support claims of improved health outcomes from those procedures.

This NCA specifically addressed the need for the continuation of the requirement for facility certification by ACS or by the ASBS (currently the American Society for Metabolic and Bariatric Surgeons (ASMBS)).

CMS Policy and Manual Changes

CMS has determined that the evidence is sufficient to conclude that continuing the requirement for certification for bariatric surgery facilities would not improve health outcomes for Medicare beneficiaries. Therefore, CMS removes this certification requirement, effective with dates of service on or after September 24, 2013.

CMS has determined that no changes need to be made to the bariatric surgery procedures that are deemed covered in Section 100.1 of the NCD Manual.

CMS plans to change the title to Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity, to better reflect the scope of the NCD and to make it clear in the manual that under the existing policy the local MACs have the authority to make coverage decisions for any bariatric surgery procedures not specifically identified as covered or non-covered by an NCD.

In addition, to the proposed decision above, CMS is renumbering and consolidating its manual for Section 100.1. This is an administrative change only to make it easier for the public to read and understand the NCD Manual. There is no change in coverage because of the renumbering and consolidation.

The additional NCDs related to bariatric surgery will be consolidated and subsumed into Section 100.1 of the NCD Manual. These include Sections 40.5, 100.8, 100.11 and 100.14.


The official instruction, CR 8484, was issued to your MAC regarding this change via two transmittals. The first is the claims processing transmittal and it is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2841CP.pdf on the CMS website. The second transmittal updates the NCD Manual and it is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R158NCD.pdf on the CMS website.





http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R158NCD.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R158NCD.pdf

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Coverage

MM8553 (Revised): Expansion of Medicare Telehealth Services for CY 2014

The Centers for Medicare & Medicaid Services (CMS) first issued the MM8553 Medicare Learning Network® (MLN) Matters article on January 7, 2014. CMS then issued a revised MM8553 article on January 8, 2014. The following reflects the revised article. This MLN Matters article and other CMS articles can be found on the CMS website at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2013-Transmittals.html

MLN Matters® Number: MM8553 Revised Related CR Release Date: December 30, 2013Related CR Transmittal #: R2848CP

Related Change Request (CR) #: CR8553 Effective Date: January 1, 2014 Implementation Date: January 6, 2014

Note: This article was revised on January 7, 2014, to amend the last paragraph of the “Background Section to show this applies to Medicare Part B, as well as Part A. All other information remains the same.


This MLN Matters® article is intended for physicians, providers, and suppliers submitting claims to Medicare administrative contractors (MACs) for services to Medicare beneficiaries.


STOP — Impact to You

This article is based on CR 8553, which updates Medicare telehealth services in the Medicare Benefit Policy Manual and the Medicare Claims Processing Manual.

CAUTION — What You Need to Know

In the calendar year 2014 physician fee schedule final rule with comment period, CMS added 2 codes to the list of Medicare telehealth services. Additionally, CMS modified regulations describing eligible telehealth originating sites to include health professional shortage areas (HPSAs) located in rural census tracts of metropolitan statistical areas effective January 1, 2014. This definition is consistent with the determinations made by the Office of Rural Health Policy (ORHP) in the Health Resources and Services Administration (HRSA). Finally, CMS modified regulations in order to establish geographic eligibility for Medicare telehealth originating sites for each calendar year based upon the status of the area as of December 31st of the prior calendar year.

GO — What You Need to Do

Make sure that your billing staffs are aware of these changes.

Background

CMS is adding the following services to the list of Medicare telehealth services for CY 2014:

yy CPT code 99495: Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least moderate complexity during the service period Face-to-face visit, within 14 calendar days of discharge.




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yy CPT Code 99496: Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of high complexity during the service period Face-to-face visit, within 7 calendar days of discharge.

This policy will allow the required face-to-face visit component of both services to be furnished through telehealth.

CMS is finalizing the regulatory definition of “rural HPSA” for purposes of determining eligibility for Medicare telehealth originating sites to include HPSAs located in rural census tracts, consistent with ORHP’s definition of “rural.” HRSA has developed a tool that will help providers determine geographic eligibility for Medicare telehealth services. This tool, the Medicare Telehealth Payment Eligibility Analyzer, is available at http://datawarehouse.hrsa.gov/telehealthAdvisor/telehealthEligibility.aspx on the Internet.

CMS is also finalizing a change in policy so that geographic eligibility for an originating site is established and maintained on an annual basis, consistent with other telehealth payment policies. Absent this proposed change, the status of a geographic area’s eligibility for telehealth originating site payment is effective at the same time as the effective date for changes in designations that are made outside of CMS. Accordingly, CMS is revising regulations at 42 Code of Federal Regulations (CFR) section 410.78(b)(4) to conform to both of these policies.

For dates of service on or after January 1, 2014, MACs will accept CPT Codes 99495 and 99496 submitted on professional claims. In addition, for dates of service on or after January 1, 2014, MACs will accept and pay CPT Codes 99495 and 99496 when submitted with a GQ or GT modifier. For Critical Access Hospitals (CAHs), MACs will accept and pay according to the appropriate physician or practitioner fee schedule amount when electing Method II on Type of Bill 85X.


Further information regarding telehealth services is available at http://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html on the CMS website.

The official instruction, CR 8553, issued to your MAC regarding this change, may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2848CP.pdf on the CMS website.


Coverage

New Local Coverage Determinations (LCD)

CGS has three new Local Coverage Determinations that will become effective for dates of service on or after January 25, 2014. The three new LCDs are: Drugs of Abuse Testing (L34457); Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (L34409); and Lumbar Epidural Steroid Injections (L34404).

CGS publishes LCDs in the Centers for Medicare & Medicaid Services (CMS) Medicare Coverage Database (MCD). Please follow the links below to view the new policies:


http://datawarehouse.hrsa.gov/telehealthAdvisor/telehealthEligibility.aspx

http://datawarehouse.hrsa.gov/telehealthAdvisor/telehealthEligibility.aspx

http://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html

http://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html



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Kentucky:

yy Part A: http://www.cms.gov/medicare-coverage-database/indexes/lcd-list.aspx?Cntrctr=239&ContrVer=1&CntrctrSelected=239*1&name=CGS+Administrators%2c+LLC+%2815101%2c+MAC+-+Part+A%29&LCntrctr=239*1&bc=AgACAAAAAAAA&

yy Part B: http://www.cms.gov/medicare-coverage-database/indexes/lcd-list.aspx?Cntrctr=228&name=CGS%20Administrators,%20LLC%20(15102,%20MAC%20-%20Part%20B)&DocStatus=Active&&ContrVer=2&CntrctrSelected=228*2&s=22&bc=AggAAAIAAAAA&#ResultsAnchor

Ohio:

y� Part A: http://www.cms.gov/medicare-coverage-database/indexes/lcd-list.aspx?Cntrctr=240&ContrVer=1&CntrctrSelected=240*1&name=CGS+Administrators%2c+LLC+%2815201%2c+MAC+-+Part+A%29&LCntrctr=240*1&bc=AgACAAAAAAAA&

y� Part B: http://www.cms.gov/medicare-coverage-database/indexes/lcd-list.aspx?Cntrctr=238&ContrVer=2&CntrctrSelected=238*2&name=CGS+Administrators%2c+LLC+(15202%2c+MAC+-+Part+B)&s=42&bc=AggAAAAAAAAA&#ResultsAnchor

End-Stage Renal Disease

MM8472 (Revised): Implementation of Changes in the End-Stage Renal Disease Prospective Payment System (ESRD PPS) for Calendar Year (CY) 2014

The Centers for Medicare & Medicaid Services (CMS) has issued a revision to the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2013-Transmittals.html

MLN Matters® Number: MM8472 Revised Related CR Release Date: December 13, 2013Related CR Transmittal #: R177BP and R2839CP

Related Change Request (CR) #: CR8472 Effective Date: January 1, 2014 Implementation Date: January 6, 2014

Note: This article was revised on December 17, 2013, to reflect the revised CR8472 issued on December 13. In the article, the CR release date, transmittal numbers and the Web addresses for accessing the CR were revised. All other information remains the same.


This MLN Matters® article is intended for End Stage Renal Disease (ESRD) facilities submitting claims to Medicare administration contractors (MACs) for ESRD services provided to Medicare beneficiaries.


This article is based on CR 8472 which implements the fourth year of the ESRD Prospective Payment System (PPS) 4-year transition period and the Calendar Year (CY) 2014 rate updates for the ESRD PPS. See the Background and Additional Information Sections of this article for further details regarding these changes, and make sure that your billing staffs are aware of these changes for 2014.

Background

In accordance with the Medicare Improvements for Patients and Providers Act (MIPPA; Section 153(b)), CMS implemented the End Stage Renal Disease (ESRD) bundled


http://www.cms.gov/medicare-coverage-database/indexes/lcd-list.aspx?Cntrctr=239&ContrVer=1&CntrctrSelected=239*1&name=CGS+Administrators%2c+LLC+%2815101%2c+MAC+-+Part+A%29&LCntrctr=239*1&bc=AgACAAAAAAAA&



http://www.cms.gov/medicare-coverage-database/indexes/lcd-list.aspx?Cntrctr=228&name=CGS%20Administrators,%20LLC%20(15102,%20MAC%20-%20Part%20B)&DocStatus=Active&&ContrVer=2&CntrctrSelected=228*2&s=22&bc=AggAAAIAAAAA&#ResultsAnchor







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Prospective Payment System (PPS) effective January 1, 2011. You can review MIPPA (Section 153(b)) at http://www.gpo.gov/fdsys/pkg/PLAW-110publ275/pdf/PLAW-110publ275.pdf on the Internet.

Calendar Year (CY) 2014 implements the fourth year of the transition where all ESRD facilities will be paid 100 percent of the ESRD PPS payment amount. Accordingly, a blended rate of the basic case-mix composite rate payment system and the ESRD PPS will no longer be provided, and there will no longer be a transition budget neutrality adjustment factor applied to the payment. Therefore, it is no longer necessary to update the basic case-mix adjusted composite rate payment system.

MIPPA, Section 153(b), was amended by the Affordable Care Act (Section 3401(h); see http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf), and stated that for 2012 (and each subsequent year), the Secretary of Health and Human Services will reduce the ESRD bundled (ESRDB) market basket increase factor by a productivity adjustment described in the Social Security Act (Section 1886(b)(3)(B)(xi)(II); see http://www.ssa.gov/OP_Home/ssact/title18/1886.htm). The ESRDB market basket increase factor minus the productivity adjustment will update the ESRD PPS base rate.

The Social Security Act (Section 1881(b)(14)(I), as added by the American Taxpayer Relief Act of 2012 (ATRA; Section 632(a); see http://www.gpo.gov/fdsys/pkg/BILLS-112hr8eas/pdf/BILLS-112hr8eas.pdf), requires that, for services furnished on or after January 1, 2014, CMS will make reductions to the single payment for renal dialysis services to reflect the CMS estimate of the change in the utilization of ESRD-related drugs and biologicals (excluding oral-only ESRD-related drugs) by comparing per patient utilization data from 2007 with such data from 2012.

Calendar Year (CY) 2014 Rate UpdatesFor CY 2014, CMS will make the following updates to the CY 2013 ESRD PPS base rate:

1. The ESRDB market basket minus a productivity adjustment of 2.8 which results in $247.09 ($240.36 x 1.028 = $247.09).

2. The wage index budget neutrality adjustment factor of 1.000454 which results in $247.20 ($247.09 x 1.000454 = $247.20).

3. The home dialysis training add-on budget neutrality adjustment factor of 0.999912 which results in $247.28 ($247.20 x 0.999912 = $247.18).

4. After the application of the ESRDB market basket, the wage index budget neutrality adjustment factor, and the home dialysis training add-on budget neutrality factor, the ESRD PPS base rate will be reduced by the drug utilization adjustment amount of $8.16. Therefore, the ESRD PPS base rate for CY 2014 is $239.02 ($247.18 - $8.16 = $239.02).

For CY 2014, CMS will make the following updates to the wage index:

1. The wage index adjustment will be updated to reflect the latest available wage data.

2. The wage index floor will be reduced from 0.50 to 0.45.

Transition Budget Neutrality AdjustmentBeginning CY 2014, there will no longer be a transition budget-neutrality adjustment.

Home Dialysis Training Add-On PaymentThe home dialysis training add-on payment will increase from $33.44 to $50.16.


http://www.gpo.gov/fdsys/pkg/PLAW-110publ275/pdf/PLAW-110publ275.pdf





http://www.gpo.gov/fdsys/pkg/BILLS-112hr8eas/pdf/BILLS-112hr8eas.pdf

http://www.gpo.gov/fdsys/pkg/BILLS-112hr8eas/pdf/BILLS-112hr8eas.pdf

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Outlier Policy ChangesFor CY 2014, CMS will make the following updates to the average outlier service Medicare Allowable Payment (MAP) amount per treatment:

1. For adult patients, the adjusted average outlier service MAP amount per treatment is $50.25.

2. For pediatric patients, average outlier service MAP amount per treatment is $40.49.

For CY 2014, CMS will make the following updates to the fixed dollar loss amount that is added to the predicted MAP to determine the outlier threshold:

1. The fixed dollar loss amount is $98.67 for adult patients.

2. The fixed dollar loss amount is $54.01 for pediatric patients.

For CY 2014, CMS will make the following changes to the list of outlier services:

1. The ESRD-related Part D drugs which are based on the most recent prices retrieved from the Medicare Prescription Drug Plan Finder will be updated to reflect the most recent mean unit cost. The list of ESRD-related Part D drugs will also be updated to reflect the most recent list of ESRD-related Part D drugs that are eligible for outlier payment. (See attachment A of CR8472, which is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2839CP.pdf on the CMS website.)

2. The mean dispensing fee of the National Drug Codes (NDC) qualifying for outlier consideration is revised to $1.42 per NDC per month for claims with dates of service on or after January 1, 2014.

CR 8472 also revises the Medicare Claims Processing Manual, (Chapter 8 (Section 20.1 (Calculation of the Basic Case-Mix Adjusted Composite Rate and the ESRD Prospective Payment System Rate); Section 50.8 (Training and Retraining); and Section 60.2.1.2 (Facilities Billing for ESRD Drugs and Biologicals Equivalent to Injectable Drugs)). The manual revisions are attached to CR 8472.


The official instruction, CR 8472, was issued to your MAC in two transmittals, which are available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R177BP.pdf and http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2839CP.pdf on the CMS website.





http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R177BP.pdf




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Fee Schedule

MM8523: Change to the Reasonable Charge Update for 2014 for Splints, Casts, and Certain Intraocular Lenses


MLN Matters® Number: MM8523 Related CR Release Date: December 13, 2013Related CR Transmittal #: R2837CP Implementation Date: January 6, 2014, for payment on a reasonable charge basis and April 7, 2014, for payment on a national fee schedule basis

Related Change Request (CR) #: CR 8523 Effective Date: January 1, 2014 for payment on a reasonable charge basis and April 1, 2014, for payment on a national fee schedule basis


This MLN Matters® article is intended for physicians, other providers, and suppliers submitting claims to Medicare administrative contractors (MACs)) for services to Medicare beneficiaries.


This article is based on CR 8523 which informs Medicare contractors about the changes in payment basis for splints, casts, and certain intraocular lenses furnished in calendar year 2014. Make sure that your billing staffs are aware of these changes.

Background

Payment has been made on a reasonable charge basis for splints and casts, and intraocular lenses (IOLs) inserted in a physician’s office with the criteria for determining reasonable charges set forth at 42 CFR part 405, subpart E of CMS regulations. However, section 1842(s) of the Social Security Act provides the authority for replacing the reasonable charge payment methodology with statewide or other area wide fee schedules to be used for payment for these items. The final rule implementing fee schedules for splints and casts, and IOLs inserted in a physician’s office was published on December 2, 2013. Effective for dates of service on or after April 1, 2014, payment for splints and casts, and IOLs inserted in a physician’s office will be made using national fee schedule amounts, and reasonable charges will no longer be calculated for these items.

For payment of splints and casts furnished from April 1, 2014, through December 31, 2014, regulations at 42 CFR 414.106 require national fee schedules be established based on 2013 reasonable charges updated by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June 2013. For subsequent years, the fee schedule amounts will be updated by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the preceding year, reduced by the productivity adjustment as described in section 1886(b)(3)(B)(xi)(II) of the Act. The splints and cast Q-codes are to be used when supplies are indicated for cast and splint purposes. This payment is in addition to the payment made under the physician fee schedule for the procedure for applying the splint or cast.




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For payment of IOLs inserted in a physician’s office furnished from April 1, 2014, through December 31, 2014, regulations at 42 CFR 414.108 require national fee schedules be established based on the national average allowed charge for the item from January 1, 2012, through December 31, 2012, updated by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 24-month period ending with June 2013. For subsequent years, the fee schedule amounts will be updated by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the preceding year, reduced by the productivity adjustment as described in section 1886(b)(3)(B)(xi)(II) of the Act.

The reasonable charge amounts for splints and casts that are effective for dates of service January 1, 2014, through March 31, 2014, are shown in Attachment A of CR 8523, which is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2837CP.pdf on the CCMS website. MACs will make payment for splints and casts based on the lower of the actual charge or the reasonable charge payment limits established for these codes. Payment will also be made on a reasonable charge basis for IOL codes V2630, V2631 and V2632 that are inserted in a physician’s office for dates of service January 1, 2014, through March 31, 2014.

MACs shall use the national fee schedule amounts listed in Attachment B of CR 8523 to pay claims for splints and casts, and IOLs inserted in a physician’s office for dates of service from April 1, 2014, through December 31, 2014. Subject to coinsurance and deductibles rules, Medicare payment for these items is to be equal to the lower of the actual charge for the item or the amount determined under the applicable fee schedule payment methodology. Please note that beginning April 1, 2014, the applicable HCPCS codes and the national fee schedule amounts for splints and casts, and IOLs inserted in a physician’s office will be included in the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) fee schedule file. For subsequent calendar years, MACs are to pay claims for splints and casts, and IOLs inserted in a physician’s office using the national fee schedule amounts available in the DMEPOS fee schedule file.









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Fee Schedule

MM8531: Calendar Year (CY) 2014 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule





This MLN Matters® article is intended for providers and suppliers submitting claims to Medicare administrative contractors (MACs) for DMEPOS items or services paid under the DMEPOS fee schedule.


CMS issued CR 8531 to advise providers of the Calendar Year (CY) 2014 annual update for the Medicare DMEPOS fee schedule. The instructions include information on the data files, update factors, and other information related to the update of the DMEPOS fee schedule. Make sure your staffs are aware of these updates.

Background and Key Points of CR 8531

The DMEPOS fee schedules are updated on an annual basis in accordance with statute and regulations. The update process for the DMEPOS fee schedule is located in the Medicare Claims Processing Manual, Chapter 23, Section 60, which is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf on the CMS website. Payment on a fee schedule basis is required for Durable Medical Equipment (DME), prosthetic devices, orthotics, prosthetics, and surgical dressings by Section1834 (a), (h), and (i) of the Social Security Act (the Act). Also, payment on a fee schedule basis is a regulatory requirement at 42 CFR Section 414.102 for Parenteral and Enteral Nutrition (PEN) and splints, casts, and certain intraocular lenses.

Fee Schedule FilesThe DMEPOS fee schedule file will also be available for providers and suppliers, as well as State Medicaid Agencies, managed care organizations, and other interested parties at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/ on the CMS website.

Healthcare Common Procedure Coding System (HCPCS) Codes Added/ DeletedThe following new codes are effective January 1, 2014;

yy A7047 in the inexpensive/routinely purchased (IN) payment category;

yy E0766 in the frequently serviced (FS) payment category; and

yy E1352.




http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf


http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched

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The following new codes are in the prosthetics and orthotics (PO) payment category: L5969, L8679, L0455, L0457, L0467, L0469, L0641-L0643, L0648-L0651, L1812, L1833, L1848, L3678, L3809, L3916, L3918, L3924, L3930, L4361, L4387, and L4397.

The following codes are deleted as of January 1, 2014: A4611, A4612, A4613, E0457, E0459, L0430, L8685, L8686, L8687, and L8688.

For gap-filling purposes, the 2013 deflation factors by payment category are listed in the following table:

Factor Category0.469 Oxygen0.472 Capped Rental0.473 Prosthetics and Orthotics0.600 Surgical Dressings0.653 Parental and Enteral Nutrition

Specific Coding and Pricing IssuesAs part of this update, fee schedules for the following codes will be added to the DMEPOS fee schedule file effective January 1, 2014:

yy A4387 Ostomy Pouch, Closed, With Barrier Attached, With Built-In Convexity, (I Piece), Each; and

yy L3031 Foot, Insert/Plate, Removable, Addition to Lower Extremity Orthotic, High Strength, Lightweight Material, All Hybrid Lamination/Prepreg Composite, Each.

CMS is adjusting the fee schedule amounts for shoe modification codes A5503 through A5507 as part of this update in order to reflect more current allowed service data. Section 1833(o)(2)(C) of the Act required that the payment amounts for shoe modification codes A5503 through A5507 be established in a manner that prevented a net increase in expenditures when substituting these items for therapeutic shoe insert codes,A5512 or A5513. To establish the fee schedule amounts for the shoe modification codes, the base fees for codes A5512 and A5513 were weighted based on the approximated total allowed services for each code for items furnished during the second quarter of CY2004. For 2014, CMS is updating the weighted average insert fees used to establish the fee schedule amounts for the shoe modification codes with more current allowed service data for each insert code. The base fees for A5512 and A5513 will be weighted based on the approximated total allowed services for each code for items furnished during the Calendar Year 2012. The fee schedule amounts for shoe modification codes A5503 through A5507 are being revised to reflect this change, effective January 1, 2014.

Off-the-Shelf OrthoticsSection 1847(a)(2)(C) of the Act mandates implementation of competitive bidding programs throughout the United States for awarding contracts for furnishing Off-The-Shelf (OTS) orthotics which require minimal self-adjustment for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit the individual. Regulations at 42 CFR 414.402 define the term “minimal self-adjustment” to mean an adjustment that the beneficiary, caretaker for the beneficiary, or supplier of the device can perform and that does not require the services of a certified orthotist, an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification or an individual who has specialized training.

As shown in the following table, 22 new codes are added to the HCPCS for OTS orthotics. In addition, as part of the review to determine which HCPCS codes for prefabricated orthotics describe OTS orthotics, it was determined that HCPCS codes


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for prefabricated orthotics describe items that are furnished OTS and items that require expertise in customizing the orthotic to fit the individual patient. Therefore, it was necessary to explode these codes into two sets of codes. One set is the existing codes revised, effective January 1, 2014, to only describe devices customized to fit a specific patient by an individual with expertise and a second set of new codes describing the OTS items.

Also, as shown in the table that follows for CY 2014, the fee schedule amounts for existing codes will be applied to the corresponding new codes added for the items furnished OTS. The cross walking of fee schedule amounts for a single code that is exploded into two codes for distinct complete items is in accordance with the instructions found in the Medicare Claims Processing Manual, Chapter 23, Section 60.3.1, which is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf on the CMS website.

Prefabricated Orthotic Codes Split into Two Codes—Effective January 1, 2014

Prefabricated Orthotic Codes Split into Two Codes—Effective January 1, 2014

Fee from Existing Code

Crosswalk to New Off-The-Shelf and Revised Custom Fitted Orthotic Codes

Fee from Existing Code

Crosswalk to New Off-The-Shelf and Revised Custom Fitted Orthotic Codes

L0454 L0455 and L0454 L1810 L1812 and L1810L0456 L0457 and L0456 L1832 L1833 and L1832L0466 L0467 and L0466 L1847 L1848 and L1847L0468 L0469 and L0468 L3807 L3809 and L3807L0626 L0641 and L0626 L3915 L3916 and L3915L0627 L0642 and L0627 L3917 L3918 and L3917L0630 L0643 and L0630 L3923 L3924 and L3923L0631 L0648 and L0631 L3929 L3930 and L3929L0633 L0649 and L0633 L4360 L4361 and L4360L0637 L0650 and L0637 L4386 L4387 and L4386L0639 L0651 and L0639 L4396 L4397 and L4396

Further information on the development of new OTS orthotic codes can be found at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/OTS_Orthotics.html on the CMS website.

Neurostimulator DevicesHCPCS codes, L8685, L8686, L8687, and L8688 are not included on the 2014 DMEPOS fee schedule file. They were removed from the file to reflect the change in the coverage indicators for these codes to invalid for Medicare (“I”) effective January 1, 2014. However, code L8679 (Implantable Neurostimulator, Pulse Generator, Any Type) is added to the HCPCS and DMEPOS fee schedule file, effective January 1, 2014, for billing Medicare claims previously submitted under L8685, L8686, L8687 and L8688. The fee schedule amounts for code L8679 are based on the established Medicare fee schedule amounts for all types of pulse generators under the previous HCPCS code E0756 Implantable Neurostimulator Pulse Generator which was discontinued effective 12/31/2005. The payment amount is based on the explosion of code E0756 into four codes for different types of neurostimulator pulse generator systems which were not materially utilized in the Medicare program. As such, payment for code L8679 will revert back to the fee schedule amounts previously established for code E0756.

Diabetic Testing SuppliesThe fee schedule amounts for non-mail order diabetic testing supplies, without KL modifier, for codes A4233, A4234, A4235, A4236, A4253, A4256, A4258, A4259 are not updated by the covered item update for CY 2014. In accordance with Section 636(a) of




http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/OTS_Orthotics.html

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/OTS_Orthotics.html

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the American Taxpayer Relief Act of 2012, the fee schedule amounts for these codes were adjusted in CY 2013 so that they are equal to the single payment amounts for mail order Diabetic Testing Supplies (DTS) established in implementing the national mail order Competitive Bidding Program (CBP) under Section 1847 of the Act. The non-mail order payment amounts on the fee schedule file will be updated each time the single payment amounts are updated which can happen no less often than every three years as CBP contracts are recompeted. The national CBP for mail order diabetic supplies is effective July 1, 2013, to June 30, 2016. The program instructions reviewing these changes are Transmittal 2709, Change Request (CR) 8325, dated May 17, 2013, and Transmittal 2661, Change Request (CR) 8204, dated February 22, 2013. You may review the MLN Matters® Articles for these CRs at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8325.pdf and http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8204.pdf on the CMS website.

Although for payment purposes the single payment amounts replace the fee schedule amounts for mail order DTS (KL modifier), the fee schedule amounts remain on the DMEPOS fee schedule file as reference data such as for establishing bid limits for future rounds of competitive bidding programs. The mail order DTS fee schedule amounts shall be updated annually by the covered item update, adjusted for Multi-Factor Productivity (MFP), which results in update of 1.0 percent for CY 2014. The single payment amount public use file for the national mail order competitive bidding program is available http://www.dmecompetitivebid.com/palmetto/cbicrd2.nsf/DocsCat/Single%20Payment%20Amounts on the Internet.

CY2014 Fee Schedule Update FactorFor CY 2014, the update factor of 1.0 percent is applied to the applicable CY 2013 DMEPOS fee schedule amounts. In accordance with the statutory Sections 1834(a)(14) and 1886(b)(3)(B)(xi)(II) of the Act, the DMEPOS fee schedule amounts are to be updated for 2014 by the percentage increase in the consumer price index for all urban consumers (United States city average) or CPI-U for the 12-month period ending with June of 2013, adjusted by the change in the economy-wide productivity equal to the 10-year moving average of changes in annual economy-wide private non-farm business Multi-Factor Productivity (MFP).

The MFP adjustment is 0.8 percent and the CPI-U percentage increase is 1.8 percent. Thus, the 1.8 percentage increase in the CPI-U is reduced by the 0.8 percentage increase in the MFP resulting in a net increase of 1.0 percent for the update factor.

2014 Update to the Labor Payment RatesThe 2014 fees for HCPCS labor payment codes K0739, L4205, and L7520 are increased 1.8 percent effective for claims with dates of service from January 1, 2014, through December 31, 2014, and those rates are as follows:

State K0739 L4205 L7520 State K0739 L4205 L7520AK $27.40 $31.22 $36.73 NC $14.55 $21.68 $29.43AL $14.55 $21.68 $29.43 ND $18.13 $31.16 $36.73AR $14.55 $21.68 $29.43 NE $14.55 $21.66 $41.04AZ $17.99 $21.66 $36.21 NH $15.62 $21.66 $29.43CA $22.32 $35.59 $41.48 NJ $19.63 $21.66 $29.43CO $14.55 $21.68 $29.43 NM $14.55 $21.68 $29.43CT $24.30 $22.16 $29.43 NV $23.18 $21.66 $40.12DC $14.55 $21.68 $29.43 NY $26.79 $21.68 $29.43







http://www.dmecompetitivebid.com/palmetto/cbicrd2.nsf/DocsCat/Single%20Payment%20Amounts



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State K0739 L4205 L7520 State K0739 L4205 L7520DE $26.79 $21.66 $29.43 OH $14.55 $21.66 $29.43FL $14.55 $21.68 $29.43 OK $14.55 $21.68 $29.43GA $14.55 $21.68 $29.43 OR $14.55 $21.66 $42.32HI $17.99 $31.22 $36.73 PA $15.62 $22.30 $29.43IA $14.55 $21.68 $35.23 PR $14.55 $21.68 $29.43ID $14.55 $21.66 $29.43 RI $17.34 $22.32 $29.43IL $14.55 $21.66 $29.43 SC $14.55 $21.68 $29.43IN $14.55 $21.66 $29.43 SD $16.26 $21.66 $39.35KS $14.55 $21.66 $36.73 TN $14.55 $21.68 $29.43KY $14.55 $27.76 $37.64 TX $14.55 $21.68 $29.43LA $14.55 $21.68 $29.43 UT $14.59 $21.66 $45.83MA $24.30 $21.66 $29.43 VA $14.55 $21.66 $29.43MD $14.55 $21.66 $29.43 VI $14.55 $21.68 $29.43ME $24.30 $21.66 $29.43 VT $15.62 $21.66 $29.43MI $14.55 $21.66 $29.43 WA $23.18 $31.77 $37.74MN $14.55 $21.66 $29.43 WI $14.55 $21.66 $29.43MO $14.55 $21.66 $29.43 WV $14.55 $21.66 $29.43MS $14.55 $21.68 $29.43 WY $20.28 $28.89 $41.04MT $14.55 $21.66 $36.73

2014 National Monthly Payment Amounts for Stationary Oxygen EquipmentCR8531 implements the 2014 national monthly payment amount for stationary oxygen equipment (HCPCS codes E0424, E0439, E1390, and E1391), effective for claims with dates of service on or after January 1, 2014. As required by statute, the payment amount must be adjusted on an annual basis, as necessary, to ensure budget neutrality of the new payment class for Oxygen Generating Portable Equipment (OGPE). The updated 2014 monthly payment amount of $178.24 includes the 1.0 percent update factor for the 2014 DMEPOS fee schedule.

Please note that when updating the stationary oxygen equipment fees, corresponding updates are made to the fee schedule amounts for HCPCS codes E1405 and E1406 for oxygen and water vapor enriching systems. Since 1989, the fees for codes E1405 and E1406 have been established based on a combination of the Medicare payment amounts for stationary oxygen equipment and nebulizer codes E0585 and E0570, respectively.

2014 Maintenance and Servicing Payment Amount for Certain Oxygen Equipment CR 8531 also updates the 2014 payment amount for maintenance and servicing for certain oxygen equipment. You can read more about payment for claims for maintenance and servicing for oxygen equipment in MLN Matters® Articles, MM6792 at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6792.pdf and MM6990 at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6990.pdf on the CMS website.

To summarize, payment for maintenance and servicing of certain oxygen equipment can occur every 6 months beginning 6 months after the end of the 36th month of continuous use or end of the supplier’s or manufacturer’s warranty, whichever is later for either HCPCS code E1390, E1391, E0433 or K0738, billed with the “MS” modifier. Payment cannot occur more than once per beneficiary, regardless of the combination of oxygen concentrator equipment and/or transfilling equipment used by the beneficiary, for any 6-month period.







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Per 42 CFR 414.210(5)(iii), the 2010 maintenance and servicing fee for certain oxygen equipment was based on 10 percent of the average price of an oxygen concentrator. For CY 2011 and subsequent years, the maintenance and servicing fee is adjusted by the covered item update for DME as set forth in Section1834(a)(14) of the Act. Thus, the 2013 maintenance and servicing fee is adjusted by the 1 percent MFP-adjusted covered item update factor to yield a CY 2014 maintenance and servicing fee of $68.73 for oxygen concentrators and transfilling equipment.




Fee Schedule

MM8533: Summary of Policies in the Calendar Year (CY) 2014 Medicare Physician Fee Schedule (MPFS) Final Rule and the Telehealth Originating Site Facility Fee Payment Amount





This MLN Matters® article is intended for physicians and non-physician practitioners (NPPs) submitting claims to Medicare administrative contractors (MAC) for services to Medicare beneficiaries.


This article, based on CR 8533, provides a summary of the policies in the CY 2014 Medicare Physician Fee Schedule (MPFS) Final Rule and announces the Telehealth Originating Site Facility Fee payment amount. Please see the “Background” and policy below for details of the changes. Make sure that your billing staffs are aware of these updates for 2014.

Background

CR 8533 provides a summary of the policies in the CY 2014 Medicare Physician Fee Schedule (MPFS). Section 1848(b)(1) of the Social Security Act (the Act) requires the Secretary to establish by regulation a fee schedule of payment amounts for physicians’ services for the subsequent year. CMS issued a final rule with comment period on November 27, 2013, that updates payment policies and Medicare payment rates for services furnished by physicians and nonphysician practitioners (NPPs) that are paid under the MPFS in CY 2014.






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The final rule addresses Medicare public comments on payment policies that were described in the proposed rule earlier this year, “Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions to Part B for CY 2014,” (displayed July 8, 2013 and published in the Federal Register on July 19, 2013).

The final rule also addresses interim final values established in the CY 2013 MPFS final rule with comment period, which was displayed November 1, 2012, and published in the Federal Register November 16, 2012. The final rule assigns interim final values for new and revised codes for CY 2014 and requests comments on these values. CMS will accept comments on those items open to comment in the final rule with comment period until January 27, 2014.

Key Provisions of the MPFS Final Rule

Sustainable Growth Rate (SGR) and MPFS conversion factor for CY 2014Without a change in the law, the conversion factor will be reduced by 20.1 percent for services in 2014. The President’s budget calls for averting these cuts and finding a permanent solution to this problem. The CY 2014 conversion factor is $27.2006, which reflects a smaller reduction in the conversion factor than the 24.4 percent reduction that CMS projected in March 2013. The smaller reduction is due in part to a 4.72 percent adjustment to the conversion factor to offset the decrease in Medicare physician payments that would otherwise have occurred due to the CY 2014 rescaling of the Relative Value Units (RVUs) so that the proportions of total payments for the work, Practice Expense (PE), and malpractice RVUs match the proportions in the final revised Medicare Economic Index (MEI) for CY 2014. This issue is discussed further below. The overall 2014 reduction in physician fee schedule payments required under the SGR methodology is unchanged by this rescaling.

On December 20, 2013, after the MPFS final rule was issued, Congress passed the Pathway for SGR Reform Act of 2013. This new law prevents a scheduled payment cut for physicians and other practitioners who treat Medicare patients from taking effect on January 1, 2014. The new law provides a 0.5 percent update through March 31, 2014. The 2014 conversion factor under this new law is $35.8228.

Medicare Economic Index:CMS finalized the proposed revisions to the calculation of the MEI, which is the price index used to update physician payments for inflation. The changes are in response to recommendations by a Technical Advisory Panel that met during CY 2012. The MEI is one of the factors used in determining the MPFS conversion factor. The final rule includes changes in the MPFS RVUs assigned to the work and practice expense categories so that the weights used in the MPFS payment calculation will continue to mirror those in the MEI. As a result, some payment is being redistributed to work from PE.

Telehealth Services:CMS modified the regulations establishing the geographic criteria for eligible telehealth originating sites to include health professional shortage areas (HPSAs) located in rural census tracts of urban areas as determined by the Office of Rural Health Policy. This change will more appropriately allow sites located within HPSAs in Metropolitan Statistical Areas (MSAs) that have rural characteristics to qualify as originating sites and improve access to telehealth services in shortage areas. In this rule, CMS also finalizes a policy that determines an originating site’s geographic eligibility based on the areas as of December 31st of the preceding year for the entire calendar year. This change will avoid mid-year changes to geographic designations (sometimes without


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advance notice to Medicare beneficiaries and providers) that could result in unexpected disruptions to established telehealth originating sites and avoid the need to make mid-year Medicare telehealth payment policy changes. In addition, we are adding transitional care management services (CPT codes 99495 and 99496) to the list of eligible Medicare telehealth services).

Telehealth Originating Site Facility Fee Payment Amount Update:Section 1834(m)(2)(B) of the Act establishes the payment amount for the Medicare telehealth originating site facility fee for telehealth services provided from October 1, 2001, through December 31 2002, at $20. For telehealth services provided on or after January 1 of each subsequent calendar year, the telehealth originating site facility fee is increased by the percentage increase in the MEI as defined in section 1842(i)(3) of the Act. The MEI increase for 2014 is 0.8 percent. Therefore, for CY 2014, the payment amount for HCPCS code Q3014 (Telehealth originating site facility fee) is 80 percent of the lesser of the actual charge, or $24.63. (The beneficiary is responsible for any unmet deductible amount and Medicare coinsurance).

Revisions To The Practice Expense Geographic Adjustment:As required by the Medicare law, CMS adjusts payments under the MPFS to reflect the local cost of operating a medical practice as compared to the national average. CMS calculates separate GPCIs to adjust the work, PE, and malpractice cost components of each payment. The law requires that we review the GPCIs every three years and adjust them as appropriate with a two-year phase-in of the new GPCIs. We are finalizing new GPCIs using updated data. The updated GPCIs will be phased in over CY 2014 and CY 2015. Additionally, we will apply the statutorily mandated 1.5 work GPCI floor in Alaska and the 1.0 PE GPCI floor for frontier states (Montana, Nevada, North Dakota, South Dakota, and Wyoming).

Misvalued Codes:Consistent with amendments made by the Affordable Care Act, CMS has been engaged in a vigorous effort over the past several years to identify and review potentially misvalued codes and make adjustments, where appropriate. We finalized the values for around 200 codes in the CY 2014 final rule. In addition, we assigned interim final values for approximately 200 services, including hip and knee replacements, mental health services, and GI endoscopy services. These interim final rates are open for public comment until January 27, 2014.

CMS is not finalizing its proposal to adjust relative values under the MPFS to effectively cap the physician PE payment for procedures furnished in a non-facility setting at the total payment rate for the service when furnished in an ambulatory surgical center or hospital outpatient setting. Instead, CMS will take additional time to consider issues raised by the public commenters and plans to address this issue in future rulemaking. In addition, for CY 2014, we are finalizing 18 codes that we identified and proposed as potentially misvalued services in consultation with MAC Medical Directors.

Application of Therapy Caps to Critical Access Hospitals (CAHs):The law applies annual limitations or “therapy caps” on per beneficiary incurred expenses for outpatient therapy services —one for physical therapy and speech-language pathology services combined and another for occupational therapy services. CMS finalized its proposal to apply the therapy caps and related policies to outpatient therapy services furnished by a CAH beginning on January 1, 2014, in order to properly apply the law that established the therapy caps.


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Compliance with State Law for Incident To ServicesCMS is requiring as a condition of Medicare payment that “incident to” services be furnished in compliance with applicable state law. This policy strengthens program integrity by allowing Medicare to deny or recoup payments when services are furnished not in compliance with state law. We also eliminated redundant regulations for each type of practitioner by consolidating the “incident to” requirements for all practitioners that are permitted to bill Medicare directly for their services, reducing the regulatory burden and making it less difficult for practitioners to determine what is required in order to bill Medicare for “incident to” services. This portion of the final rule with comment period is effective on January 27, 2014.

The Outpatient Mental Health Treatment Limitation:Section 102 of the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 amends Section 1833(c) of the Social Security Act to phase out the outpatient mental health treatment limitation over a 5-year period, from 2010-2014. The limitation had resulted in Medicare paying approved lower percentage of the allowed amount under the MPFS for outpatient mental health treatment rather than the 80 percent that is paid for most other services. This limitation expires on January 1, 2014. In CY 2014, Medicare will pay the same percentage of the MPFS amount for outpatient mental health services as other Part B services (i.e. 80 percent of the MPFS amount).

Primary Care and Chronic Care Management:As part of its ongoing efforts to appropriately value primary care services, Medicare will begin making a separate payment for chronic care management services beginning in 2015. Chronic care management services include the development, revision, and implementation of a plan of care; communication with the patient, caregivers, and other treating health professionals; and medication management. Medicare beneficiaries with multiple chronic conditions who wish to receive these services can choose a physician or other eligible practitioner from a qualified practice to furnish these services over 30-day periods. The rule indicates that CMS intends to establish practice standards necessary to support payment for furnishing care management services through the CY 2015 MPFS.


The final rule will appear in the December 10, 2013, Federal Register. For more information, see https://www.federalregister.gov/articles/2013/12/10/2013-28696/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-clinical-laboratory on the Internet.




https://www.federalregister.gov/articles/2013/12/10/2013-28696/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-clinical-laboratory





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Hospital

Change Request 8508 (Revised): Immediate Suspension of Postpayment Patient Status Reviews of Inpatient Hospital Admissions 10/1/13-12/31/13

The Centers for Medicare & Medicaid Services (CMS) has issued the following Change Request (CR). This CR and other CMS articles can be found on the CMS website at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2013-Transmittals.html.

Pub. 100-20 Transmittal: 1329 Date: December 26, 2013 Change Request: 8508

Transmittal 1315, dated November 15, 2013, is being rescinded and replaced by Transmittal-1329, dated 12/26/2013, to clarify the dates of admission (business requirement (BR) 8508.1) and to remove reference to a dual-chamber pacemaker National Coverage Decision (BR 8508.1.1). All other information remains the same.

EFFECTIVE DATE: October 1, 2013

IMPLEMENTATION DATE: December 2, 2013

I. GENERAL INFORMATION

A. Background: On August 2, 2013 the Centers for Medicare & Medicaid Services (CMS) issued Final Rule CMS-1599-F updating fiscal year FY 2014 Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital Prospective Payment System (LTCH PPS). The final rule modifies and clarifies CMS’s longstanding policy on how Medicare contractors review inpatient hospital admissions for payment purposes. The rule is applicable to admissions at acute care inpatient hospital facilities, Long Term Care Hospitals (LTCHs), Critical Access Hospitals (CAHs) and Inpatient Psychiatric Facilities (IPFs), but is not applicable to beneficiary admissions at Inpatient Rehabilitation Facilities (IRFs). IRFs are specifically excluded from the 2-Midnight inpatient admission and medical review guidelines per CMS-1599-F.

Reviews to check compliance with Final Rule CMS-1599-F are called “patient status” reviews. The purpose of this Change Request is to provide the contractors with instruction regarding their post-payment medical review strategy, particularly related to “patient status” reviews.

Medicare Administrative Contractors (MACs), Recovery Auditors, and the Supplemental Medical Review Contractor shall not conduct postpayment patient status reviews for inpatient claims with dates of admission 10/1/13 – 12/31/13. However, claims with evidence of systematic gaming, abuse or delays in the provision of care in an attempt to surpass the 2 midnight presumption could warrant medical review at any time.

MACs, Recovery Auditors and the Supplemental Medical Review Contractor may continue other types of inpatient hospital review (i.e. reviews for purposes other than determining the appropriateness of the inpatient admission versus treatment as an outpatient/observation, which are known as “patient status” reviews).

B. Policy: Fiscal Year 2014 Hospital IPPS Final Rule CMS-1599-F:

Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2014 Rates; Quality Reporting Requirements for Specific


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Providers; Hospital Conditions of Participation; Payment Policies Related to Patient Status

The official instruction, CR 8508 may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1329OTN.pdf on the CMS website.


Hospital

SE1342: Systematic Validation of Payment Group Codes for Prospective Payment Systems (PPS) Based on Patient Assessments


MLN Matters® Number: SE1342 Related CR Release Date: July 18, 2012Related CR Transmittal #: R2495CP

Related Change Request (CR) #: CR 7760 Effective Date: October 1, 2012 Implementation Date: October 1, 2012


This MLN Matters® Special Edition article is intended for Inpatient Rehabilitation Facilities (IRF¡¦s) submitting claims to Medicare A/B Medicare administrative contractors (MACs) for services to Medicare beneficiaries.


This article conveys editing requirements within the Fiscal Intermediary Shared System (FISS) system, for Inpatient Rehabilitation Facility Prospective Payment System (IRF PSS) claims and the matching process with the IRF-Patient Assessment Instrument (PAI). Make sure billing staff are aware of these changes.

Background

Section 1886(j)(2)(D) of the Social Security Act (http://www.socialsecurity.gov/OP_Home/ssact/title18/1886.htm) requires IRFs to transmit sufficient patient data to allow CMS to administer the IRF prospective payment system. These data are necessary to assign beneficiaries to the appropriate case-mix groups, to monitor the effects of the IRF PPS on patient care and outcomes, and to determine whether adjustments to the case-mix groups are warranted.

To administer the PPS, CMS requires IRFs to electronically transmit a PAI for each IRF stay to CMS’s National Assessment Collection Database (the Database). Each IRF must report the date that it transmitted the PAI to the Database on the claim that it submits to the MAC. If an IRF transmits the PAI more than 27 calendar days from (and including) the beneficiary’s discharge date, the IRF’s payment rate for the applicable case-mix group should be reduced by 25 percent.

The Office of Inspector General (OIG) has recommended in various reports, that CMS consider establishing a process that would allow the FISS to interface with the CMS National Assessment Collection Database to identify, on a prepayment basis, IRF claims with incorrect PAI transmission Health Insurance Prospective Payment System (HIPPS)


http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1329OTN.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1329OTN.pdf



http://www.socialsecurity.gov/OP_Home/ssact/title18/1886.htm

http://www.socialsecurity.gov/OP_Home/ssact/title18/1886.htm

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codes and/or dates.

In CR 7760, Medicare systems were enhanced to allow communication with the CMS National Assessment Collection Database for IRF-PAI. This will ensure that the HIPPS code on claims received by MACs match the payment group on the IRF-PAI received by the CMS’s National Assessment Collection Database and ensure the late assessment reduction is applied accurately. The system changes required by this enhancement were considerable and required an extended testing period to validate the effectiveness of the communication via file transfers between FISS and the CMS National Assessment Collection Database. Such testing is ongoing.

The first step was to ensure that the enhancements worked correctly in a test environment, then to validate that the same processes worked in production environments. We conducted a one (1) day production validation in November 2013. It was determined that an extended period of validation was needed in production to test all the aspects of the new matching process, so a two (2) week validation period was approved starting on December 6, 2013.

IRF claims submitted to FISS, during the two (2) week validation period will suspend with Reason Code 37069. These claims will suspend in status Location S-MFRX0 while FISS communicates with the CMS National Assessment Collection Database requesting for a match of the claim with the assessment to be made and additional information submitted on the assessment. Each nightly cycle the Status/Location changes the last digit until 4 nightly cycles are completed (i.e., S-MFRX1, S-MFRX2, S-MFRX3, and S-MFRX4). If no return file is received after the 4th nightly cycle the claim is released to continue processing. If a return file is received by the A/B MAC, the following outcomes are possible:

yy A match is found. Claim information matches the IRF-PAI HIPPS and transmission date, so the claim will continue processing;

yy A match is found. Claim information matches the IRF-PAI HIPPS, but the transmission date is different causing the claims processing system to use the date documented at the CMS National Assessment Collection Database for claims processing purposes. If it is determined that the IRF-PAI was transmitted late based on the information found on the CMS National Assessment Collection Database, then the 25% penalty will be applied;

yy A match is found. Claim information does not match the IRF-PAI HIPPS information, but the transmission date matches causing the claims processing system to use the assessment HIPPS information documented at the CMS National Assessment Collection Database for claims processing purposes;

yy A match is found. Claim information does not match IRF-PAI HIPPS information, and the transmission date information is different causing the claims processing system to use the assessment HIPPS information and date documented at the CMS National Assessment Collection Database for claims processing purposes;

yy A match is not found. Claim information is submitted, however no corresponding IRF-PAI match is found at the CMS National Assessment Collection Database causing the claim to Return to Provider (RTP) with Reason Code 37096;

Feedback from MACs and providers during this validation process has been very positive with the exception of one (1) issue that had not been anticipated. It appears that providers are submitting claims to their MAC prior to the IRF-PAI completing processing at the CMS National Assessment Collection Database. This causes Reason Code 37096 to return the claim to the provider. It is important to remember that prior to submission of your IRF claim to FISS, you must have an IRF-PAI that has completed processing at the CMS National Assessment Collection Database. The provider can verify this by


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reviewing their IRF-PAI validation report.

If a provider has inadvertently submitted their claim prior to IRF-PAI completing processing and it has RTP’d with Reason Code 37096, simply resubmit claim once the IRF-PAI has completed processing at the CMS National Assessment Collection Database. This will require communication between the provider’s billing office and their clinical staff that submits their IRF-PAI to the CMS National Assessment Collection Database. If you are using a provider/vendor created software to code your claims and transmitting your IRF-PAI to the CMS National Assessment Collection Database at a later point, you are reminded that you cannot submit your claim until the IRF-PAI has completed processing at the CMS National Assessment Collection Database. There is no need to call the QIES Technical Support Office (QTSO) help desk for such billing issues.

If a provider has submitted an IRF-PAI prior to submission of the claim with information that is different from the claim submission for any of the following information:

yy Beneficiary HIC number (IRF-PAI item 2);

yy Beneficiary date of birth (IRF-PAI item 6);

yy Provider CCN (IRF-PAI item 1B);

yy Claim statement covers through dates (IRF-PAI item 40); and

yy Claim admission date (IRF-PAI item 12).

The claim or the IRF-PAI should be corrected (depending on which item had the error) prior to the claim submission. If the claim is submitted without correcting the appropriate information, the matching IRF-PAI will not be found since it does not exist and the claim will be RTP’d with Reason Code 37096.

However, most cases that have been brought to our attention are showing that the claim is being submitted one (1) day prior to the finalization of the IRF-PAI at the CMS National Assessment Collection Database. Providers may want to add an additional claim hold day(s) on their claim submission to allow IRF-PAI completing processing and to avoid claims being RTP’d with Reason Code 37096.

To assist providers with the appropriate contact information the following charts have been provided.


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Attachment 1:Sect. 3004-IRF RTI International November 16, 2012

IRF Provider, with a question about:

Quality Reporting Program & Quality Reporting Itemsyy Pressure ulcer

codingyy Pressure ulcer

stagingyy Woundsyy General quality

reporting questionsyy Other quality

measures (as released)

Data Submission & Data Validationyy Accessing QIES

(username and password)yy Data/record

submissions Submission/validation reportsyy CASPER reportsyy jIRVEN

IRF-PAI Clinical Itemsyy Clinical questions

not related to quality indicators

IRF Medicare Policyyy IRF Medicare

reimbursementyy Claims/billingyy Eligibility and

coverage requirementsyy Therapy time

requirementsyy Assessment

requirements (for non-quality sections)

CDC & NHSNyy Centers for

Disease Control (CDC) Quality Measures (such as Catheter Associated Urinary Tract Infections (CAUTI))yy National

Healthcare Safety Network enrollment and reporting

[email protected]

[email protected]

[email protected]

[email protected]

[email protected] 1.800.232.4636 TTY: 1.888.232.6348

Inpatient Rehabilitation Facility Help Desks

Attachment 2:Sect. 3004-IRF RTI International November 16, 2012

IRF Provider, with a question about:

Vendor Issues:yy Data specificationsyy VUT (vendor tool to ensure software meets

CMS requirements and will pass ASAP edits)yy Technical questions related to data specifications

[email protected]


You may want to review the related article to CR 7760 at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7760.pdf on the CMS website.














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Medical Review

SE1343: Medicare System Project for Electronic Submission of Medical Documentation (esMD)


News Flash: Electronic Submission of Medical Documentation (esMD) has arrived. Since September 2011, the Centers for Medicare & Medicaid Services (CMS) has implemented the esMD program for providers to submit medical documentation in response to requests from Medicare review contractors. For more information, please read this article.

MLN Matters® Number: SE1343 Related CR Release Date: N/ARelated CR Transmittal #: N/A

Related Change Request (CR) #: N/A Effective Date: N/A Implementation Date: N/A


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.


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

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:

yy 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).

yy 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.

yy In June 2013, CMS enabled automated Prior Authorization Review Results Responses from Medicare review contractors to Health Information Handlers (HIHs) via the esMD Gateway.




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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:

yy 449,460 Unique Medical Record Transactions have been submitted;

yy 30,199 Medicare Providers are using esMD to respond to medical record requests;

yy 55 Medicare Providers use esMD to submit Prior Authorization Requests;

yy 24 HIHs are certified by CMS to offer esMD services; and

yy 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:

yy Larger providers, such as hospital chains, may choose to build their own gateway;

yy 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.


For more information, visit the esMD Web page 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.


http://go.cms.gov/RevCon

http://go.cms.gov/RevCon

http://go.cms.gov/esmd-HIH

http://www.cms.gov/esmd

http://www.cms.gov/MLNMattersArticles/downloads/SE1024.pdf

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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.


RHC/FQHC

MM8469: Announcement of Medicare Rural Health Clinic (RHC) and Federally Qualified Health Centers (FQHC) Payment Rate Increases





This MLN Matters® article is intended for RHCs and FQHCs submitting claims to Medicare administrative contractors (MACs) for services to Medicare beneficiaries.


This article is based on CR 8469, which provides instructions to Medicare contractors for the calendar year (CY) 2014 Payment Rate Increases for RHC and FQHC services. Make sure that your billing staffs are aware of these changes.

Background

CR 8469 provides instructions for the calendar year (CY) 2014 Payment Rate Increases for RHC and FQHC services that can be found in Medicare Claims Processing Manual, Chapter 9, section 20.

RHCs: The RHC upper payment limit per visit is increased from 79.17 to 79.80 effective January 1, 2014, through December 31, 2014, (i.e., CY 2014). The 2014 rate reflects a 0.8 percent increase over the 2013 payment limit in accordance with the rate of increase in the Medicare Economic Index (MEI) as authorized by section 1833(f) of the Social Security Act.

FQHCs: The FQHC upper payment limit per visit for urban FQHCs is increased from 128.00 to 129.02 effective January 1, 2014, through December 31, 2014, (i.e., CY 2014), and the maximum Medicare payment limit per visit for rural FQHCs is increased from 110.78 to 111.67 effective January 1, 2014, through December 31, 2014, (i.e. CY 2014). The 2014 FQHC rates reflect a 0.8 percent increase over the 2013 rates in accordance with the rate of increase in the MEI.

This effective date of January 1, 2014, is necessary in order to update RHC and FQHC payment rates in accordance with section 1833(f) of the Social Security Act. To avoid unnecessary administrative burden, MACs will not retroactively adjust individual RHC/FQHC bills paid at previous upper payment limits. The MAC does, however, retain the discretion to make adjustments to the interim payment rate or a lump sum adjustment to


http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Downloads/RAC-Contact-Information-AbbrState-Apr2013.pdf





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total payments already made to take into account any excess or deficiency in payments to date.




Therapy

MM8458 (Revised): Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius


MLN Matters® Number: MM8458 RevisedRelated CR Release Date: December 13, 2013Related CR Transmittal #: R176BP


Note: This article was revised on December 16, 2013, to reflect the revised CR 8458 issued on December 13. In the article, the CR release date, transmittal number, and the Web address are revised. All other information remains the same.


This MLN Matters® article is intended for skilled nursing facilities (SNFs); inpatient rehabilitation facilities (IRFs); home health agencies (HHAs); providers and suppliers of therapy services under the Outpatient Therapy (OPT) Benefit — including critical access hospitals (CAHs), hospitals, rehabilitation agencies, SNFs, HHAs, physicians, certain non-physician practitioners, and therapists in private practice — submitting claims to Medicare contractors (Parts A/B Medicare Administrative Contractors (MACs) and Medicare Advantage Organizations) for services to Medicare beneficiaries, including physical therapy, occupational therapy, and speech-language pathology services.


This article is based on CR 8458, which updates portions of the Medicare Benefit Policy Manual (MBPM) to clarify key components of SNF, IRF, HH, and OPT coverage requirements pursuant to the settlement agreement in the case of Jimmo v. Sebelius. Nothing in this settlement agreement modifies, contracts, or expands the existing eligibility requirements for Medicare coverage.






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Background

In accordance with the Jimmo v. Sebelius Settlement Agreement, the Centers for Medicare & Medicaid Services (CMS) has agreed to issue revised portions of the relevant program manuals used by Medicare contractors, in order to clarify that coverage of skilled nursing and skilled therapy services “ . . . does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.” Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.

The following are some significant aspects of the manual clarifications now being issued:

yy No “Improvement Standard” is to be applied in determining Medicare coverage for maintenance claims in which skilled care is required. Medicare has long recognized that even in situations where no improvement is expected, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition). For example, the longstanding SNF level of care regulations, specify that the “. . . restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities. For example, a terminal cancer patient may need . . . skilled services . . . .” [42 CFR 409.32(c)] (This regulation is available at http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-sec409-32.pdf on the Internet.)

While the example included in this provision pertains specifically to skilled nursing services, we also wish to clarify that, the concept of skilled therapy services can similarly involve not only services that are restorative in nature (or “rehabilitative” therapy in the OPT setting) but, if certain standards are met, maintenance therapy as well:

y� Restorative/Rehabilitative therapy. In evaluating a claim for skilled therapy that is restorative/rehabilitative (i.e., whose goal and/or purpose is to reverse, in whole or in part, a previous loss of function), it would be entirely appropriate to consider the beneficiary’s potential for improvement from the services. We note that such a consideration must always be made in the IRF setting, where skilled therapy must be reasonably expected to improve the patient’s functional capacity or adaptation to impairments in order to be covered.

y� Maintenance therapy. Even if no improvement is expected, under the SNF, HH, and OPT coverage standards, skilled therapy services are covered when an individualized assessment of the patient’s condition demonstrates that skilled care is necessary for the performance of a safe and effective maintenance program to maintain the patient’s current condition or prevent or slow further deterioration. Skilled maintenance therapy may be covered when the particular patient’s special medical complications or the complexity of the therapy procedures require skilled care.

Accordingly, these revisions to the MBPM clarify that a beneficiary’s lack of restoration potential cannot serve as the basis for denying coverage in this context. Rather, such coverage depends upon an individualized assessment of the beneficiary’s medical condition and the reasonableness and necessity of the treatment, care, or services in question. Moreover, when the individualized assessment demonstrates that skilled care is, in fact, needed in order to safely and effectively maintain the beneficiary at his or her maximum practicable level of function, such care is covered (assuming all other applicable requirements are met).


http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-sec409-32.pdf

http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-sec409-32.pdf

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Conversely, coverage in this context would not be available in a situation where the beneficiary’s maintenance care needs can be addressed safely and effectively through the use of nonskilled personnel.

Medicare has never supported the imposition of an “Improvement Standard” rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient’s condition. Thus, such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves. The manual revisions now being issued will serve to reflect and articulate this basic principle more clearly. Therefore, denial notices should contain an accurate summary of the reason for denial, which should be based on the beneficiary’s need for skilled care and not be based on lack of improvement for a beneficiary who requires skilled maintenance nursing services or therapy services as part of a maintenance program in the SNF, HH, or OPT settings.

In the MBPM (the manual within which all revisions were made by CR 8458), the revised Chapter 15, Section 220 specifically discusses Part B coverage under the OPT benefit. In that chapter, both rehabilitative and maintenance therapy are addressed. Rehabilitative therapy includes services designed to address recovery or improvement in function and, when possible, restoration to a previous level of health and well-being. A “MAINTENANCE PROGRAM (MP) means a program established by a therapist that consists of activities and/or mechanisms that will assist a beneficiary in maximizing or maintaining the progress he or she has made during therapy or to prevent or slow further deterioration due to a disease or illness.” No mention of improving the patient’s condition is noted within the MP definition.

y� Enhanced guidance on appropriate documentation. Portions of the revised manual provisions now include additional material on the role of appropriate documentation in facilitating accurate coverage determinations for claims involving skilled care. While the presence of appropriate documentation is not, in and of itself, an element of the definition of a “skilled” service, such documentation serves as the means by which a provider would be able to establish and a Medicare contractor would be able to confirm that skilled care is, in fact, needed and received in a given case. Thus, even though the terms of the Jimmo settlement do not include an explicit reference to documentation requirements as such, CMS has nevertheless decided to use this opportunity to introduce additional guidance in this area, both generally and as it relates to particular clinical scenarios. An example of this material appears in a new Section 30.2.2.1 of the MBPM’s revised Chapter 8, in the guidelines for SNF coverage under Part A.

We note that this material on documentation does not serve to require the presence of any particular phraseology or verbal formulation as a prerequisite for coverage (although it does identify certain vague phrases like “patient tolerated treatment well,” “continue with POC,” and “patient remains stable” as being insufficiently explanatory to establish coverage). Rather, as indicated previously, coverage determinations must consider the entirety of the clinical evidence in the file, and our enhanced guidance on documentation is intended simply to assist providers in their efforts to identify and include the kind of clinical information that can most effectively serve to support a finding that skilled care is needed and received—which, in turn, will help to ensure more accurate and appropriate claims adjudication.

Further, as noted in the discussion of OPT coverage under Part B in Section 220.3.D of the MBPM, Chapter 15, care must be taken to assure that documentation justifies the necessity of the skilled services provided. Justification for treatment would include, for example, objective evidence or a clinically supportable statement of expectation that:


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y� In the case of rehabilitative therapy, the patient’s condition has the potential to improve or is improving in response to therapy; maximum improvement is yet to be attained; and, there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.

y� In the case of maintenance therapy, the skills of a therapist are necessary to maintain, prevent, or slow further deterioration of the patient’s functional status, and the services cannot be safely and effectively carried out by the beneficiary personally or with the assistance of non-therapists, including unskilled caregivers.

The Settlement Agreement. The Jimmo v. Sebelius settlement agreement itself includes language specifying that “Nothing in this Settlement Agreement modifies, contracts, or expands the existing eligibility requirements for receiving Medicare coverage.” Rather, the intent is to clarify Medicare’s longstanding policy that when skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration. As such, the revised manual material now being issued does not represent an expansion of coverage, but rather, provides clarifications that are intended to help ensure that claims are adjudicated accurately and appropriately in accordance with the existing policy.


The official instruction, CR 8458, issued to your Medicare contractor regarding this change, may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R176BP.pdf on the CMS website. All of the revised portions of the Medicare Benefit Policy Manual are a part of CR 8458.


Helpful Information

Contact Information for CGS Part A

Department Contact InformationAppeals, including:

• Requests for Redeterminations (first level appeals)

• 935 Appeals related to Overpayments

Note: Appeals must be filed within 120 days of the initial claim determination, with very few exceptions.

You must complete the first level of appeal before filing a subsequent level of appeal.

Registered users of the myCGS portal (http://www.cgsmedicare.com/myCGS/index.html) may submit Redetermination requests and supporting documentation electronically.

Access the Redetermination Request form at http://www.cgsmedicare.com/parta/pubs/news/2011/0911/53.pdf

Mailing address: CGS J15 Part A Appeals PO Box 20006 Nashville, TN 37202

Fax: 1.803.462.2585

Fed Ex/UPS/Certified Mail: CGS J15 Part A Appeals 2 Vantage Way Nashville, TN 37228

935 appeals related to overpayments: CGS J15 Part A Overpayments Appeals PO Box 20022 Nashville, TN 37202




http://www.cgsmedicare.com/myCGS/index.html

http://www.cgsmedicare.com/myCGS/index.html

http://www.cgsmedicare.com/parta/pubs/news/2011/0911/53.pdf

http://www.cgsmedicare.com/parta/pubs/news/2011/0911/53.pdf

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Department Contact InformationBeneficiary Customer Service Center (only Medicare beneficiaries should use this number)

Phone: 1.800.MEDICARE (1.800.633.4227)

TTY: 1.877.486.2048

Website: http://www.medicare.govCost Reports, including:

• Checks related to cost reports

Cost Reports (no checks):

Fed Ex/UPS/Overnight Courier: CGS J15 Cost Report 3021 Montvale Drive, Suite C Springfield, IL 62704

Cost Report Overpayment Address (checks only):

OH: CGS KY: CGS Part A Ohio - Lockbox # 957635 Part A KY - Lockbox # 957582 1005 Convention Plaza 1005 Convention Plaza SL-MO-C1WS SL-MO-C1WS St. Louis, MO 63101 St. Louis, MO 63101

Credit Balance Reporting Regular and Certified Mail: CGS Attn: J15 Credit Balance Reporting PO Box 20023 Nashville, TN 37202

Fed Ex/UPS/Overnight Courier: CGS J15 Credit Balance Reporting 2 Vantage Way Nashville, TN 37228

Reports may be faxed to: MCBR Receipts Attn: Credit Balance Reporting 1.803.462.2584

VRU: 1.803.763.6418

All e-mail inquiries: [email protected] Electronic Data Interchange (EDI), including:

• EDI enrollment

• Administrative Simplification and Compliance Act (ASCA)

• Electronic Remittance Advice (ERA)

• PC-ACE Pro32 (billing software)

• Direct Data Entry (billing software): enrollment, RACF IDs, passwords, problems with your claims being accepted (for other DDE questions, call 1.866.590.6703, option 1, to speak with a customer service representative)

Address: J15 - Part A EDI CGS PO Box 20014 Nashville, TN 37202

EDI Help Desk: 1.866.590.6703 (choose option 2)

Investigational Device Exemption Requests

Email: [email protected]


1.800.MEDICARE

http://www.medicare.gov

mailto:Credit.Balance%40PalmettoGBA.com?subject=

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Department Contact InformationMedical Affairs

• Carrier Medical Director

Address: CGS J15 Part A Medical Affairs Dr. Michael Montijo PO Box 20200 Nashville, TN 37202

Email: [email protected]

Medical Review

• Responding to Additional Documentation Requests (ADRs)

• Responses to our requests for medical records

Address: CGS J15 Part A Medical Review PO Box 20021 Nashville, TN 37202

Fax: 1.803.462.2596

FedEx/UPS/Overnight Courier: CGS J15 Part A Medical Review 2 Vantage Way Nashville, TN 37228

Medicare Secondary Payer (MSP): Coordination of Benefits Contractor

• Questions regarding beneficiary’s primary or secondary records

COBC: 1.800.999.1118

TTY/TDD: 1.800.318.8782 for the hearing and speech impaired.

Hours: Mon. through Fri. from 8:00 a.m. to 8:00 p.m. ET, except holidays.

Mailing address: Medicare - Coordination of Benefits PO Box 33847 Detroit, MI 48232

Overpayments

• Overpayments

• Checks for cost report and credit balances

• Immediate offset requests

Checks: CGS - J15 Part A Kentucky CGS - J15 Part A Ohio PO Box 957582 PO Box 957635 St. Louis, MO 63195-7582 St. Louis, MO 63195-7635

Extended Repayment Schedules: J15 Part A Overpayments CGS PO Box 22029 Nashville, TN 37202-2029

Provider Inquiries:

For telephone assistance regarding overpayments, please call the Provider Contact Center at 1.866.590.6703

To request an immediate offset, fax your request, including this form to 1.615.664.5932

To access the immediate offset form, go to: http://www.cgsmedicare.com/forms/J15_PartA_HHH_OffsetRequest.pdf

Provider Audit, including issues related to:

• Questions about cost reports, desk reviews, audits, and settlements

• Filing cost report appeals and reopenings

Provider Audit (regular and overnight delivery): CGS J15 Provider Audit 3021 Montvale Drive, Suite C Springfield, IL 62704

Appeals and Reopenings:

Regular Mail: J15 Appeals and Reopenings PO Box 100148 (AG-350) Columbia, SC 29202

FedEx/UPS/Overnight Courier: J15 Appeals and Reopenings 2300 Springdale Dr. (AG-350), Building One Camden, SC 29020

Email address for filing cost report appeals: [email protected]

Email address for filing cost report reopenings: [email protected]


mailto:CMD.inquiry%40cgsadmin.com?subject=

http://www.cgsmedicare.com/forms/J15_PartA_HHH_OffsetRequest.pdf

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Department Contact InformationProvider Enrollment

• General Enrollment questions

• Initial Enrollment and Change of Ownership questions

• Change address, add a location

• Electronic Funds Transfer (EFT) CMS 588 form

• How to obtain a National Provider Identifier (NPI)

Address: CGS J15 Part A Provider Enrollment PO Box 20004 Nashville, TN 37202

For telephone assistance, please call the Provider Contact Center at 1.866.590.6703

Access Internet-based PECOS at: https://pecos.cms.hhs.gov/pecos/login.do

(Note: Your facility’s Authorized Official must register first)

Obtain electronic CMS 855 application forms at: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/EnrollmentApplications.html

Provider Outreach and Education (POE)

• Request education or training

• Request a speaker for association meetings in your state

Address: CGS J15 Part A POE PO Box 20200 Nashville, TN 37202

To complete your request electronically go to: http://www.cgsmedicare.com/parta/help/forms/pdf/eduation_request.pdf

Provider Reimbursement

• Interim rate information

• Reimbursement issues

• Reimbursement specialist

• Submission of certificates

Address: CGS J15 Provider Reimbursement PO Box 20020 Nashville, TN 37202

Phone: 1.803.763.5554

Email: J15.reimbursement@ palmettogba.com

Quality Improvement Organization (QIO) - Ohio

• Quality of care concerns regarding Medicare beneficiaries

• Quality Improvement Plans

• Electronic Health Records (EHR) and Meaningful Use of Technology

Address: Ohio KePro Rick Run Center, Suite 100 5700 Lombardo Center Drive Seven Hills, OH 44131

Phone: 1.800.385.5080

Website: http://www.ohiokepro.com

Quality Improvement Organization (QIO) - Kentucky

• Quality of care concerns regarding Medicare beneficiaries

• Quality Improvement Plans

Address: Health Care Excel of Kentucky, Incorporated 1941 Bishop Lane, Suite 400 Louisville, KY 40218

Phone: 1.502.454.5112

Website: http://www.hce.orgQualified Independent Contractor (QIC) Part A West Jurisdiction (KY and OH)

• Second-Level Appeals (Reconsiderations)

Address: MAXIMUS Federal Services, Inc. QIC Part A West Project PO Box 62410 King of Prussia, PA 19406

Standard Reconsiderations: 1.484.688.8900

Website: http://www.maximus.com

Reopenings Please access the Clerical Error Reopening Form at: http://www.cgsmedicare.com/parta/help/forms/pdf/clerical_error_reopening.pdf

Address: CGS J15 Part A Claims PO Box 20211 Nashville, TN 37202


https://pecos.cms.hhs.gov/pecos/login.do

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/EnrollmentApplications.html



http://www.cgsmedicare.com/parta/help/forms/pdf/eduation_request.pdf



mailto:J15.reimbursement%40palmettogba.com?subject=

mailto:J15.reimbursement%40palmettogba.com?subject=

http://www.ohiokepro.com

http://www.hce.org

http://www.maximus.com

http://www.cgsmedicare.com/parta/help/forms/pdf/clerical_error_reopening.pdf

http://www.cgsmedicare.com/parta/help/forms/pdf/clerical_error_reopening.pdf

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Department Contact InformationZone Program Integrity Contractor (ZPIC)

• Suspected fraud

• Potential abuse

• Questionable billing practices

Address: Cahaba Safeguard Administrators, LLC 375 Riverchase Parkway East Birmingham, AL 35244

Website: http://cahabasafeguard.com


http://cahabasafeguard.com

Documents

Medicare Bulletin - February 2014